The Complex Relationship Between Lower Urinary Tract Symptoms and Sexual Health

Evaluation of psychological stress, cortisol awakening response, and heart rate variability in patients with chronic prostatitis/chronic pelvic pain syndrome complicated by lower urinary tract symptoms and erectile dysfunction

BACKGROUND

Mental stress and imbalance of its two neural stress systems, the autonomic nervous system (ANS) and the hypothalamic-pituitary-adrenal (HPA) axis, are associated with chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) and erectile dysfunction (ED). However, the comprehensive analyses of psychological stress and stress systems are under-investigated, particularly in CP/CPPS patients complicated by lower urinary tract symptoms (LUTS) and ED.

MATERIALS AND METHODS

Participants were 95 patients in CP/CPPS+ED group, 290 patients in CP/CPPS group, 124 patients in ED group and 52 healthy men in control group. The National Institutes of Health Chronic Prostatitis Symptom Index (NIH-CPSI), the International Index of Erectile Function-5 (IIEF-5) and the International Prostate Symptom Score (IPSS) were used for assessing the disease severity of CP/CPPS, LUTS and ED. Psychometric self-report questionnaires including the Beck Anxiety Inventory (BAI), Perceived Stress Scale (PSS), Type A Personality Test (TAPT) and Symptom Checklist 90 (SCL-90) were completed for distress from physical symptoms. Twenty-five subjects per group were randomly selected for further investigating the changes of the HPA axis and ANS. Saliva samples were taken on 3 consecutive days at 8 specific times with strict reference to time of morning awakening for evaluation of free cortisol. Heart rate variability (HRV) as marker of the ANS was measured using 24 h electrocardiography, and time-and frequency-domain variables were analyzed.

RESULTS

The BAI and SCL-90 scores were significantly higher in the CP/CPPS+ED, CP/CPPS and ED groups compared with the control group (p < 0.01). The PSS scores of both groups with ED were significantly higher than the control group (p < 0.01). Compared with the CP/CPPS group, the differences of PSS, SCL-90 and TAPT scores were statistically significant in CP/CPPS+ED patients (p < 0.01). The IPSS scores were shown to have significantly positive correlations with BAI (r = 0.32, p < 0.0001), PSS (r = 0.18, p < 0.01) and SCL-90 (r = 0.19, p < 0.01) in the CP/CPPS patients. However, in all subjects, the IIEF-5 scores were shown to have significantly negative correlations with BAI (r = -0.17，p < 0.001), PSS (r = -0.25，p < 0.0001), SCL-90 (r = -0.20，p < 0.001) and quality of life score in NIH-CPSI (r = -0.14，p = 0.0075). Cortisol awakening response (CAR) parameters and diurnal cortisol levels did not significantly vary between the four groups. Time-dependent parameters of HRV also did not differ significantly across groups. In the frequency domain analysis, low frequency (LF) was significantly lower in ED patients when compared with CP/CPPS+ED patients (p = 0.044) and healthy controls (p = 0.005), high frequency (HF) power was significantly higher in healthy controls compared to patients with ED (p < 0.001), CP/CPPS (p < 0.001) and CP/CPPS+ED (p < 0.001), and the CP/CPPS+ED group had significantly higher LF/HF ratio than the control group (p = 0.001).

CONCLUSION

CP/CPPS and ED patients score exceedingly high on most psychosocial variables. The symptom scores of LUTS and ED positively correlate with the severity of psychological stress. Our findings also suggest that the ANS sympathovagal imbalance is associated with ED and LUTS in CP/CPPS, whereas HPA axis activity is not.

Risk Factors Affecting Decreased Libido Among Middle-Aged to Elderly Men; Nocturnal Voiding is an Independent Risk Factor of Decreased Libido

Introduction

Decreased libido in middle-aged and elderly men is often difficult to treat, and identifying the risk factors affecting decreased libido is important for the clinical management of decreased libido. However, limited information is available regarding specific risk factors in this population.

Aim

The present study investigated the risk factors for decreased libido among middle-aged and elderly men.

Methods

Patients who attended our male andropausal outpatient clinic between 2009 and 2015 were enrolled. All patients completed a self-administered questionnaire, which included the Aging Male Symptoms (AMS) scale, International Prostate Symptom Score (IPSS), and Sexual Health Inventory for Men (SHIM). Information on waist size, body mass index, present illness, present use of any medication, and lifestyle habits were collected by each attending physician. Blood biochemical data such as free testosterone, total cholesterol, triglyceride, high density lipoprotein-cholesterol (HDL-Chol), and hemoglobin A1c values were assessed. Libido was assessed based on AMS scale question 17, and a score of 4 or higher was defined as severely decreased libido (severe group).

Main Outcome Measure

The clinical factors associated with severely decreased libido were analyzed based on multiple regression analysis.

Results

A total of 292 subjects were included in the analysis, 111 (38%) of which belonged to the severe group. The mean age of study subjects was 66.2 years, and the mean FT value was 7.1 ± 2.2. Comparisons of each variable among the severe and not severe groups showed significant differences in older age, current cigarette smoking, AMS scale, IPSS, frequency of nocturnal voiding, SHIM score, and HDL-Chol value. Multivariate regression analysis revealed that current cigarette smoking, frequent nocturnal voiding, and a low SHIM score were the independent risk factors for severely decreased libido. Furthermore, the frequency of nocturnal voiding significantly increased with severity of decreased libido.

Conclusion

Current cigarette smoking, frequent nocturnal voiding, and a low SHIM score were the independent risk factors for a severely low libido.

K Shigehara, Y Kato, M Iijima, et al. Risk Factors Affecting Decreased Libido Among Middle-Aged to Elderly Men; Nocturnal Voiding is an Independent Risk Factor of Decreased Libido. Sex Med 2021;9:100426.

The interaction between inflammation, urinary symptoms and erectile dysfunction in early-stage prostate cancer treated with brachytherapy

Erectile function has been shown to decline as a function of increasing peripheral blood inflammatory markers, namely the neutrophil-to-lymphocyte ratio (NLR). We evaluated if the association between NLR and erectile dysfunction (ED) applies to patients with localised prostate cancer. We included 1,282 patients who underwent brachytherapy. ED was classified before treatment according to the Terminology Criteria for Adverse Event Scale version 3.0. ED was defined as the need for the use of oral pharmacologic or mechanical assistance to have satisfactory sexual function. We found that patients with ED were older (p < .001), more likely to have hypertension (p = .002), statin use (p = .002), diabetes (p < .001) or an IPSS ≥ 8 (p < .001). On univariable logistic regression analysis, an NLR of ≥3 was statistically significantly associated with ED (OR 1.32, p = .029). But on multivariable analysis, the association between elevated NLR and ED was not statistically significant (p = .17). Significant were age (OR 1.12, p < .001), IPSS ≥ 8 (OR 1.50, p = .008), the presence of hypertension, hyperlipidemia and diabetes (OR 2.27, p < .001), and prostate volume (OR 0.99, p = .041). The NLR does appear to be a surrogate marker of chronic inflammation that causes baseline ED in patients with localised prostate cancer.

How can we Preserve Sexual Function after Ablative Surgery for Benign Prostatic Hyperplasia?

Our aim was to provide a narrative review regarding the prevalence, the associated pathophysiologic pathways and the potential management methods of sexual dysfunction related to ablative surgical techniques for Benign Prostatic Enlargement (BPE). Men suffering from BPE are at high risk of sexual dysfunction due to the disease itself, comorbidities, and pharmacological/surgical treatments. Transurethral resection of the prostate, as the gold standard treatment option for BPE, has historically been associated with relatively high rates of postoperative sexual dysfunction problems, mainly retrograde ejaculation but also erectile dysfunction. Ablative surgical techniques, including photoselective vaporization of the prostate (PVP), transurethral needle ablation (TUNA), Transurethral Microwave Therapy (TUMT), Convective Water Vapor Energy Ablation (Rezum®) and Aquablation®, have been proposed as treatment methods able to reduce treatment-related complications for BPE patients, including adverse effects on erectile and ejaculatory function, without compromising the efficacy rates for BPE. The neurovascular bundles can be damaged during TURP due to posterolateral capsular perforation. Ablative techniques and especially PVP theoretically seem to skip this hazard, as the distance created from the necrotic area to the capsule is generally larger compared to the distance induced after TURP. However, indirect thermal injury of erectile nerves, which could also be induced by the majority of available ablative techniques, could potentially lead to ED. Two special technical characteristics (physiological saline use for tissue ablation and real time penetration depth control) of Aquablation® could be proved beneficial with regard to the effect of the method on erectile function. In general, ablative techniques seem to have a minor impact on sexual function. However, low methodological quality characterizes most of the studies included in this review mainly due to the impossibility, in many cases, to perform blind randomization. Also, many studies did not have an erectile and ejaculatory function as primary outcomes limiting that way their statistical power to identify significant variations. Management of sexual dysfunction problems arising from ablative surgeries for BPE treatment could be divided into two levels. Firstly, intraoperatively the avoidance of manipulation of crucial structures regarding ejaculatory (bladder neck or ejaculatory ducts) and erectile function (neurovascular bundles) could possibly decrease the negative effect of these procedures on sexual function. Thus, in this direction, modifications of classic ablative techniques have been proposed resulting in encouraging outcomes regarding postoperative sexual function. Secondly, if EjD and/or ED are established, the already known treatment choices should be chosen in order for sexual function rehabilitation to be achieved. Thus, regarding ED: PDE5i daily or on-demand remains the gold standard first-line treatment choice followed by intracavernosal alprostadil injections in cases of failure, while penile prosthesis implantation must be kept as the final definitive solution when all the other methods have failed. Regarding ejaculation disorders (retrograde ejaculation or anejaculation): medical therapy with a-agonists (pseudoephedrine), sperm retrieval from the urine, bladder neck reconstruction, prostatic massage, electroejaculation, penile vibratory stimulation and surgical sperm retrieval are the available treatment options. Furthermore, high-quality studies are required to investigate the potential side effects of BPE surgery on sexual function and efficient treatment methods to manage them.