Men's experience with penile rehabilitation following radical prostatectomy: a qualitative study with the goal of informing a therapeutic intervention.

Probably not a substantial claim: may not pass S3 (load-bearing).

Erectile dysfunction is consistently associated with depressive symptoms and reduced general happiness, as documented in quantitative and qualitative reports.

“ED has consistently been associated with depressive symptoms and a reduction of general happiness in life, which has been documented in both quantitative and qualitative reports (7, 10, 16).”

• cites [7] sourceNot checked — no full text of the source
• cites [10] sourceNot checked — no full text of the source
• cites [16] sourcePartly supported

  In “Initial reaction to erectile dysfunction” (page unavailable), the qualitative study says participants’ reactions sometimes led to depression. The Introduction (page unavailable) describes questionnaire studies reporting poorer quality of life and an expectation of depressed mood. These passages support an association, but the paper says only that some studies suggest a psychological effect; it does not establish a consistent reduction in general happiness. (LLM, conf=0.83)

  Experimental — accuracy not yet measured

May combine two claims.

Men reported deep disappointment and distress from erectile dysfunction, including feelings of frustration, shame, anxiety, devastation, and not feeling like a man.

“When asked to talk about their experience with erectile dysfunction, the men expressed a sense of deep disappointment and distress. They reported feelings of “frustration,” “shame,” and “anxiety.” Men characterized the experience as “devastating” and reflected that they did not “feel like a man.””

• Also stated in: § Results · plain

  “negative emotional impact of ED”

May combine two claims.

Participants identified common barriers to consistent penile injection use, including lack of spontaneity, unnaturalness, timing, worry about correct injection site, fear of priapism, and storage of medicine.

“The participants also identified several common barriers to consistently using penile injections. Many discussed the “lack of spontaneity” and “unnatural” component of obtaining an erection. Logistical issues such as timing, worry related to achieving the correct injection site, fear of priapism, and storage of the medicine were also concerns.”

Probably not a substantial claim: may not pass S3 (load-bearing).

The majority of the sample was Caucasian (83%).

“The majority of the sample was Caucasian (83%), married (83%), and were at least college educated (86.6%, Table 1).”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

The 30 participants had a mean age of 59 years (SD=7), with ages ranging from 41 to 72.

“The mean age of the sample was 59 years old (SD = 7), and age ranged from 41 to 72 years.”

• Also stated in: § Results · plain

  “Average age was 59 (SD=7)”

Probably not a substantial claim: may not pass S3 (load-bearing).

The majority of the sample was married (83%).

“The majority of the sample was Caucasian (83%), married (83%), and were at least college educated (86.6%, Table 1).”

May combine two claims.

The men reported that needle stick pain was minimal and was not a common reason for avoiding injections.

“The men reported the pain of the needle stick was minimal and was not a common reason for avoidance of injections.”

Probably not a substantial claim: may not pass S3 (load-bearing).

The majority of the sample was at least college educated (86.6%).

“The majority of the sample was Caucasian (83%), married (83%), and were at least college educated (86.6%, Table 1).”

May combine two claims.

Negative thoughts about erectile dysfunction and injections included not being a real man, a partner leaving if unable to perform, prediction of failure to finish sexually, and injections being barbaric, brutal, and unnatural.

“Examples of these negative thoughts related to ED include men thinking they were not a “real man,” that their wife/partner will leave if they cannot “perform,” or the prediction that they will fail and “not be able to finish” sexually. The negative cognitions related to injections included that they are “barbaric”, “brutal,” and “unnatural.””

May combine two claims.

Many men stated they had no one to talk to about their experience, or had difficulty initiating discussions even if they knew someone who had had radical prostatectomy.

“Many men stated they did not have anyone to talk to about their experience, or reported that even if they knew someone who had had a RP they had difficulty initiating discussions about their struggles.”

May combine two claims.

Men who focused on long-term benefit believed injections were necessary to avoid deterioration, allow a sex life again, and feel like a man again.

“Those that were focused on the long-term benefit realized that injections were something you must do so that you “don't deteriorate”, to allow for a sex life again, and the opportunity to “feel like a man again.””

May combine two claims.

Continued use of injections led to a reduction in anxiety related to injections and a reduction of negative affect associated with sexual situations.

“The continued use of injections lead to a reduction in anxiety related to injections and a reduction of negative affect associated with sexual situations.”

May combine two claims.

These men were willing to go through the hassle of injections and possible emotional let-down if failures occurred so that they would not deteriorate and would return to feeling like a man again.

“These men noted a willingness to go through the “hassle” of using the injections and possibly enduring some emotional let-down if failures occurred so that they would not “deteriorate” and return to feeling “like a man again.””

May combine two claims.

Impediments such as pain, loss of spontaneity, logistical issues, emotional distress, and shame related to erectile dysfunction were prevalent.

“Impediments such as pain, loss of spontaneity surrounding sex, logistical issues (e.g., when and where to inject), and emotional distress and shame related to ED were prevalent.”

May combine two claims.

Men in this cycle reported negative cognitions that often predicted failure and subsequent shame and humiliation.

“Men in this cycle reported a number of negative cognitions that often predicted failure and subsequent feelings of shame and humiliation.”

May combine two claims.

Some men reported significant fear and anxiety about entering sexual situations when not confident in erections, and considerable dread and anxiety about using penile injections.

“some men reported significant fear and anxiety related to entering a sexual situation when they were not confident in their erections, and discussed considerable dread and anxiety related to using penile injections.”

May combine two claims.

These men kept their eye on the prize and saw rehabilitation as getting back to the life they wanted.

“These men kept their “eye on the prize” and saw the process of rehabilitation as “getting back to the life I want.””

May combine two claims.

The analysis of the qualitative data produced six primary themes describing men's frustration with erectile dysfunction and barriers to using penile injections, potentially leading to avoidance of injections or decreased compliance.

“The analysis of the qualitative data produced six primary themes describing men's frustration with ED and barriers to using penile injections, potentially leading to the avoidance of injections or, conversely, decreased compliance.”

Probably not a substantial claim: may not pass S3 (load-bearing).

A well-established link exists between erectile dysfunction and depressive symptoms.

“The link between ED and depressive symptoms is now well established (7)”

• cites [7] sourceNot checked — no full text of the source

May combine two claims.

ACT has potential as a conceptual basis for a psychological intervention to reduce avoidance of penile injections and improve adherence to an erectile rehabilitation program.

“As such, ACT has the potential to serve as a conceptual underpinning of a psychological intervention to help men reduce avoidance to penile injections and adhere to an ER program.”

May combine two claims.

Frustration about erectile dysfunction can lead men to avoid sexual situations and ED treatments, which negatively affects adherence to an erectile rehabilitation program.

“Men's frustration surrounding ED can lead to avoidance of sexual situations and ED treatments, which negatively impact men's adherence to an ER program.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Radical prostatectomy is a gold-standard treatment for early-stage prostate cancer with established long-term benefit.

“One of the “gold standard” treatments for early stage prostate cancer is radical prostatectomy (RP), which has established long-term benefit (2-5).”

• cites [2] sourceNot checked — no full text of the source
• cites [3] sourceNot checked — no full text of the source
• cites [4] sourceNot checked — no full text of the source
• cites [5] sourceNot checked — no full text of the source

May combine two claims.

In committed relationships, depression and bother from ED can affect the couple, leading to avoidance of sex, reduced intimacy, and ultimately relationship stress and conflict.

“For men in committed relationships, this depression and bother can impact the couple, and can result in an avoidance of sexual situations and a loss of intimacy, which in turn can lead to relationship stress and conflict (9-15).”

• cites [9] sourceNot checked — no full text of the source
• cites [10] sourceNot checked — no full text of the source
• cites [11] sourceNot checked — no full text of the source
• cites [12] sourceNot checked — no full text of the source
• cites [13] sourceNot checked — no full text of the source
• cites [14] sourceNot checked — no full text of the source
• cites [15] sourceNot checked — no full text of the source

Classified as probably not a substantial claim.

The study did not require any particular level of adherence success, as it aimed to capture both successful and unsuccessful experiences.

“We did not designate any eligibility requirement related to men's success adhering to the program as we were interested in a range of men's experiences with rehabilitation (i.e., successful and unsuccessful).”

Probably not a substantial claim: may not pass S3 (load-bearing).

Using multiple analysts to review qualitative data is thought to increase the trustworthiness of the findings.

“When multiple analysts review and synthesize qualitative data - a form of analyst triangulation – it is proposed to heighten the integrity of these results (32, 33).”

• cites [32]Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

• cites [33]Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

May combine two claims.

These processes seemed to start a cycle that ended in successful use of injections and maintaining commitment to the rehabilitation process.

“These processes seemed to start a cycle that ended in the successful use of injections and maintaining a commitment to the rehabilitation process.”

Probably not a substantial claim: may not pass S3 (load-bearing).

Achieving important goals is usually accompanied by some form of psychological anxiety.

“The next step is an acceptance that achieving important goals is usually accompanied with some form of psychological anxiety.”

• cites [36]Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

Probably not a substantial claim: may not pass S3 (load-bearing).

The team did not pre-plan to structure the themes with an ACT framework.

“There was also no a priori plan to organize these themes using an ACT framework as we have done in the Discussion.”

May combine two claims.

Men's experience of penile rehabilitation is poorly understood, and qualitative knowledge is limited regarding why compliance is poor, dropout is high, and how to help.

“Although there is some literature exploring why men stop using injections (e.g., anxiety, cost, pain) (25), little is understood about men's experience of penile rehabilitation, nor is there significant qualitative understanding of the reason for poor compliance and high drop-out, or potential ways to offer assistance to facilitate this process.”

• cites [25] sourceNot checked — no full text of the source

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Thirty of the 36 recruited men attended the four focus groups; five missed for unknown reasons and one for transportation problems.

“A total of 36 men were recruited for four focus groups. Five men did not attend for unknown reasons, and one could not attend due to transportation issues. The remaining 30 participants attended one of the four focus groups.”

May combine two claims.

During healing, men may be unable to achieve natural erections, potentially causing penile tissue atrophy, structural changes, and venous leak.

“Men may fail to have natural erections during this time which can lead to penile tissue atrophy, structural alterations, and venous leak (17).”

• cites [17] sourceNot checked — no full text of the source

• AssumptionRests on an assumption: The cavernous nerves, which lie on both sides of the prostate, are needed for erection.

May combine two claims.

For men after radical prostatectomy, not adhering to ED treatment may be especially harmful, as early and consistent intervention is considered crucial for rehabilitation.

“This non-compliance may be particularly harmful for men post-RP, since as stated above, the research suggests early and consistent intervention is crucial for erectile rehabilitation (17, 26).”

• cites [17] sourceNot checked — no full text of the source
• cites [26] sourceNot checked — no full text of the source

Probably not a substantial claim: may not pass S2 (checkable).

An important element of an intervention may be to help men understand the cycle of avoidance and control and the cycle of acceptance and commitment related to erectile rehabilitation.

“An important element of an intervention may be to help men understand the cycle of avoidance and control, and the cycle of acceptance and commitment related to erectile rehabilitation.”

Probably not a substantial claim: may not pass S2 (checkable). May combine two claims.

The Acceptance and Commitment Therapy framework may provide a useful way to organize the themes, explain the process of avoidance, and provide a structure transferable to a clinical intervention.

“the framework may provide a useful way to organize these themes in a way that helps to logically explain the process of avoidance and provides a structure that can be transferred to a clinical intervention (Figure 1 and Figure 2).”

Classified as probably not a substantial claim.

The avoidance and control cycle starts with focus on a problem, leading to a negative emotional reaction.

“Hayes et al. states that the avoidance and control cycle starts with the focus on a problem, which leads to a negative emotional reaction to that problem (36).”

• cites [36]Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

May combine two claims.

Even with nerve-sparing surgery, the cavernous nerves can be stretched and bruised during the operation, and healing may require 18 to 24 months.

“Despite nerve sparing surgery, the cavernous nerves are stretched and bruised inter-operatively and may take 18 to 24 months post-surgery to heal.”

• cites [17] sourceNot checked — no full text of the source

• AssumptionRests on an assumption: The cavernous nerves, which lie on both sides of the prostate, are needed for erection.

Classified as probably not a substantial claim. May combine two claims.

Participants were recruited one to three years after surgery to include both those still in rehabilitation and those who had finished the two-year program.

“We selected a time frame of one to three years post-surgery to allow for a range of experience with the program from, men who were currently active in rehabilitation as well as men who progressed through the two year time frame and could reflect on their experience.”

May combine two claims.

Avoiding thinking about or acting on the problem reduces negative emotions short-term but leads to long-term life restriction and continued struggle.

“This avoidance leads to a short-term reduction in the negative affect (i.e., relief) but also leads to long-term life restriction and continued struggle with the problem.”

• cites [36]Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

Classified as probably not a substantial claim. May combine two claims.

Anxiety can be mitigated or defused to some extent but can never be eliminated, and at some point willingness to experience emotional pain while moving toward the goal is needed.

“This anxiety can be mitigated or “defused” to some extent; however, it realistically can never be eliminated and at some point there needs to be a willingness to experience this emotional pain while moving toward the goal.”

• cites [36]Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

Probably not a substantial claim: may not pass S3 (load-bearing).

Most coders, including the qualitative expert leading the analysis, had minimal prior familiarity with ACT.

“The majority of coders, including the qualitative expert who facilitated the analysis, had little, if any, prior knowledge of ACT concepts.”

Classified as probably not a substantial claim.

Supporting men to seek and consistently use ED treatments could substantially improve quality of life for patients and their partners.

“Considering erectile function recovery is an important survivorship issue in men with prostate cancer, helping men pursue and consistently use ED treatments has the potential to significantly improve the quality of life for these patients and couples.”

Probably not a substantial claim: may not pass S3 (load-bearing).

The authors' institutional review board approved the study.

“The study was approved by the Institutional Review Board at our institution.”

Classified as probably not a substantial claim.

These qualitative interviews provide valuable guidance for developing a psychological intervention designed to help men use penile injections and adhere to a rehabilitation program.

“In all, these qualitative interviews provide valuable guidance to the development of a psychological intervention designed to help men use penile injections and adhere to a rehabilitation program.”

Probably not a substantial claim: may not pass S3 (load-bearing).

To assess the relevance of themes, the team checked whether different reviewers arrived at similar conclusions, a form of analyst triangulation.

“Primarily, there was an examination of the conclusions reached by the numerous reviewers and whether analogous conclusions regarding review of the focus group transcripts were attained.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

An experienced mental health professional led the focus groups using a semi-structured format; each lasted about 90 minutes.

“The focus groups were facilitated by an experienced mental health professional using a semi-structured format and lasted approximately an hour and a half.”

Probably not a substantial claim: may not pass S2 (checkable).

Educating men on this framework and coaching them on focusing on the long-term goal while accepting short-term anxiety may help them adhere to these programs.

“Educating men on this framework and coaching them on important concepts, such as focusing on the long-term goal while having the willingness to accept short-term anxiety, may help them adhere to these programs.”

May combine two claims.

Avoidance leads to short-term psychological relief but restricts engagement in important activities such as sexual activity or using injections.

“This avoidance then leads to short-term psychological relief; however this restricts the man from potentially important activities such as engaging in sexual activity or using injections.”

Classified as probably not a substantial claim.

The acceptance and commitment cycle begins with a focus on important or meaningful goals.

“The contrast to this cycle of avoidance is the cycle of “acceptance and commitment,” which Hayes et al. states first begins with a focus on important or meaningful goals (36).”

• cites [36]Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

Probably not a substantial claim: may not pass S3 (load-bearing).

A qualitative analysis expert with over a decade of experience moderated the coders' discussions.

“The discussion amongst the coders was moderated by an expert in qualitative analysis with more than 10 years of experience in analyzing qualitative data.”

Classified as probably not a substantial claim.

An existing Acceptance and Commitment Therapy framework describes a theoretical rationale for avoidance.

“We applied an existing psychological framework based on Acceptance and Commitment Therapy, which describes a theoretical rationale for avoidance (35)”

• cites [35] sourceNot checked — no full text of the source

Classified as probably not a substantial claim. May combine two claims.

Within the Acceptance and Commitment Therapy framework, a cycle of control and avoidance and a cycle of acceptance and commitment are articulated.

“Within this framework, a cycle of “control and avoidance” is articulated as well as a cycle of “acceptance and commitment.””

• cites [35] sourceNot checked — no full text of the source

May combine two claims.

Movement toward a goal leads to life flexibility and engagement in important life activities, and success over time can reduce anxiety related to the goal.

“This movement toward a goal leads to life flexibility and engagement in important life activities. This success over time can then lead to a reduction in anxiety related to the goal.”

• cites [36]Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

May combine two claims.

Penile injections are a proven, reliable second-line treatment that works without healthy cavernous nerves.

“An effective second-line treatment is penile injections, which does not require healthy cavernous nerves and is a proven, reliable treatment (20).”

• cites [20] sourceNot checked — no full text of the source

• AssumptionRests on an assumption: The cavernous nerves, which lie on both sides of the prostate, are needed for erection.

Probably not a substantial claim: may not pass S3 (load-bearing).

Themes that recurred across the four transcripts were evaluated and included in the results.

“In addition, the extent to which similar themes emerged and repeated across the four transcripts was evaluated and these themes were included in the results (32, 34).”

• cites [32]Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

• cites [34]Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

Probably not a substantial claim: may not pass S2 (checkable).

The potential benefit of peer support indicates that a peer support component to an intervention may be beneficial.

“The potential benefit of peer support also indicates that a peer support component to an intervention may be beneficial.”

May combine two claims.

The high education of the group and lack of racial and ethnic diversity in the sample is a weakness and may limit the generalizability of the findings.

“The high education of the group and lack of racial and ethnic diversity in the sample is another weakness and may limit the generalizability of the findings.”

Classified as probably not a substantial claim. May combine two claims.

This highlights the importance of increased support, information, and emotional processing for this population.

“highlighting the importance of increased support, information, and emotional processing for this population.”

Classified as probably not a substantial claim.

The number of focus groups and attendance at these groups allowed a thorough exploration of the themes resulting in thematic saturation.

“the number of focus groups and attendance at these groups allowed a thorough exploration of the themes resulting in thematic saturation”

Probably not a substantial claim: may not pass S3 (load-bearing).

The analysis was moderated by a researcher experienced in qualitative methodology, which allowed for a robust and productive discussion of the themes.

“the analysis which was moderated by a researcher experienced in qualitative methodology allowed for a robust and productive discussion of the themes.”

Classified as probably not a substantial claim. May combine two claims.

Incorporating the partner, or including information on how men can discuss rehabilitation with their partner, is an important component of an intervention in this area.

“This indicates that incorporating the partner, or including information on how men can discuss rehabilitation with their partner, is also an important component to an intervention in this area.”

Probably not a substantial claim: may not pass S2 (checkable). May combine two claims.

Interventions in this area need flexibility to coach men on engaging in rehabilitation with supportive and unsupportive partners, as well as how to help men without a partner.

“Thus, interventions in this area need to have flexibility to coach men on how to engage in a rehabilitation program with supportive and unsupportive partners as well as how to help men without a partner.”

Probably not a substantial claim: may not pass S3 (load-bearing).

This finding is consistent with other qualitative reports that have explored men's experience with prostate cancer treatments.

“This is consistent with other qualitative reports which have explored men's experience with prostate cancer treatments (37-40).”

• cites [37] sourceNot checked — no full text of the source
• cites [38] sourceNot checked — no full text of the source
• cites [39] sourceNot checked — no full text of the source
• cites [40] sourceNot checked — no full text of the source

Probably not a substantial claim: may not pass S2 (checkable). May combine two claims.

This gives strong justification to start interventions before surgery to help men understand the potential impact of surgery and provide education about the long-term benefits of rehabilitation.

“As such, this gives strong justification to start interventions in this area pre-surgery to help men understand the potential impact of surgery and provide the proper education related to the long-term benefits of rehabilitation.”

Classified as probably not a substantial claim.

The ability to organize these themes using an Acceptance and Commitment Therapy framework suggests that Acceptance and Commitment Therapy concepts may serve as a useful theoretical underpinning for an intervention in this area.

“The ability to organize these themes using an ACT framework suggest ACT concepts may serve as a useful theoretical underpinning for an intervention in this area (35).”

• cites [35] sourceNot checked — no full text of the source

Classified as probably not a substantial claim.

An Acceptance and Commitment Therapy framework can be used to place the themes highlighted in this analysis into a theoretical construct that outlines both a cycle of avoidance and a cycle of commitment.

“An Acceptance and Commitment Therapy (ACT) framework can be used to place the themes highlighted in this analysis into a theoretical construct, which outlines both a cycle of avoidance and a cycle of commitment.”