Introduction

Benign prostatic hyperplasia (BPH) is a highly prevalent disease in men over 50 years old, and its incidence increases with age. Prevalence of BPH is estimated as 50% of men in their 50s, and reaches 80% for men over 80 years [1].  Patients with BPH often present with varying severity of lower urinary tract symptoms (LUTS), although these can occur in the absence of BPH and vice versa [2]. The primary aim of therapy of BPH is to reduce LUTS, which ultimately improves quality of life (QoL) [3]. Despite the advancements in pharmacological treatment of BPH during the last decades, surgery currently remains a fundamental option in the management of the patient. Surgical treatment of BPH is indicated in patients who are refractory or intolerant to medical therapy and in patients with complications resulting from the disease [4]. It is widely accepted that surgical procedures for BPH may determine sexual dysfunctions (SD). Numerous sexual side effects, including erectile ejaculatory and orgasmic dysfunctions, were reported with the majority of surgical treatments for BPH [5,6]. Nevertheless, some studies showed no change or even a possible improvement in the sexual function of patients with BPH undergoing surgical therapy [7].

Pathophysiology

The worsening of sexual function can result from several mechanisms following BPH surgery [8-13].

• Injury of the internal urinary sphincter. Ejaculatory dysfunction represents the most commonly reported side effect of many treatments for BPH. In the normal genitourinary tract, the involuntary smooth muscle of the internal urethral sphincter plays a critical role in maintaining antegrade ejaculatory function. Disruption of this mechanism is the predominant factor underlying BPH surgery-related retrograde ejaculation (RE). Psychological repercussions of RE can affect sexual satisfaction and contribute to erectile dysfunction (ED).
• Psychological impact of recent surgery on sexual desire and on sex-related distress.
• Direct injury of neurovascular bundles following capsular perforation. This is a rare adverse event (AE).
• Indirect thermal injury to neurovascular bundles. It is a controversial pathophysiological mechanism.
• Urinary catheter. It mechanically prevents sexual intercourse in the first days after BPH surgery.

The improvement of sexual function can arise from two main factors following BPH surgery [14-18].

• Discontinuation of medical therapy for BPH. Drugs for BPH, taken by patients before surgery and suspended after the procedure, have a negative impact on sexual function. Alpha-blockers are associated with RE or anejaculation, while 5-alpha reductase inhibitors can cause decreased libido and ED. It is important to emphasize that discontinuing medical treatment for BPH can be a confounding factor in clinical trials evaluating sexual function, however, it is difficult to limit this bias due to ethical reasons.
• Improvement of LUTS. SD and LUTS are both highly prevalent and frequently co-associated in the same aging male group. In recent years, the investigators have hypothesized a common pathophysiology to explain this correlation regardless of shared risk factors, although a specific causal relationship has not yet been defined. It is essential to emphasize that since SD often pre-exist BPH surgery, patients should be adequately evaluated prior to surgical procedure to avoid mistakenly considering them as postoperative complications.

While surgical factors (surgical technique, characteristics of energy, experience of the surgeon) must be considered, patient factors should also be taken into account. Patient characteristics could predict which subjects are more likely to have modifications of the sexual function following BPH surgery. Patients with normal erectile function are at more risk of having a reduction in erectile function following surgical treatment; on the contrary, the worse the erectile function is before surgery, the more the patient has to gain in erectile function due to treatment. Similarly, the greater the severity of the LUTS, the greater the improvement that can be achieved by surgical treatment and consequently the positive impact on sexual function [7].

The evidence

Most studies focus on surgical and functional outcomes of BPH surgery, while sexual outcomes are often uninvestigated or under-investigated. Male sexual function is a complex interplay of psychological, neurogenic, vascular, and hormonal factors. Although it consists of different domains (sexual desire, erectile function, orgasmic function, ejaculatory function, sexual satisfaction), in most cases only erectile and ejaculatory functions are evaluated, being ED and RE the most frequently reported sex-related complications. The use of non-validated and arbitrary tools is extremely common for the assessment of sexual outcomes. The International Index of Erectile Function (IIEF) and its abbreviated forms (IIEF-5, IIEF-EF) are the most widely used validated questionnaires for the evaluation of erectile function, while Male Sexual Health Questionnaire (MSHQ) and its short form (MSHQ-EjD-SF) are the most commonly used tools for the assessment of ejaculatory function. Orgasmic function, sexual satisfaction, and sexual desire are very rarely investigated and the use of validated instruments to measure these outcomes is unusual. Finally, most of the studies on BPH surgery including the assessment of sexual outcomes are case series with no control group, this methodological issue limits the strength of the resulting evidence [4,19,20].

Transurethral resection of the prostate (TURP) remains the gold standard surgical treatment for BPH in patients with small prostates (30-80 mL), being the reference procedure in most comparative studies [4]. TURP is associated with a high prevalence of RE (70-90%), however, it does not seem to have a negative impact on erectile function. No difference in sexual AEs between monopolar and bipolar TURP are clearly demonstrated [21-24]. Laser surgery for BPH is currently part of common clinical practice, with laser enucleation becoming the treatment of choice for patients with large prostates (>80 mL) [4]. Overall, no significant differences were found in the RE rate compared with TURP. No negative effect was demonstrated on erectile function, similarly to TURP [25,26]. Several ejaculation preservation techniques were developed to preserve the ejaculatory function (e.g., ep-TURP, ep-HoLEP, etc.). They seem reasonable options for this purpose but only limited and heterogeneous evidence is available [27].

In the recent years, there was an increased interest in the development of minimally invasive treatments for BPH, such as Prostatic Urethral Lift (PUL, UroLift®), Water Vapor Thermal Therapy (WVTT, Rezūm™), Waterjet Prostate Ablation (WPA, AquaBeam®), and Temporarily Implanted Nitinol Device (iTIND) to achieve symptomatic improvement similar to traditional surgery, while maintaining sexual function [19]. PUL demonstrated an impact similar to sham therapy and significantly less than TURP on ejaculatory function, besides, it showed an effect not significantly different from sham therapy and TURP on erectile function [28,29]. According to European Association of Urology Guidelines, PUL should be offered in man interested in preserving ejaculatory function [4]. Literature reported an impact of WVTT on erectile and ejaculatory functions comparable to sham therapy [30]. WPA was associated with significantly better ejaculatory function and similar erectile function in comparative studies with TURP [31]. Very limited evidence is available for iTIND, however, sexual function was found stable through years, with no reports of SD [32].

Conclusions

Sexual activity remains an essential component of overall quality of life in most men regardless of age, therefore, the benefit of reducing LUTS with surgery should be weighed with the risk of causing SD. While more extensive data on sexual outcomes are available for traditional BPH surgery, such as TURP, there is only limited evidence for other surgical procedures. Minimally invasive treatments seem to minimize SD and could be discussed as an alternative, especially in patients who wish to preserve their sexual function. Further studies investigating the impact of BPH surgery on sexual function are needed to improve knowledge of scientific community on the topic and ultimately allow better patient counseling at the moment of therapeutic choice.

References

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