The Co-occurring Syndrome—Coexisting Erectile Dysfunction and Benign Prostatic Hyperplasia and Their Clinical Correlates in Aging Men: Results From the National Health and Nutrition Examination Survey

Ablative minimally invasive surgical therapies for benign prostatic hyperplasia: A review of Aquablation, Rezum, and transperineal laser prostate ablation

INTRODUCTION

Benign prostatic hyperplasia (BPH) is one of the most common diseases affecting men and can present with bothersome lower urinary tract symptoms (LUTS). Historically, transurethral resection of the prostate (TURP) has been considered the gold standard in the treatment of LUTS due to BPH. However, TURP and other traditional options for the surgical management of LUTS secondary to BPH are associated with high rates of sexual dysfunction. In the past decade, several novel technologies, including Aquablation therapy, convective water vapor therapy (Rezum), and transperineal prostate laser ablation (TPLA), have demonstrated promising evidence to be safe and effective while preserving sexual function.

METHODS

In this review, we discuss three ablative minimally invasive surgeries: Aquablation, Rezum, and TPLA. We review their techniques, safety, as well as perioperative and functional outcomes. We go into further detail regarding sexual function after these ablative minimally invasive surgical therapies.

RESULTS

Aquablation is a surgeon-guided, robot-executed, heat-free ablative waterjet procedure with sustained functional outcomes at 5 years while having no effect on sexual activity. Rezum is an innovative office-based, minimally invasive surgical option for BPH that delivers convective water vapor energy into prostate adenoma to ablate obstructing tissue. Rezum leads to significant improvements in Qmax, IPSS while preserving sexual function. TPLA is another office-based technology which uses a diode laser source to produce thermoablation. It leads to improvement in Qmax, IPSS, and QoL while preserving ejaculatory function.

CONCLUSIONS

Overall, ablative minimally invasive surgical therapies have demonstrated excellent safety and efficacy profiles while preserving sexual function. These modalities should be discussed with patients to ensure informed and shared decision-making. Ablative minimally invasive surgical therapies may be particularly interesting to patients who value the preservation of their sexual function.

Transperineal laser ablation as a new minimally invasive surgical therapy for benign prostatic hyperplasia: a systematic review of existing literature

Introduction

Transperineal laser ablation (TPLA) of the prostate is a new, minimally invasive technique for benign prostatic hyperplasia (BPH) with promising effectiveness and safety outcomes. This systematic review aims to provide an update of existing literature.

Methods

A literature review was performed in Pubmed/MEDLINE, Embase, Cochrane Library, and clinicaltrials.gov from January 2000 up to April 2023. Data extraction and risk of bias were performed independently by three authors.

Results

A total of 11 studies were included, among which 9 were observational, 1 randomized controlled trial, 1 animal study, while 2 of them were comparative (1 with prostatic artery embolization and 1 with transurethral resection of the prostate). Functional outcomes were improved in the majority of studies both for objective (maximum flow rate and post-void residual) and subjective outcomes (improvement of International Prostate Symptom Score and quality of life). Complication rates ranged between 1.9% and 2.3% for hematuria, 3.7% and 36.3% for dysuria, 1.9% and 19% for acute urinary retention, 0.6% and 9.1% for orchitis/urinary tract infections, and 0.6% and 4.8% for prostatic abscess formation. Regarding sexual function, >95% of patients retained their ejaculation while erectile function was maintained or improved.

Conclusion

TPLA of the prostate is an innovative, minimally invasive technique for managing patients with BPH. Existing studies indicate an effective technique in reducing International Prostate Symptom Score and quality of life scores, post-void residual reduction, and increase in Qmax, albeit the measured improvements in terms of Qmax are not equal to transurethral resection of the prostate. Although sexual function is maintained, the mean catheterization time is 7 days, and no long-term data are available for most patients.

Preservation of Sexual Function 5 Years After Water Vapor Thermal Therapy for Benign Prostatic Hyperplasia

Background

Erectile dysfunction (ED) and ejaculatory dysfunction (EjD) are known outcomes of traditional surgery and some pharmacotherapies for treatment of benign prostatic hyperplasia (BPH). Minimally invasive treatment options, including water vapor thermal therapy (WVTT), are now available to treat lower urinary tract symptoms (LUTS) due to BPH.

Aim

The objective of this analysis was to evaluate long-term impact of a single water vapor thermal therapy procedure on erectile and ejaculatory function in subjects enrolled in the Rezum II prospective, multicenter, randomized, blinded controlled trial.

Methods

Fifteen centers enrolled 197 subjects with International Prostate Symptom Score (IPSS) ≥ 13, maximum flow rate (Qmax) ≤ 15 mL/s, and prostate volume 30–80 cc. Subjects were randomized (2:1) to (WVTT) or sham procedure (control) and followed for 5 years. Erectile and ejaculatory functions were quantitatively assessed at baseline and yearly thereafter. After 3 months, control subjects could opt to requalify for cross-over to WVTT and were followed for 5 years. Results of the per protocol analysis were reported previously. The current post hoc analysis was performed on all treated subjects who were sexually active at baseline with no other surgical or medical management for BPH during the 5-year study period.

Outcomes

LUTS was evaluated using IPSS, Benign Prostatic Hyperplasia Impact Index (BPHII), and Qmax. Sexual function was assessed using the International Index of Erectile Function (IIEF-EF) and Male Sexual Health Questionnaire for Ejaculatory Dysfunction (MSHQ-EjD).

Results

A total of 197 subjects (136 treated, 61 control) were enrolled in the study, and 53 control subjects opted to cross-over and receive WVTT. All subgroups experienced significant, durable improvement in IPSS (P < .0001). Subjects with normal sexual function at baseline had little change in function over 5 years (IIEF-EF: −2.4 ± 8.9, P = .1414; MSHQ-EjD Function: −1.6 ± 3.2, P = .0083; MSHQ-EjD Bother: −0.5 ± 1.6, P = .1107). Subjects with baseline medical history of ED and EjD showed slight decline over time that was not clinically significant (ED, IIEF-EF: −3.0 ± 10.1, P = .1259; MSHQ EjD Function: −2.3 ± 4.7, P = .0158; MSHQ-EjD Bother: −0.1 ± 2.6, P = .7764; EjD, IIEF-EF: −4.1 ± 9.2, P = .0127; MSHQ EjD Function: −1.6 ± 4.8, P = .1970; MSHQ-EjD Bother: −0.4 ± 2.6, P = .440).

Clinical Implications

Treatment for BPH with Rezum durably improved IPSS without clinically significant impact on sexual function. Patients with baseline ED/EjD may expect continued decline from other causes but are unimpacted by the therapy.

Strengths & Limitations, Conclusion

The results are limited by the post-hoc nature of the analysis and attrition over the 5-year follow-up but provide long-term evidence of durable outcomes after treatment with Rezum without impact on sexual function scores. McVary KT, El-Arabi A, Roehrborn C. Preservation of Sexual Function 5 Years After Water Vapor Thermal Therapy for Benign Prostatic Hyperplasia. Sex Med 2021;9:100454.

Correlation between body mass index and prostate volume in benign prostatic hyperplasia patients undergoing holmium enucleation of the prostate surgery

Background

Benign prostatic obstruction (BPO) due to benign prostatic hyperplasia (BPH) is a leading cause of morbidity in men over the age of 40. This study examined whether there was an association between body mass index (BMI) and pre-operative prostate volume and whether expression of two genes, alpha-2-macroglobulin (A2M) and transforming growth factor beta 3 (TGFB3), was correlated with BMI, pre-operative prostate volume, and age at surgery.

Methods

Medical records of patients who underwent holmium enucleation of the prostate surgery for treatment of BPO were retrospectively reviewed. Surgical specimens were obtained from formalin-fixed paraffin-embedded blocks, and expression of the targeted genes was quantified using a real time PCR approach. Linear regression analysis was performed to assess association between BMI and prostate volume adjusting for demographic characteristics and co-morbidity. Spearman’s correlation was used to examine whether gene expression was correlated with BMI, prostate volume, and age at surgery.

Results

A total of 278 patients were identified, including 62.9% European Americans (n = 175) and 27.7% Hispanic Americans (n = 77). BMI was significantly correlated with prostate volume (Spearman’s rho = 0.123, P = 0.045). In linear regression analysis, BMI was positively associated with prostate volume (β = 0.01, P = 0.004), while hyperlipidemia was negatively associated with prostate volume (β = −0.08, P = 0.02). A trend for a positive association was also observed for diabetes (β = 0.07, P = 0.099). In the race/ethnicity stratified analysis, age at surgery showed a trend for significantly positive association with prostate volume in European Americans (β = 0.005, P = 0.08), but not in Hispanic Americans. Expression of the A2M gene in the stroma was negatively correlated with age at surgery (P = 0.006). A2M expression in the gland was positively correlated with prostate volume among older men (Age ≥ 70, P = 0.01) and overweight men (BMI 25–30, P = 0.04). TGFB3 expression in the gland was positively correlated with BMI (P = 0.007) among older men.

Conclusions

This study demonstrated the positive correlation between BMI and prostate volume. Expression of TGFB3 and A2M was correlated with BMI, prostate volume, and age at surgery.

Supplementary information

Supplementary information accompanies this paper at 10.1186/s12894-020-00753-9.

Associations between body mass index, waist circumference and erectile dysfunction: a systematic review and META-analysis

Growing evidence reports that obesity might play a role in erectile dysfunction (ED), but limited knowledge is available. We conducted a meta-analysis to estimate the prevalence of ED in overweight men and men with obesity. We performed a systematic review up to 01/04/2019 to investigate the associations between obesity and ED. Applying a random-effect model, we calculated the prevalence of ED, the odds ratio (OR) for the presence of ED by Body Mass Index (BMI) categories and the mean differences between ED and controls in BMI and Waist Circumference (WC). Among 3409 studies, we included 45 articles with 42,489 men (mean age = 55 years). Taking normal weight men as reference, the prevalence of ED was significantly higher in overweight (OR = 1.31; 95%CI: 1.13-1.51; I² = 72%) and in men with obesity (OR = 1.60; 95%CI: 1.29-1.98; I² = 79%). Adjusting our analyses for potential confounders, the results were confirmed in men with obesity (OR = 1.46; 95%CI: 1.24-1.72; I² = 72%). ED was associated with significant higher values of BMI (MD = 0.769; 95%CI: 0.565-0.973 Kg/m²; I² = 78%) and WC (MD = 5.251 cm; 95%CI: 1.295-9.208; I² = 96%). Considering the high prevalence of ED among men with obesity, clinicians should screen for this clinical condition in this population. Findings from the present study suggest that reducing adiposity is a crucial approach in patients with ED who are affected by obesity.

[Influence of medical BPS treatment on sexual function]

BACKGROUND

Benign prostate syndrome is frequently associated with sexual dysfunction. The therapeutic options discussed in the S2e guideline may be able to improve existing sexual dysfunctions but can also worsen disorders or even trigger new ones.

OBJECTIVES

What are the effects of therapeutic options as described in the S2e guideline on sexual function?

METHODS

By selective literature search related to benign prostate syndrome and sexual dysfunction adverse effects of drugs mentioned in the S2e guideline have been evaluated.

RESULTS

Serenoa repens extracts do not have adverse effects on sexual function; this is also true for muscarine receptor antagonists. 5α-Reductase inhibitors frequently worsen erectile function, libido and ejaculation; selective α₁-blockers have an adverse effect on ejaculation. Phosphodiesterase (PDE)-5 inhibitors can improve sexual function. A combination of α₁-blockers and 5α-reductase inhibitors worsens sexual functions significantly.

CONCLUSIONS

A suitable therapy for benign prostate syndrome should be chosen jointly by the patient and the treating physician and should be adapted to personal needs. Effects on sexual functions have to be taken into consideration when choosing a therapy.

Changes in the Prevalence and Risk Factors of Erectile Dysfunction during a Decade: The Korean Internet Sexuality Survey (KISS), a 10-Year-Interval Web-Based Survey

Purpose

Although the prevalence of erectile dysfunction (ED) can be affected by social changes, this association has not been well evaluated. We aimed to evaluate the prevalence and risk factors of ED through a 10-year-interval web-based survey using the previous database of same group of panels, with same methodology.

Materials and Methods

We sent e-mails and surveyed the panels registered in the Internet survey agency.

Results

In total, 900 participants were recruited in 2016. The age-adjusted overall prevalences of self-reported ED (self-ED) and International Index of Erectile Function-5-assessed ED (IIEF-5-ED; score ≤21) in the 2016 study were 3.2% and 44.8%, respectively, which were lower than the prevalences of 8.1% (p=0.036) and 51.4% (p=0.323), respectively, in the 2006 study. The risk factors of IIEF-5-ED in their 20s and 30s in 2016 were psycho-social factors such as depression, low frequency of conversation about sex with sexual partner. The risk factors of IIEF-5-ED in their 40s to 60s in 2016 were organic factors, such as hypertension, diabetes mellitus, smoking, alcohol use, and self-reported premature ejaculation.

Conclusions

Although the age-adjusted overall prevalence of self-ED has decreased during a decade, there was no difference in the age-adjusted overall prevalence of IIEF-5-ED. Psycho-social support may be important for young men with ED and overall healthcare can be helpful for elderly men with ED.

Changes in Erectile Function after Photoselective Vaporization of the Prostate with a 120-W GreenLight High-Performance System Laser: 2-Year Follow-Up

Purpose

To evaluate the impact of photoselective vaporization of the prostate (PVP) with a 120-W GreenLight high-performance system on erectile function in a 2-year follow-up study.

Materials and Methods

One hundred seventy-seven patients who underwent PVP during 2008 to 2012 were analyzed retrospectively. The patients were divided into 5 groups according to their preoperative 5-item International Index of Erectile Function (IIEF-5) scores: Group I (IIEF-5: 5~7, n=28), II (IIEF-5: 8~11, n=47), III (IIEF-5: 12~16, n=43), IV (IIEF-5: 17~21, n=34), and V (IIEF-5: 22~25, n=25). The patients were assessed before surgery and 6, 12, and 24 months after the PVP. Their International Prostate Symptom Score/quality of life, maximum urinary flow rate/post-void residual urine volume, and IIEF-5 scores were measured at each visit.

Results

The mean age and presence of hypertension were significantly different among the 5 groups. Perioperative parameters and postoperative complication rates showed no statistical differences. After PVP, voiding parameters were significantly improved in all the groups and sustained during the 2-year follow-up. The postoperative IIEF-5 scores fell slightly overall, while group V showed the largest significant deterioration. In multivariate analysis, body mass index (BMI) was the only independent predictor of decreased erectile function after PVP.

Conclusions

Erectile function declined in all the groups after PVP, with the most extensive deterioration observed in patients with normal erectile function preoperatively. Preoperative BMI was the only independent risk factor for a meaningful decrease in erectile function after PVP.

Perspective on the Rezūm® System: a minimally invasive treatment strategy for benign prostatic hyperplasia using convective radiofrequency water vapor thermal therapy

Convective radiofrequency (RF) water vapor thermal therapy is a minimally invasive office or outpatient procedure for the treatment of bothersome moderate-to-severe lower urinary tract symptoms associated with benign prostatic hyperplasia (BPH). It provides an option for patients seeking rapid and durable relief of urinary symptoms, improved quality of life, and preservation of sexual function as an alternative to long-term use of drugs and avoidance of the potential side effects of pharmaceuticals or invasive BPH surgery. The procedure is also applicable for the treatment of the median lobe or elevated bladder neck from central zone hyperplasia. This perspective presents a comprehensive overview of the Rezūm® System convective RF thermal therapy device, the principles upon which it is based, the operative procedure, and the clinical evidence accrued to this point in time.

The Epidemiology of Benign Prostatic Hyperplasia Associated with Lower Urinary Tract Symptoms: Prevalence and Incident Rates

This article assesses the reported prevalence and incidence rates for benign prostatic hyperplasia and lower urinary tract symptoms (BPH/LUTS) by age, symptom severity, and race/ethnicity. BPH/LUTS prevalence and incidence rates increase with increasing age and vary by symptom severity. The BPH/LUTS relationship is complex due to several factors. This contributes to the range of reported estimates and difficulties in drawing epidemiologic comparisons. Cultural, psychosocial, economic, and/or disease awareness and diagnosis factors may influence medical care access, symptom reporting and help-seeking behaviors among men with BPH/LUTS. However, these factors and their epidemiologic association with BPH/LUTS have not been thoroughly investigated.