Sexual Dysfunction and Lower Urinary Tract Symptoms (LUTS) Associated with Benign Prostatic Hyperplasia (BPH)

Abstract

Sexuality is an essential aspect of a couple's relationship and has a significant impact on life satisfaction. Benign prostatic hyperplasia (BPH) is a condition that commonly affects older men and is often associated with lower urinary tract symptoms (LUTS) and sexual dysfunction. Men with moderate-to-severe LUTS are at increased risk for sexual dysfunction, including moderate-to-severe erectile dysfunction (ED), ejaculatory dysfunction (EjD), and hypoactive desire (HD). The results of several recent large-scale studies have shown a consistent and strong relationship between LUTS and both ED and EjD. It appears that the pathophysiological mechanisms of LUTS and the related prostatic enlargement of BPH as well as certain treatments for this condition may have an impact on both the erection and ejaculation components of the sexual response. Validated questionnaires that assess sexual function provide clinicians with valuable information to help guide treatment selection decisions. Effective medical therapies for LUTS associated with BPH include α₁-adrenergic receptor antagonists (i.e., alfuzosin, doxazosin, tamsulosin, and terazosin) and 5α-reductase inhibitors (i.e., finasteride and dutasteride). The side effects of these medications, including sexual dysfunction, are important distinguishing features. The successful management of patients with LUTS associated with BPH should include assessments of sexual function and monitoring of medication-related sexual side effects. For men with LUTS and sexual dysfunction, an appropriate integrated management approach, based on each patient's symptoms and outcome objectives, is warranted.

Introduction

Until recently, it was widely assumed that symptoms of male sexual dysfunction, including erectile dysfunction (ED; persistent inability to achieve and maintain an erection sufficient for satisfactory sexual performance [1]), ejaculatory dysfunction (EjD; any disturbance in the male ejaculatory reflex, including loss of ejaculation, ejaculation with a decreased amount of semen, premature ejaculation, delayed ejaculation, and retrograde ejaculation [2]), and hypoactive desire (HD; loss of desire or decreased desire) were a natural consequence of the aging process. As a result, many older men did not seek help for their sexual problems and healthcare providers frequently failed to ask their patients about their sexual concerns. Recent studies have shown that a decrease in sexual function and sexual activity is not an inevitable consequence of aging. Furthermore, effective and well-tolerated treatments (e.g., phosphodiesterase type 5 inhibitors for the treatment of ED) are available for managing many of these conditions.

Various studies have assessed the prevalence of different types of male sexual dysfunction, often using varying definitions for the condition being assessed. The results of a large-scale, population-based study of men aged 40 to 70 years, the Massachusetts Male Aging Study (MMAS), demonstrated that ED had a high prevalence (52%), with nearly 35% of the men reporting moderate-to-severe ED [3]. The prevalence of complete ED was age-dependent, increasing from 5% for men aged 40 years to 15% for those aged 70 years. However, ED was also significantly associated with various age-independent predictor variables [3]. Based on MMAS data, it has been estimated that the worldwide prevalence of ED will be 322 million men in 2025 [4]. Other study results indicated that older individuals retain significant interest in sexuality and that a large proportion of older men and women remain sexually active [5], [6]. Furthermore, sexuality is a factor that correlates with individuals’ perception of their well-being and quality of life [7]. With the development of new measures for assessing sexual function and new medications for the treatment of ED, regular discussions between healthcare providers and patients on sexual problems can lead to effective management strategies and improvements in patient quality of life.

Lower urinary tract symptoms (LUTS; urinary frequency, urgency, decreased urine flow rates, nocturia) are common problems in aging individuals. Benign prostatic hyperplasia (BPH) is the primary cause of LUTS in men aged 50 years and older. The presence of histological BPH at autopsy is approximately 8% in men aged 31 to 40 years, 50% in those aged 51 to 60 years, 70% in those aged 61 to 70 years, and 90% in those aged 81 to 90 years [8]. Unfortunately, the MMAS did not evaluate LUTS as a possible predictor variable for ED. Thus, although both male sexual dysfunction and LUTS were known to be age-dependent, the exact relationship between these 2 conditions remained unclear. However, more recent large-scale epidemiological studies with different population samples and various measurement approaches have demonstrated consistent and compelling evidence of a relationship between LUTS and sexual dysfunction in aging men that is independent of the effects of age or other comorbidities. These studies, including the Multinational Survey of the Aging Male (MSAM-7) [6], and new pathophysiological insights have provided valuable information on the relationship between LUTS and sexual dysfunction in aging men. Moreover, these advances have resulted in new approaches to the evaluation of these disorders and the selection of treatment options. The present review article provides an overview of current knowledge on the relationship between male sexual dysfunction and LUTS, with a particular focus on LUTS associated with BPH, as well as medical treatment options for symptomatic BPH and their effects on sexual function.