AGE WELL
By Assoc Prof Dr CHRISTOPHER C.K. HO
Sunday June 24, 2012
Aside from urinary problems, benign prostate hyperplasia can also affect a
man’s sex life.
BENIGN prostate hyperplasia (BPH) is a common condition seen in middle-aged
and elderly men. It is an enlargement of the prostate gland, which — although
not cancerous — may cause problems, as it may impede the flow of urine out of
the bladder.
It may also cause bleeding during urination, and predispose to infection of
the urine.
If urine is totally obstructed from passing out of the bladder, it will cause
a build-up of pressure and urine in the bladder, which when severe, may cause
back-pressure, as well as reflux of urine into the kidney. This will eventually
cause renal failure.
BPH and sex
Aside from all the problems described above, BPH may also affect a man’s
sexual life.
Multiple studies have shown that BPH and sexual dysfunction are
inter-related.
Sexual dysfunction refers to sexual problems, such as erectile dysfunction
(unable to maintain satisfactory erection of the penis for sexual intercourse),
ejaculatory dysfunction (failure to expel semen), and low sexual desire.
BPH has been found to be a risk factor for erectile dysfunction, independent
of age.
BPH has also been found to be a stronger predictor of sexual dysfunction
compared to diabetes, heart disease or hypertension. In fact, erectile function
has been shown to deteriorate in tandem with worsening symptoms of BPH.
How does BPH cause worsening of sexual function?
There are a few theories, which include the nitric oxide/cyclic guanosine
monophosphate pathway, rhokinase, overactivity of the autonomic pathway, and
pelvic organ atherosclerosis.
All these theories have one thing in common — failure of relaxation of the
smooth muscle.
Relaxation of the smooth muscle in the erectile tissue of the penis is needed
for engorgement of the penis with blood.
Similarly, relaxation of the smooth muscle in the prostate and bladder neck
is needed for urine to pass out of the bladder through the penis.
When there is failure of relaxation of the smooth muscle in the penis, this
leads to erection difficulties; while in the prostate and bladder neck,
urination difficulties occur.
Treating BPH
Treatment of BPH consists of medical, as well as surgical interventions.
So, does treating BPH improve the symptoms of BPH?
It depends on the medication given. There are basically two groups of
medication for BPH, ie alpha blockers and the 5α reductase inhibitors.
Examples of alpha blockers include terazosin, doxazosin, alfuzosin,
tamsulosin and silodosin.
There are only two types of 5α reductase inhibitor in the market, ie
finasteride and dutasteride.
Alpha blockers have been shown to improve erectile function. Those with worse
erectile function had better improvement with alpha blockers.
However, not all the alpha blocker drugs have similar effects on ejaculation.
Alpha blockers that act more specifically on the prostate (uroselective), like
silodosin, have been shown to have detrimental effects on ejaculation. There is
no effect on sexual desire.
The 5α reductase inhibitors act by inhibiting the conversion of testosterone
to dihydrotestosterone.
Dihydrotestosterone is the potent hormone that causes growth of the prostate.
It is also commonly known as the male hormone responsible for male
characteristics.
Therefore, it is no surprise that 5α reductase inhibitors are associated with
a decrease in sexual desire and erectile dysfunction. It is also detrimental to
ejaculatory function as well.
However, these sexual dysfunctions are seen mainly during the first year of
treatment. The incidence of these problems decreases with longer duration of
therapy.
Sometimes, both the alpha blockers and 5α reductase inhibitors are used in
combination to treat BPH.
Although symptoms of BPH show better improvement with combination therapy,
the incidence of sexual dysfunction increases as well. In fact, the incidence of
sexual dysfunction is much worse compared to using either medication alone.
What about surgical treatment?
The gold standard for treatment of BPH is still transurethral resection of
the prostate (TURP).
The evidence for sexual dysfunction after TURP is debatable. There are
studies which show that it worsens sexual function, but conversely, there are
also other studies that show otherwise.
However, what is consistent is the evidence that minimally-invasive treatment
of BPH like transurethral microwave therapy (TUMT) and transurethral needle
ablation (TUNA), is less detrimental to sexual function compared to TURP.
Unfortunately, the long-term success rate for treatment of BPH symptoms with
these minimally-invasive therapies are not well established, and may be lower
than TURP.
Restoring sexual ability
All is not lost if sexual dysfunction occurs as a result of BPH or its
treatment.
If erectile dysfunction occurs, phosphodiestaerase-5 inhibitor medications
like vardenafil, tadalafil and sildenafil, can be used.
However, there is a higher risk of postural hypotension (drop in blood
pressure) when it is taken together with alpha blockers.
In this situation, the alpha blocker used should be a more uroselective drug
(like tamsulosin), which has less complications of hypotension.
Other treatments include intracavernosal prostaglandin injections (injecting
a medication known as prostaglandin into the penis), vacuum pump devices, as
well as penile prostheses (implanting a medical device into the penis).
If ejaculation is a problem, the alpha blocker can be switched to one that
has been proven to have less ejaculatory side effects (like alfuzosin).
There are also other modalities of treatment. However, all these problems are
best managed by urologists.
BPH may cause sex-related problems. Similarly, its treatment may also cause
sexual dysfunction.
There are treatments available to help alleviate these sexual problems.
Consultation with a urologist would be the best step to take.
References:
1. Braun MH, Sommer F, Haupt G, Mathers MJ, Reifenrath B, Engelmann UH.
Lower urinary tract symptoms and erectile dysfunction: co-morbidity or typical
‘Aging Male’ symptoms? Results of the ‘Cologne Male Survey’. Eur Urol 2003; 44:
588–94.
2. Rosen R, Altwein J, Boyle P et al. Lower urinary tract symptoms and
male sexual dysfunction: the Multinational Survey of the Aging Male (MSAM-7).
Eur Urol 2003; 44: 637–49.
3. Mirone V, Sessa A, Giuliano F, Berges R, Kirby M, Moncada I. Current
benign prostatic hyperplasia treatment: impact on sexual function and management
of related sexual adverse events. Int J Clin Pract. 2011;65(9):1005-13
4. AUA Practice Guidelines Committee. AUA guideline on management of
benign prostatic hyperplasia (2003). Chapter 1: Diagnosis and treatment
recommendations. J Urol 2003;170:530-47.
5. Mebust WK, Holtgrewe HL, Cockett AT, Peters PC. Transurethral
prostatectomy: immediate and postoperative complications. A cooperative study of
13 participating institutions evaluating 3,885 patients. J Urol 2002; 167:
999–1003
6. Jadaine M et al. Effect of TURP on Erectile Function: A Prospective
Comparative Study. Int J Impot Res 2010; 22: 146-51
7. Mishriki SF et al. TURP and sex: patient and partner prospective 12
years follow up study. BJU Int 2011; 109: 745-50
8. Hoffman RM, Monga M, Elliot SP, Macdonald R, Wilt TJ. Microwave
thermotherapy for benign prostatic hyperplasia. Cochrane Database Syst Rev 2007;
CD004135
9. Bouza C, López T, Magro A, Navalpotro L, Amate JM. Systematic review
and meta-analysis of transurethral needle ablation in symptomatic benign
prostatic hyperplasia. BMC Urol 2006; 6: 14
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