Quality of Life in Sexually Active Men with Symptomatic Benign Prostatic Hyperplasia

Quality of life (QOL), sexuality in particular, has become an important consideration in treatment decisions for men with lower urinary tract symptoms (LUTS) related to benign prostatic hyperplasia (BPH). To determine the impact of these conditions on sexual function and QOL in older men, this article provides a review of clinical data on the relationship between sexual dysfunction and symptom severity, effective clinical assessment, treatment options, and the influence of current therapies on sexual function and QOL. The various symptoms of BPH can adversely affect sexual functioning and therefore QOL. Moreover, there may be a direct association between symptom severity and sexual dysfunction that may affect QOL.

Patients base their decisions regarding treatment choices for BPH more on anticipated relief of lower urinary tract symptoms and improved QOL (including sexual functioning) than on improvements in physical measures. Although medications and surgery may relieve LUTS, sexual dysfunction is a common adverse result. Newer pharmacological interventions such as specific a-adrenergic blocking agents like tamsulosin may help improve sexual function and QOL in men with symptomatic BPH.

benign prostatic hyperplasia (BPH), an enlargement of the prostate gland, is a common disorder in older men who suffer from poor prostate health. By the age of 85 years, >90% of men have microscopic prostatic hyperplasia. Clinically, reports suggest that approximately 75% of men >50 years of age will experience lower urinary tract symptoms (LUTS) suggestive of BPH: difficulty urinating, urgency, frequency, hesitancy, retention and dribbling.

The relationship between BPH and LUTS is complex, since not all men with benign prostatic enlargement develop LUTS, and not all LUTS are associated with BPE. Since outlet obstructions are the source of clinical difficulties, this paper refers to BPH, recognising that the literature does not always distinguish precisely between tissue-diagnosed BPH and benign prostatic enlargement.

Information on the natural history of BPH helps separate the effects of intervention from what might be expected without it. However, little is known about the natural history of BPH because of numerous problems with diagnostic methods. Surrogate measures, such as the symptom severity measures of LUTS, have been used to try to better define the natural history of BPH, but each of these measures has problems or limitations as well, because of the natural effect of detrusor function on each of these measures. Thus, impaired detrusor function can lead to increased symptom severity and decreased flow rates. Alternatively, urethral strictures or other sources of outflow obstruction can decrease flow rates. Incontinence or prostatitis can increase symptom scores while being unrelated to BPH. Although any of these factors can increase prostate volume, not all men with an enlarged prostate have symptoms. Thus no single dimension lends itself well to use in epidemiological studies, which is a major reason for our limited understanding of the natural history of BPH.

BPH can result in severe morbidity as a result of bladder outlet obstruction, with the potential for bladder stones, overflow incontinence, dilation of the upper urinary tract, recurrent urinary tract infections, gross (prostatic) haematuria, and urinary retention. More serious, potentially life-threatening complications include urosepsis and renal failure.

BPH is not always associated with acute urinary retention (AUR), and does not always progress in every patient. Studies have shown that some men who have LUTS and do not undergo surgery may have improvement or no change of their symptoms with no particular medical intervention. More recent studies have identified urinary symptoms that are more likely to be associated with BPH that progresses to AUR and thus requires surgical intervention. Patients with greater numbers of these risk factors may be more likely to experience AUR or to require surgery.

Nocturia is a symptom that persons with BPH may consider bothersome. There are many other causes of nocturia such as congestive heart failure, decreased nocturnal release of antidiuretic hormone, recumbency, and drinking fluids prior to bedtime. All occur more commonly in older persons, and this symptom can be especially refractory to treatment with either medications or surgery.

Beyond medical complications, BPH and its treatments profoundly affect many daily aspects of quality of life (QOL) including sexual functioning. However, many men do not ask for medical help despite symptoms that limit these activities. Some elderly men may believe that urinary symptoms and sexual dysfunction are a normal part of aging. This same conclusion might be drawn by younger physicians after noting that prevalence of BPH increases with age. Other patients may be embarrassed about discussing these problems with a healthcare professional, especially if they are concerned that LUTS may be related to sexual function. This article reviews the importance of QOL and sexual functioning in assessing and treating men with BPH, and the potential benefits of available treatments. A comprehensive review of the literature was conducted. All articles addressing BPH and QOL were reviewed. Newer prepublication information (where available) was also considered. Standardised review methodology was applied when considering including any reference.

Men with BPH are more likely than men who do not have BPH to report interference with daily routines (e.g. restricting fluid intake, avoiding places that may not have a toilet and limiting travel) and express fear about prostate cancer. Those with predominantly irritative symptoms are more likely to report that their QOL is affected than are those with predominantly obstructive symptoms. Patients base their decisions regarding treatment for BPH more on anticipated relief of symptoms and improved QOL (reduced invasive symptoms and sexuality) than on improvements in physical measures of urinary symptoms, such as peak urinary flow rates.

Many symptoms of BPH are difficult to evaluate in a standardised manner because they are subjective, and the severity of symptoms does not correlate well with the risk of urinary complications. How- ever, the degree to which a patient is bothered by his symptoms is a significant factor in treatment decisions. Although many patients adapt well to bothersome symptoms, others with minimal symptoms will find them unacceptable and pursue treatment enthusiastically.

The International Prostate Symptom Score (IPSS), which is identical to the American Urological Association Symptom Index (UASI), was revised to include the question: "If you were to spend the rest of your life with your urinary condition just the way it is now, how would you feel about that?" This question determines the degree of how bothersome symptoms are to a patient and is often referred to as the bother score. The BPH Impact Index (BII) contains four questions that focus on how BPH affects health and ability to function. The IPSS and BII can be supplemented with the BPH-QOL9, a nine-item health-related QOL questionnaire that includes three questions associated with patients' perceived sexual-life status that include levels of sexual desire, ability to achieve erection, and satisfaction with sexual life. Although such scales represent some advance, their usefulness remains limited; they focus primarily on erectile dysfunction (ED) and do not adequately address overall sexual function (e.g. sexual desire, sexual function and orgasm). To address these limitations, clinicians should ask patients directly about the impact of their symptoms on their QOL and sexual functioning.

Despite perceptions that aging and declining sexuality go hand in hand, many older men remain sexually active. One study of men between the ages of 50 and 80 years reported that 13% considered sex very important, 29% said sex was important, and 41% reported sex as occasionally enjoyable, with only 17% indicating that they could live without it. Undeniably, physiological changes associated with aging do affect the sexual response cycle. Reduced penile vasocongestion, testicular elevation, and delayed erection are all part of aging. Orgasm is of shorter duration in older men, with fewer and less forceful prostatic secretions and urethral discharge. Such changes appear to be related, at least in part, to a decrease in circulating and bioavailable testosterone. It is well established that concomitant diseases, such as vascular, endocrine, neurological and psychological disorders, also play a major role in causing erectile dysfunction.

The prevalence of sexual problems and dysfunction increases in older men with urinary symptoms. Older men with LUTS were reportedly more worried about sexual function, had worsened sexual performance, expressed greater dissatisfaction with sexual performance, had reduced sexual drive, and reported more frequent erectile dysfunction when sexually stimulated than did men without LUTS. The Multinational Survey of the Aging Male (MSAM-7), conducted to systematically investigate the relationship between LUTS and sexual problems in aging men, found that ejaculatory disorders were about as prevalent as erectile dysfunction, and the bothersomeness of these sexual disorders was strongly associated with the severity of LUTS. For all age categories evaluated, the problems in each domain of sexual function (erection, intercourse/orgasmic satisfaction, sexual desire and overall satisfaction) were strongly associated with the severity of LUTS, independent of other comorbidities.

Among patients with BPH assessed before prostatectomy, those with more severe urinary symptoms had more sexual difficulty, primarily because of erectile dysfunction. Ejaculatory disorders and decreased sexual desire and satisfaction have also been reported. Severe urinary symptoms secondary to BPH may be associated with sleep disturbances and anxiety together with poor sexual function (including erectile dysfunction and ejaculatory disorders), particularly a lack of satisfaction with, frequency of and ability to have sexual intercourse. Patients with BPH-related LUTS accompanied by sexual dysfunction experience more severe symptoms with significantly reduced libido, greater difficulty in maintaining an erection, and lower levels of sexual satisfaction than those with less severe LUTS. The established relationship between sexual dysfunction and LUTS/BPH severity confirms the need to include a comprehensive assessment of sexual function in the initial evaluation of patients with LUTS/BPH. Findings may be useful in establishing not only the degree of LUTS, but in treatment selection and planning.

In the past, surgery was the only treatment option for patients with symptoms of BPH. Surgical interventions have an established record in providing symptom relief and preventing further complications. However, many men have been fearful of surgery and its side effects, especially those related to sexual function, and have remained 'silent sufferers'. Now that a significant shift toward medical management of this condition has occurred in recent years, many more individuals can now be successfully treated. Although medical interventions and less invasive surgical interventions have not yet demonstrated long-term success, an increasing body of evidence suggests that they may be highly effective in alleviating urinary symptoms. Transurethral vaporisation of the prostate has been associated with a significant amount of sexual dysfunction, and certain medications, such as the older less selective a-adrenergic blocking agents, have also adversely affected sexuality and cardiovascular health. Because the pharmacological and surgical treatment for LUTS related to BPH can impact sexual function, discussions of sexuality, side effects and other QOL issues should become a vital part of the therapeutic decision-making process. Such discussions should define the patient´s level of urinary symptoms, degree of annoyance from these symptoms, perceptions of QOL, and concerns about sexual function. Thus, while surgery and drug therapy will successfully treat many patients, others will have persistent symptoms and will require referral for supportive counselling.

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