Sexual intercourse as a new option in the medical expulsive therapy of distal ureteral stones in males: a prospective, randomized, controlled study

Efficacy of sexual stimulation in the treatment of distal ureteral stones: A meta-analysis

Introduction

This study aimed to compare the clinical efficacy of sexual stimulation with that of placebo in the treatment of distal ureteral stones.

Methods

We searched PubMed, Web of Science, Cochrane Library, and Google Scholar from January 1, 2000 to December 31, 2022 for studies comparing the efficacy of sexual stimulus with that of placebo for the treatment of distal ureteral stones. RevMan 5.3 software was used to pool the data. The study protocol was registered on PROSPERO (Registration Number: CRD42023432408).

Results

A total of six randomized controlled trials comprising 535 cases of distal ureteral stones were included in this study. Among these, 273 cases were associated with sexual intercourse or masturbation 3-4 times a week, while 262 cases only received symptomatic treatment. The pooled results showed that the 2-week [risk ratios (RR) = 1.77, 95 % confidence interval (CI): 1.34, 2.33] and 4-week [RR = 1.48, 95 % CI: 1.29, 1.69] ureteral stone expulsion rates of the sexually stimulated group were significantly higher than those of the placebo group (ps < 0.01). Additionally, sexual stimulation was associated with a shorter ureteral stone expulsion time [weighted mean differences (WMD) = -3.74, 95 % CI: -6.27, -1.22, p < 0.01] and a decreased prevalence of renal colic attacks [WMD = -0.61, 95 % CI: -1.01, -0.22, p < 0.01] compared with those of the placebo group.

Conclusion

Appropriate sexual stimulation can enhance the spontaneous expulsion of distal ureteral stones in patients presenting with tolerable pain.

Alpha-blockers: the magic pill for endourology-The great delusion

PURPOSE

The present paper takes a different and more critical look at the role of alpha-blockers, sometimes nicknamed as "magical pills", in particular for stone disease and medical expulsive therapy (MET).

METHODS

A non-systematic narrative review was performed, synthesizing pertinent information from selected articles, and critically evaluating their conclusions. Sometimes different views on alpha-blockers were laid bare, including curiosities or other entertaining nuances suitable to the present topic, but always maintaining sharp objectivity and the foremost scientific rigor.

RESULTS AND CONCLUSIONS

Alpha-blockers seem to be a panacea, being used to treat a wide variety of non-urological diseases and conditions. Urological applications include erectile dysfunction to benign prostatic hyperplasia, from incontinence to urinary retention, or even to facilitate urinary stone passage along the urinary tract. Due to its versatility, alpha-blockers appear to be the Swiss army knife of urological medications. However, the efficacy of alpha-blockers for MET, pain management, or facilitating upper tract access is very disappointing, bringing no, or in some instances, only marginal benefits. Their treatment results are far from being significant or impressive let alone magical. Regular sexual intercourse is an effective alternative to alpha-blockers, providing faster ureteral stone expulsion rates and reducing the need for pain medication. Most of the research supporting alpha-blockers has been based on single-center, underpowered, low-quality studies. These low-quality studies biased several subsequent meta-analyses, contaminating them with their low-quality data, enhancing and prolonging this delusion. These results emphasize the need for large, multi-centric, unbiased, randomized, double-blinded, placebo-controlled trials to prevent future year-long delusions that may afflict any medical field.

Efficacy of sexual intercosurse in the spontaneous passage of distal or intramural ureteral stones: a randomsized controlled trial

Background

The role of sexual intercourse as an alternative treatment approach for ureteral stones (UTSs) is a recent area of investigation with only small sample-sized studies. This study aims to evaluate the role of sexual intercourse in the spontaneous passage of distal or intramural UTSs via a larger sample size.

Materials and methods

The study population included cases that had either a distal ureteric or an intramural radiopaque stone. The patients were divided into two groups; group A was instructed to engage in sexual intercourse two to three times per week while also receiving symptomatic treatment for 4 weeks. Group B received symptomatic treatment alone and was instructed to abstain from sexual intercourse or masturbation for the same period.

Results

A total of 160 male patients were enrolled in this study. The ages of the patients ranged from 21 to 58 years. The rate of stone expulsion after 2 weeks was 68.18% in group A and 53% in group B (P=0.053). The expulsion rate after 4 weeks was 80% in group A and 68.4% in group B (P=0.072). The mean expulsion time was 13.9±5.4 days for the experimental group and 15.2±6.7 days for the control group (P=0.179). The experimental group required fewer analgesic injections in comparison to the control group (P<0.05).

Conclusion

While the role of sexual intercourse in facilitating the passage of distal or intramural UTSs cannot be fully established, it may aid to some extent. However, it should not be relied upon as a standalone treatment modality.

Comparison of the Efficacy of Male Sexual Activity Versus Alpha-Blockers in the Expulsion of Distal Ureteric Stones: A Systematic Review and Meta-Analysis

Globally, the prevalence of urolithiasis is increasing, with limited effective treatment options. Though debate exists within the literature, the use of medical expulsive therapy (MET) for distal ureteric stones in the form of alpha-blockers is commonplace. Alpha-blockers work via the inhibition of norepinephrine, resulting in a small degree of distal ureteric relaxation. Nitric oxide (NO), the main neurotransmitter involved in penile erection, causes smooth muscle relaxation of the distal ureter. It is hypothesised that these alternative pathways may achieve the same desire clinical effect. To our knowledge, this is the first meta-analysis comparing the efficacy of male sexual activity, in the form of intercourse or masturbation, to alpha-blockers in the expulsion of ureteric stones. We conducted a comprehensive search of electronic databases (PubMed, MEDLINE, EMBASE, SCOPUS, CENTRAL and Google Scholar), identifying studies comparing male sexual activity versus alpha-blockers, in male patients with distal ureteric stones. The Cochrane risk-of-bias tool was used to assess the included studies. For data analysis, a random effects model was used in the event of significant heterogeneity (>75%), with fixed-effects modelling in the event of low-moderate heterogeneity. A search of electronic databases found three randomised control trials (RCTs), enrolling a total of 262 patients. There was no statistically significant difference observed when patients engaged in sexual activity rather than alpha-blocker, when looking at stone expulsion rate at two weeks (P=0.36), expulsion rate at four weeks (P=0.57), or the mean stone expulsion time (P=0.21). Furthermore, there was no significant difference observed when looking at analgesic requirements (P=0.43), or the requirement for additional procedures (P=0.57). Our meta-analysis demonstrated that male sexual activity as an alternative therapy for distal ureteric stones had comparable outcomes to the use of alpha-blocker, proving a viable alternative therapy in those patients wishing to avoid pharmacological management.

Evaluation of the efficacy of masturbation on distal ureteral stones: a prospective, randomized, controlled study

PURPOSE

To evaluate the effect of masturbation on the spontaneous expulsion of distal ureteral stones 5-10 mm in size.

MATERIAL AND METHODS

A total of 128 men with distal ureteral stones were randomly divided into 3 groups. All patients received standard medical therapy. Patients in group 1 (n = 43) were instructed to masturbate at least 3-4 times a week, patients in group 2 (n = 41) received tamsulosin 0.4 mg/day, and patients in group 3 (controls, n = 44) received standard medical therapy alone. Rates of expulsion, need for analgesic, and ureterorenoscopic lithotripsy were compared between the groups.

RESULTS

The mean ages of the patients in groups 1, 2, and 3 were 37 ± 5.0, 37.6 ± 4.6, and 38.4 ± 6.8 years, respectively (p = 0.7). The mean stone size in each group was 6.93 ± 1.1 mm, 7.1 ± 0.9 mm, and 6.87 ± 1.1 mm, respectively (p = 0.4). Spontaneous passage rates in groups 1, 2, and 3 were 81.4%, 80.5%, and 43.2%, respectively, and were significantly higher in group 1 (p = 0.001) and group 2 (p = 0.001) when compared with group 3. Analgesic requirement in groups 1, 2, and 3 was 1.7 ± 0.6, 1.5 ± 0.6, and 1.8 ± 0.6 times per day, respectively, and was significantly lower in the tamsulosin group than in the control group (p = 0.004) CONCLUSION: Masturbation and tamsulosin increased the spontaneous passage of distal ureteral stones 5-10 mm in size. Masturbating at least 3-4 times a week was as effective as tamsulosin. Masturbation and tamsulosin also reduced the need for ureterorenoscopic lithotripsy.

Evaluation of the efficacy of sexual intercourse on distal ureteral stones in women: a prospective, randomized, controlled study

AIM

To evaluate the efficacy of sexual intercourse in the expulsion of distal ureteric stones in women.

MATERIALS AND METHODS

A total of seventy woman patients with distal ureteral or intramural stone were randomly divided into two groups. Group 1 included 35 patients who were advised to do sexual intercourse 3-4 times/week with the administration of symptomatic treatment, and group 2 (control group) included 35 patients receiving symptomatic treatment only and were instructed not to do sexual intercourse or masturbation during the study. After 4 weeks follow up; the expulsion rate, need for analgesic and ureterorenoscopic lithotripsy were compared for each group.

RESULTS

The mean ages of the patients in groups 1 and 2 were 36.4 ± 10.8, 37.1 ± 12.4, respectively. The mean stone size was 7.01 ± 1.6 in group 1, 6.67 ± 1.4 mm in group 2 (p: 0.3). Stone expulsion rate, in the first 2 weeks for group 1 was 80% (28/35), while 51.4% (18/35) in group 2 (p < 0.001). In the 4th week, the expulsion rate for group 1 was 85.7%, but 60% in group 2 (p < 0.001). The mean expulsion time was shorter in group 1 (12 ± 4.2 days) than group 2 (16.1 ± 6.4 days) (p < 0.01). The analgesic needs in groups 1 and 2 were found to be 1.9 ± 0.7, 2.6 ± 0.8 times/a day respectively, and were significantly lower in group 1 (p < 0.001).

CONCLUSION

At least three or four sexual intercourses per week seem to increase the spontaneous passage for distal or intramural ureteral stones in women. Furthermore, sexual intercourse reduces the need for analgesics.

Can serum procalcitonin levels be useful in predicting spontaneous ureteral stone passage?

Background

Medical expulsive therapy (MET) is recommended for ureteral stones when there is no indication for interventional treatment. Spontaneous passage (SP) may not always be perceived in patients undergoing MET. We aimed to demonstrate the effects of inflammatory factors on spontaneous ureteral stone passage in patients undergoing MET.

Methods

Our study was conducted between August and November, 2016, in healthy volunteers and patients with a single distal ureteral stone between 5 and 10 mm in diameter and no indications for interventional therapy. Blood and urine samples from all patients and healthy volunteers were tested. The patients were followed up every 2 weeks for 1 month unless emergency situations appeared. Patients with stone-free status at follow-up were concluded to have achieved complete stone passage [SP(+)], and failure [SP(−)] was concluded if the patient had not passed the stone by the end of the study. Blood samples of the patients and the control group were analyzed, recording WBC (white blood cell), CRP (c-reactive protein), SED (sedimentation), MPV (mean platelet volume), NLR (neutrophil-to-lymphocyte ratio), and serum procalcitonin levels. Abnormalities in urine samples were recorded. All patients received diclofenac sodium 75 mg/day, tamsulosin 0.4 mg/day, and at least 3 l/day fluid intake. Patients were followed for a month with kidney, ureter, bladder (KUB) plain films, ultrasonography (USG), and unenhanced abdominal CT scans while undergoing MET. Comparative statistical analyses were performed between the SP(+) and SP(−) groups.

Results

The procalcitonin levels of the SP(−) group were significantly higher (207 ± 145.1 pg/ml) than in the SP(+) group (132.7 ± 28.1 pg/ml) (p = 0.000). The leucocyturia rate of the SP(−) group was significantly higher than in the SP(+) group (p = 0.004). Based on the ROC curve analysis, 160 pg/ml (86.7% sensitivity, 70.8% specificity, p < 0.001; AUC: 0.788 95% CI (0.658–0.917) was identified as the optimal cut-off value for procalcitonin. In logistic regression analysis, a significant efficacy of procalcitonin and leucocyturia was observed in the univariate analysis on spontaneous passage. In the multivariate analysis, significant independent activity was observed with procalcitonin. (p < 0.05).

Conclusion

Our findings suggest that high procalcitonin levels and the presence of leucocyturia have a strong negative effect on SP of ureteral stones between 5 and 10 mm in diameter. This relationship can be explained by stone impaction, possibly caused by increased mucosal inflammation.

Rapid localization of ureteral calculi in patients with renal colic by "ultrasonic ureteral crossing sign"

In this study, the term "ultrasonic ureteral crossing sign" is defined, and the diagnostic accuracy of this sign in the rapid localization of ureteral calculi is assessed. Between January 2017 and June 2018, 535 patients underwent ultrasound examination for suspected ureteral calculi. The "ultrasonic ureteral crossing sign" was classified as either positive or negative and correlated with the location of ureteral calculi. Of the 451 patients who were ultimately diagnosed with ureteral calculi, 263 patients had a positive sign, of which 258 patients had distal ureteral calculi, and 188 patients had a negative sign, of which 164 patients had proximal ureteral calculi. Eighteen stones were located in the ureter across the iliac vessels. For patients with a positive "ultrasonic ureteral crossing sign", we observed a 91% sensitivity, 97% specificity, 98% PPV, 87% NPV, and AUC of 0.94 for distal ureteral calculi. For patients with a negative "ultrasonic ureteral crossing sign", we observed a 97% sensitivity, 91% specificity, 87% PPV, 98% NPV, and AUC of 0.94 for proximal ureteral calculi. The "ultrasonic ureteral crossing sign" was found to accurately predict the location of ureteral calculi, significantly improve the efficiency of ultrasound examination, and provide a useful basis for follow-up treatment.

Meta-analysis of the efficacy of sexual intercourse for distal ureteric stones

OBJECTIVE

This meta-analysis was performed to evaluate the efficacy of sexual intercourse for treatment of distal ureteral stones.

METHODS

Randomized controlled trials (RCTs) of sexual intercourse for treatment of distal ureteral stones were searched using PubMed, EMBASE, and the Cochrane Controlled Trials Register.

RESULTS

Three RCTs comprising 240 patients were included in the meta-analysis, which showed that sexual intercourse was effective in treating distal ureteral stones. The expulsion rate of distal ureteral stones at the second week (odds ratio [OR] = 6.61, 95% confidence interval [CI]: 3.66 to 11.94), expulsion rate of distal ureteral stones at the fourth week (OR = 4.00, 95% CI: 2.09 to 7.64), and number of analgesic injections (mean difference [MD] = -0.79, 95% CI: -1.51 to -0.08) indicated that sexual intercourse was more effective than placebo. However, the mean expulsion time of distal ureteral stones (MD = -3.98, 95% CI: -8.77 to 0.81) showed no difference between sexual intercourse and placebo.

CONCLUSIONS

Compared with placebo, sexual intercourse exhibited greater efficacy for the treatment of distal ureteral stones, whilst potentially alleviating pain.

Alpha-blockers as medical expulsive therapy for ureteral stones

BACKGROUND

Ureteral colic is a common reason for patients to seek medical care. Alpha-blockers are commonly used to improve stone passage through so-called medical expulsive therapy (MET), but their effectiveness remains controversial. This is an update of a 2014 Cochrane review; since that time, several large randomised controlled trials (RCTs) have been reported, making this update relevant.

OBJECTIVES

To assess effects of alpha-blockers compared with standard therapy for ureteral stones 1 cm or smaller confirmed by imaging in adult patients presenting with symptoms of ureteral stone disease.

SEARCH METHODS

On 18 November 2017, we searched CENTRAL, MEDLINE Ovid, and Embase. We also searched ClinicalTrials.gov and the WHO Portal/ICTRP to identify all published/unpublished and ongoing trials. We checked all references of included and review articles and conference proceedings for articles relevant to this review. We sent letters to investigators to request information about unpublished or incomplete studies.

SELECTION CRITERIA

We included RCTs of ureteral stone passage in adult patients that compared alpha-blockers versus standard therapy.

DATA COLLECTION AND ANALYSIS

Two review authors screened studies for inclusion and extracted data using standard methodological procedures. We performed meta-analysis using a random-effects model. Primary outcomes were stone clearance and major adverse events; secondary outcomes were stone expulsion time, number of pain episodes, use of diclofenac, hospitalisation, and surgical intervention. We assessed the quality of evidence on a per-outcome basis using the GRADE approach.

MAIN RESULTS

We included 67 studies with 10,509 participants overall. Of these, 15 studies with 5787 participants used a placebo.Stone clearance: Based on the overall analysis, treatment with an alpha-blocker may result in a large increase in stone clearance (risk ratio (RR) 1.45, 95% confidence interval (CI) 1.36 to 1.55; low-quality evidence). A subset of higher-quality, placebo-controlled trials suggest that the likely effect is probably smaller (RR 1.16, 95% CI 1.07 to 1.25; moderate-quality evidence), corresponding to 116 more (95% CI 51 more to 182 more) stone clearances per 1000 participants.Major adverse events: Based on the overall analysis, treatment with an alpha-blocker may have little effect on major adverse events (RR 1.25, 95% CI 0.80 to 1.96; low-quality evidence). A subset of higher-quality, placebo-controlled trials suggest that alpha-blockers likely increase the risk of major adverse events slightly (RR 2.09, 95% CI 1.13 to 3.86), corresponding to 29 more (95% CI 3 more to 75 more) major adverse events per 1000 participants.Patients treated with alpha-blockers may experience shorter stone expulsion times (mean difference (MD) -3.40 days, 95% CI -4.17 to -2.63; low-quality evidence), may use less diclofenac (MD -82.41, 95% CI -122.51 to -42.31; low-quality evidence), and likely require fewer hospitalisations (RR 0.51, 95% CI 0.34 to 0.77; moderate-quality evidence), corresponding to 69 fewer hospitalisations (95% CI 93 fewer to 32 fewer) per 1000 participants. Meanwhile, the need for surgical intervention appears similar (RR 0.74, 95% CI 0.53 to 1.02; low-quality evidence), corresponding to 28 fewer surgical interventions (95% CI 51 fewer to 2 more) per 1000 participants.A predefined subgroup analysis (test for subgroup differences; P = 0.002) suggests that effects of alpha-blockers may vary with stone size, with RR of 1.06 (95% CI 0.98 to 1.15; P = 0.16; I² = 62%) for stones 5 mm or smaller versus 1.45 (95% CI 1.22 to 1.72; P < 0.0001; I² = 59%) for stones larger than 5 mm. We found no evidence suggesting possible subgroup effects based on stone location or alpha-blocker type.

AUTHORS' CONCLUSIONS

For patients with ureteral stones, alpha-blockers likely increase stone clearance but probably also slightly increase the risk of major adverse events. Subgroup analyses suggest that alpha-blockers may be less effective for smaller (5 mm or smaller) than for larger stones (greater than 5 mm).