Response

Abstract

First of all, we thank you for your critical and valuable comments concerning our study. The treatment of (malignant) genital diseases almost always restricts male sexual functioning, and therefore several instruments have been developed for examination. The questionnaire method (by the patient's self-report) itself may favor symptomatic patients, who are more likely to respond than asymptomatic patients. This may result in an overestimation of the prevalence of chronic testis pain and of sexual dysfunction (eg, ejaculatory problems) after testicular cancer treatment. With a view to similar results in a previous study (Pühse et al, 2010), we are confident that the reported prevalence is not influenced by a major selection bias. Methodically, there might be a recall bias concerning the exact extent of preoperative pain; the other parameters mentioned reflect the patients' actual discomfort (at different time points). We do not doubt that sexual function fluctuates over time (Tuinman et al, 2010), but chronic pain and its influence on sexual function persist for a long time after therapy. Following completion of primary cancer treatment and many years thereafter, specific symptoms continue to affect cancer survivors negatively (Harrington et al, 2010). The association of chronic pain and negative sexual function is the crucial point in our study. In andrology, comparative data were found in patients experiencing chronic pelvic pain syndrome (CPPS). Although a comparison with a benign disease must be handled with caution, CPPS patients differed from controls by reporting significantly less frequent sexual desire or thoughts, less frequent sexual activities, less arousal or erectile function, less orgasm function, and higher frequencies of genital pain during or after intercourse (Aubin et al, 2008). The assessment of these characteristics in subgroups (eg, patients with contralateral testicular intraepithelial neoplasia [TIN]) also may be of importance to learn what biases may exist in our understanding of our patients experiencing damage from cancer therapies. For this study, we explicitly excluded patients with contralateral tumor or TIN in order to have a more homogenous study population concerning contralateral testicular function. The aspects of sexual functioning that are predominated by cognition, perception, and emotion may be affected by the psychotraumatic experience of having cancer, but also by physiologic factors, like chronic pain (Kwan et al, 2005). The best way to assess whether the intensity of presurgical and postsurgical pain is confounding the patients' reporting is to carry out the survey at several time points before and after surgery and oncologic therapy, and during follow-up. Therefore, we introduced our questionnaire into the testis cancer routine follow-up program for a prospective evaluation of the problem. Improvement (or impairment?) of sexual function over time is multifactorial and has to be analyzed intraindividually over time. We have to clarify that (not only) pain is one of the causes that may result in sexual dysfunction due to the treatment for testis cancer. Identifying associations between cancer treatment and sexual dysfunction in men could be helpful to choose equally effective but less toxic treatment, and to optimize counseling for our testis cancer patients.