Ejaculatory disorders and lower urinary tract symptoms

Ejaculatory duct obstruction: current diagnosis and treatment

Ejaculatory duct obstruction is an infrequent cause of obstructive azoospermia, occurring in up to 5 % of such patients. However, it is potentially correctable and warrants consideration in the differential diagnosis of the patient presenting for infertility evaluation. This review provides an overview of ejaculatory duct obstruction: its various etiologies, presentation, and associated clinical assessment. It includes a description of diagnostic imaging and interventional studies available to the practicing urologist and concludes with a discussion of current endoscopic management.

[From lab to clinical activity: adrenergic receptors and human uro-genital tissues]

BACKGROUND

Nowadays translational medicine is acquiring a more and more important role in connecting laboratory experimental results on human tissues to clinical findings and drug employment. We want to underline the importance of in vitro studies, which have been extensively performed on animal organs, but few studies have been performed on human tissues. Nevertheless, a more accurate result when compared to the in vivo use of drugs can be given only by testing the very same human tissues in a lab. We related clinical treatments of different pathologies with the results obtained in laboratory studying in vitro fragments of human organs extracted during surgery exposed to different mediators and drugs.

METHODS

Fragments of urethers, bladder (detrusorial muscle and bladder neck muscle fibers), corpora cavernosa, and vas deferens were extracted during demolitive surgery trying not to traumatize the tissue, in order to keep it alive and not to ruin its contractile fibers. The fragments were then put into polisaline solution and, once in the laboratory, fixed on suitable isolated organ support, fixed at one side of the thermostatic pool and on the other side connected to a digital monitoring system. The contractility was then studied after adding different mediators.

RESULTS

The urethers have shown a stronger response to NE and PGF2a, with a different contractility in their distal part due to a major concentration of alpha-receptors; the bladder neck has also shown a strong contractile response to NE and PGF2a, and is inhibited by alpha-blockers; the bladder detrusor, instead, responds to ACH (acetylcholine) and PGF2a; the vas deferens shows a different type of contractility in the prostatic part compared to the epididimary part when stimulated with noradrenaline and PGF2a; the corpora cavernosa respond to NE and PGF2a.

CONCLUSIONS

The results obtained after stimulating the fragments can explain and prove the receptorial activity of inner mediators and of commonly used drugs which have, for years, been used empirically; the simplicity and repetitivity of the method can be considered and used not only to research the physiological functioning of different organs, but also the functioning of new drugs before testing them on patients, being more reliable and accurate than tests on animal tissues. This experimental work has shown that using human tissues in testing specific mediators is the most reliable laboratory method.

Pharmacology of α1-adrenoceptor antagonists in the lower urinary tract and central nervous system

The main use of alpha(1)-adrenoceptor (AR) antagonists in urology has been to treat lower urinary tract symptoms (LUTS) in men with benign prostatic obstruction (BPO). The beneficial effects of these agents are primarily assumed to be because of relaxation of prostatic and urethral smooth muscle. The weak correlation between LUTS and prostatic enlargement, outflow obstruction, or both, however, has refocused interest on the role of extraprostatic alpha-ARs in the pathogenesis of LUTS and their treatment. The alpha(1)-ARs present in the bladder, urethra, vas deferens, peripheral ganglia, nerve terminals, and in the central nervous system could all potentially influence LUTS and, when the receptors are blocked, contribute to both the therapeutic and adverse effects of alpha(1)-AR antagonists. The relevance of alpha(1)-AR-subtype selectivity on the clinical usefulness of existing drug therapies has not been firmly established but it seems that blockade of both alpha(1A/L)- and alpha(1D)-ARs is necessary for the optimum balance between clinical efficacy and adverse effects.

"Ejaculatory disorders and alpha1-adrenoceptor antagonists therapy: clinical and experimental researches"

BACKGROUND

It is well known that the use of the alpha-adrenergic receptor antagonists in the BPH therapy may induce ejaculatory disorder. A review of clinical literature shows a greater incidence of ejaculatory disorder during the use of tamsulosin compared with alfuzosin. Anejaculation has been until now referred to retrograde ejaculation due to relaxation of prostatic and bladder neck smooth muscle tone. In a recent researches was evaluated the effect of tamsulosin and alfuzosin on rat vas deferent "in vitro", concluding that tamsulosin may "cause ejaculatory dysfunction by altering the progression and emission of sperm". An abnormal increase of contraction would be the cause of ejaculatory disorder. The aim of our paper is to compare human and rat vas deferens contractile activity and to evaluate with a clinical study if tamsulosin causes retrograde ejaculation disorder.

METHODS

We have revaluated the human and rat vas deferens contractile activity in vitro according to our experience and literature. We have also performed a clinical study on 10 patients (48-72 y) affected by anejaculation. Post-coital urine was examined to search spermatozoa.

RESULTS

Human and rat vas deferens activity is not comparable. Contractile activity induced by norepinephrin after tamsulosin incubation in rat prostatic vas deferens strips is similar to the contractile activity evoked by norepinephrin in human strips. Spermatozoa were found in post coital urine of 6 patients.

CONCLUSION

In our opinion the treatment with tamsulosin may induce retrograde ejaculation but not other ejaculatory disorder due to abnormal sperm progression.

Treatment of lower urinary tract symptoms suggestive of benign prostatic hyperplasia: sexual function

Lower urinary tract symptoms suggestive of benign prostatic hyperplasia (LUTS/BPH), and sexual dysfunction, are common, highly bothersome conditions in older men, and the prevalence of both disorders increases with age. Sexual dysfunction manifests mainly as erectile dysfunction (ED), ejaculatory disorders, or decreased libido/hypoactive sexual desire (HSD). Whereas both reduced rigidity and reduced ejaculate volume are highly prevalent in ageing men, reduced rigidity and pain on ejaculation are considered to be most bothersome. Sexual dysfunction is much more prevalent in patients with LUTS/BPH than in men with no LUTS/BPH, even after controlling for confounding variables such as age or comorbidities. Hence LUTS/BPH is considered an independent risk factor for sexual dysfunction. Whether this is because of a common underlying pathology, or whether the considerable bother associated with LUTS/BPH leads to reduced sexual functioning, remains to be elucidated. Despite a decline in the frequency of sexual intercourse, as well as in overall sexual functioning, most ageing men report regular sexual activity and consider their sex life as an important dimension of their quality of life (QoL). However, most patients with LUTS/BPH experience a negative effect of their LUTS on their sex life. Hence, treatment of LUTS/BPH should aim to at least maintain or, if possible, improve sexual function. Current medical treatment of LUTS/BPH consists of monotherapy with alpha1-adrenoceptor (AR) antagonists, 5alpha-reductase inhibitors (RIs) or a combination of these. Whereas 5alpha-RIs increase the risk of ED, ejaculatory disorders and HSD, alpha1-AR antagonists can induce ejaculatory disorders, but do not provoke HSD or ED. Combined therapy carries the cumulative risk for sexual dysfunction associated with either type of drug. As already indicated, ED is generally perceived as more bothersome than ejaculatory disorders. In addition, alpha1-AR antagonists slightly improve overall sexual function, possibly by increasing blood flow in the penis through alpha1-AR blockade and/or to an increased overall QoL from the relief of LUTS. It can be concluded that alpha1-AR antagonists constitute a first-line therapy for LUTS/BPH because they combine good treatment efficacy with very few adverse effects on sexual function.