Post-Prostatectomy Questionnaires: Which is Best?
By: Matthew J. Sloan, MD; Caleb A. Cooper, MD; Omer A. Raheem, MD | Posted on: 01 Dec 2021
Patients who undergo radical prostatectomy (RP) face a number of postoperative challenges, spanning from initial recovery and surgical wound healing to more long-term concerns such as regaining urinary and sexual function. Numerous questionnaires have been developed and are utilized regularly in post-prostatectomy care for the purpose of providing patient-directed assessments of symptoms. Here we present an overview of commonly utilized questionnaires, with domains including sexual and erectile function, urinary function and satisfaction, and other post-prostatectomy considerations, aiming to provide practicing urologists balanced views on what are the “best” questionnaires (see table).
Erectile Function Questionnaires
The 2018 AUA Guidelines on Erectile Dysfunction (ED) give an expert opinion that “validated questionnaires are recommended to assess the severity of ED, to measure treatment effectiveness, and to guide future management.”1 While not specific to post-prostatectomy ED, this guideline highlights the importance of using questionnaires to guide therapy.
The first questionnaire developed for the measure of erectile function was the International Index of Erectile Function (IIEF). Developed in 1997, it is a 15-question device that established a framework for questionnaires in this space.2 It is sensitive to treatment effects across a variety of treatment modalities and benefits from many validation and bridging studies. However, the IIEF imparts little information on sexual domains outside of erection and is of little value in patients who do not engage in penetrative vaginal intercourse. An abridged iteration of the IIEF referred to as “IIEF-5,” or more commonly as the “Sexual Health Inventory for Men” (SHIM), is a questionnaire in widespread use.2 The main advantages of the SHIM questionnaire when compared to the IIEF include its abbreviated structure (5 vs 15 items) as well as cutoffs for moderate and severe ED. However, similar to the IIEF, it is validated only in sexually active, heterosexual men and has a 6-month recall period, limiting its utility for prospective, long-term followup of erectile function.
Table. Summary of post-prostatectomy questionnaires
|No. Questions||Mins Admin Time||Strengths||Weaknesses|
|IIEF||15||10–15||• Many validation and bridging studies
• Sensitive to treatment effects across a variety of different treatments
|• Little information on sexual domains outside of erection
• Assumes the patient is sexually active; of little value in patients who do not engage in penetrative vaginal intercourse
• Does not discuss treatment
|SHIM||5||2–3||• Reduced questionnaire length relative to IIEF
• Distinct cut-off indicate no ED (>21) & severe ED (<8)
|• 6-Month recall period makes it less suitable for prospective, long-term, or longitudinal follow-up
• Validated in sexually active heterosexuals in long term relationships
|MSHQ||25||15–20||• Cultural sensitivity, ease of comprehension, and focus on ejaculation and satisfaction, as well as erection problems
• Does not assume heterosexual intercourse as the primary or sole form of sexual activity
|• Relatively long|
|PROMIS-SexFS v2.0||Variable||30–45||• Customizable
• Excellent validity and consistency
• Validated as an assessment of postsurgical recovery of erectile function
|• Time intensive
• Administrator needs to purposefully select questions
|EHS||1||1||• Single item, highly specific
• Correlates to IIEF
• Positive correlation between erection hardness and psychosocial measures i.e. self esteem, confidence, and relationship satisfaction
|• Simplified view of erectile function as hardness
• Does not discuss ability to maintain erection
|PFE||1||1||• Single item
• Predicts long-term potency rates after RP (<24% of erectile fullness indicates significantly greater risk of long-term ED)
|• Administered at 90 days after RP|
|ICIQ-SF||4||5–10||• Generally correlates well to 1- and 24-hour pad weight||• Correlation lost at more severe scores|
|24-Hour pad weight||N/A||N/A||• Historic gold standard||• No cutoffs to determine severity|
|PDQ||15||10–15||• All domains validated and confirmed with good consistency and reliability
• Shown to be highly responsive to treatment
|• Does not focus on erection quality
• Requires vaginal intercourse in the last 3 months
|BAPS||10||5–10||• Assess psychological symptoms of perceived penile size
• Potential use in treatment planning
|• Not yet validated in the context of post-prostatectomy patients|
|USC patient-reported penile length loss||1||1–2||• Incorporated penile length loss with IIEF-5||• Not validated|
In contrast, the Male Sex Health Questionaire (MSHQ) is a 25-question device that does not assume heterosexual intercourse as the primary form of sexual activity.2 It has the benefit of being more culturally sensitive with a focus on ejaculation and satisfaction in addition to erectile function.
The Patient-Reported Outcomes Measurement Information System Sexual Function & Satisfaction Measures 2.0 (PROMIS-SexFS v2.0) survey is the longest of the commonly utilized sexual function questionnaires.3 It is a comprehensive, customizable device with questions across 17 domains and exhibits excellent validity and consistency, including in postsurgical recovery. However, this questionnaire is time intensive and requires an administrator to tailor questions.
Deviating in design, both the Percent Full Erection (PFE) and Erection Hardness Score (EHS) questionnaires contain only a single item relating to a patient’s perceived degree of erectile fullness/hardness.2,4 The PFE has been validated in men undergoing robotic assisted RP and provides an added prognostic benefit, with a score of 0%–24% being associated with a significantly greater risk of long-term ED.4
Urinary Function and Incontinence Questionnaires
Per the 2019 AUA/SUFU guidelines on incontinence after prostate treatment, “clinicians should evaluate patients with incontinence after prostate treatment with history, physical examination, and appropriate diagnostic modalities to categorize type and severity of incontinence and degree of bother.”5
In contrast to erectile function, fewer validated questionnaires exist to aid in evaluating post-prostatectomy urinary incontinence. The International Consultation on Incontinence Questionnaire Short Form (ICIQ-SF) is a 4-question Likert scale device validated in men with incontinence.6 While found to generally correlate well to the 1-hour and 24-hour pad tests in post-prostatectomy patients, Soto-González et al noted that severe ICIQ-SF scores did not correlate well with severe 24-hour pad test scores.7
The 24-hour pad weight, while not strictly a questionnaire per se, has been utilized as an objective method for estimating the degree of urinary incontinence, correlating well with the number of pads per day.7 Unfortunately, no cutoffs have been established to categorize severity of incontinence using these methods.
In addition to the common post-prostatectomy concerns of ED and urinary incontinence, men are often faced with additional issues, such as changes in penile shape and length.
Approximately 11%–16% of men will develop Peyronie’s disease after RP.8 Consequently, it is important to address and monitor the degree of bother patients may experience from this complication. The Peyronie’s Disease Questionnaire (PDQ) is a 15-question Likert scale device evaluating domains including psychological and physical symptoms, including bother and pain.2 It has been shown to be highly responsive to treatment with good consistency and reliability. However, it has not been validated in the post-prostatectomy patient population and does not focus on the quality of erections.
Post-prostatectomy patients can expect approximately 1 cm of penile length shortening after RP; however, studies have shown a return to baseline for most patients at 48 months.9 The Beliefs About Penis Size (BAPS) questionnaire assesses the psychological symptoms patients experience regarding their penis size, with the potential for use in treatment planning.10 It is a 10-item Likert scale design previously validated in men ashamed of their penis size. Unfortunately, it has not yet been validated in the post-prostatectomy population. The USC Patient-Reported Penile Length Loss survey is a 1-item device used in men undergoing cystoprostatectomy and measures 3 domains: perceived length loss, amount of length loss and erectile function.9 It is easily incorporated into the IIEF-5, but has not yet been validated.
There are a number of questionnaires that assist in the evaluation of issues commonly faced by the post-prostatectomy population. As such, we aimed to provide a global overview of the most utilized questionnaires in order to provide practicing urologists balanced views on what are the “best” questionnaires in the post-prostatectomy setting. Notwithstanding, there is no single questionnaire that is “best,” and perhaps the best questionnaire is the one designed and validated for the purpose of studying and investigating a specific urological population and condition that is being evaluated.
- Burnett AL, Nehra A, Breau RH et al: Erectile dysfunction: AUA guideline. J Urol 2018; 200: 633.
- Yafi FA, Huynh LM, Ahlering T et al: What is a “validated questionnaire”? A critical review of erectile function assessment. J Sex Med 2020; 17: 849.
- Weinfurt KP, Lin L, Bruner DW et al: Development and initial validation of the PROMIS® sexual function and satisfaction measures version 2.0. J Sex Med 2015; 12: 1961.
- Huynh LM, Osann K, Skarecky D et al: Predictive modelling of 2-year potency outcomes using a novel 90-day erection fullness scale after robot-assisted radical prostatectomy. BJU Int 2018; 122: 249.
- Sandhu JS, Breyer B, Comiter C et al: Incontinence after Prostate Treatment: AUA/SUFU Guideline. J Urol 2019; 202: 369.
- Abrams P, Avery K, Gardener N et al: The International Consultation on Incontinence Modular Questionnaire: www.iciq.net. J Urol 2006; 175: 1063.
- Soto-González M, Da Cuña-Carrera I, Gutiérrez-Nieto M et al: Assessment of male urinary incontinence postprostatectomy through the Consultation on Incontinence Questionnaire-Short Form. Prog Urol 2020; 30: 209.
- Tal R, Heck M, Teloken P et al: Peyronie’s disease following radical prostatectomy: incidence and predictors. J Sex Med 2010; 7: 1254.
- Loh-Doyle JC, Han J and Ghodoussipour S: Factors associated with patient-reported penile length loss after radical cystoprostatectomy in male patients with bladder cancer. J Sex Med 2020; 17: 957.
- Veale D, Eshkevari E, Read J et al: Beliefs about penis size: validation of a scale for men ashamed about their penis size. J Sex Med 2014; 11: 84.