Introduction

Clinically, benign prostatic hyperplasia (BPH) with lower urinary tract symptoms (LUTS) in elderly men is one of the most common diseases.¹ With the proliferation of epithelial and smooth muscle cells within the transitional zone of the prostate, urinary flow resistance through the prostatic urethra increases, leading to irritative (nocturia, urgency, and frequency) and obstructive (straining, sense of incomplete bladder emptying, weak stream) symptoms. The treatment for LUTS secondary to BPH includes watchful waiting, medical therapies, and surgical treatment. In males with moderate to severe symptoms, however, medical or surgical management is often recommended as this reduces the risk for disease progression as well as improves the individual’s quality of life (QOL).²

The surgical approach remains one of the most effective treatment options for BPH with severe and complicated conditions or LUTS refractory to medical therapy. Despite the fact that the transurethral resection of the prostate (TURP) has been regarded as the gold standard surgical option for LUTS due to BPH, the high rate of intraoperative or postoperative complications associated with TURP motivated investigators to search for modifications or alternative procedures.³

One of the late and common complications of TURP is male sexual dysfunction (SD) [retrograde ejaculation (RE), dry ejaculate, decreased ejaculation, premature ejaculation, and erectile dysfunction (ED)]. More extensive resection of the prostate can cause a higher incidence of SD in those who have normal sexual function before. RE is attributed to bladder neck incompetency after TURP and lower volume of seminal vesicles.⁴

The reported rate of sexual in particular ED after TURP in elderly males is from 5% to 29% in different studies.^5,6

The present study will report the frequency of ED after TURP in the local population of Khyber Pakhtunkhwa province of Pakistan.

Methods

This descriptive study was conducted in the Institute of Kidney Disease, Peshawar, from March 21, 2022 to September 21, 2023 on 82 male patients of 40 to 60 years of age presenting with BPH having LUTS. Detailed history, examination, and investigations such as a full blood count, coagulation profile, ultrasound kidney, urinary bladder, and prostate with pre and post-void residual urine were performed on every patient. Pre-operative erectile function was assessed by using the international index of erectile function (IIEF-5) which is the sum of the ordinal responses to the five items. It was interpreted as: a score of 22-25 = No ED, a score of 17-21 = Mild ED, a score of 12-16 = Mild to moderate ED, a score of 8-11 = Moderate ED, a score of 5-7 = Severe ED .⁷ All patients underwent TURP using mono-polar diathermy and were managed according to standard protocol till his discharge from the hospital. Post-TURP erectile function was assessed after 6 months using the same IIEF-5. Any increase or decrease in the score was noted. All the data such as name, age, duration of BPH, pre and post-operative IIEF-5 score, and degree of ED (mild, moderate, and severe) were recorded.

Results

The mean age of the patients was 50.71 ± 5.72 years. The mean duration of LUTS was 5.26 ± 1.77 months. The mean preoperative IIEF-5 score was 22.41 ± 2.30. The mean postoperative IIEF-5 score was 22.41 ± 3.68 (Table 1).

Regarding the age distribution, there were 45 (54.9%) patients in the age group of 40 to 50 years and 37 (45.1%) patients in the age group of 51 to 60 years.

The frequency of sexual ED in our study was 8 (9.8%)with 4 (4.9%) patients showing mild ED, and 2 (2.4%) patients each with moderate and severe ED.

Stratification of ED with age is shown in Table 2 where most of the participants with ED were less than 50 years of age.

Distribution of ED with LUTS and BMI is shown in Tables 3 and 4 which depict that more ED was observed in patients with prolonged duration of LUTS and higher BMI levels.

Discussion

BPH is a highly prevalent disease in men over 50 years of age and its incidence increases with age. Prevalence of BPH is estimated as 50% in men in their 50s, and reaches 80% for men over 80 years.¹ Patients with BPH often present with varying severity of LUTS, although these can occur in the absence of BPH and vice versa.^2,4 The primary aim of therapy of BPH is to reduce LUTS, which ultimately improves QOL. Despite the advancements in pharmacological treatment of BPH during the last decades, surgery currently remains a fundamental option in the management of these patients.⁸ 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. It is widely accepted that surgical procedures for BPH may determine ED. Numerous sexual side effects, including erectile ejaculatory and orgasmic dysfunctions, were reported with the majority of surgical treatments for BPH. Nevertheless, some studies showed no change or even a possible improvement in the sexual function of patients with BPH undergoing surgical therapy.^8,9

Table 1. Clinical characteristics of n = 82 patients.

Table 2. Stratification of ED with age (Chi-square test).

Table 3. Stratification of ED with duration of LUTS (Chi-square test).

Table 4. Stratification of ED with BMI (Chi- square test).

Injury of the internal urinary sphincter resulting in 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 ante grade ejaculatory function. Disruption of this mechanism is the predominant factor underlying BPH surgery-related RE. Psychological repercussions of RE can affect sexual satisfaction and contribute to ED.^10,11

The frequency of sexual ED in our study was 9.8%, this rate is significantly lower as compared to the reported rate of 19% by Muntener et al.¹² . Yousuf et al.¹³ reported an ED rate of 45% in the initial days post TURP, which is significantly higher. These significant differences in results may be due to patient’s demographics and the small sample size in our study.

In our study, 4.9% of patients experienced mild ED while 2.4% each experienced moderate and severe ED. These results are consistent with most of the previous studies. Mishra et al.¹⁴ reported that the severity of LUTS is directly proportional to Post TURP ED which is contrary to our results. This contradiction may be due to follow up protocols.

LUTS and ED are both highly prevalent and frequently co-associated in the same aging male group. In recent years, 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 ED often pre-exist BPH surgery, patients should be adequately evaluated prior to surgical procedure to avoid mistakenly considering them as postoperative complications.^12,13

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 being the most frequently reported sex-related complications.¹⁴ The use of non-validated and arbitrary tools is extremely common for the assessment of sexual outcomes. The 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.⁷ 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.^15,16

Conclusion

The frequency of ED after TURP for BPH is seen more frequently in younger age groups in our population. Preoperative sexual function must be assessed for better comparison with post-operative erectile function.

Acknowledgement

The authors would like to acknowledge the staff and doctors of the Urology Department of Institute of Kidney Diseases and Renal Transplant Peshawar, Pakistan, who actively participated in the execution of this research project.

List of Abbreviations

Conflict of interest

None to declare.

Grant support and financial disclosure

None to disclose.

Ethics approval

Ethics approval was granted by the office of chairman of research and ethics committee, Institute of Kidney Diseases, Peshawar, ref # 321, dated 08/02/2022.

Authors’ contributions

IU: Main concept and design of the study, acquisition and analysis of data, drafting of manuscript, critical intellectual input.

MA, SU, SAS, MSK: Drafting of manuscript and data analysis and acquisition, critical scientific and technical input

ALL AUTHORS: Approval and responsibility for the final version of the manuscript to be published.

Authors’ Details

Ikramullah¹, Muhammad Asif², Samiullah³, Syed Ameeron Shah⁴, Muhammad Salman Khan⁵

1. Associate Professor of Urology, Institute of Kidney Diseases and Renal Transplant, Peshawar, Pakistan
2. Associate Professor, Department of Urology, Lady Reading Hospital Peshawar, Peshawar, Pakistan
3. Post Graduate Trainee Urology, Institute of Kidney Diseases and Renal Transplant, Peshawar, Pakistan
4. Consultant Urologist, Institute of Kidney Diseases and Renal Transplant, Peshawar, Pakistan
5. Post Graduate Trainee, Department of Urology, Lady Reading Hospital Peshawar, Peshawar, Pakistan

References

1. Oka AA, Duarsa GW, Novianti PA, Mahadewa TG, Ryalino C. The impact of prostate-transurethral resection on erectile dysfunction in benign prostatic hyperplasia. Res Rep Urol. 2019 Apr 10;11:91–6. https://doi.org/10.2147/RRU.S189414
2. Leong JY, Patel AS, Ramasamy R. Minimizing sexual dysfunction in BPH surgery. Curr Sex Health Rep. 2019 Sep 15;11:190–200. https://doi.org/10.1007/s11930-019-00210-1
3. Liu Y, Cheng Y, Zhuo L, Liu K, Xiao C, Zhao R, et al. Impact on sexual function of endoscopic enucleation vs transurethral resection of the prostate for lower urinary tract symptoms due to benign prostatic hyperplasia: a systematic review and meta-analysis. J Endourol. 2020 Oct 1;34(10):1064–74. https://doi.org/10.1089/end.2020.0141
4. Ng BH, Chung E. A state-of-art review on the preservation of sexual function among various minimally invasive surgical treatments for benign prostatic hyperplasia: impact on erectile and ejaculatory domains. Investig Clin Urol. 2021 Mar;62(2):148. https://doi.org/10.4111/icu.20200392
5. Hossain F, Rehman S, Rahman H, Alam AKMK, Faruque MDS, Rahman Z. Sexual function status after transurethral resection of prostate (TURF). J Med Sci Clinic Res. 2018;6(10):1275–78.
6. Millán H, Romero JL. Sexual activity and surgery of benign prostatic hyperplasia. Archivos Espanoles de Urologia. 2001 Jan 1;54(1):53–60.
7. The British Association of Urological Surgeons. Available from: www.baus.org.uk/_userfiles/pages/files/Patients/Leaflets/iief.pdf
8. Li B, Hao L, Pang K, Zang G, Wang J, Yang C, et al. Assessment of sexual outcomes in patients undergoing thulium laser prostate surgery for management of benign prostate hyperplasia: a systematic review and meta-analysis. Sex Med. 2022 Apr;10(2):100483. https://doi.org/10.1016/j.esxm.2021.100483
9. La Vignera S, Condorelli RA, Cannarella R, Giacone F, Calogero AE. Arterial erectile dysfunction is an early sign of vascular damage: the importance for the prevention of cardiovascular health. Ann Transl Med. 2019 Jul;7(Suppl 3):S124. https://doi.org/10.21037/atm.2019.05.61
10. Rew KT, Heidelbaugh JJ. Erectile dysfunction. Am Fam Physician. 2016 Nov 15;94(10):820–7. https://doi.org/10.12968/indn.2009.4.12.77146
11. Elshal AM, El-Assmy A, Mekkawy R, Taha DE, El-Nahas AR, Laymon M, et al. Prospective controlled assessment of men’s sexual function changes following holmium laser enucleation of the prostate for treatment of benign prostate hyperplasia. Int Urol Nephrol. 2017 Oct;49:1741–9. https://doi.org/10.1007/s11255-017-1649-0
12. Muntener M, Aellig S, Kuettel R, Gehrlach C, Sulser T, Strebel RT. Sexual function after transurethral resection of the prostate (TURP): results of an independent prospective multicentre assessment of outcome. Eur Urol. 2007 Aug 1;52(2):510–6. https://doi.org/10.1016/j.eururo.2007.01.088
13. Yousuf MA, Shahzad I, Awan KH, Pathan GM, Manzoor M, Ahmed T. Erectile dysfunction after transuretheral resection of the prostate in patients with benign prostatic hyperplasia. J Health Rehabil Res. 2023 Dec 30;3(2):951–8. https://doi.org/10.61919/jhrr.v3i2.294
14. Mishra J, Choudhury S, Sinha S, Kundu G, Mondal PP, Bera M. Assessment of prevalence of sexual dysfunction in patients having lower urinary tract symptoms with benign prostatic hyperplasia and effect of various treatment modalities on sexual function. Urologia. 2024 Nov;91(4):715–19https://doi.org/10.1177/03915603241254717.
15. Gan ZS, Ehlers ME, Lin FC, Wright ST, Figler BD, Coward RM. Systematic review and meta-analysis of cycling and erectile dysfunction. Sex Med Rev. 2021;9(2):304–11. https://doi.org/10.1016/j.sxmr.2020.01.002
16. Manfredi C, García-Gómez B, Arcaniolo D, García-Rojo E, Crocerossa F, Autorino R, et al. Impact of surgery for benign prostatic hyperplasia on sexual function: a systematic review and meta-analysis of erectile function and ejaculatory function. Eur Urol Focus. 2022 Nov;8(6):1711–32. https://doi.org/10.1016/j.euf.2022.06.007