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- Original Article -
Erectile dysfunction after transurethral prostatectomy for lower urinary tract symptoms: results from a center with over 500 patients
Vassilis Poulakis, Nikolaos Ferakis, Ulrich Witzsch, Rachelle de Vries, Eduard Becht
Department of Urology and Pediatric Urology, Northwest Hospital, Frankfurt am Main D-60488, Germany
Abstract
Aim: To identify possible risk factors for erectile dysfunction (ED) after transurethral resection of prostate (TURP)
for benign prostatic hyperplasia (BPH).
Methods: Between March 1999 and March 2004, 629 patients underwent
TURP in our department for the treatment of symptomatic BPH. All patients underwent transrectal ultrasound
examination. In addition, the flow rate, urine residue, International Prostate Symptom Score (IPSS) and quality of life
(QOL) were recorded for those who presented without a catheter. Finally, the erectile function of the patient was
evaluated according to the International Index of Erectile Function Instrument (IIEF-5) questionnaire. It was
determined that ED existed where there was a total score of less than 21. The flow rate, IPSS and QOL assessment were
performed at 3 and 6 months post-treatment. The IIEF-5 assessment was repeated at a 6-month follow-up. A logistic
regression analysis was used to identify potential risk factors for ED.
Results: At baseline, 522 (83 %) patients answered the IIEF-5 questionnaire. The mean patient age was (63.7 ± 9.7) years. The ED rate was 65 %. After 6
months, 459 (88 %) out of the 522 patients returned the IIEF questionnaire. The rest of the group was excluded from
the statistical analysis. Six months after TURP, the rate of patients reporting ED increased to 77 %. Statistical
analysis revealed that the only important factors associated with newly reported ED after TURP were diabetes mellitus
(P = 0.003, r = 3.67) and observed intraoperative capsular perforation
(P = 0.02, r = 1.12).
Conclusion: The incidence of postoperative, newly reported ED after TURP was 12 %. Risk factors for its occurrence were diabetes
mellitus and intraoperative capsular
perforation. (Asian J Androl 2006 Jan; 8: 69-74)
Keywords: benign prostatic hyperplasia; transurethral resection of prostate; erectile dysfunction
Correspondence to: Dr Vassilis Poulakis, M.D., PhD, Department of
Urology and Pediatric Urology, Krankenhaus
Nordwest, Steinbacher Hohl 2-26, Frankfurt am Main D-60488, Germany.
Tel: +49-69-7601-4123, Fax: +49-69-7601-3648
E-mail: poulakis@em.uni-frankfurt.de; vpoulakis@aol.com
Received 2005-03-18 Accepted 2006-06-23
DOI: 10.1111/j.1745-7262.2006.00088.x
1 Introduction
It is accepted that sexual function is important to the
quality of life (QOL) of individuals. Population surveys
have shown high levels of sexual dysfunction in men over
the age of 50 years [1, 2]. Recent evidences from both
community and clinical trials have suggested a link
between lower urinary tract symptoms (LUTS) and sexual
dysfunction [3-5]. Transurethral resection of prostate
(TURP), the standard surgical therapy for the relief of
LUTS, is reported to cause sexual dysfunction as well.
According to a systematic review, approximately
75 % of sexually active and potent patients experience retrograde
ejaculation and over 13 % become impotent after TURP
[6]. One important drawback of the studies dealing with
sexual dysfunction after TURP is the lack of a standard
definition of sexual dysfunction.
The aim of this study was to evaluate the incidence
of erectile dysfunction (ED) after TURP in a hospital
using the validated International Index of Erectile
Function Instrument (IIEF-5) [7]. A second aim was to
identify the possible risk factors associated with its
occurrence in this particular patient cohort.
2 Material and methods
Between March 1999 and March 2004, 629 patients
underwent TURP in our department for the treatment of
symptomatic benign prostatic hyperplasia (BPH).
Table 1 lists the inclusion and exclusion criteria for treatment.
All patients underwent transrectal ultrasound (TRUS)
(Performa, Dornier MedTech, Wessling, Germany). In
addition, the flow rate, urine residue, International
Prostate Symptom Score (IPSS) and QOL were recorded
for those who presented without a catheter. Finally, the
erectile function of the patient was evaluated according
to the IIEF-5 questionnaire [7]. ED was defined as a
total score of less than 21.
The flow rate, IPSS and QOL assessment were performed at 3 and 6 months postoperatively. IIEF-5
assessment was repeated at a 6-month follow-up.
The elaboration of data was accomplished with the
Statgraphics Statistical Package (Manugistics, Rockville,
MD, USA) [8]. Data were expressed as mean ± SD.
Normality was assessed with the Kolmogorov-Smirnov
test. Comparison of the groups was done with
paired t-test. Correlation was calculated according
to Spearman¡¯s
correlation coefficient. Forward logistic regression
analysis was used to identify potential risk factors for ED [9].
P < 0.05 was considered statistically significant.
3 Results
At baseline, 522 (83 %) patients answered the
IIEF-5 questionnaire. The mean patient age was (63.7 ± 9.7) years.
ED was evident in 339 (65 %) patients. There was a
significant correlation between age and ED
(P < 0.01). Patients presenting with ED at baseline had significantly
higher symptom scores than those without ED. Table 2
shows a univariate analysis of the risk factors for ED at
baseline. Diabetes (P < 0.001), coronary heart disease
(P = 0.006), age (P < 0.01), hypertension
(P = 0.02) and severity of the IPSS
(P = 0.03) were the most important
parameters. Intraoperative capsular perforation occurred
in 26 (5 %) patients. Severe hemorrhage requiring blood
transfusion was observed in 21 (4 %) patients. TURP
syndrome occurred in 11 (2 %) patients. Of the 63
patients who were lost during the 6-month follow-up, 22
(34.9 %) were potent. This finding suggests that the
distribution of potent patients in the baseline patient group
is almost equal to that of the group that was lost in
follow-up.
Mean values in clinical parameters at baseline and at
6 months in patients treated with TURP are presented in
Table 3. In this table we separated the patients who did
not have a pretreatment indwelling catheter
(n = 366, 70 %) from those who did have an indwelling catheter
due to urinary retention prior to treatment
(n = 156, 30 %). We evaluated the IIEF data and the other clinical
parameters for each of these two groups. As seen in Table 4,
preoperative urinary retention (pretreatment catheter) was
not related to newly diagnosed postoperative ED. After
6 months, 459 (88 %) out of the 522 patients returned
the IIEF questionnaire. The rest were excluded from
the statistical analysis. At 6 months, 353
(77 %) out of the 459 patients reported ED. There was a
12 % increase in the ED rate. Table 5 presents the distribution
of IIEF scores at baseline and at 6 months.
Forward logistic regression analysis revealed that the
only important factors associated with newly
reported ED after TURP were diabetes mellitus
(P = 0.003, r = 3.67),
and reported intraoperative capsular perforation
(P = 0.02, r = 1.12) (Table 4).
4 Discussion
BPH is a common condition in aging men and is
associated with a range of sexual dysfunction. Treatments
for BPH are also associated with ED and sexual dysfunction. Ejaculatory dysfunction is the most
common problem associated with both medical and surgical
treatment. We present our experiences of treating 522
patients with TURP over a time span of 5 years; 156 of
these patients had a pretreatment catheter.
The incidence of ED after TURP for BPH is still debated.
It has been reported to occur in between 4 % and
35 % of patients [10-12] and to be associated with age or a
pre-existing ED [12, 13]. Various suggestions have been
made as to the origin of this condition (e.g. cavernous
nerve damage [12, 14], fibrosis and thrombosis of the
cavernous arteries [12], or psychological changes due
to ejaculatory failure or urethral sphincter insufficiency
[11]), but no conclusive determination has been made.
In our study, diabetes mellitus and reported
intraoperative capsular perforation were the only significant risk
factors for newly observed postoperative ED. Thirty
percent of the patients with diabetes mellitus developed
postoperative ED, while 62 % of the patients with
intraoperative capsular perforation reported ED 6 months
after the operation. Capsular perforation was also a risk
factor for impaired postoperative erectile function in the
study of Tscholl et al. [12]. This could also cause a
direct injury to the cavernous nerves, which run a few
millimeters from the prostatic capsule. Tscholl
et al. [12] reported that a small adenoma was a risk factor for
postoperative ED probably because of a higher risk of
capsular perforation. Conversely, in cases of large adenoma,
the cavernous nerves are more protected because of their
distance from the site of resection. The negative effect
of perioperative capsular perforations adjacent to the
neurovascular bundles on the potency after TURP was
advocated also in the studies of Hanbury and Sethia
[13] and Bieri et al. [14]; in these studies, the overall rate of newly
diagnosed postoperative ED was 17.5 % and
32.5 %, respectively.
It is not surprising that the ED correlates so strongly
with the capsular penetration. In a study [15] on
transurethral resection of adenoma of the posterior urethra
in 131 young males, no ED or any sexual dysfunction
(e.g. hemospermia and retrograde ejaculation) was reported
postoperatively, because only the tumor of the posterior
urethra was resected and the prostate was left intact.
Diabetes mellitus was also a significant risk factor
for postoperative ED in the study by Taher [16], who
made a link between this and the higher susceptibility of
the cavernous nerves of patients to damage from heat,
contributed by chronic hyperglycemia. In that study,
the rate of newly diagnosed postoperative ED was
14 %.
There are more studies that have found other risk
factors for postoperative ED in patients undergoing
transurethral resection for BPH. For example, the
association between age and postoperative ED was reported by
Tscholl et al. [12]. In 8.3 % of the patients newly
diagnosed, postoperative ED was observed, and being
aged more than 65 years was one of the factors
associated with its occurrence. Perera and Hill [17] observed
a postoperative newly diagnosed ED rate of
17.3 % in their study of 253 patients treated with TURP.
Significant risk factors for its occurrence were presentation
with acute retention and the development of profuse
primary hemorrhage.
Finally, Zohar et al. [18], in an earlier study, reported
that patients who became impotent following prostate
surgery had a higher level of anxiety, and that those
without extensive preoperative counseling (including
information on sexual function) were significantly more likely
to complain of impotence after TURP.
To our knowledge, this is the largest prospective study
evaluating risk factors for the occurrence of ED after
transurethral resection for the treatment of obstructive BPH in
patients with and without pretreatment catheters. Patients,
reporting ED for the first time after the operation,
according to a validated questionnaire [7], did not differ
from those not reporting ED with respect to age,
prostate mass and pretreatment symptom scores. Also, the
two groups did not differ in the amount of tissue they had
had resected. The only parameters that significantly
differed between the two groups were the rate of patients
with diabetes, the rate of reported capsular perforation
and the rate of profuse hemorrhage necessitating
transfusion (P < 0.01 for all three parameters). The forward
logistic regression model considered diabetes mellitus and
the presence of intraoperative capsular perforation as
significant independent risk factors for presentation of a
new postoperative ED.
The incidence of preoperative ED in patients with
obstructive BPH was 65 %. In our study population,
using the strict criteria of a validated questionnaire [7],
the incidence of the preoperative ED of
65 % appeared quite high. However, this is not a normal male
population but patients with lower urinary tract symptoms, in
whom a TURP was indicated. Furthermore,
30 % of the patients had an indwelling catheter because of acute
urinary retention for a mean time of 6.8 (range: 1-65)
days. Additionally, our pre-TURP ED rates are lower
than those reported by other authors [19]
(65 % vs. 70 %) who evaluated an analogous patient population.
As presented in Table 5, only 67 (13 %) patients had
moderate-to-severe ED; the majority of the patients
(n = 272, 52 %) had mild ED. Six months after TURP,
the rate of patients reporting ED increased to
77 %. Risk factors associated with this increase were diabetes
mellitus and intraoperative capsular perforation.
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