|Year : 2004 | Volume
| Issue : 2 | Page : 86-89
Sexual function status before and after transurethral resection of prostate (TURP) in Indian patients with benign hyperplasia of prostate
Narmada P Gupta, Daresh D Doddamani, Rajeev Kumar
Department of Urology, All India Institute of Medical Sciences, New Delhi, India
Narmada P Gupta
Department of Urology, AIIMS, Ansari Nagar, New Delhi - 110 029
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Objectives : To evaluate the change in sexual function status after TURP in a select population of Indian elderly males presenting with benign prostatic hyperplasia (BPH).
Methods : One hundred and thirty-six patients presenting with BPH and treated with transurethral resection of prostate (TURP) during the period from August 1999 to July 2001 were evaluated for pre and postoperative sexual function using a 10-question proforma.
Results : The mean age of the patients was 64.9 years while the mean duration of lower urinary tract symptoms was 1.9 years. Of the 109 patients with a living wife/partner, 54 (49.54%) had active sex lives with coital frequency ranging from once a week to less than once a fortnight. Preoperatively, 48 of these patients had good erections whereas 6 had weak erections though they were able to have satisfactory penetration. All 54 had normal ejaculation prior to TURP. In the postoperative follow up, 10 (18.5%) of these 54 patients reported an improvement in their sex life in terms of increased libido and improved erections. Twenty-six (48.1 %) had no change in their status after TURP, but were satisfied with their sex life. Out of these 36 patients, 4 patients had preserved ante grade ejaculation. The remaining 18 (33.33%) had deterioration in their status in terms of decreased libido and poor erections. None of our patients who were sexually inactive before TURP regained sexual activity.
Conclusions: About 50% of patients with a living spouse/partner are sexually active at the time of undergoing TURP for BPH. TURF leads to a deterioration of sexual function in up to 33% of these patients. This includes both loss of libido and erections. It is also associated with a loss of ante grade ejaculation in over 85% patients. Very few patients who are sexually inactive pre-operatively recover sexual function after surgery. This study suggests that sexual counseling during informed consent should be a regular feature prior to TURP.
Keywords: BPH, erectile dysfunction, sexual dysfunction, prostatec-tomy, wedge loop.
|How to cite this article:|
Gupta NP, Doddamani DD, Kumar R. Sexual function status before and after transurethral resection of prostate (TURP) in Indian patients with benign hyperplasia of prostate. Indian J Urol 2004;20:86-9
|How to cite this URL:|
Gupta NP, Doddamani DD, Kumar R. Sexual function status before and after transurethral resection of prostate (TURP) in Indian patients with benign hyperplasia of prostate. Indian J Urol [serial online] 2004 [cited 2019 Jul 22];20:86-9. Available from: http://www.indianjurol.com/text.asp?2004/20/2/86/20728
| Introduction|| |
There is a gradual decline in sexual function with increasing age in the elderly male. The prevalence of erectile dysfunction in the western population has been found to vary from 3% in those aged 50-54 years to 26% in those aged 70-78 years. ,, Similarly, in Japan, the incidence of erectile dysfunction was 14% in those aged 50-59 years and 27.9% in those aged 70-79 years. , These men are commonly afflicted by lower urinary tract symptoms, of which the commonest cause remains benign prostatic hyperplasia.  The prevalence of BPH in the Massachussets male aging study was 33.5% in those aged 60-70 years.  Prostatectomy may have adverse consequences for the patient in terms of disturbance in sexual function due to erectile dysfunction or secondarily due to voiding difficulties. ,,, Hernandez et al  followed patients for 6 months after TURP and found 5.6% deterioration in sexual function. They also found that of those with no sexual activity before TURP, 66.2% recovered sexual activity after surgery. In a study of 131 BPH patients Baniel et al, reported a 44.5% incidence of unsuccessful coitus in those with severe lower urinary tract symptoms as compared to 13.1 % in those with mild symptoms.  Based on subjective patient data, various studies have shown a 5-40% incidence of impotence following prostatectomy. ,,,,, .
There is no data available on sexual function of the aging Indian male. There is also no Indian data on the effects of BPH on sexual function and its improvement or deterioration after TURP. This study aims to answer these questions.
| Patients and Methods|| |
One hundred and thirty six consecutive patients of BPH aged more than 50 years and planned for TURP for standard indications were evaluated for sexual function status before and after surgery during the period from August 1999 to July 2001. A 10-point questionnaire [Table - 1] was used to subjectively assess sexual function before surgery and at 3 and 6 months after treatment. Some patients were evaluated at 12 months also. All patients underwent TURP either with the standard loop (Karl Storz, Germany) or thick loop (WING TM , Richard Wolf, Germany) according to the preference of the operating surgeon and the size of the prostate. Out of 136 patients, 49 underwent thick loop resection of the prostate. The MARTIN ME 410 TM electro surgical generator (Gebruder Martin, Tuttlingen, Germany) was used with a cutting current setting of 70-80 w and a coagulating current of 40-50 w for the standard loop and 180-210 w and 50-60 w respectively for the thick loop.
Sterile 1.5% glycine solution was used as the irrigating fluid. A 22 French 3 way Foley catheter was inserted at the end of the procedure and bladder irrigation continued for 12 to 24 his till the return was clear. The catheter was removed the following morning or in some cases on the second postoperative morning. All patients voided satisfactorily after the catheter removal. There was no incidence of TUR syndrome. Two patients had secondary hemorrhage necessitating blood transfusions. Follow-up visits were advised at 1 month, 3 months and 6 months.
| Results|| |
All 136 patients answered the questionnaire. Those who were unable to read (84) were read out the questions and their answers recorded. Patient data is summarized in [Table - 2].
Out of the 136 patients, 27 (19.85%) had no sex partners or wives. Of the remaining 109, 54 (49.54%) were sexually active before onset of their bothersome symptoms. This included 10 (9.17%) patients who were catheterized later, but were sexually active before developing acute retention. Their sex frequency ranged from once a week to less than once a fortnight. Four patients had sex only occasionally. The oldest males with active sex life were 78 years old (2 patients). Age wise distribution of the sexually active patients is shown in [Table - 2]. Of the 109 patients, 54 were sexually active and 48 of them had good erections. Seventeen of these 54 patients underwent thick loop resection while 37 had standard loop surgery. All patients were followed up for at least 6 months after surgery [Table - 3]. Ten (18.5%) patients reported an improvement in their sex lives in terms of increased libido and erections. Twenty-six (48.1 %) patients had no change in their sexual performance status but were satisfied with their sex life. Four of these 54 patients had their antegrade ejaculation preserved. The remaining 18 patients had poor libido or erections though they had considerable improvement in their urinary symptoms.
Of 17 patients who underwent a thick loop resection, 2 had deterioration in their sexual function, one due to prolonged incontinence lasting for six months and the other due to a stricture urethra. There was no correlation with return or change in sexual function with duration of catheterization or adequacy of voiding after TURP. Improvement was more in those aged less than 65 years.
| Discussion|| |
Libido and potency decline in men with age. This has been effectively demonstrated in various studies from the western countries and Japan. ,,,, The Cologne male survey,  found that the average prevalence of erectile dysfunction was 19.2% (6% of 38-47 year olds were sexually inactive compared to 71.35% of 60-70 years old). The Krimpen Male aging study surveying 1688 men found 3% incidence of erectile dysfunction in those 50-54 years old and 26% in those 70-80 years old. 
Sexual dysfunction beyond the middle age is not considered a major problem in India where other issues of basic existence take a priority. It is often assumed that there is no need to discuss sexual function or the effect of surgery on it in elderly males who form the patient group undergoing TURP. Hernandez et al evaluated 189 patients before and after TURP and found 59% of patients were sexually active prior to surgery.  Postoperatively they found a 5.65% incidence of deterioration in sexual function. The overall incidence of deterioration in sexual performance after prostatectomy in other studies ranges from 7% to 40%. ,,, .
There is no Indian data addressing these issues. We conducted this preliminary study to evaluate these parameters and found 50% of patients who had a spouse or regular partner were sexually active. This number was fairly consistent over the age range of 50 to 80 years with the eldest active individuals being 78 years old [Table - 2]. We noted a decline in sexual function in 33% of our patients after surgery. Thus number is comparable to the 26% noted by Arai  but much high than that found by Hernandez (5.65%).  The deterioration in function may be a result of damage to neurovascular bundles, altered body image or complications such as incontinence or stricture. It may also be related to technique of surgery such as TURP/ Wedge loop. Another postulated cause for decline in sexual function is loss of antegrade ejaculation.  However, among our patients, only 4 had preserved antegrade ejaculation though 36 showed an improvement or preservation of sexual function.
Aria et al  compared TURP, TUMT (transurethral microwave thermotherapy), interstitial laser coagulation and transurethral needle ablation and found no difference between the four groups. They found mild to moderate decrease in erectile function in 26.5% of those treated by TURP and 18% to 20% in those treated by laser, TUMT or interstitial needle ablation respectively. Francisca et al compared the effect of high-energy transurethral microwave thermotherapy with TURP on sexual function and found no difference between the two modalities of treatment.  In their series, 27% of TURP and 74% of TUMT treated patients had preserved antegrade ejaculation. However, only 21 % of TURP and 55% of TUMT treated patients were sexually satisfied after 1 year of follow up, again suggesting a possible association between antegrade ejaculation and sexual function. Mishriki et al, in a study of 120 sexually active men before TURP, found all of them sexually active at 6 months following TURP.  Of those with previous dysfunction, 17% reported improved sexual activity and erections quality at 6 months postoperatively.
Another issue relates to the recovery of sexual function after TURP. While Hernandez  reported an improvement in 66% of their patients, none of our patients who were inactive pre-operatively showed any improvement. However, 18% of those previously active had an improvement.
| Conclusions|| |
Up to 50% of Indian males undergoing surgery for BPH are sexually active. A third of them may experience a decline in sexual function after surgery. Any recovery of sexual function after surgery in inactive patients is unlikely. These facts necessitate adequate sexual counseling of patients undergoing these procedures.
| References|| |
|1.||Braun M, Wassmer G, Klotz T, Reifenrath B, Mathers M. Engelmann U. Epidemiology of erectile dysfunction: results of the `Cologne finale survey'. Int J Impot Res 2000; 12(6): 305-11. |
|2.||Avis NE. Sexual function and aging in men and women: community and population-based studies. J Gend Specif Med 2000; 3(2): 37-41. |
|3.||Blanker MH, Bosch JL, Groeneveld FP, Bohnen AM, Prins A, Thomas S, Hop WC. Erectile and ejaculatory dysfunction in a community-based sample of men 50 to 78 years old: prevalence, concern and relation to sexual activity. Urology 2001; 57(4): 763-8. |
|4.||Weidner W, Altwein J. Hauck E, Beutel M, Brahler E: Sexuality in the elderly: Urol Int 2001; 66: 181-4. |
|5.||Marumo K, Nakashima J, Murai M. Age-related prevalence of erectile dysfunction in Japan: assessment by the International Index of Erectile Function. Int J Urol 2001; 8(2): 53-9. |
|6.||Mebust WK, Holtgrewe HL, Cockett AT, Peters PC. Transurethral prostatectomy: immediate and postoperative complications. A cooperative study of 13 participating institutions evaluating 3885 patients. J Urol 1989; 141: 243-247. |
|7.||Meigs JB, Mohr B, Barry MJ, Collins MM, Mckinlay JB. Risk factors for clinical benign prostate hyperplasia in a community-based population of healthy aging men. J Clin Epidemiol 2001; 54(9): 953-44. |
|8.||Ichikawa T, Takao A, Nakayama Y, Saegusa M. Aramaki K. Sexual function in men with lower urinary tract symptoms. Hinyokika Gakkai Zasshi Nippon 2001; 92(3): 464-9. |
|9.||Schill WB. Fertility and sexual life of men after forties and in older age. Asian J Androl 2001: 3(1): 1-7. |
|10.||Brahler E. Sexuality in the elderly. Urol Int 2001; 66: 181-4. |
|11.||Hernandez Millan I. Salinas Sanchez A, Romero JL, Segura Martin M, Virseda Rodriguez J. Sexual activity and surgery of benign prostatic hyperplasia. Arch Esp Urol 2001; 54(1): 53-60. |
|12.||Baniel J, Israilov S. Schmeuli J, Segenriech E, Livne PM. Sexual function in 131 patients with benign prostatic hyperplasia before prostatectomy. Eur Urol 2000; 38: 53-8. |
|13.||Holtgrewe HL, Valk WL. Late results of transurethral prostatectomy. J Urol 1964; 92: 51-5. |
|14.||Finkle AL, Prian DV. Sexual potency in elderly men before and after prostatectomy. JAMA 1966; 196: 139-43. |
|15.||Zlotta AR, Schulman C. BPH and sexuality. Eur Urol 1999; 36: 107-12. |
|16.||Hargreave TB, Stephenson TP. Potency and prostatectomy. Br J Urol 1977; 49(7): 683-8. |
|17.||Arai Y, Aoki Y. Okubo K, Maeda H, Terada N, Matsuta Y et al. Impact of interventional therapy for benign prostatic hyperplasia on quality of life and sexual function. A prospective study. J Urol 2000; 164: 1206-11. |
|18.||Francisca EAE, D'Ancona FCH, Meuleman EHJ, Debruyne FMJ, De La Rosette JJMCH. Sexual function following high energy microwave thermotherapy: Results of a randomized controlled study comparing transurethral microwave thermotherapy to transurethral prostatic resection. J Urol 1999; 161: 486-490. |
|19.||Mishriki FS, Cohen NP, Mawas A, Gibbons B. TURP can improve your sex life. Abstract no. 1501, AUA 2001. |
|20.||Talic RF. Erectile function following high energy thick loop prostatectomy. Scand J Urol Nephrol 2001; 35: 300-4. |
[Table - 1], [Table - 2], [Table - 3]