The Prevalence and the Use of the Questionnaire’s Related to the Neglected Sexual Side Effects After Prostate Cancer Treatment: A Scoping Review of the Literature

Background: Early prostate cancer (PCa) treatment interventions may leave men with debilitating sexual side effects. These side effects may remain permanent, often undiagnosed, and undermanaged. The objective of this study was to map the evidence pertaining to the prevalence, and use of questionnaires, related to the neglected sexual side effects (NSSE) after PCa treatment consisting of radical prostatectomy (RP) surgery or radiation treatment (RT). Methods: This systematic scoping review’s search strategy involved the search of PubMed, Science Direct, and Google Scholar databases. Following title searching, two-independent reviewers conducted screening of abstracts and full articles. The screenings were guided by the eligibility criteria. Data were extracted from the included studies and the emerging themes were analysed. The review team analysed the implications of the ndings in relation to the research question and aims of the study. The Mixed Method Appraisal Tool was employed for quality appraisal of included studies. Discussion: Twenty-three studies about the prevalence and questionnaire use for NSSE after early PCa treatment were included. Two studies investigated most of the collective group of NSSE’s, and all the other studies mostly looked at a single NSSE. No single validated questionnaire was found that investigates the NSSE after early PCa treatment. Most studies incorporated some aspects of other questionnaires. Two studies used non-validated questionnaires that picked up on the majority of the collective group of NSSE. Conclusion: NSSEs are prevalent in men after RP and RT. Peyronie’s Disease, orgasmic Dysfunction and Penile Length Shortening are all similarly prevalent after RP and RT. Anejaculation was only found to be prevalent after RT*. Orgasm associated incontinence resulted from RP and RT, but the prevalence in RP patients was 6 times that of RT patients. Study participants felt inadequately informed about possible sexual side effects caused by their treatment choices. Questionnaires are effective at detecting NSSE after PCa treatment, but there is no valid and reliable questionnaire currently available to detect all the collective NSSE after PCa treatment. There is a scope to develop a validated and reliable PCa NSSE questionnaire. The NSSE questionnaire must be quick, straightforward, and effective.


Background
Prostate cancer (PCa) is a major cause of disease and morbidity among men and it is the second most common cancer affecting men on a global scale (1). Early PCa or localized PCa is cancer contained within the prostate described as being stage I or II on the tumour-node-metastasis system (2). Early PCa treatment consisting of radical prostatectomy surgery or radiotherapy, either through external beam radiotherapy or brachytherapy, results in side effects including sexual dysfunction. Other side effects could include both pain and incontinence (3) as well as less common physical deformities such as penile length shortening (PLS) and penile curvature changes (Peyronies disease) (4,5). Sexual dysfunction from PCa treatment is common regardless of whether the treatment modality included surgical or non-surgical interventions. Sexual dysfunction was found to increase during each year of follow-up after the initial intervention and it affects an average of 50% of patients within 5 years of receiving treatment (6).
Most men generally recover from pain and incontinence after a prostatectomy but sexual side effects often remain untreated, leaving them with long-lasting and debilitating sexual dysfunction (7). Men and their partners also suffer psychologically after prostate cancer treatment due to anxiety and depression related to sexual dysfunction (8). Speci c conditions related to physical sexual dysfunction are common after PCa treatment. These conditions include orgasm-associated incontinence, (OAI) urinary incontinence during sexual stimulation (UIDSA), altered perception of orgasm, orgasm pain (OP), anejaculation, PLS, and penile deformity/Peyronie's disease (PD) (4,5,7,9). These conditions are collectively referred to as the "Neglected Sexual Side Effects" (NSSE) and the symptoms are reportedly prevalent in 20-93% of post-prostatectomy patients (7).
Only a fth of the men who had been diagnosed with PCa will ever discuss issues related to sexual dysfunction with their health care practitioners (HCP) (10). A questionnaire may be useful as a nonthreatening strategy to initiate such a discussion and allow the patient to indicate their presenting symptoms. Two validated questionnaires, the Expanded Prostate Cancer Index Composite (EPIC) (11) and International Index of Erectile Function (IIEF) (12) were recommended for use in this context in 2015 (3).

Reason for this review
While the EPIC and IIEF both help to stimulate the conversation around general urinary and sexual function, they do not address the NSSE after PCa treatment. There is currently a lack of evidence about the availability of a possible questionnaire to speci cally address the NSSE after PCa treatment. It was therefore important to conduct a systematic scoping review to improve our understanding of the prevalence of NSSE and to highlight knowledge gaps on the role of questionnaires in the assessment of the NSSEs.

Term
De nition Erectile Dysfunction Consistent or recurrent inability to attain and/or maintain penile erection su cient for sexual satisfaction (clinical principle).

Anorgasmia
The inability to reach an orgasm despite adequate and prolonged sexual stimulation leading to adequate sexual arousal. Anorgasmia might or might not lead to personal distress Painful Ejaculation or Orgasm The occurrence of genital and/or pelvic pain during or shortly after ejaculation or orgasm (clinical principle).

Anejaculation
The absence of normal antegrade ejaculation during orgasm owing to the absence of the emission and expulsion phases of the ejaculation re ex (clinical principle).
Other De nitions (14) Orgasmic dysfunction Inability to achieve an orgasm, markedly diminished intensity of orgasmic sensations or marked delay of orgasm from any kind of sexual stimulation.
Peyronie's disease Named after the French physician Francois de la Peyronie, is an acquired disorder of the tunica albuginea, characterized by the formation of a plaque of brous tissue and often accompanied by penile pain, deformity on erection, and ED. Fractured penis, intracavernosal injection, and other trauma may also cause Peyronies disease. During these injuries, the tunica albuginea is injured and heals with brosis and scar tissue which results in the deformity in genetically susceptible individuals. Cavernosal brosis can occur following low ow priapism, corporeal surgery (e.g. Insertion of a prosthesis) as well as the other causes of Peyronies disease (trauma, injections, etc). Table 1 De nitions according to the 4 th International Consultation on Sexual Medicine (13) Methodology A protocol for this scoping review has previously been submitted for publication; It may be accessed at: https://dx.doi.org/10.21203/rs.3.rs-27667/v1 A systematic scoping review was conducted to map the evidence on: 1. the prevalence of NSSE after early treatment PCa, and 2. the literature on the use of questionnaires in the assessment of NSSE after early treatment for PCa.
The scoping review followed the ve steps described by (15)  Quality assessment of each of the included primary studies was be done as directed by (16) Identifying the research question The research question aimed to identify current academic literature on the NSSE after men have undergone early treatment for PCa.
The research sub-questions were as follows: What is the prevalence of NSSE after early treatment for PCa?
Which questionnaires are being used to assess NSSE after early treatment for PCa?

Eligibility criteria
The Population Concept Context (PCC) framework was used to determine the eligibility of the research question as illustrated in Table 2. Only studies that matched our aims mentioned above in their titles were selected for further processing.

Study selection
The identi cation of the relevant literature followed a systematic approach. The results of all three databases were combined into one Excel spreadsheet after applying the search parameters.
A total of 1369 articles were identi ed. After removing 207 duplicates, 1162 articles remained. The titles were screened, and after applying the including and excluding criteria (Table 3), another 1096 articles were removed with reasons. The abstracts of 66 articles were screened, and a nal 23 articles were selected for full-text review. All 23 articles review matched the criteria and were selected for the nal inclusion. No additional studies were included after consulting previous searches and reference lists, making the nal number of articles included 23. Figure 1 explains the study selection process. Charting the data A data extraction tool (appendix1) was developed to organize information about each included study. Table 4 illustrates the information that was charted from each included study. Non-surgical approaches/radiation therapy (RT).

Quality Appraisal
An electronic version of the Mixed Method Appraisal Tool (MMAT) (17) was adapted to assess the quality of the included studies. The study designs included in this scoping review included qualitative, quantitative descriptive, and mixed methods studies. The speci c criteria to determine the appropriateness of each included study are outlined in appendix 2.
Two reviewers assigned a score to assess each article that assessed the appropriateness of the study's aims and its relevance for inclusion in the review. The overall quality for each included study was calculated according to the following MMAT guidelines (score = number of criteria met/total score in each domain). 1 point was to be given for each question and a total score out of 5 was calculated. This score is represented as a percentage which correlates to the quality of the included studies. (Appendix 2) The results used the following descriptors.

Results
The results were synthesised and presented according to the objectives (A or B) of the study which was to report on, 1. the prevalence of the common NSSE's following early PCa treatment through surgical interventions/RP (Fig. 2). 2. the prevalence of each of the common NSSE after PCa after non-surgical interventions/RT (Fig. 2). 3. Mapping the evidence on the role and use of questionnaires in detecting NSSE studies after early PCa treatment (Fig. 2).
A total of 23 studies were included that reported on the NSSE after PCa treatment. As indicated in Table 4, the NSSE reported after surgical interventions were collectively reported 27 times in the included studies, whereas NSSE's about non-surgical interventions were reported 12 times.
Very poor quality (20%) where minimal criteria are met Poor quality (40%) where less than half the criteria is not met Fair quality (60%) where just more than half the criteria is met Good quality (80%) where most of the criteria are being met Excellent quality (100%) all criteria are met The overall quality of a combination of components cannot be more than its weakest component when it comes to mixed-methods studies, making the overall score equal to the lowest-scoring component (17).
Collating, summarizing and reporting on the data The ndings of this scoping review were analysed using a content analysis approach of the themes emerging from the extracted data. The themes were collated to answer each research question. The review team discussed ndings, resolved issues, and nalised ndings. The review team analysed the implications of the study ndings in how they relate to the study's aims and further research in the eld.
The collected data was organized into subgroups according to Fig. 2. The ndings were analysed and reported concerning the research question and the objectives of the scoping review. The data relating to the prevalence of the NSSE was quantitative, and the data about the use of a questionnaire yielded either one of 3 results being i) a commonly used standardized questionnaire, ii) and informal questionnaire, or iii) no questionnaire. In addition to the above-mentioned methodologies, the Preferred Reporting Items for Systematic reviews and Meta-Analysis extension for Scoping Reviews (PRISMA-ScR) checklist (18) were used to guide the write up of the scoping review (appendix 3). Six studies met the inclusion criteria (5,(19)(20)(21)(22)(23). The 2017 study reported on 415 men with an average of 60 years, where a questionnaire had been used by participants to rate their orgasmic function (OF) on a scale. They used this scale preoperatively and described the OF as either worsening, being stable, or improving preoperatively, and were asked to repeat the rating for a period up to 36 months postoperatively (19). Only 9,4% of participants reported an improved OF after 36 months while OF worsened in 60,1% and remained stable in 30,5% of participants respectively. This study concluded that patients who were younger than age 50 at the time of surgery, patients who had undergone nerve-sparing RP, and patients who had better (higher) OF before surgery could expect a higher rate of OF postoperatively.
A study by Ostby-Deglum et al (2016) reported on the ability to reach orgasm in men (n = 609 men) of an average age of 63 years, 3 years after their robotic-assisted laparoscopic prostatectomy (RALP). They reported poor ability to reach orgasm in 73% of the participants (20). Of the 27% of participants who were able to achieve orgasm after the procedure, 34% relied on erectile aids intermittently or always. Unfortunately, no pre-operative data on the ability to reach orgasm was taken from participants.
Frey et al (2014) investigated 316 patients between 3-36 months after their RP. Participants were an average age of 64 years (5). Five percent of the sexually active participants reported anorgasmia and 57% reported having delayed orgasms.
A 2011 study investigated OF in men (n = 408) of 60 years average age who were potent preoperatively and who had underwent RALP 3 years prior (21). The report found that 88,4% of participants younger than 60 years and 82,6% of participants older than 60 years were able to achieve an orgasm. The study also reported that 90,7% of bilateral nerve sparring (BNS) procedure patients were able to achieve orgasm, compared to 82,1% of the unilateral nerve-sparing (UNS) procedure participants.
One study retrospectively reviewed previous clinical notes of patients (n = 1021) of an average age of 64 who had undergone a radical retropubic prostatectomy ( RRP ) for 30 years. The procedures were performed by different surgeons (22). The review speci cally focussed on OF in a subgroup (n = 458) of participants. The study found that only 66, 8% of the men who had an orgasmic function before the surgery also attained OF afterward. They also concluded that a normal expected age-related decline in OF was prevalent, in such a way that patients under the age of 60 years would have a 77,4% probability of maintaining their ability to orgasm.
The 2010 study by Salonia et al investigated the improvement of OF over an extended period. The study was conducted with 334 men of average age 62 years, over 48 months after a nerve-sparring surgical procedure (23). An inability to achieve orgasm was reported by 37% of the participants. The study concluded that the OF had increased in these participants over 48 months after RP surgery. The study also reported that OF deteriorated after RP with advancing age. A 2013-study with participants (n = 1288) of 63 years average age who had undergone RP between 6 months and 5 years previously (24), reported OP in 11% of the participants in the previous 6 months. Of this group, the patients who had bilateral seminal vesicle sparing, 21% reported OP compared to 12% of the patients who had unilateral seminal vesicle sparing.

Prevalence of Altered
A similar result was reported in a 2012 study of 702 participants of an average age of 64 years, with 12% of their patients experiencing OP after RP (25). They further found that 72%, 26%, and 7% of the study participants complained of pain during orgasm at 12, 18, and 24 months respectively. Pain of 6/10 or more measured on the visual analogue scale (VAS) was experienced by 26% of their participants at 6 months, and 16% of participants at 24 months after the RP.
A 2010 study previously mentioned, reported that 14% of participants reported pain during orgasm over 28 months after their nerve-sparring RP (23).
Another 2014-study investigated the prevalence of OAI in participants (n = 412) who had RP, RT, or both (26). The average age of the participants was 62, 2 years for the RP group, and 65 years for the RT group.
The study reported a prevalence of OAI in 22.6% of the total study group and OAI prevalence of 28,3% of RP participants.
A 2012 video-urodynamic study by Manserro et al was included, as its rst objective was to investigate the incidence of OAI in a group of 84 potent and continent men who had undergone a bladder neck sparring RP at least a year prior (27). Of this group, 28,6% reported experiencing OAI. The study further evaluated 7 participants with a video-urodynamic evaluation and concluded that the functional urethral length was signi cantly lower in the OAI group, and that this could explain OAI in RP patients.
Nilsson et al; (2011) reported from their study of 1261 participants of an average age of 63 years 2 years after their RP (28). OAI was experienced by 21% of the participants in the previous 6 months. Of the total study population, only 55% were sexually active, and of this group, 4% had OAI during every orgasm, 39% had had an incidence of OAI and 7% of the group had OAI more than half the time. They also found that patients who experienced OAI reported a decreased ability to satisfy their sexual partner, and these patients avoided sexual activity due to fear of failing, inferior orgasmic satisfaction, and a lower frequency of sexual intercourse.
The oldest study (2011) included in this review investigated 1421 men of an average age of 58,4 years over 24 months after a RP (29). The study reported on inconvenience related to UIDSA. The study describes UIDSA as a combination of OAI and incontinence during masturbation or foreplay. Researchers reported 44% of their participants experiencing di culty with incontinence during sexual activity at 3 months. The study found that UIDSA decreased to 36, 1% amongst the participants at 24 months. In the same group, 22, 4% of participants reported major di culty from UIDSA at 3 months and UIDSA remained a problem for 12,1% of the participants at 24 months.

Prevalence of Anejaculation after Surgery (RP)
No studies in the current review reported on this issue.*

Prevalence of Penile Sensory Changes after Surgery (RP)
Only a study by Frey et al 2014 investigated patients (n = 316) at 3-36 months after their RP. Participants were an average of 64 years old (5). Twenty-ve percent of the total participant group reported sensory changes in their penises.

Prevalence of Penile Shortening after Surgery (RP)
Eight studies that met the inclusion criteria were found (5,(32)(33)(34)(35)(36)(37)(38). The most recent study included for review investigated looked at 507 participants who had RP (32). The participants were grouped into a complete recovery (CR) group of an average age of 59, 3 years, and an incomplete recovery (IR) group, with an average age of 62 years. A 2013 study reported on 364 men of an average age of 64 years and had concluded that 72% of the study population lost the ability to ejaculate in an anterograde fashion after a 6 year follow up period (31). Anejaculation was experienced at 1, 3, and 5 years after RT by 16%, 69%, and 89% of the respondents respectively. The study further linked that the failure to ejaculate increases in men with a higher dose of RT, older age, and smaller prostates at the time of RT.
A 2009 study of 241 men of an average age of 65 years found that at 36 months after RT (Brachytherapy), 81,3% of the sexually active study participants were able to ejaculate (30). A total of 84.9% of participants however experienced a reduction in volume and a deterioration in their orgasm after treatment compared to 26,9% before. The number of participants with rare/no ejaculations doubled after the treatment from 7,5% before to 18,7% after treatment. A total of 10% of the study respondents experienced no orgasms during sexual activity. Dry ejaculations increased from 0% before the RT to 18,7% of the participants after the RT.

Prevalence of Penile Sensory Changes; Penile Deformity and Penile length Shortening
The 2017 study by Frey and colleagues reported on all three of these conditions.
The study reported on the prevalence of some penile sensation changes in 27% of the participants (4) Prevalence of Penile Deformity/Peyronie's Disease after RT : Frey et al: (2017) reported that 12% of the participants reported an altered curvature of their penis (4) Prevalence of Penile Shortening after RT : The 2017 study reported that 42% of participants reported more than 1 cm subjective PLS. (4) A 2013 study by Parekh and colleagues of men (n = 948) mostly aged between 60-80 who reported selfperceived PLS (35). The study participants consisted of 22, 5% RT participants. That study reported 0% self-perceived PLS amongst the RT participants.  (19). The questionnaire enquired about OD in a study of 415 men, reporting on how the symptoms change over 36 months.
A 2016 study used the EPIC-26 questionnaire that only included one item to obtain data pertaining to orgasmic function. The question asked, "How would you rate your ability to reach orgasm" (20). The study concluded that only 23% of participants had a good ability to reach orgasm after 3 years.
A 2011 study used the EPIC-26 questionnaire, and the IIEF questionnaire preoperatively, and the EPIC questionnaire at regular intervals after surgery to investigate the orgasmic outcomes in participants 3 years after their RALP (21). In addition, patients were asked to evaluate their orgasm, and state whether they experienced any pain during orgasms.
Dubbelman et al did not use any questionnaire in their 2010 study. They rather interviewed their participants using structured questioning to explore issues regarding orgasmic function (22). Salonia et al's study used the IIEF questionnaire, particularly the IIEF-OF domain to enquire about OF in their study (23).
Both studies by Frey and colleagues conducted in 2014 and 2017 respectively enquired into OD as part of a set of NSSEs by using a study-speci c questionnaire (4,5). The RT study showed that 5% of participants reported OD (4), compared to 24% of the RP participants(5)  (29). OAI after RP (28,3%) was compared to OAI in RT ((5, 2) in one study (26) Anejaculation A 2013 study used the IIEF and in particular question 9 (when you had sexual stimulation or intercourse, how often did you ejaculate?) and 10 ( when you had sexual stimulation or intercourse, how often did you have the feeling of orgasm or climax?) (31). The participants were rstly interviewed by a sexual medicine physician and were questioned about their ejaculatory function (presence/absence, intensity and ease of achievement) and orgasm (presence/absence, intensity and ease of achievement). Those who were sexually active were asked to complete the IIEF questionnaire.
The 2009 study asked participants to complete the IIEF-5 questionnaire to assess erectile dysfunction, and a modi ed version ( 5 items not 7) of the Male Sexual Health Questionnaire (MSHQ) that speci cally addressed: i) frequency ii) volume iii) dryness, iv) pleasure and v) pain during ejaculation. The single study by Tal et al; (2010) did not report any questionnaire being used, but rather that the baseline data was collected by a urologist before the RP (speci cally assessing the penis for PD plaque presence), and the same procedure afterward as well as an assessment of a penile curvature with a goniometer if the patient reported a curvature (39).

Prevalence of Combined NSSE after RP/RT (Objective A)
Two studies were the most important of all the studies, as they investigated most of the collective group of NSSE (4,5). A similar approach was used in both studies in that they used the same set of questions to determine the presence of various NSSE from participants in the different treatment approaches, making the comparison of NSSE between the two approaches easy. These results will be discussed under each NSSE category.

Prevalence of Orgasmic Dysfunction after RP/RT
A varied range of OD was reported between studies, but OD featured in RP and RT participants. Twothirds of men reported poor ability to orgasm at 3 years (19,20), and no orgasm by one-third of men at 2-5 years after an RP (22,23). Although OF improved postoperatively over time (23), it also deteriorated with age (19,(21)(22)(23). Nerve sparring RP procedures predicted better post-operative OF (19,21). Increased time needed to reach orgasm was experienced by almost half the men, 5 years after RT (4).

Prevalence of Altered Perception of Orgasm after RP/RT
Similar results were found in an RP study and an RT study, where, the RP study (5) reported that 60% of participants vs almost 50% of the RT participants (4) reported a decrease in orgasm intensity.

Prevalence of Orgasm Associated Pain/Dysorgasmia after RP/RT
OP after an RP was reported on in 4 studies compared to 1 RT study. Similar results were found between the RP studies, in that between 10-12% reported OP in RP participant groups in all the OP studies (5,24,25). One study further described that the pain felt was mostly (70% of the time) felt in the penis (25), while another made the association between bilateral seminal vesicle sparing procedures as the possible cause of OP (24).

Prevalence of Orgasm Associated Incontinence/Climacturia after RP/RT
Climacturia is an NSSE in men after RP and RT. Five studies looked at OAI after RP, compared to two studies after RT. This NSSE was reported by anywhere between 21% (28) to 38% (5) of participants across the ve RP studies after 12-24 months (28) (5,26,27,29) OAI in RT was reported to be much lower, affecting only 4% of participants in one study (4). This notion was concurred by the only study that compared RP and RT participants experiencing OAI. This study concluded that the OAI rates after RP were six times more than that of RT (28,3% vs 5,2%) (26). Climacturia is associated with major sexual inconvenience/bother (28).

Prevalence of Anejaculation after RP/RT
According to this review, anejaculation is a consequence of RT (30,31). Anejaculation becomes worse over time after RT until it reaches its peak at 5 years after treatment with 89% of the study group being affected (31). An older study reported a con icting rate of anejaculation with 81,3% of their participants having conserved their ejaculatory function (30). This study was however done on a shorter average post-RT follow up time of 3 years(30), compared to the latest study who had a population with higher stage diseases receiving higher RT doses, possibly explaining the increased anejaculation rates (31). The one study did report that 75% of the participants had a reduction in ejaculate volume, and that 19% of the men experienced a dry ejaculation (30). Higher RT dose, older age, and smaller prostates at the time of treatment increased the likelihood of failure to ejaculate (31).
*Anejaculation is however also a given consequence of RP, as the ejaculatory apparatus (prostate, seminal vesicles, and ejaculatory ducts) are removed (7,40), but the authors were unable to source any studies within our search parameters that met the study inclusion criteria.

Prevalence of Penile Sensory Changes after RP/RT
Similar results were seen across 2 studies, one on each intervention type. The RP study (5) reported that 25% of their participants had penile sensory changes, while the RT study reported the same for 27% of participants (4).
Prevalence of Penile Shortening after RP/RT PLS was reported found in two RT studies (4,35), and eight RP studies (5,(32)(33)(34)(35)(36)(37)(38). The one study reported on both RT and RP, and concluded that no RT participants had PLS (35). PLS was worst at 7-10 days postoperatively (32, 33), but started recovering at 3-6 months (38). Self-perceived PLS is however still experienced by 55% of men 2 years after RP, and a nerve-sparing procedure reduced the risk of self-perceived PLS (36). Men who eventually do not fully regain their PL, can experience up to a 24% PL loss at 7 days postoperatively (32). Younger age and better pre-operative erectile function is associated with complete PL recovery (32), and PLS is associated with treatment regret (35).

Prevalence of Penile Deformity/Peyronies Disease after RP/RT
Two studies on RP participants found that 10-15,9% of participants reported the presence of a penile curvature or PD (5,39). The average reported curvature angle was 31 Degrees (39). A similar result was reported in the only RT study. They concluded that 12% of their participants reported an altered curve of the penis (4)

Questionnaire used in Assessing NSSE (Objective B)
It is clear from all the retrieved studies that there is no single validated questionnaire available that investigates the NSSE after early PCa treatment. Most studies incorporated some aspects of other questionnaires, or simply made their up their questionnaires. Two studies used a non-validated questionnaire that was able to pick up on the majority of the collective group of NSSE (4,5). These two studies looked particularly and the prevalence and predicting factors of the NSSE. The Epic-26 (11) questionnaire featured in a few studies pertaining to OD (19)(20)(21), but couldn't su ciently be used to report on OD, and thus additional orgasm rating questions were asked to participants (19,21). One study used the Dysorgasmia Frequency Scale (25). The IIEF was used in many studies (5,21,23,27,31,33,34,37,38), but had no purpose in detecting any of the NSSE. The EHS (41) was used in a few studies (5, 33), but once again had no role to play in detecting the NSSE. The SHIM questionnaire (a modi ed 5 item version of the IIEF) was used in one study (19,32), and another study (30) based their informal questionnaire on the Male Sexual Health Questionnaire (42).

Study Limitations
The inclusion and exclusion criteria only allowed original research to be considered, and many reviews that matched the study objectives could not be included. The data search was done only done on three databases, although allowance was made for appropriate articles not contained in the databases to be included.

Conclusion
NSSEs are prevalent in men after RP and RT. PD, OD, and PLS are similarly prevalent after RP and RT.
Anejaculation after RP studies could not be sourced, as only RT studies met the study inclusion criteria.
OAI/Climacturia was shown to be caused by RP and RT, but the prevalence found in the RP patients was PR conceived the study and participated in the design involved in drafting and nalising the manuscript. RS revised the manuscript and provided clinical input and approved the manuscript for nal submission.
JM came up with the study idea and provided clinical input and revised the manuscript for nal submission. JvW participated in the conceptual design of the study, drafting the manuscript and revising it critically providing nal approval of the version to be published.