Sexual Function and Benign Prostatic Hyperplasia

Benign Prostatic Hyperplasia

REVIEWING THE LITERATURE Benign Prostatic Hyperplasia Sexual Function and Benign Prostatic Hyperplasia Claus G. Roehrborn, MD The University of Texas Southwestern Medical Center Dallas [Rev Urol. 1999;1(3):158-159] he 1994 Agency for Health Care Policy and Research (AHCPR) Guideline on the diagnosis and treatment of benign prostatic hyperplasia (BPH) stated that “there is no evidence to suggest that BPH itself, independent of an increasing prevalence of sexual dysfunction related to age, affects sexual function.”1 This statement was based on an overview of the available literature at the time. It was estimated that erectile dysfunction in men between the ages of 60 and 70 was seen in approximately 30% of the general population, and between the ages of 70 and 80, in about 50% to 60% of the population. The limited evidence at the time suggested the prevalence of erectile dysfunction was basically the same in patients diagnosed with clinical BPH and lower urinary tract symptoms (LUTS). Furthermore, it was estimated that the mean probability of a patient becoming impotent following a transurethral resection of the prostate (TURP) would be approximately 13.6% with a 90% confidence interval of 3.4% to 32.4%. This needs to be considered in the context of a 4.3% erectile dysfunction rate following an unrelated general surgical procedure, undoubtedly attributable to a “sham” effect. The AHCPR Guideline correctly suggested that further research was needed to determine the “number of patients who subsequently developed impotence, ejaculatory dysfunction, incontinence, and drugrelated side effects” following treatment.1 The belief that TURP could be responsible for erectile dysfunction based on relatively poor evidence from uncontrolled studies published prior to 1994 was shattered in 1995 by the publication of data from a VA Cooperative Study comparing the outcomes of TURP and watchful waiting in 556 men with moderate LUTS.2 In this study, TURP was not associated with changes in either general well-being, social activities, or sexual performance (P=0.92). In fact, at the end of the 3-year study, 19% of patients in the surgery group and 21% of those in the watchful waiting group reported that their sexual performance was worse, while 3% in each group reported it was improved. In general, the spouses or T partners thought that the patients’ sexual performance was unaffected over the course of the study. Despite this evidence, multiple authors have since then carefully analyzed sexual function before and after either minimally invasive treatments for patients with BPH or surgical resection of benignly enlarged prostates. In the majority of these cases, sexual function was affected at least in a small cohort. It appeared safe to assume erectile dysfunction would not follow a TURP in as high a percentage as estimated originally but that some patients would have some deterioration of sexual function due to the intervention. References 1. McConnell JD, Barry MJ, Bruskewitz RC, et al. Clinical Practice Guideline, Number 8: Benign Prostatic Hyperplasia: Diagnosis and Treatment. Rockville, Md: US Department of Health and Human Services, Agency for Health Care Policy and Research; 1994. AHCPR publication 94-0582. 2. Wasson JH, Reda DJ, Bruskewitz RC, et al, for the Veterans Affairs Cooperative Study Group. A comparison of transurethral surgery with watchful waiting for moderate symptoms of benign prostatic hyperplasia. N Engl J Med. 1995;332:75- 79. The Evaluation of Sexual Function in Men Presenting With Symptomatic Benign Prostatic Hyperplasia Namasivayam S, Minha S, Brooke J, et al. Br J Urol. 1998;82:842-846. In this study, 168 men with LUTS and clinical BPH underwent evaluation by the International Prostate Symptom Score (IPSS), the BPH Impact Index, flow rate recording, residual urine measurement, and Sexual Function Inventory Questionnaire by O’Leary1 in the domains of sexual drive, erections, and ejaculations. For each of these domains, both the symptoms and the problems associated with it were assessed as well as the overall sexual satisfaction. While there was a statistically significant correlation between age and the symptoms of sexual drive (r=-0.44; P<0.001) and the symptoms of ejaculation (r=-0.52; P<0.001), the only significant correlation between problems associated with SUMMER 1999 REVIEWS IN UROLOGY 157 Prostatic Hyperplasia sexual function was between age and sexual drive (r=-0.48; P<O.001). Overall, sexual satisfaction was not correlated with age and weakly correlated to the total IPSS (r=-0.29). It was, however, more significantly correlated with the BPH Impact Index (r=-0.38). These findings suggest that older patients are just as bothered by their sexual dysfunction as younger men. Overall, a significant number of patients with LUTS and clinical BPH appear to have sexual dysfunction with a proportion increasing with advancing age. Because older men still have a high degree of bother from their symptoms, it is important to assess sexual function prior to initiating any form of invasive therapy for BPH. Since patients do not always volunteer this information, and since the treatment discussion will not always take into consideration the desire of the patients to either remain sexually active or to become sexually active again, it is important for physicians to recognize this phenomenon and to incorporate sexual function questionnaires as an integral part of the initial assessment of patients with LUTS and clinical BPH as well as make them a part of the follow-up after treatment. References 1. O’Leary MP, Fowler FJ, Lenderking WR, et al. Brief male sexual function inventory for Urology. Urology. 1995;46:697-706. Sexual Function Following High Energy Microwave Thermotherapy: Results of a Randomized, Controlled Study Comparing Transurethral Microwave Thermotherapy to Transurethral Prostatic Resection Francisca EAE, D’Ancona FCH, Meuleman EJH, et al. J Urol. 1999;161:486-490. In this study, 147 patients were randomized to either undergo TURP or transurethral microwave thermotherapy (TUMT) using a high energy protocol. Patients were given a selfadministered questionnaire before the treatment and 3 and 12 months after the treatment. While LUTS improved in both treatment groups, the magnitude of the improvement was clearly greater in the TURP group compared with the TUMT group. However, at 3 months, only 27% of the TURP group had antegrade ejaculation compared with 74% of the TUMT group. These numbers were unchanged at the 1 year followup point. One can therefore state that approximately twothirds of men will suffer retrograde ejaculation following TURP versus only one-third of men following high energy microwave thermotherapy. Changes in sexual function were experienced in 36% of patients undergoing TURP versus 17% undergoing TUMT. Patients were asked regarding their overall satisfaction with sexual function, and it was interesting to note that, in the TUMT group, 76% were either very satisfied or satisfied prior to treatment versus 81% after 3 months. In the TURP group, 69% were either very satisfied 158 REVIEWS IN UROLOGY SUMMER 1999 or satisfied before treatment versus 85% following treatment. In contrast, 20% of the TUMT-treated patients were unsatisfied or very unsatisfied at baseline, and 20% were also either unsatisfied or very unsatisfied at 3 months, while in the TURP-treated patients, the number fell from 31% unsatisfied or very unsatisfied patients to 15% at 3 months. At the 3 month mark, 55% of the TUMT-treated patients were very satisfied versus only 21% of the TURP-treated patients. Problems with erection were reported in 20% of the TUMT and 17% of the TURP-treated patients. Despite the claims of the authors that TUMT is a better therapeutic option compared with surgical therapy in patients who wish to preserve sexual function, this is not entirely clear from the data presented. A distinct advantage exists only in regard to preservation of antegrade ejaculation, which does not necessarily preclude patients from experiencing sexual activity as pleasant. The sensation of orgasm might be preserved despite the absence of antegrade ejaculation. Based on these data, TUMT is a better therapeutic option for those men interested in preserving antegrade ejaculation and in fathering children in the future. It is clear that, with the aging of the population and with increased awareness, more and more patients will seek professional help for LUTS and clinical BPH. In addition, with the growing treatment armamentarium available for erectile dysfunction, patients will also seek help regarding erectile dysfunction. Erectile dysfunction and LUTS occur in the same patient population—namely the aging male. Whether the 2 are related and whether more severe symptoms correlate with higher degrees of sexual dysfunction is of interest, but from a practical point of view, less relevant. The fact is that sexual dysfunction exists in men wishing to be treated for LUTS and BPH, and that patients wish to be evaluated and treated for erectile dysfunction, while at the same time suffering from LUTS and having BPH. Thus, a careful history needs to take into consideration both voiding LUTS as well as sexual function. Psychometrically validated and selfadministered instruments are readily available for physicians to make an initial assessment of sexual function and LUTS during the first consultation with such patients. It is imperative that we take advantage of these tools, understand our patients’ concerns, and address these concerns in both our initial assessment as well as in our discussion of therapeutic options. It is clear that some of our therapeutic options are more likely than others to induce sexual dysfunction, and this needs to be discussed with patients in an open and fact-based manner. We clearly need more data regarding the effect of surgery as well as minimally invasive treatment alternatives on sexual function/dysfunction to better counsel our patients. Fortunately, with the availability of questionnaires and assessment instruments, these data should be forthcoming and welcomed by all of us. ■