Relationship between LUTS/BPH and Sexual Function

Although the mechanism of action for the relationship between lower urinary tract symptoms attributed to benign prostatic hyperplasia (LUTS/BPH) and erectile dysfunction (ED) has not been firmly established, community-based studies have repeatedly provided strong evidence of an age-independent association between these disorders. What is apparent from this relationship is that men with LUTS/BPH are at high risk of developing ED and vice versa. Because theses disease are so closely intertwined it is important to always consider the impact of a LUTS/BPH treatment on the man's sexual function.

Role of Medical Treatments and Impaired Sexual Function

Men often experience a decline in sexual function with the progression of LUTS/BPH. Unfortunately, the treatment of LUTS/BPH is also fraught with risk to sexual function. The AUA Guidelines recommend alpha blockers and 5-alpha reductase inhibitors (5ARIs) as early treatments for men with LUTS/BPH. Although these agents used alone or in combination are efficacious, they also have been shown to adversely affect erectile and ejaculatory function and overall sexual quality of life. ¹ The commonly reported adverse effects of certain alpha blockers include anejaculation (6%). The agents with greatest prostate selectivity (eg tamsulosin, silodosin) have fewer systemic adverse effects but are associated with a higher frequency of ejaculation problems. Meanwhile, the most commonly reported adverse effects of 5ARIs include erectile dysfunction, decreased libido and ejaculatory dysfunction. Phosphodiesterase type 5 inhibitors (PDE5i) have been shown to be beneficial in improving symptoms scores in patients with LUTS/BPH and improve erectile function even though there no significant changes in urine flow rates and other urodynamic measures. As mentioned above, because men with LUTS/BPH frequently suffer from concomitant ED, the use of PDE5i has certain obvious advantages in this population.

Role of Surgery Treatments and Impaired Sexual Function

Many men will abandon medical therapy within the first year of treatment for a variety of reasons including lack of efficacy, side effects and personal aversion to required ongoing treatment and therefore consider surgical intervention. Before proceeding to a surgical intervention, the patient should be informed about potential complications of all available procedures, including ejaculatory dysfunction (EjD) and ED. The patient's attitude toward sexual dysfunction risk may influence their choice of procedure. This issue is particularly critical given the emergence of newer therapies that have little or no impact on sexual function (see below).

In the last several decades minimally invasive surgical therapy (MIST) has been widely adopted across many therapeutic specialties in response to an aging population that increasingly places greater value on factors such as lower perioperative complication rates and faster recovery. As it relates to patients with LUTS/BPH who failed to achieve satisfactory symptom relief with lifestyle changes or oral medications, transurethral resection of the prostate (TURP) is considered the gold standard treatment as this surgery provides clinically meaningful and durable relief from LUTS. However, TURP suffers when considering net health outcome balancing efficacy, morbidity and patient experience. The key benefits of TURP are offset by several major drawbacks including the need for regional/general anesthesia and hospitalization, increased anesthetic risk in older patients with coexisting medical conditions and high rates of postoperative sexual dysfunction. Consequently, enthusiasm for TURP has been declining and interest has grown in developing MISTs that are efficacious, provide a more favorable risk profile and better align with patient preferences.

Data on the sexual side effects of more traditional prostate surgery are difficult to ascertain as many studies were not designed to answer this question. As such, many studies evaluate sexual side effects by looking at reported adverse events only rather than prospectively assessing sexual function with the intervention. Doing so will likely underestimate the impact of a procedure on ED or EjD. In addition, patients may not only be undergoing a surgical procedure but also stopping the previous medical therapy, which can confound interpretation of postoperative sexual function. Regardless, given the strong relationship between ED and LUTS/BPH, this group of men is at high risk for worsening sexual dysfunction postoperatively. Importantly, sexual side effects from surgical treatments are more likely to be permanent than those from medical treatments, which can often be reversed by stopping medical treatment. Men with symptomatic LUTS/BPH who need treatment beyond medications and wish to avoid surgery can now consider MISTs, which have dominated the BPH landscape in the last few years, each with ejaculatory and erectile preservation as a key benefit over traditional operations.

Figure 1.

Rationale for MIST: Balance of BPH Outcomes with Minimal Impact on Sexual Function

As many men discontinue medical therapy yet proportionately few seek surgery, there is a demand for treatments that are less invasive than surgery and spare sexual function. This is space that the newer MISTs are trying to fill, but this choice must balance the reduced sexual dysfunction risk at the cost of a less robust BPH outcome. Urologists and patients seemed to be poised on a fulcrum, trying to balance acceptable (if not as robust) LUTS/BPH outcomes while minimizing risk to sexual function (fig. 1).

Convective water vapor therapy (Rezūm®). Convective water vapor energy ablation (Rezūm System, BostonScientific, Inc., Marlborough, Massachusetts) provides a minimally invasive thermal therapy without a discernible thermal gradient. This convective thermal therapy uses radiofrequency to generate wet thermal energy in the form of water vapor (steam). No thermal effects occur outside the prostate or targeted treatment zone. Therefore, this technology is able to provide rapid and meaningful improvement of LUTS regards of prostatic topography without significantly impacting sexual function.

In a randomized controlled trial of convective water vapor therapy vs sham the men in the study arm exhibited a 50% improvement in their International Prostate Symptom Score compared to a 20% improvement in the control arm (11.4 vs 4.2 points, p <0.0001) while Q _max improved by 67% (from 9.9 ml/sec to 16.1 ml/sec) compared to no change within the control group. ² Reports at 2, 3, 4 and 5 years note a durable voiding improvement. ³ Retreatment at 5 years appears low with 4% and 11% for surgical and medications restarts (respectively). Meanwhile, longer-term data have confirmed preservation of erectile and ejaculatory function. At 1 year postoperatively no significant difference in IIEF responses were noted, while only 3% of men (4 of 136) reported EjD. This preservation of sexual function has been maintained through year 4 of followup (fig. 2).

Figure 2.

Prostatic Urethral Lift (UroLift ^®) . Prostatic urethral lift (PUL; Urolift, Teleflex, Wayne, Pennsylvania) is a unique nonablative approach to treating LUTS/BPH. This transprostatic tissue compression consists of a nitinol capsular anchor connected to a stainless steel urethral end piece by a monofilament suture tensioned in vivo that mechanically relieves obstruction without ablation or resection. PUL provides durable relief of LUTS through 5 years with few detriments to sexual function. ⁴ However, returns to the operative room for additional treatment and medication restarts are higher (24.3% at 5 years). Implant misplacement, malfunction, encrustation or infection are other potential indications for surgical device explant that are unique to PUL and drive the risk of re-treatment even higher. ⁵ What appears consistent is the favorable perioperative experience as many patients avoid catheterization. ⁴

Conclusions

Men with LUTS/BPH often experience deterioration in sexual function as an independent risk factor in the natural history of the disease. The first line medical treatments are efficacious, but also have been shown to adversely affect sexual function. Men with LUTS/BPH who need treatment but wish to avoid surgical interventions may consider MISTs, most of which have a proven ability to preserve sexual function. Decisions regarding adoption of new technologies require understanding of any impact on sexual quality of life as well as duration and expense of treatment.