Lower urinary tract symptoms and erectile dysfunction; links for diagnosis, management and treatment

Minimizing Sexual Dysfunction in BPH Surgery

Purpose of Review

To review the prevalence and risks of sexual dysfunction associated with current treatment options for benign prostatic hyperplasia and to characterize techniques and methods to manage postoperative sexual dysfunction-related side effects.

Recent Findings

Current surgical therapies available for the treatment of benign prostatic hyperplasia are associated with a substantial risk of both ejaculatory and erectile function. However, many of the novel minimally invasive treatment alternatives have demonstrated the ability to preserve postoperative sexual function to a better degree, all while providing significant relief of lower urinary tract symptoms in an equally safe and efficacious manner.

Summary

Benign prostatic hyperplasia remains a highly prevalent disease among the aging population. While surgical treatments are often necessary to relieve bothersome urinary symptoms, these procedures are associated with an increased risk of sexual dysfunction. As such, there has been an increased interest in the development of minimally invasive therapies, such as the UroLift®, Rezum®, and Aquablation®, with the hopes of achieving similar symptomatic relief while maintaining sexual function. Aside from reporting lower rates of sexual dysfunction, these procedures have also demonstrated comparable safety, durability, and efficacy to current gold standard therapies. Some procedures can even be performed in an outpatient setting, avoiding the need for general anesthesia altogether. Overall, an individualized, shared decision-making approach is necessary to determine the ideal treatment option for each patient.

The Effect of LUTS/BPH and Treatments on Ejaculatory Function

As men age, there is an increased incidence of lower urinary tract symptoms (LUTS), often from benign prostatic hyperplasia (BPH) which can adversely affect sexual function. There are many different treatments for these symptoms; however, many of the treatments also affect sexual quality of life, specifically in the realm of ejaculation. Our paper will review the medications, surgical procedures, minimally invasive procedures, and even investigational procedures used to treat LUTS/BPH and the effect they have on ejaculation. The aim of this paper is to help practitioners counsel patients more effectively on treatment options when ejaculation is a concern.

Erectile Dysfunction in Chronic Prostatitis/Chronic Pelvic Pain Syndrome: Outcomes from a Multi-Center Study and Risk Factor Analysis in a Single Center

The aim of this study was to investigate the prevalence of erectile dysfunction (ED) in patients with chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) and explore the influence of UPOINT domains, National Institutes of Health-CP symptom index (NIH-CPSI) and other factors on ED prevalence. This was a prospective study of consecutive patients with CP/CPPS seen at 11 tertiary hospitals during January–July 2014. ED was diagnosed as a score of<21 on the International Index of Erectile Function (IIEF-5). Patients from one center were evaluated by the UPOINT system and NIH-CPSI. Each patient was assessed using clinical examination, asocio-demographic questionnaire, the Patient Health Questionnaire (PHQ), the Pain Catastrophizing Scale (PCS), NIH-CPSI and IIEF-5.1406 patients from 11 centers (mean age, 32.18 years; range 18–60 years) were enrolled. ED was found in 638/1406 patients (45.4%), and was categorized as mild in 291(45.6%), moderate in 297(46.6%) and severe in50(7.7%). 192 patients from one center(mean age,31.3 years; range 18–57 years) were further studied.IIEF-5 score correlated negatively with NIH-CPSI(r = 0.251), PHQ (r = 0.355) and PCS (r = 0.322)scores (P<0.001).PHQ score correlated positively with NIH-CPSI (r = 0.586) and PCS(r = 0.662) scores (P<0.001).NIH-CPSI, PHQ, PCS and IIEF-5 scores did not differ significantly between class IIIA and IIIB CP/CPPS. Multivariate logistic regression showed that UPOINT psychological (P) domain and NIH-CPSI symptom severity were independent risk factors for ED in CP/CPPS. It is concluded that psychological factors and symptom severity are independent risk factors for ED in CP/CPPS.

Phosphodiesterase Type 5 Inhibitor and Erectile Dysfunction in Lower Urinary Tract Symptoms

Benign prostatic hyperplasia (BPH) is one of the most common diseases in older men and mostly induces lower urinary tract symptoms (LUTS). Multiple studies have shown that BPH inducing LUTS are intensely correlated with erectile dysfunction (ED) and that severity of LUTS was proportional to ED severity. Although a direct causal relationship has not been clarified, a tentative pathophysiology has been suggested to interpret the relationship between two disorders. Androgen plays an important role in the maintenance of the functional and structural integrity of the lower urinary tract and penis. Low testosterone, especially free testosterone, worsened detrusor overactivity and replacement of testosterone improved LUTS in the hypogonadal BPH patients. Nitric oxide synthase and nitric oxide are decreased in the transition zone of the hyperplastic prostate but phosphodiesterase types 4, 5, 11 are prominent in transition zone of hyperplastic prostate. Phosphodiesterase type 5 (PDE5) inhibitor with a long half-life could obtain the desired effect; therefore, tadalafil and undenafil frequently have been used to evaluate the effects in the two disorders. In clinical trials, tadalafil showed improvement of BPH-induced LUTS, but few of the studies showed a significant improvement on uroflowmetry. PDE5 inhibitors increase the concentration of cyclic guanosine monophosphate (cGMP) in plasma and smooth muscle, promoting erection of the penis, as well as relaxation of the bladder neck and prostate, leading to natural voiding. Sexual function and LUTS should be assessed and discussed with the patient when choosing the appropriate strategy and the patient's response to treatment should also be evaluated at the same time.

Prostate myths: What is the prostate awareness in the general male population in Turkey?

OBJECTIVE

The aim of the study was to evaluate prostate awareness in the general male population and discover the common misinformation about prostate diseases (PDs).

MATERIAL AND METHODS

A cross-sectional population sampling was performed in the general population for men between the ages of 18-70 with a survey conducted by medical students. The survey consisted of 15 questions addressing different aspects of PDs and common misinformation in the general population. All participants were stratified according to age, degree of education, occupation and whether the person himself or a close relative had visited a urologist for PDs. All questionnaires were anonymous, and patients were informed about the confidentiality of the results.

RESULTS

A total of 1004 men between the ages of 18-70 were included in the study (mean age 38.0±12.9 years). Of those included, 20.2% were primary school graduates, 8.6% were secondary school graduates, 25.5% were high school graduates, 39.8% were university graduates, and 5.8% had a doctorate or higher education. Of all 1004 men, 31.5% had seen a urologist or attended an interview with a close relative for a PDs-related visit in a urologist's office; 56.2% reported "prostate" as a disease and only 16.5% as an organ. In terms of beliefs, 50.2% believed that all men had a "prostate," 5.4% said that sexual activity would cause PDs, 13% thought that sexual activity would prevent PD, 24.9% reported that a rectal exam would affect sexual activity, and 63.5% believed that urinating when squatting would prevent prostate hyperplasia. Prostate cancer transmission to sexual partners was marked as true by 5% of the men. As many as 41.3% of the participants believed that early prostate surgery for BPH would prevent prostate cancer, and 13% reported that sexual activity ceases with prostate surgery and that retrograde ejaculation or anejaculation is the end of sexual activity in men.

CONCLUSION

The survey clearly showed that prostate awareness is still very unsatisfactory in the Turkish male population and that urologists need to better inform the general population. PD knowledge is still lacking throughout all education levels. This is a unique study showing a cross-sectional analysis of the Turkish community; however, the applicability of these results to other communities should be evaluated.

Testosterone and the Prostate

INTRODUCTION

Late-onset hypogonadism, lower urinary tract symptoms (LUTS) due to benign prostatic enlargement (BPE), and prostate cancer commonly coexist in the aging male. Due to a better understanding of the physiology and impact of testosterone on benign and malignant diseases of the prostate, the view toward testosterone replacement therapy (TRT) in these individuals has changed dramatically over time.

AIM

This communication evaluates the effects of testosterone on benign prostatic growth and prostate cancer and reviews the evidence for TRT for men with BPE and prostate cancer.

METHODS

A literature review was performed with regards to TRT in men with prostate cancer as well as the effect of testosterone on the growth of benign prostate tissue and prostate cancer carcinogenesis.

MAIN OUTCOME MEASURE

To evaluate the evidence for an effect of testosterone on the growth of benign prostate tissue and the development of prostate cancer and TRT in men with prostate cancer.

RESULTS

TRT does not exacerbate LUTS. Current evidence is lacking but suggests that TRT may not increase the risk of subsequent diagnosis of prostate cancer, and is unlikely to impact recurrence or progression for men with treated prostate cancer, but longer follow-up is needed.

CONCLUSIONS

There is no evidence to suggest that TRT is contraindicated in men with BPE or effectively treated prostate cancer. Tan RBW, Silberstein JL, and Hellstrom WJG. Testosterone and the prostate. Sex Med Rev 2014;2:112-120.

A review of the use of tadalafil in the treatment of benign prostatic hyperplasia in men with and without erectile dysfunction

Epidemiological data link erectile dysfunction (ED) and benign prostatic hyperplasia (BPH)-associated lower urinary tract symptoms (LUTS), two highly prevalent conditions in aging men, assuming common pathophysiological pathways. Tadalafil 5 mg once daily has been approved for the treatment of men with LUTS with or without comorbid ED. The aim of this review is to provide an overview of current knowledge on the epidemiological and pathophysiological links between ED and LUTS and to focus on tadalafil as a new treatment option in men with BPH-associated LUTS. A Medline search was completed using the Medical Subject Headings (MESH® keywords) 'prostatic hyperplasia' and 'phosphodiesterase inhibitors'. This search revealed 125 relevant references (entire Medline database up to 11 March 2014). The efficacy of tadalafil 5 mg once daily for the treatment of LUTS has been reported by several well-designed studies. Tadalafil improves significantly the total International Prostate Symptom Score (IPSS), the voiding and storage subscores, the IPSS Quality of Life (QoL) and the BPH Impact Index (BII). Its efficacy is irrelevant to the erectile function status of the patients. However, in the majority of these studies tadalafil is not associated with improvement in maximum urine flow or post-void residual volume (PVR). Its safety profile is well established and no new or unexpected adverse events other than those reported in ED studies have been recorded. Tadalafil is today a new treatment alternative to other established drugs for LUTS such as the α-adrenergic antagonists or 5α-reductase inhibitors. However, it is not just an alternative, since sexual adverse events associated with these drugs are avoided and tadalafil is the only drug that can treat both ED and LUTS at the same time.

Association of lower urinary tract symptoms and the metabolic syndrome: results from the Boston area community health survey

PURPOSE

In this study we investigated the relationship between lower urinary tract symptoms as defined by the American Urological Association symptom index and the metabolic syndrome, and determined the relationship between individual symptoms comprising the American Urological Association symptom index and the metabolic syndrome.

MATERIALS AND METHODS

The Boston Area Community Health Survey used a 2-stage cluster design to recruit a random sample of 2,301 men 30 to 79 years old. Analyses were conducted on 1,899 men who provided blood samples. Urological symptoms comprising the American Urological Association symptom index were included in the analysis. The metabolic syndrome was defined using a modification of the Adult Treatment Panel III guidelines. The association between lower urinary tract symptoms and the metabolic syndrome was assessed using odds ratios and 95% confidence intervals estimated using logistic regression models.

RESULTS

Increased odds of the metabolic syndrome were observed in men with mild to severe symptoms (American Urological Association symptom index 2 to 35) compared to those with an American Urological Association symptom index score of 0 or 1 (multivariate OR 1.68, 95% CI 1.21-2.35). A statistically significant association was observed between the metabolic syndrome and a voiding symptom score of 5 or greater (multivariate adjusted OR 1.73, 95% CI 1.06-2.80) but not for a storage symptom score of 4 or greater (multivariate adjusted OR 0.94, 95% CI 0.66-1.33). Increased odds of the metabolic syndrome were observed even with mild symptoms, primarily for incomplete emptying, intermittency and nocturia. These associations were observed primarily in younger men (younger than 60 years) and were null in older men (60 years old or older).

CONCLUSIONS

The observed association between urological symptoms and the metabolic syndrome provides further evidence of common underlying factors between lower urinary tract symptoms and chronic conditions outside the urinary tract.

Assessing the Influence of Benign Prostatic Hyperplasia (BPH) on Erectile Dysfunction (ED) among patients in Poland

INTRODUCTION

Erectile dysfunction (ED) and the lower urinary tract symptoms caused by benign prostatic hyperplasia (LUTS/BPH) are highly prevalent among aging men. More data are needed from studies evaluating the impact of LUTS/BPH on ED. This study aimed to assess ED in patients with LUTS/BPH independent of comorbidities.

MATERIAL AND METHODS

During 2007 and 2008, we examined 10,932 patients aged 50 to 69 years with LUTS/BPH (IPSS = 8-19 points) using questionnaires: Sex-Score and International Index of Erectile Function 5 (IIEF-5). Patients who used alcohol and/or cigarettes and those with hypertension, diabetes, or hyperlipidemia and cholesterolemia were excluded from meta analyses, which left 4,354 patients with LUTS/BPH without any comorbidity for the analyses. The main survey instruments used were the Sex-Score and IIEF-5.

RESULTS

Regarding sexual coexistence, 1,497 (34.4%) and 2,638 (60.6%) patients considered it very important or important respectively; however, 219(5%) patients reported no sexual activity. After excluding sexually inactive patients, only 1,088 (25%) patients had the ability to obtain an erection during sexual activity always or nearly always. However, that erection was only strong enough to penetrate their partner almost always or most of the time in 218 (5%) and 826 (19%) patients respectively and only 610 (14%) patients were always able to maintain their erection during sexual intercourse. While only 87 (2%) patients had no difficulty maintaining their erection until the completion of intercourse, 174 (4%) and 914 (21%) patients stated that sexual intercourse gave satisfaction nearly always or most of the time respectively.

CONCLUSIONS

The impact of ED on patients with LUTS/BPH is evident across domains.

Are statin medications associated with lower urinary tract symptoms in men and women? Results from the Boston Area Community Health (BACH) Survey

PURPOSE

Statins may ameliorate lower urinary tract symptoms (LUTS) through anti-inflammatory or other pathways. We investigated the association between statin use and storage, voiding, and overall LUTS symptoms.

METHODS

The Boston Area Community Health Survey is an epidemiologic study of Boston, MA residents (2301 men; 3202 women) 30-79 years of age. LUTS, voiding, and storage symptoms were ascertained through an interviewer-administered questionnaire and defined as scores of greater than or equal to 8, greater than or equal to 5, and greater than or equal to 4, respectively, on relevant components of the American Urologic Association Symptom Index. Participants were included if they had a history of provider-diagnosed high cholesterol or recently used statin medications (n = 1346). Associations were estimated using odds ratios (ORs) and 95% confidence intervals (CI) from multivariate logistic regression.

RESULTS

In multivariate models, statin use had no association with LUTS (OR= 1.03, 95% CI: 0.70, 1.51) among women. No associations were observed for any LUTS among younger (<60) men, but among older (60+) men, we observed significant inverse associations for voiding (OR= 0.23, 95% CI: 0.08, 0.66), storage (OR = 0.24, 95% CI: 0.11, 0.56), and overall LUTS (OR = 0.15, 95% CI: 0.05, 0.44).

CONCLUSIONS

Our results suggest that use of statins is associated with a lower prevalence of urologic symptoms among older men but not among women or younger men.

The impact of irritative lower urinary tract symptoms on erectile dysfunction in aging Taiwanese males

OBJECTIVE

This study assessed the possible associations between lower urinary tract symptoms (LUTS) and erectile dysfunction (ED) in aging Taiwanese males and investigated the impact of various aspects of LUTS on ED.

METHODS

A free health screening for aging males (> or =40 years old) was conducted in Kaohsiung Medical University Hospital. All the subjects had completed clinical data and answered questionnaires. ED and LUTS were assessed by validated symptom scales: the International Index of Erectile Function-5 (IIEF-5) and the International Prostate Symptom Score (IPSS).

RESULTS

A total of 339 eligible patients enrolled in this study with a mean age of 60.1 years old. In multiple logistic regression analysis, age and IPSS (p < 0.001 and p = 0.013, respectively) were significantly associated with ED after controlling other comorbidities. In a further age-adjusted multiple regression analysis, our results showed that irritative symptoms (p = 0.042) have a more significant association with ED than the obstructive symptoms (p = 0.101).

CONCLUSIONS

Our results indicate that age and LUTS are the two most independent risk factors for ED. Aging Taiwanese males with LUTS are at increasing risk for ED, especially for those with significant irritative symptoms.

Association of lower urinary tract symptoms and the metabolic syndrome: results from the Boston Area Community Health Survey

PURPOSE

In this study we investigated the relationship between lower urinary tract symptoms as defined by the American Urological Association symptom index and the metabolic syndrome, and determined the relationship between individual symptoms comprising the American Urological Association symptom index and the metabolic syndrome.

MATERIALS AND METHODS

The Boston Area Community Health Survey used a 2-stage cluster design to recruit a random sample of 2,301 men 30 to 79 years old. Analyses were conducted on 1,899 men who provided blood samples. Urological symptoms comprising the American Urological Association symptom index were included in the analysis. The metabolic syndrome was defined using a modification of the Adult Treatment Panel III guidelines. The association between lower urinary tract symptoms and the metabolic syndrome was assessed using odds ratios and 95% confidence intervals estimated using logistic regression models.

RESULTS

Increased odds of the metabolic syndrome were observed in men with mild to severe symptoms (American Urological Association symptom index 2 to 35) compared to those with an American Urological Association symptom index score of 0 or 1 (multivariate OR 1.68, 95% CI 1.21-2.35). A statistically significant association was observed between the metabolic syndrome and a voiding symptom score of 5 or greater (multivariate adjusted OR 1.73, 95% CI 1.06-2.80) but not for a storage symptom score of 4 or greater (multivariate adjusted OR 0.94, 95% CI 0.66-1.33). Increased odds of the metabolic syndrome were observed even with mild symptoms, primarily for incomplete emptying, intermittency and nocturia. These associations were observed primarily in younger men (younger than 60 years) and were null in older men (60 years old or older).

CONCLUSIONS

The observed association between urological symptoms and the metabolic syndrome provides further evidence of common underlying factors between lower urinary tract symptoms and chronic conditions outside the urinary tract.

The associations among eNOS G894T gene polymorphism, erectile dysfunction, and benign prostate hyperplasia-related lower urinary tract symptoms

INTRODUCTION

A number of literature has now identified the role of impaired nitric oxide synthase/nitric oxide pathway in the endothelium as the central to the development of erectile dysfunction (ED) and benign prostate hyperplasia-related lower urinary tract symptoms (BPH/LUTS). Recently a few studies have reported the associations between endothelial nitric oxide synthase (eNOS) G894T gene polymorphisms and ED. However, there has been no report investigating the eNOS G894T genetic susceptibility factor for both ED and BPH/LUTS.

AIM

To investigate the possible associations among eNOS G894T polymorphism, ED, and BPH/LUTS in a Taiwanese population.

MAIN OUTCOME MEASURES

Patients with ED were defined as those having a 5-item International Index of Erectile Function-5 <21.

METHODS

In all, 372 Taiwanese men underwent a free health screening were enrolled. All the men had complete clinical data and questionnaires taken. The eNOS G894T polymorphisms were determined using the polymerase chain reaction-restriction fragment length polymorphism method.

RESULTS

Three hundred seventy-two men had a mean (standard deviation) age of 60.2 (8.8) years. With multivariate analysis, our data identified that aging, diabetes mellitus (DM), and eNOS G894T gene polymorphism were three independent common risk factors for both ED and BPH/LUTS (P < 0.001, P = 0.036, and P = 0.039 for ED; P = 0.034, P = 0.004, and P = 0.016 for BPH/LUTS, respectively). The eNOS 894T allele carriers had significantly higher prevalence of ED (77.9% vs. 60.4%, P = 0.012) and higher International Prostate Symptom score (IPSS) (13.3 +/- 10.7 vs. 9.3 +/- 7.8, P = 0.001) than G allele carriers.

CONCLUSIONS

Our results showed that aging, DM, and eNOS 894T allele carrier gene polymorphism were the three independently common risk factors for both ED and BPH/LUTS in the Taiwanese population. The eNOS 894T allele carriers had significantly higher frequencies of ED and higher IPSS, suggesting that eNOS G894T gene polymorphisms may play an implication as a genetic susceptibility factor for both ED and BPH/LUTS.

Risk factors for lower urinary tract symptoms suggestive of benign prostatic hyperplasia in a community based population of healthy aging men: the Krimpen Study

PURPOSE

We explored risk factors for lower urinary tract symptoms suggestive of benign prostatic hyperplasia in the open population.

MATERIALS AND METHODS

A longitudinal, population based study with a followup of 6.5 years was done in 1,688 men who were 50 to 78 years old. Data were collected on transrectal ultrasound of prostate volume, urinary flow rate, ultrasound estimated post-void residual urine volume, generic and disease specific quality of life, and symptom severity based on the International Prostate Symptom Score. Lower urinary tract symptoms suggestive of benign prostatic hyperplasia were defined as an International Prostate Symptom Score of greater than 7 after a report of a score of less than 7 in the previous round. A multivariate Cox proportional hazard model was constructed to determine risk factors for clinical benign prostatic hyperplasia after correcting for patient age.

RESULTS

Total followup was 4,353 person-years. During followup 180 events of attaining an International Prostate Symptoms Score of greater than 7 occurred. Multivariate analysis showed that functional bladder capacity, post-void residual urine volume, treatment for cardiac diseases, education level, antidepressant use, calcium antagonist use, erectile function or dysfunction, prostate specific antigen and a family history of prostate cancer were determinants with a significant HR.

CONCLUSIONS

In addition to age, we established 9 significant determinants for lower urinary tract symptoms suggestive of benign prostatic hyperplasia. However, not all risk factors for lower urinary tract symptoms suggestive of benign prostatic hyperplasia are accounted for since we can conclude that 1 of 3 men without these risk factors will still be diagnosed with lower urinary tract symptoms suggestive of benign prostatic hyperplasia between ages 50 and 80 years.