Stesura Seveso Archivio Italiano di Urologia e Andrologia 2015; 87, 18 ORIGINAL PAPER Sexual dysfunctions after transurethral resection of the prostate (TURP): Evidence from a retrospective study on 264 patients Carlo Pavone, Daniela Abbadessa, Giovanna Scaduto, Giovanni Caruana, Cristina Scalici Gesolfo, Dario Fontana, Luigi Vaccarella Section of Urology, Department of Surgical, Oncological and Stomatological Sciences, University of Palermo, Italy. Objectives: Benign prostatic hyperplasia (BPH) and sexual dysfunctions are diseases with a high prevalence in aged men. Several studies have found a link between BPH and LUTS resulting from deterio- ration in sexual function in men aged 50 years and older for whom TURP is considered the gold standard. The impact of TURP on sexual functions still remain uncertain, nor is it clear what pathophysiological mechanism underlying the emergence of new episodes of Erectile Dysfunction (ED) fol- lowing TURP in patients with normal sexual function before surgery, while retrograde ejaculation and ejaculate volume reduction represent a clear side effect; derived from BPH treatment. The aim of this study was to retrospectively evalu- ate the effects of transurethral resection of the prostate (TURP) on sexual function in patients operated in the period 2008-2012 at the Department of Urology of the University Hospital P. Giaccone, and at Villa Sofia-Cervello Hospital- Palermo. Secondary objective was to reconnect the sample data to interventional practice and international standards. Materials and methods: The retrospective longitudinal study was conducted on 264 of the 287 recruitable patients, aged between 50 and 85 years, suffering from BPH who underwent to TURP in the period 2008-2012. Telephone interviews were conducted and the International Index of Erectile Function (IIEF) was administered to assess sexual function. Patients enrolled were asked to respond to the test by referring at first to their sexual status in the period before surgery and subse- quently to the state of their sexual function after treatment so as to obtain, for each patient, a pre- and post-TURP ques- tionnaire in order to get comparisons that corresponding to reality and to avoid overestimation of the dysfunctional phe- nomenon. Results: In the pre-TURP, the 94.32% of the sample reported being sexually active, with good erectile function in 41.3% of cases, ED mild/moderate in 51.5% and complete ED in 1, 5% of cases; good libido in 62.9% of cases, lack of libido in 31.4% of cases and absent in 5.7% of cases (the latter data corre- sponded to patients not sexually active); to be sexually satis- fied in 29.5% of cases, slightly dissatisfied in 11, 7% of cases, moderately in 35.3% of cases, dissatisfied and very dissatis- fied in 23.5% of cases (of which 17.8% sexually active and 5.7% non-active).In the post-TURP 89.4% of the sample Summary No conflict of interest declared. INTRODUCTION Benign prostatic hyperplasia (BPH) and sexual dysfunc- tions are disorders that occur with high prevalence in aged men. Several studies have found a link between Low Urinary Tract Symptoms (LUTS) due to BPH and deterioration of sexual function in men over the age of 50 (1) and for which transurethral resection of the prostate (TURP) is considered the gold standard treat- DOI: 10.4081/aiua.2015.1.8 reported being sexually active, with good erectile function in 39.1% of cases, DE mild/moderate in 46.9% and complete DE in 4% of cases; good libido in 53.8% of cases, lack of libido in 33.7% of cases and absent in 13.5% of cases (including 1.9% of sexually active and 10.6% of non-active); to be sexually satisfied in 29.5% of cases, slightly dissatis- fied in 9.5% of cases, moderately in 35.3% of cases, dissatis- fied and very dissatisfied in 17.8% of cases (of which 14.8% sexually active and 10.6% inactive). Retrograde ejaculation was referred in 47.8% of those sexually active after TURP (42.8% if we consider the whole sample). Conclusions: TURP had no negative impact on erectile func- tion in contrast to ejaculatory function. Of the109 patients with good erectile function in pre-TURP, 5.8% reported a worsening of erectile function after TURP. Among the 136 patients with ED moderate/mild pre-TURP 3.7% reported a worsening in the post-TURP, 16.2% reported an improve- ment, while 9.5% stopped any sexual activity. In 3.7% of the cases a complete ED was reported after TURP, while a decline of libido and sexual satisfaction was detected in all patients with worsening of sexual function. Retrograde ejac- ulation was observed in 48% of those sexually active after TURP. Particular attention has to be paid to the psychologi- cal aspects, bothbefore surgery and in the postoperative period, which may become an important factor in the decline of sexual activity. KEY WORDS: Benign prostatic hyperplasia (BPH); Erectile Dysfunction (ED); Transurethral resection of the prostate (TURP), International index of erectile function (IIEF); Low urinary tract symptoms (LUTS). Submitted 30 July 2014; Accepted 30 August 2014 Pavone_Stesura Seveso 02/04/15 10:14 Pagina 8 9Archivio Italiano di Urologia e Andrologia 2015; 87, 1 Sexual dysfunctions after transurethral resection of the prostate (TURP): Evidence from a retrospective study on 264 patients ment despite the new minimally invasive surgical options (2, 3). However, the impact of TURP on sexual function still remain uncertain and contradictory, with a number of patients who actually refers new episodes of ED following endoscopic resection (4). Nor is It clear what pathophysiological mechanism is underlying the emergence of new episodes of ED after TURP in patients with normal sexual function before surgery. Recent stud- ies have shown that the treatment of LUTS by TURP lead to an overall improvement of sexual function in patients suffering from ED and ejaculatory discomfort existing before surgery, and that this proportion of patients is still higher than that of those who have any kind of sexual disorders as a result of TURP (5, 6). Similar considera- tions also apply to other aspects of sexual function, such as libido, ejaculatory orgasm and comfort, with the exception of retrograde ejaculation and ejaculate volume reduction which represent a clear side effect derived from BPH treatment. Several comparative studies that have linked sexual outcomes after TURP with those obtained with the use of new minimally invasive tech- niques have also shown similar results except for retro- grade ejaculation (7). However, to date none of these new techiniques in respect to TURP in the treatment of BPH (8). Therefore primary objective of this study was to understand if the sexual dysfunction’s area, especially erectile dysfunction, should be considered severable from the long-term complications of endoscopic resec- tion surgery as the more recent literature would seem to indicate. Secondary objective was to connect our data to surgery good practice and international standards. MATERIALS AND METHODS At the Departmentof Urology of the University Hospita “P. Giaccone” and the “Villa Sofia-Cervello” Hospital of Palermo, according to the inclusion criteria listed in Table1, was conducted a longitudinal retrospective study on a group of 287 recruitable patients who underwent to TURP after diagnosis of BPH from January 2008 to December 2012 (Table 1). The patient list was obtained by consulting University Hospital’s electronic archives and by verification of Villa Sofia-Cervello Hospital’s records. All patients were contacted by telephone and, after explaining the purpose of the study, they were inter- viewed after obtaining consent to participate in total anonymity about the sensitive data. Telephone interviews were conducted and the International Index of Erectile Function (IIEF) was administered to assess sexual func- tion. Patients enrolled were asked to respond to the test by referring at first to their sexual status in the period before surgery and subsequently to the state of their sex- ual function after treatment so as to obtain, for each patient, a pre- and a post-TURP questionnaire in order to get information about outcomes corresponding to reality and avoid over estimation of dysfunctional phenomenon. Speculation about libido, its eventual decay and overall satisfaction derived from sexual intercourse may also allow to have a complete picture of the psychological component of sexual health and to hypothesize the impact on the recovery of sexual function after surgery. RESULTS Of the 287 patients recruitable, 23 were lost for various reasons (refusal to join the study, health status deteriorat- ed, inability to understand the questions and/or not com- pliance to the test, patients not found by phone). Therefore, the sample was composed of 264 patients aged between 50 and 85 years. To overcome the bias “age” relat- ed to the time frame of the study (5 years), the average age of the sample was calculated to T0 (before-TURP) = 67.9 years and T1 (after-TURP) = 71.3 years. Of the 264 patients enrolled, 249 (94.32%) reported having been sex- ually active in the pre-TURP and at IIEF 109 (41.3%) reported adequate erectile function; 136 (51.5%) reported episodes of mild or moderate ED; while only 4 cases (1.5%) reported complete erectile dysfunction (Figure 1). Also before-TURP, libido (Figure 2) was reported as good in 166 patients (62.9%), while it was poor in 83 patients (31.4%) in combination with mild to moderate ED. The 15 patients (5.7%) not sexually active claimed that they had no sexual desire, and we have no other data about the status of their sexual function. Regarding the satisfaction derived from sexual activity pre- TURP (Figure 3), among the sexually active patients: 78 (29.5%) were satisfied; 31 (11.7%) were slight dissatisfied; 93 (35.3%) were moderately dissatisfied; the remaining 47 (17.8%) showed a severe degree of dissatisfaction. The sexually active patients in the post prostatic resec- tion period were 236 (89.4%) and at IIEF: 103 (43.6%) reported a satisfactory erection capacity; 124 (52.5%) a moderate or mild ED; while the presence of complete erectile dysfunction was found in 9 individuals (3.8%) (Figure 4). Following TURP, 89 patients (37.7%) among those sexu- ally active had low libido; in 28 patients (10.6%) who had not had sexual intercourse after surgery, libido was absent. Furthermore, while in 4 patients suffering from Severe ED before surgery was not found a decreased libido, in 5 new cases of ED following TURP was present a total decay of sexual desire (Figure 5). After TURP, 89 patients (37,7%) among sexually active ones had low libido; no libido was present in 28 patients (10,6%) who had not had sexual intercourses after oper- ation. Moreover while no decrement of libido was detect- ed in 4 patients with complete ED before surgery, in 5 new cases of ED after TURP a complete decrement of sexual desire was found (Figure 5). After operation 78 patients (29,5%) kept on being satis- fied; 25 patients (9,5%) were a little unsatisfied; 94 (35,6%) mildly unsatisfied; 39 sexually active patients (14,8%) were highly unsatisfied, as well as 13 patients Table 1. Inclusion criteria. – Aged between 50 and 85 years – Suffering from BPH and LUTS symptoms – Undergoing TURP in the period January 2008 - December 2012 – Compliance to the interview and IIEF Pavone_Stesura Seveso 02/04/15 10:14 Pagina 9 Archivio Italiano di Urologia e Andrologia 2015; 87, 1 C. Pavone, D. Abbadessa, G. Scaduto, G. Caruana, C. Scalici Gesolfo, D. Fontana, L. Vaccarella 10 Figure 1. Erectile function before-TURP. Figure 2. Sexual desire before-TURP. Figure 3. Sexual satisfaction before-TURP. Figure 4. Erectile function after-TURP Figure 5. Sexual desire after-TURP. Pavone_Stesura Seveso 02/04/15 10:14 Pagina 10 11Archivio Italiano di Urologia e Andrologia 2015; 87, 1 Sexual dysfunctions after transurethral resection of the prostate (TURP): Evidence from a retrospective study on 264 patients who stopped sexual activity after operation and became not sexually active. Absence of ejaculation or an important dicrease of ejacu- lated volume, before surgery, were seen after TURP in 113 patients (47.8% considering the sexually active patients; 42.8% considering the whole sample). DISCUSSION The survey about the sexual dysfuncions before and after surgery for bph allowed to obtain post-surgical outcomes scientifically verified. It is noteworthy (Figures 1 and 4) that 103 of 109 patients with good sexual function before TURP main- tained the same state of functionality after operation, in contrast to 6 patients who referred a low or mild decre- ment. However, considering the average age of the sam- ple, there is the doubt that this decrement may be relat- ed to increasing age, as the epidemiological data suggest. Comparing our data pre and post-TURP (Figure 7) we may infer there are no significant variations in erectile function. In addition we found that in 22 (16.2%) of 136 patients with low/mild ED pre-TURP little improvements of the frequency of dysfunctional episodes were detected. Even the percentage of patients with mild/low ED reporting a noteworthy pejorative change of the sexual condition in the questionnaire about the post-operative period is restrained: only 13 (9.5%) of 136 initial patients stopped any sexual activity after operation. In these patients, con- sidering the retrospective study, there is no way to eval- uate the possible onset of functional worsening but we may suppose the onset of (psychological vicious circle) major psychological agitation related to operation. A further factor making us to think there might be a pos- sible psychological cause for the decrement of sexual function in patients with LUTS in BPH, and eventually also in the same patients after surgical therapy, was the finding of a contemporary decrement of libido. In 83 (61%) of 136 patients who already had a mild/low ED before surgery, a poor sexual desire was detected in association with a low satisfaction from sexual inter- course. Several Authors have explained this situation (9), finding out a condition of psychophysical discomfort due to symptoms of BPH, that could act on the patient's feeling of a disease state. Such feeling, that often lasts more than the moment of surgery and, therefore, the subsequent overcoming of symptoms, would affect the sexual desire significantly, inducing setbacks on frequen- cy and quality of patient's sexual activity. Moreover, a further decrement of libido has been always detected in 24 patients who referred a worsening of their sexual function after operation, in terms of higher inci- dence of ED and interruption of sexual activity (Figure 8). In similar studies (10) analogous data have been related to a psychological effect due to operation itself that may interfere with consciousness of own sexual capacity (11). Figure 6. Sexual satisfaction after-TURP. Figure 7. Changes in sexual function after-TURP. Pavone_Stesura Seveso 02/04/15 10:14 Pagina 11 Archivio Italiano di Urologia e Andrologia 2015; 87, 1 C. Pavone, D. Abbadessa, G. Scaduto, G. Caruana, C. Scalici Gesolfo, D. Fontana, L. Vaccarella 12 The satisfaction derived from sexual intercourse, highly connected to the capacity of completing the sexual inter- course successfully, indeed, decreases with the increase of frequency of ED episodes, and it expires in patients who have a complete ED or no sexual activity. Considering other specific aspects of sexual functionality, the patients did not report any problems in the orgasm or in a possible painful or late ejaculation when they had a complete sexual intercourse. On the contrary, as we expected, the failed ejaculation or a considerable decre- ment of ejaculation volume, not present in the preopera- tive period, were detected in 47.8% of sexually active patients after TURP (the 42.8% of sample). These condi- tions are caused by the operation of prostatic resection that wreaks a lesion of closure mechanism of bladder neck during ejaculation with consequent retrograde ejaculation. It is important to underline that the absence of a normal ejaculation might be felt as a deficiency of patient's sex- ual capacity what does not allow him to complete nor- mally a sexual intercourse. Therefore this functional con- sequence of TURP would deserve higher attention dur- ing the preoperative counselling (12). It must be emphasized that the data referred to cases of patients with complete ED pre-TURP (1.6% of total pre- TURP sexually active patients, 1.5% of sample) are com- patible with indexes of incidence of the phenomenon in the general population (Figure 9) (13, 14). At the same time, the increase of number of completely dysfunction- al patients after TURP (3.4% of sexually active patients after TURP), among patients who had ED already before therapy, may not be indicative of a possible damage caused by the surgery. In fact, this condition should be related with patients' age, as a consequence of the ageing or other newly occurring diseases during the period of observation, in some cases as long as 5 years. Several authors have reported some peri-operative com- plications after TURP, such as drilling of prostatic capsule or a not well known effect of thermal lesion on the sur- rounding nervous structures, may represent important risk factors for the progress of ED in the short or long term (15). Through our survey it was not possible to determine if such complication has presented. However, not detecting significant data about a higher presence of de novo ED episodes after TURP is somehow re-assuring, considering the frequency of these peri-opera- tive complications in the surgical reality. Finally, the data about a low im - proving of erectile function in a restricted group of patients of our sample, condition detected in other similar studies (5), do not allow to confirm an effective bene- fit to sexual health in its various aspects due to the operation of Figure 9. Effect of varying degrees of ED in the general population (Adapted by writers from data by Feldman HA et al., 1994 and Lyngdorf P. et al., 2004). Figure 8. Association between decreased libido and impaired sexual function. Pavone_Stesura Seveso 02/04/15 10:14 Pagina 12 13Archivio Italiano di Urologia e Andrologia 2015; 87, 1 Sexual dysfunctions after transurethral resection of the prostate (TURP): Evidence from a retrospective study on 264 patients prostatic resection. Moreover, in our sample the frequency of sexual dysfunction significantly from the incidence of dysfunctional situation in the general population with same age. In addition it must be said there is an over-eval- uation of the sexual deficit considered consequent to TURP, because we were not able to search the presence of contemporary diseases and risk factors that notoriously may influence adversely the sexual activity. However, TURP is demonstrated to influence adversely none of sexual health aspects, except for ejaculatory function. Since in case of ED a variable level of decrement of libido was always detected, we might consider the psychologi- cal aspect may have a certain importance in dysfunction- al patients, even when it is not the “primum movens”. CONCLUSIONS The identified concordance between the latest literature about this thorny topic and our results, although with the limits of a retrospective study, allows us to deduce a com- mon consciousness of the effects of TURP on sexual func- tion is going to be gleaned. From the analysis of our data no direct correlation between ED and the most used sur- gical therapy for BPH is found out. Always considering the effects on ejaculation, that by now notoriously affect a large proportion of patients, the TURP is in any case the gold standard in the treatment of symptomatic prostatic adenoma. It derives that the specialist can indicate TURP with science and consciousness as a preferential option of treatment for patients who ask for this kind of therapeutic approach, wishing anyway a recovery of their sexual life. It is apparent that the specialist must pay particular attention to the psychological implications, both in the preoperative and in the postoperative time, that may start a vicious circle and become cause, in some cases primary cause, of the decay with consequent avoidance of sexual activity in this kind of patients. According to actual researches, the patient can be reas- sured and correctly taught about the real possibilities of recovery and/or improvement of his own sexual func- tion. In addition it would be desirable requiring assess- ments to evaluate the patient's sexual history before the prostatic resection that might help doctor (and patient himself) to understand what results will be present in the post-operative period. 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Epidemiology of erectile dysfunction and its risk factors: a practice-based study in Denmark. Int J of Impot Res. 2004; 16:105-111. 15. Poulakis V, Ferakis N, Witzsch U, et al. Erectile dysfunction after transurethral prostatectomy for lower urinary tract symptoms: results from a center with over 500 patients. Asian J Androl. 2006; 8:69-74. Correspondence Carlo Pavone, MD, Professor (Corresponding Author) carlo.pavone@unipa.it Daniela Abbadessa, MD Giovanna Scaduto, MD Giovanni Caruana, MD Cristina Scalici Gesolfo, MD Dario Fontana, MD, Professor dariofontana1987@yahoo.it Luigi Vaccarella, MD Section of Urology, Department of Surgical, Oncological and Stomatological Sciences, University of Palermo, Palermo, Italy Pavone_Stesura Seveso 02/04/15 10:14 Pagina 13