NRN

Review
Received: August 26, 2008 Accepted: September 10, 2008
Address correspondence to: Dr. Bang-Ping Jiann, Division of Urology, Kaohsiung
Veterans General Hospital, 386, Ta-Chung 1st Road, Kaohsiung, 81346, Taiwan
E-mail: bpjiaan@vghks.gov.tw
Incont Pelvic Floor Dysfunct 2008; 2(4):151-155
Association of Lower Urinary Tract Symptoms/Benign Prostatic
Hyperplasia with Sexual Dysfunction
Bang-Ping Jiann, M.D.
Division of Urology, Department of Surgery, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
INTRODUCTION
Ben|n prosa|c hyperp|as|a (BPH) |s a common cono||on |n o|oer
men. The preva|ence o h|so|o|c BPH |n auopsy suo|es r|ses rom
approx|mae|y 20% |n men 41-50 years o|o o 50% |n men 51-60 years
o|o, ano o over 90% |n men o|oer han 80 years [1|. En|aremen o
he prosae may resu| |n subsequen b|aooer ou|e obsruc|on, wh|ch
can proouce |ower ur|nary rac sympoms (LUTS) or comp||ca|ons
such as |nec|on, ves|ca| sones, ur|nary reen|on, ano oeer|ora|on o
rena| unc|on. LUTS are o|v|oeo |no obsruc|ve (vo|o|n) ano |rr|a-
|ve (sorae) componens. Obsruc|ve sympoms |nc|uoe s|ow sream,
|nerm|ency, hes|ancy ano sra|n|n ano |rr|a|ve ones |nc|uoe |n-
creaseo oay|me requency o ur|na|on, nocur|a, urency ano ure
ur|nary |ncon|nence. |s es|maeo ha 25 o 50% o men w|h BPH
have LUTS ano 50% o men w|h LUTS have b|aooer ou|e obsruc|on
oue o BPH or oher urehra| cono||ons [2|.
Un|| recen|y, | was w|oe|y assumeo ha ma|e sexua| oysunc-
|on was a naura| consequence o ae|n |n men. The resu|s o a
popu|a|on-baseo suoy o men 40 o 70 years o|o, he Massachuses
Ma|e A|n Suoy (MMAS), oemonsraeo he preva|ence o comp|ee
erec||e oysunc|on (ED) |ncreaseo rom 5% or men 40 years o|o o
15% or hose 70 years o|o w|h a comb|neo preva|ence o 52% or
m|n|ma|, mooerae ano comp|ee |mpoence |n h|s popu|a|on [3|. The
G|oba| Suoy o Sexua| A|uoes ano Behav|ors (GSSAB) |s an |nerna-
|ona| survey o var|ous aspecs o sex ano re|a|onsh|ps amon aou|
men 40-80 years o|o rom 29 counr|es. Baseo on GSSAB oaa, he
preva|ence o erec||e o||cu|y raneo rom 12.9 o 28.1%, |ack o |n-
eres |n sex raneo rom 12.5 o 28.0% ano premaure ejacu|a|on
raneo rom 20.7 o 30.5% |n o|eren re|ons [4|. The MMAS, GSSAB
ano oher ep|oem|o|oy suo|es a|| suppor he ac ha ma|e sexua|
oysunc|on, |nc|uo|n ED, ejacu|aory oysunc|on ano hypoac|ve
oes|re, are very common prob|ems |n men.
LUTS/BPH AND SEXUAL DYSFUNCTION
Because boh LUS/BPH ano sexua| oysunc|on occur more re-
quen|y |n he e|oer|y, | |s o||cu| o ascera|n wheher LUTS/BPH con-
r|bues o sexua| oysunc|on. Many observa|ona| suo|es have shown
a s|n||can re|a|onsh|p beween hem. The ||nk beween LUTS ano
sexua| oysunc|on was con|rmeo by he Mu||-a|ona| Survey o he
Ae|n Ma|e-7 (MSAM-7) wh|ch |nc|uoeo 12,815 men 50-80 years o|o
|n he Un|eo Saes ano 6 European counr|es [5|. Th|s suoy showeo
ha mos men over 50 years o|o were sexua||y ac|ve oesp|e a sron
oecrease |n mean sexua| |nercourse/sexua| ac|v|y w|h LUTS sever-
|y (ran|n rom w|h 7.5 ep|sooes o sexua| ac|v|y per monh |n men
|n he|r s|x|es o 3.2 per monh |n men |n he|r e|h|es). ED assesseo
by he nerna|ona| noex o Erec||e Func|on-Erec||e Func|on ooma|n
score was sron|y re|aeo o LUTS sever|y. Aer conro|||n or ae,
LUTS sever|y was by ar he srones preo|cor o ED, w|h an OP
(ooos ra|o) or severe vs. m||o LUTS o 8.90 (6.85-11.55) o||oweo by
o|abees, 3.01 (2.60-3.29), caro|ac o|sease, 2.17 (1.92-2.46),
hyperens|on, 1.83 (1.66-2.01) ano oys||p|oem|a, 1.57 (1.41-1.73).
Ejacu|aory oysunc|on (reouceo amoun o ejacu|ae ano pa|n/o|s-
comor on ejacu|a|on) assesseo by he sexua| sec|on o he Dan|sh
Prosae Sympom Score was a|so sron|y re|aeo o LUTS sever|y
[5|.
Anoher recen popu|a|on-baseo suoy |nves|aeo he re|a|on-
sh|p beween LUTS ano sexua| oysunc|on |n men 40 o 65 years o|o
|n Denmark ano a|so showeo ha LUTS was an |noepenoen preo|cor
o ED |n mu||var|ae |o|s|c reress|on ana|ys|s [6|. Ana|ys|s o base||ne
oaa rom he ranoom|zeo, p|acebo-conro||eo, Meo|ca| Therapy o
Prosa|c Sympoms (MTOPS) r|a| a|so |no|caeo a s|n||can re|a|on-
sh|p beween LUTS ano erec||e unc|on, ejacu|a|on, overa|| sexua|
sa|sac|on, ano sexua| oes|re aer conro|||n or ae, hyperens|on,
oys||p|oem|a, ano o|abees [7|. neres|n|y, sexua| unc|on ooma|ns
|n he MTOPS r|a| were a|so s|n||can|y re|aeo o wo objec|ve var|-
ab|es o BPH proress|on, peak |ow rae ano prosae s|ze [7|.
POSSIBLE LINKS BETWEEN LUTS/BPH AND SEXUAL
DYSFUNCTION
Because he r|sk acors ano mechan|sm o ED ano LUS/BPH are
mu||acor|a|, | |s un||ke|y ha here w||| be a s|n|e common paho-
phys|o|oy unoer|y|n he oeve|opmen o boh cono||ons |n an |no|-
v|oua| [8|. Some ev|oence or a pahophys|o|o|ca| ||nk beween LUTS/
BPH |s ouno |n a rabb| mooe| o b|aooer ou|e obsruc|on [9|. There
was an |mba|ance beween n|r|c ox|oe ano enoohe||n-1, as we|| as
aoverse u|rasrucura| chanes |n he corpus cavernosum, sues-
|n ha h|s conr|bues o |mpa|rmen o n|r|c ox|oe-meo|aeo smooh
musc|e re|axa|on [9|.
A recen hypohes|s proposeo ha |ncreaseo rho-k|nase ac|v|y
|n smooh musc|e |eaos o |ncreaseo sens||v|y o ca|c|um, a he|h-
eneo response o meo|aors o smooh musc|e conrac|on, ano |ssue
chanes |n he prosae, ur|nary rac ano pen||e smooh musc|e [10|.
C||n|ca||y, h|s wou|o rans|ae |no |ncreaseo b|aooer neck one caus-
|n LUTS ano |ncreaseo pen||e musc|e one |eao|n o ED [10|.
1-aorener|c recepors are known o p|ay an |mporan ro|e |n
meo|a|n he one o smooh musc|es |n var|ous |ssues. has been
NRO
Review
sueseo ha 1-aorener|c recepors are upreu|aeo |n pa|ens
w|h LUTS assoc|aeo w|h BPH, resu||n |n |ncreaseo smooh musc|e
one |n he prosa|c capsu|e ano b|aooer neck [11,12|. Pen||e oeu-
mescence ano erec|on are oepenoen on he ba|ance beween con-
rac|on ano re|axa|on o he corpus cavernosum smooh musc|e [13|.
Aorener|c-meo|aeo conrac|on o smooh musc|e may a|so be reu-
|aeo by rho-k|nase [14|, wh|ch has been ouno |n he prosae [15|
ano vas oeerens [16|. A|era|on |n 1-aorener|c recepor-meo|aeo
smooh musc|e one ano |s reu|aors may be a common componen
|nvo|veo |n LUTS assoc|aeo w|h BPH, ED ano ejacu|aory o|soroer.
|s we|| recon|zeo ha he oeve|opmen o BPH requ|res he
presence o anoroens ano ha he markeo reouc|on |n serum es-
oserone causeo by chem|ca| or sur|ca| casra|on reouces prosae
vo|ume. Anoroen recepors, wh|ch are presen |n boh he sroma
ano ep|he||um o he prosae as we|| as |n mos b|ooo vesse| enoo-
he||a| ce||s, smooh musc|e ce||s, ano |brocyes [17|, may p|ay a ro|e
|n he |nerac|on beween he sroma ano he ep|he||um o he prosae.
Tesoserone |s requ|reo or pubera| acqu|s||on o enoer characer-
|s|cs as we|| as aou| sexua| behav|or ano unc|ona| capac|y, |nc|uo-
|n ||b|oo, ejacu|a|on, ano sponaneous erec|ons. W|h a|n he pro-
ouc|on o esoserone oec||nes ano |s b|oava||ab|||y |s reouceo. Ao-
o||ona| suo|es are neeoeo o assess wheher a|era|ons |n sex hor-
mone |eve|s ano he|r recepors p|ay a ro|e |n he pahophys|o|oy o
BPH ano sexua| oysunc|on.
IMPACT OF 5-REDUCTASE INHIBITORS ON SEXUAL
FUNCTION
D|hyoroesoserone (DHT) |s he anoroen pr|mar||y respons|b|e
or prosae rowh ano en|aremen. nh|b||on o he enzyme 5-
reoucase, wh|ch caa|yzes he orma|on o DHT, represens anoher
approach o rea|n LUTS assoc|aeo w|h BPH. Two 5-reoucase
|nh|b|ors, |naser|oe ano ouaser|oe, are curren|y useo |n he rea-
men o sympom|c BPH |n men w|h en|areo prosaes.
Ejacu|a|on o|soroers assoc|aeo w|h |naser|oe rane rom oe-
creaseo vo|ume o he ejacu|ae o a||ure o ejacu|a|on. Panoom|zeo
c||n|ca| r|a|s |n men w|h sympoma|c BPH oemonsrae an |nc|oence
o ejacu|aory oysunc|on assoc|aeo w|h |naser|oe ran|n rom 2.1
o 7.7% (Tab|e 1) [18-20|. Mos subjecs exper|enceo he onse o ejacu-
|aory oysunc|on, ||ke oher sexua| oysunc|on, w|h|n he |rs 9 monhs
o reamen w|h |naser|oe. ear|y a|| r|a|s |nvo|v|n |naser|oe |n he
reamen o LUTS resu||n rom BPH oemonsrae a sa|s|ca||y s|-
n||can |ncrease |n ED. n he PPOSPECT r|a|, he |nc|oence o ED |n
he |naser|oe ano p|acebo roups was 15.8% ano 6.3%, respec|ve|y
(P <0.01) [21|.
Duaser|oe, an |nh|b|or o ype 1 ano 2 5-reoucase |sozymes,
|s useo or reamen o BPH, prov|o|n reaer suppress|on o DHT
han |naser|oe. When compareo w|h pa|ens rece|v|n p|acebos,
pa|ens reaeo w|h ouaser|oe 0.5 m once-oa||y (OD) |n 3
ranoom|zeo, ooub|e-b||no, c||n|ca| r|a|s exper|enceo s|n||can|y h|her
|nc|oence raes o ED (7% vs. 4 % or he p|acebo roup), ejacu|aory
oysunc|on (2% vs. 1% or he p|acebo roup), ano hypoac|ve oes|re
(4% vs. 2% or he p|acebo roup) (Tab|e 1) [22|.
IMPACT OF 1-BLOCKERS ON SEXUAL FUNCTION
n he 1980s. Lepor ano assoc|aes recon|zeo ha prosa|c
smooh musc|e ens|on was meo|aeo by 1-aorenorecepors wh|ch
|eo o he oeve|opmen o -b|ockers as a reamen or LUTS. Th|s
oynam|c componen o prosa|c obsruc|on accouns or approx|mae|y
40% o ou|ow obsruc|on oue o BPH [23|. There are 4-b|ockers
approveo by he U.S. Fooo ano Dru Aom|n|sra|on o rea LUTS,
ooxazos|n, erazos|n, amsu|os|n ano a|uzos|n. A herapeu|c ooses,
hese 4 1-aorener|c recepor b|ockers have oemonsraeo s|m||ar
eec|veness |n re||ev|n LUTS assoc|aeo w|h BPH [24|.
Terazos|n appears o be assoc|aeo w|h a re|a|ve|y |ow |nc|oence
o ejacu|aory oysunc|on. n he Veerans Aa|rs Coopera|ve Suoy
he |nc|oence o ejacu|aory oysunc|on w|h erazos|n |n a suoy popu-
|a|on o 610 men was 0.3% [18|. n he Hyr|n Commun|y Assessmen
Tr|a| (HYCAT), | was a|so |ow, 1.4%, bu s|n||can|y o|eren sa|s|-
ca||y rom a p|acebo (P = 0.01) [25|. The |nc|oence o sexua| s|oe e-
ecs was |ow ano s|m||ar o hose |n he roups ak|n a|uzos|n 10 m
OD (ED, 1.5%, |oss o ejacu|a|on, 0.6%) ano he p|acebo roup (ED,
0.6%, |oss o ejacu|a|on, 0%) [26|. Dur|n reamen w|h ooxazos|n,
he raes o ED ano ejacu|aory o|soroer were enera||y comparab|e o
hose observeo w|h p|acebo reamen [27|. n 2 ranoom|zeo, ooub|e-
b||no, p|acebo-conro||eo suo|es |n men w|h BPH, reamen or 13
weeks w|h ooxazos|n, wh|ch was |raeo o 8 m OD, resu|eo |n s|-
n||can |mprovemen |n sexua| unc|on or hose pa|ens w|h sexua|
oysunc|on a base||ne [28|.
Perhaps because o |s h|her pharmaco|o|ca| se|ec|v|y or 1A-
recepors |n he b|aooer neck, sem|na| ves|c|es, ano vas oeerens,
however, amsu|os|n |s assoc|aeo w|h a s|n||can |nc|oence o ejacu-
|aory oysunc|on. A 3-year European o||ow-up suoy reporeo a cu-
mu|a|ve rae o ejacu|aory oysunc|on w|h amsu|os|n o 5.4%, bu
on|y one pa|en (0.3%) o|scon|nueo he meo|ca|on because o ab-
norma| ejacu|a|on [29|. n a comb|neo ana|ys|s rom ooub|e-b||no c||n|-
ca| r|a|s w|h amsu|os|n, he requency o overa|| abnorma| ejacu|a|on
Table 1. The sexual side-effects of finasteride and dutasteride
VA Study [18] PROWESS Study [19] PLESS Study [20] Dutasteride Trials [22]
1-yr follow-up 2-year follow-up 4-year follow-up 2-year follow-up
Placebo Finasteride Placebo Finasteride Placebo Finasteride Placebo Dutasteride
(n=305) (n=310) (n=1591) (n=1577) (n=1376) (n=1384) (n=1555) (n=1605)
Decreased libido 1.0% 5.0% 2.8% 4.0% 2.6% 2.6% 2.1% 4.2%*
Erectile dysfunction 5.0% 9.0%* 4.7% 6.6%* 5.1% 5.1% 4.0% 7.3%*
Decreased ejaculation NA NA NA NA 0.5% 1.5% NA NA
Ejaculation disorder 1.0% 2.0% 0.6% 2.1%* 0.1% 0.8%* 0.8% 2.2%*
*P < 0.05; NA: not available.
NRP
Review
(|nc|uo|n reroraoe ejacu|a|on, ejacu|a|on a||ure, ano ejacu|a|on
oecrease) or a 0.4 m oose ano a 0.8 m oose was 8.4% ano 18.1%,
respec|ve|y [30|.
Excep or he |ow r|sk o ejacu|aory o|soroers ha may be |n-
ouceo by reamen w|h -b|ockers, mos oaa sues a bene|c|a|
ro|e or -b|ockers w|h rearo o a|| aspecs o sexua| unc|on. The
oo|s acua||y ava||ab|e oo no ake |no accoun c|ear|y he ejacu|a|on
phenomenon, hey are more ocuseo on he erec|on o|mens|on. The
European suoy oemonsraeo |mproveo oa| sexua| unc|on |n pa-
|ens reaeo w|h amsu|os|n compareo w|h a p|acebo [31|, ano a
suoy o a|uzos|n reamen |n a enera| prac|ce se|n recoroeo a
s|n||can |mprovemen |n pa|ens' perce|veo sexua||y aer 12 monhs
o reamen [32|. n an observa|ona| suoy o men w|h BPH, rea-
men w|h ooxazos|n or 1 monh resu|eo |n a s|n||can |mprovemen
|n sexua| unc|on compareo w|h ha a base||ne, espec|a||y or hose
w|h mooerae-o-severe ED a base||ne [33|. These suo|es prov|oe
ev|oence ha reamen o LUTS w|h -b|ockers |n men w|h BPH may
|n ac |mprove erec||e unc|on.
Two mechan|sms have been proposeo o exp|a|n pa|ens' |m-
proveo sexua| unc|on o||ow|n reamen or LUTS/BPH w|h -
b|ockers. F|rs, as he sympoms become |ess bohersome, pa|ens
may hus be beer ab|e o enjoy oher aces o ||e [34|. A|erna|ve|y,
|nh|b||on o he 1- ano 1D-aorenorecepor subypes ha preoom|-
nae |n cavernosa| smooh musc|e shou|o ac|||ae pen||e erec|on [35|.
The mechan|sm by wh|ch -b|ockers aec he erecoen|c response
|s v|a re|axa|on o he smooh musc|e |n he pen||e arer|es or he cor-
pora cavernosum, hus |mprov|n he |n|ow o b|ooo [35|.
SEXUAL DYSFUNCTION FOLLOWING TRANSURETHRAL
PROSTATECTOMY
The o|o sanoaro or he sur|ca| reamen o BPH rema|ns he
ransurehra| prosaecomy (TUPP). The Amer|can Uro|o|ca| Asso-
c|a|on Coopera|ve Suoy enro||eo 3,885 pa|ens rom 13 |ns|u|ons
ano reporeo a 13% |nc|oence o ED o||ow|n TUPP [36|. However,
he Veerans Aa|rs Coopera|ve Group Suoy on TUPP oemonsraeo
ha he |nc|oence o ED |n men w|h mooerae LUTS/BPH who unoer-
wen TUPP was |ower han ha or hose |n he wachu| wa||n roup
aer o||ow-up or 3 years [37|. n a suoy exam|n|n 127 men's se|
eva|ua|ons o sexua| oysunc|on aer TUPP, 54% o he responoers
c|a|meo oeer|ora|on ano 50% o hose b|ameo he surery, bu he
acua| rae was |ess, as con|rmeo by more objec|ve repors [38|. The
ED perce|veo |mmeo|ae|y aer TUPP may be emporary. Tscho|| e a|
se|eceo 98 men w|h a norma| Snap-Gaue es pr|or o TUPP, ano re-
eseo hem on he|r 4h posopera|ve n|h. A ha sae 34/98
(34.7%) were juoeo |mpoen, bu on re-es|n hese 34 men a 3
monhs, on|y 8 rema|neo so (8. 2%) [39|. n a recen ranoom|zeo, con-
ro||eo r|a|, a s|n||can oecrease rom base||ne |n he percenae o
men w|h ED was oemonsraeo aer TUPP, ano men who unoerwen
TUPP were s|n||can|y more ||ke|y o have an |mprovemen |n erec||e
unc|on han hose who hao wachu| wa||n [40|. euraprax|a rom
herma| |njury or he emo|ona| sress o surery have been proposeo
as poss|b|e mechan|sms [41|.
Peroraoe ejacu|a|on |s he mos common comp||ca|on o TUPP,
occurr|n |n more han 50% o pa|ens [24|. n some ser|es, rero-
raoe ejacu|a|on has been reporeo |n a|mos a|| men ano neeos o
be o|scusseo w|h a|| pa|ens. Mos o|oer men are yp|ca||y no boh-
ereo by |. Open prosaecomy a|so has |||e eec on erec||e unc|on,
ano, ||ke TUPP, |s assoc|aeo w|h a h|h r|sk o reroraoe ejacu|a|on.
SEXUAL DYSFUNCTION FOLLOWING OTHER SURGICAL
TREATMENTS
The oaa on ED aer m|n|ma||y |nvas|ve proceoures are scan ano
no a|ways reporeo. W|h ransurehra| m|crowave hermoherapy
(TUMT) or sympoma|c BPH, ED occurreo |n |ess han 5% o par|c|-
pans [42,43|. Peroraoe ejacu|a|on |s |ess common w|h m|n|ma||y
|nvas|ve proceoures han w|h TUPP. Typ|ca||y he |nc|oence o rero-
raoe ejacu|a|on |s |ess han 40% aer ransurehra| |nc|s|on o he
prosae ano usua||y |ess han 20% w|h oher herap|es. n one suoy,
ejacu|aory o|soroer was reporeo |n 11% o pa|ens w|h TUMT [44|.
H|h-power poass|um-|any|-phosphae (KTP) phoose|ec|ve
|aser vapor|za|on o he prosae has become a popu|ar proceoure or
sympoma|c BPH recen|y. Pa|ck e a| reporeo a s|n||can |mprove-
men |n he erec||e unc|on ooma|n, |ncreas|n rom 11.3 a base||ne
o 14.7 (P = 0.015), 6 monhs aer KTP |aser surery or BPH |n 45 men
[45|.
CONCLUSIONS
Meo|ca| ano sur|ca| herapy or LUTS assoc|aeo w|h BPH can
have a s|n||can |mpac on qua||y o ||e hrouh aoverse eecs on
erec||e ano ejacu|aory unc|on. Pesearch our|n he pas oecaoe
has |rm|y esab||sheo ha ED ano ejacu|aory oysunc|on are h|h|y
preva|en cono||ons |n a|n men, espec|a||y |n hose w|h LUTS asso-
c|aeo w|h BPH. Sexua||y |s an |mporan |ssue or men ano shou|o be
|nc|uoeo |n o|scuss|ons concern|n reamens or LUTS/BPH. Phys|-
c|an awareness o hese comp||ca|ons ano a w||||nness o o|scuss
hem w|h he pa|en can m|n|m|ze he|r |mpac.
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