Saving Your Sex Life: A Guide for Men With Prostate Cancer. John P. Mulhall

you to go to our website at www. nomograms.org to survey the nomograms available for a variety of cancers, including prostate, bladder, kidney and breast. We have developed a prediction model for erectile dysfunction after radical prostatectomy and are in the process of developing one for radiation therapy also.

      Appended at the end of this chapter are three nomograms. The first is a preoperative nomogram which helps men who come into the office before their surgeries to define what the long-term erectile function will be. The second is a postoperative nomogram used when a patient comes in after surgery knowing what his nerve sparing status has been. And finally, the 12–month nomogram is for men who return 12 months after surgery, and this uses their 12 month-function to predict their long-term erectile function. These nomograms predict erectile function recovery 24 months after surgery and all of them include the patient’s age at the time of surgery, the patient’s erectile function at the time of surgery, the number of other medical problems (high blood pressure, cholesterol problems, diabetes, coronary artery disease) a patient has, the nerve sparing status of the patient for the postoperative nomogram and the erectile function at 12 months after surgery for the 12–month nomogram.

      The erectile function before surgery and the predicted erectile function at two years after surgery is based on the score from the International Index of Erectile Function, which has been appended to this chapter. This is a six-question questionnaire, which asks you about your ability to get and keep erection as well as your confidence in your ability to function sexually. Each question is scored on a 15–point scale, and the higher the overall score (maximum score is 30), the better the erectile function. To be able to have sexual intercourse consistently, a score of around 24 is required. While the official normal score is 26, there are many patients who are able to have intercourse with scores just below this level. You can score yourself and then you can use the nomograms to predict what your long-term erectile function recovery will be. It is important to understand that there is approximately a 10% error rate in nomograms, but they give you at least a crude guide as to what the potential is for erectile function recovery after surgery.

      Thus, you can already get a feel for the complexities that go into not just the decision about which treatment you will pursue, but also whom you are going to have perform the procedure. I recommend you sit and make a decision in a thoughtful manner without rushing to get rid of the cancer, which is often the gut reaction immediately after the diagnosis of prostate cancer has been given to you.

      APPENDIX 2

      Nomograms for the prediction of recovery of erectile function after radical prostatectomy

      For each nomogram, the left-hand side has the factors that you will need to plug into the prediction model. Your baseline IIEF score you can glean from Appendix 1 in this chapter. My advice is to use your IIEF score based on your erection function during sexual sactivity (partner of self) from a time-point before your prostate cancer diagnosis. Your age should be age in years (rounded up) at the time of surgery. You should then add up how many comorbidities (medical conditions associated with erectile dysfunction) you have. For example diabetes, high blood pressure, cholesterol problems, coronary artery disease, stroke, cigarette smoking. Add this number up and this is the number of comorbidities you have (having diabetes and cigarette smoking, now or in the past gives you a score of 2). For the postoperative and the 12–month nomogram an added factor is your nerve sparing score. For a guide on the Memorial Sloan Kettering Cancer Center nerve sparing score see the text in this chapter. If you have been told you had nerve sparing surgery your score should be between 2 (perfect nerve sparing) and 4 (reasonable nerve sparing). Finally for the 12–month nomogram there is one further extra factor, which is the 12 month IIEF score (that IIEF score at 12 months after surgery).

      Each factor will give you a point score by drawing a vertical line from each horizontal line up to the points line at the top of the nomogram. For example, in the preoperative nomogram, an age of 50 years at the time of surgery will give approximately 73 points, an IIEF score of 24 will yield 46 points and 3 comorbidities will yield 0 points. Next, add up all of these points (for the example above, a total of 119 points). Then draw a line down from total points line to the 24 month IIEF score. For the example cited above, this gives an IIEF score of 19 (mild erectile dysfunction). This is your predicted erectile function 2 years after surgery.