Prostate Cancer and Prostatic Diseases (2001) 4, Suppl 1, S12–S16 ß 2001 Nature Publishing Group All rights reserved 1365–7852/01 $15.00 www.nature.com/pcan Impact of treatment of BPH on sexuality C Schulman1* 1Department of Urology, Erasme Hospital, University Clinics of Brussels, Belgium Benign prostatic hyperplasia (BPH) can have a profound affect on a patient’s quality of life and sexual function and is considered by patients to be one of the most important aspects affected by the disease. Different treatments can produce a variable response in terms of the patient’s quality of life, including sexual activity and satisfaction. Varying rates of erectile dysfunction (ED) and retrograde ejaculation following surgery for BPH have been reported. In general, the incidence of these side-effects is less after minimally invasive therapies, such as interstitial laser coagulation and transurethral microwave therapy, but the data available are limited. The lowest rates of sexual dysfunction are reported with medical therapies. The 5a-reductase inhibitor, finasteride, can result in ED in 5 – 9% of patients and ejaculation disorders in 0.8 – 2.0%. With the exception of tamsulosin, a1 blockers are associated with a low rate of sexual dysfunction. No cases of ED have been reported with alfuzosin and abnormal ejaculation with terazosin or alfuzosin is negligible. Indeed, early research suggests a beneficial effect of a1 blockers on sexual function. In addition to information on the efficacy of a particular therapy, patients should be informed of side effects, in particular those relating to sexual function, in order that they can make informed treatment decisions. Prostate Cancer and Prostatic Diseases (2001) 4, Suppl 1, S12–S16. Keywords: benign prostatic hyperplasia; sexual function; a1 blockers; finasteride; surgical therapy Introduction activities, but above all sexual activities and satisfaction with sexual relationships. Although not considered to be a life-threatening disease, benign prostatic hyperplasia (BPH) can seriously affect the patient’s normal physical and social activities, and Evaluation of sexual function may have a profound effect on quality of life.1,2 From the urologist’s point of view, this impact of treatment on The most useful and comprehensive study of the epide- sexuality, be it medical, surgical or instrumental, has miology of erectile dysfunction (ED) at present is the often been poorly investigated and neglected. Massachusetts Male Aging Study (MMAS), which was From the patient’s perspective, one of the major aspects conducted between 1987 and 1989.4 This cross-sectional, of quality of life is sexuality following treatment for BPH.3 random sample survey of health status and related issues A recent study evaluated which aspects of quality of life was conducted in men between the ages of 40 and 70 y. were most affected by prostatic symptoms and those Analysis of data on 1209 men indicated that the mean which the patient considered most important.3 A self- probability of some degree of ED was 52.0%. Between the administered questionnaire composed of 89 items was fifth and seventh decades, the probability of complete ED completed by 117 patients with an International Prostate almost tripled from 5.1% to 15%. Symptom Score (IPSS) > 7. The aspects reported to be Helgason et al showed that only 17% of men over 50 y most affected and the most important were sleep, anxiety reported that they could live without a sex life.5 Another and worry about the disease, mobility, leisure, daily study evaluated the sexual function of an unselected population referred for hospital treatment for clinical BPH.6 A total of 401 patients completed a questionnaire, which included three questions on sexuality: erection, ejaculation volume and pain/discomfort during ejacula- *Correspondence: C Schulman, Department of Urology, Erasme Hospital, University Clinics of Brussels, Route de Lennik 808, B-1070 tion. Analysis of the results showed that the incidence of Brussels, Belgium. ED increased with age and related bother was much [email protected] greater in younger males. Treatment of BPH and sexuality C Schulman S13 An important issue when discussing BPH and sexu- completed a questionnaire on personal evaluation of ality is to identify what specific aspects of sexual function sexual function, including erection, ejaculation, libido are being considered; whether it is ED, ejaculation dys- and satisfaction. Of the responders, 54% stated that function, decreased libido or overall decreased sexual there was deterioration in all of these factors and impor- satisfaction. Assessment of sexual function is another tantly, 50% attributed this to the surgery they had under- important concern. Sexual dysfunction often occurs in gone, ie TURP. the same subpopulation of men who are affected by symptomatic BPH. Consequently, the direct or indirect side effects of treatment for BPH on sexual function may Minimally invasive therapies be difficult to assess. The lack of reproducible instruments to measure sexual A number of minimally invasive treatments have been function is another obstacle. Several different question- developed for symptomatic BPH, including transurethral naires are available including: needle ablation (TUNA), transurethral microwave ther- motherapy (TUMT), interstitial laser coagulation (ILC). 7 The Brief Sexual Function Inventory (SFI) The effect on sexual function of these therapies has been 8 The International Index of Erectile Function (IIEF) evaluated; however, a variety of assessment methods 9 Urolife Scale were used. 10,11 The Danish Prostatic Symptom Score (DAN-PSS) With regard to ILC, retrograde ejaculation was Of these, the SFI and the IIEF have been developed reported in 6% of patients in a study by Arai et al17 and specifically to measure male sexual function. 0 – 11.9% in others;18 no cases of ED have been described with ILC.18,19 The incidence of sexual dysfunction is negligible after TUNA; several studies reported no ED or retrograde ejaculation.20 – 22 Only one study, a prospec- Impact of treatment on sexual function tive multicentre trial in the US, found less than 1 and 2% of retrograde ejaculation and ED, respectively.23 Different treatments can have the same impact on symp- Limited data are available on TUMT. Francisca et al toms but may produce a variable response in terms of the studied 50 patients treated with TUMT or by sham and patient’s quality of life, which is influenced by the found that 20% of patients treated with either modality patient’s preferences and values. For example, some had a worsened sexual function at 26 weeks post-treat- patients with BPH may be more concerned about preser- ment.24 The overall incidence of retrograde ejaculation ving or improving their actual sexuality than decreasing was 11% and for lack of orgasms, 14%. Interestingly, at their potential risk of acute urinary retention by a mod- baseline and at 12 and 26 weeks post-treatment, there was erate percentage. For some patients, retrograde ejacula- no statistically significant difference between TUMT and tion following transurethral resection of the prostate sham treatment with regard to quality of life related to (TURP) may be an acceptable side effect of surgery if it sexual function. has been properly discussed beforehand, while for others it represents a major issue. The actual impact that the various treatments have on sexual function is discussed Medical therapy below. Finasteride. Finasteride is a selective 5a-reductase inhibi- Surgery tor that reduces the conversion of testosterone to dihy- Potential late sequelae of surgery for BPH include retro- drotestosterone. It has been shown to improve symptoms grade ejaculation and ED. Dependent on the series, 25 – in patients with BPH over a period of 3 – 6 months, and 99% of men lose ejaculation after surgery.12 The impact of the efficacy of the drug appears to be related to prostate 25 surgery on sexual function is difficult to assess and is also size over 40 ml. The effect of finasteride on sexual 26 – 28 dependent on the patient’s perception of his sexual ability function is summarised in Table 1. Increased risk of before and after surgery, as well as on the presence of a various side effects related to sexual function were sexual partner. This is also reflected by the variable rates demonstrated with finasteride. of ED that have been reported to occur after TURP or open prostatectomy. Phytotherapy. There are very few placebo controlled The American Urological Association (AUA) Coopera- studies on phytotherapy for BPH evaluating the impact tive Study reported a 13% incidence of ED following on sexual function. A 6 month study compared the effects TURP.13 A comparative study was conducted in which of Serenoa repens, a plant extract, with finasteride in 1098 men were randomised to treatment with TURP or trans- men with moderate BPH.29 The effect on sexual function urethral vaporisation of the prostate (TUVP). Postopera- was assessed in a sexual questionnaire and indicated that tive ED was reported in 17 and 11% and retrograde Serenoa repens resulted in fewer complaints of decreased ejaculation in 72 and 89% of patients treated with TURP libido and ED, although the percentages reported were and TUVP, respectively.14 A second comparative trial low. resulted in retrograde ejaculation in 68 and 35% of patients undergoing TURP and transurethral incision of a1 blockers. Avarietyofa1 blockers are available and their the prostate (TUIP), respectively.15 use generally results in a 6 –