Published-Ahead-of-Print October 4, 2006, DOI:10.2164/jandrol.106.000372
Journal of Andrology, Vol. 28, No. 2, March/April 2007
Copyright © American Society of Andrology
DOI: 10.2164/jandrol.106.000372
Change of Sexual Function in Patients Before and After Ho:YAG Laser Enucleation of the Prostate
FANWEI MENG*,
BAOHUA GAO*,
QIANG FU
,
JUN CHEN*,
YUQIANG LIU*,
BENKANG SHI* AND
ZHISHUN XU*
From the * Department of Urology, Qilu Hospital,
Shandong University and the Department of
Urology, Shandong Province Hospital, Jinan, China.
|
Correspondence to: Dr ZhiShun Xu, Director of Department of Urology, Qilu
Hospital of Shandong University, Jinan 250012, China (e-mail:
xuzhishunxinxiang{at}163.com). |
| Received for publication May 23, 2006;
accepted for publication October 2, 2006. |
 |
Abstract
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The aim of this study is to evaluate the effect of Ho:YAG laser enucleation
of the prostate (HOLEP) to the sexual function of patients with benign
prostatic hyperplasia (BPH). In the course of the study, 108 patients with BPH
were recruited and accepted treatment with HOLEP. The effectiveness of
treatment was evaluated by flow rate and the International Prostate Symptom
Score (IPSS) before HOLEP and 6 months afterwards. Meanwhile, the sexual
functions were evaluated with the Danish Prostate Symptom Score Sexual
Function Questionnaire (DanPSS Sex). Before and 6 months after HOLEP
treatment, the mean residual urine volume was reduced from 106.0 ± 51.7
mL to 5.6 ± 1.7 mL (P < .01), maximum flow rate was
improved from 7.2 ± 3.9 mL/s to 21.7 ± 1.3 mL/s (P <
.01), nocturia frequency was reduced from 5.5 to 1.5 (P < .01),
and the mean IPSS score was decreased from 19.4 ± 5.6 to 7.4 ±
2.6 (P < .01). The proportion of patients satisfied with their
libido was 55% before HOLEP and 57% 6 months afterwards, while 23.5% of the
patients had no libido before and after HOLEP; 37% of the patients were
satisfied with their erection before HOLEP and 40% after 6 months; 30% of the
patients had completely satisfactory sex life before HOLEP, and 32% did 6
months later. The corresponding percentages of fully impotent patients
increased from 33% before the procedure to 35% 6 months postoperation. Early
morning erections were reported by 45% of the patients before the procedure
and by 62% 6 months later (P < .01). In 70% of the patients with
normal sex life, ejaculation was retrograde 6 months after HOLEP (P
< .01). HOLEP does not affect the sexual function of patients with BPH but
does did improve the ability of early morning erection, while causing
retrograde ejaculation.
Key words: Surgery, HOLEP, erection
Recently, studies (Namasivayam et al,
1998; Baniel et al,
2000) have indicated a correlation between lower urinary tract
symptoms caused by benign prostatic hyperplasia and some aspects of sexual
problems; 44.2% of patients with severe urinary symptoms had unsuccessful
coitus, compared to 13.1% of patients with milder dysfunction
(Baniel et al, 2000). Another
study identified a correlation between lower urinary tract symptoms and other
sexual dysfunctions, including ejaculation disorders, a decreased sexual
desire, and a diminished satisfaction
(Burger et al, 1999).
Ho:YAG laser enucleation of the prostate (HOLEP) is a new and promising
technique for the resection of prostatic tissue
(Chepurov, 1999;
Elzayat et al, 2005;
Kim et al, 2005). Ho:YAG laser
technique possesses unique characteristics such as narrow range of thermal
injury (only 0.5
1.0 mm) and good hematischesis
(Stephenson et al, 2001).
Ho:YAG laser technique enables the operating area to be kept clean and reduces
the likelihood of breaking through the prostatic surgery membrane. The Ho:YAG
laser rarely hurts the erectile nerves or penile blood vessels. HOLEP provides
quick alleviation of symptoms and has been proven to be safe. It may, however,
have some side effects, among which disturbances of sexual function were most
often suspected. To evaluate the effect of HOLEP on sexual function, studies
have been conducted, and the results are reported below.
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Materials and Methods
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The primary study population included 108 patients with benign prostatic
hyperplasia (BPH) for at least (or about) 2 years in Qilu Hospital of Shandong
University and Shandong Province Hospital. The mean age of the patients was
69.2 years, ranging from 54 to 82 years. The mean prostatic volume detected by
transrectal sonography was 50.8 cm3, ranging from 15.0 to 106.0
cm3. Patients were asked about their medical history. The
investigation showed that 11% of the patients suffered from diabetes and 14%
from hyperpiesia; 33% of the patients reported smoking, while 43% had a
history of frequent use of alcohol. About 27% of the patients lived alone.
Only 3% of the 108 patients had been treated by pharmacotherapy for impotence
before HOLEP.
The patients were treated with HOLEP. The laser energy was applied directly
to the prostatic tissue by using a standard 550-micron end-firing fiber. The
mean weight of the enucleated prostate tissue in HOLEP was 31.7 g, ranging
from 12 to 102 g. By analysis of the tissue, a definite pathologic diagnosis
was conducted.
The effectiveness of treatment was evaluated by flow rate and the
International Prostate Symptom Score (IPSS) before HOLEP and 6 months
afterwards. Each patient also filled in the Danish Prostate Symptom Score
Sexual Function Questionnaire (DanPSS Sex) before the HOLEP treatment and 6
months after it. The questionnaire consisted of 22 items, including patients'
general health, libido, satisfaction with their current sex life, occurrence
of early morning erections, coital frequency, sexual potency, satisfaction
with erection and ejaculation, percentage of successful intercourse, and the
possible impairing effect of the procedure on potency. The patients completed
the same questionnaire 6 months after HOLEP. The SPSS 11.0 method (SPSS Inc,
Chicago, Ill) was applied to analyze and compare data.
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Results
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As shown in the Table, before and 6 months after HOLEP treatment the mean
residual urine volume was reduced from 106.0 ± 51.7 mL to 5.6 ±
1.7 mL (P < .01). Maximum flow rate was improved from 7.2 ±
3.9 mL/s to 21.7 ± 1.3 mL/s (P < .01), nocturia frequency
was reduced from 5.5 to 1.5 (P < .01), and the mean IPSS score was
decreased from 19.4 ± 5.6 to 7.4 ± 2.6 (P < .01).
The Table shows that it is obvious patients' symptoms improve greatly after
HOLEP treatment.
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Figure 1. Proportions of the patients' degree of satisfaction with their sex life
before and 6 months after HOLEP. There are no significant differences between
groups (P > .05).
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Figure 2. Findings on libido before HOLEP and 6 months later; 55% of the patients
reported normal libido before HOLEP, while 57% did after 6 months (P
> .05).
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As shown in Figures 1,
2,
3,
4, the questionnaire data
indicated that the percentage of patients satisfied with their sex life was
30% before the HOLEP treatment versus 32% after the treatment
(Figure 1). The percentage of
satisfactory libido changed from 55% to 57% after the HOLEP treatment, while
23.5% of the patients had no libido before and after HOLEP treatment
(Figure 2). The percentage of
patients satisfied with their erection increased slightly from 37% to 40%
after HOLEP treatment, the same increase as the percentage of fully impotent
patients from 33% to 35% (Figure
3). No significant change was observed for the orgasm rate (76% to
70%) (Figure 4). Significant
change was observed for early morning erections, which increased from 45% to
62% (P < .01), and for the ejaculation rate; 21% of patients felt
pain or discomfort on ejaculation. In 70% of the patients, ejaculation was
retrograde 6 months after HOLEP (P < .01).
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Figure 3. Data on erection before and 6 months after HOLEP. Only 37% of the patients
had satisfactory erections before HOLEP, but 40% of the patients reported
satisfactory erection after 6 months. Still, there were 33% of the patients
who had no erection before and 35% 6 months later. HOLEP appeared to have no
significant effect on erection. Early morning erections were reported by 45%
of the patients before the procedure, and by 62% 6 months later. The
difference before and after HOLEP was significant (P < .01).
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Figure 4. Experience of orgasm before and 6 months after HOLEP. Orgasm was
experienced during intercourse in half or more than half of the occasions by
76% of the patients before the procedure, and by 70% 6 months afterwards
(P > .05).
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Discussion
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According to the results above, patients' erections showed no significant
change, which suggests that HOLEP has fewer side effects on erection activity.
But the HOLEP could affect sexual function in other ways, which were divided
into 2 categories: psychogenic and physiologic effects. Psychogenically,
patients could be affected negatively due to worrying about the invasive
procedure; physiologically, patients could be affected by injury to the
urethra due to feeling pain during erection.
The erection ability of some patients seemed improved: 15% of patients
reported that they had better early morning erections than before. Studies
(Pekka et al, 1998;
Mishriki et al, 2001) also
reported a similar phenomenon after transurethral resection of the prostate
(TURP). Our data indicate that the change can most likely be attributed to the
improvement of the quality of sleep due to the reduction of nocturia frequency
(Table). The survey showed that when patients experienced difficulty of
urination caused by BPH, they would prefer to avoid suffering from this
condition by ceasing to pursue sex. Subsequently, their libido remained in a
comparatively low state. After HOLEP treatment, dysuria vanished. As the
result, the pressure above was released, the libido became normal, and the
patients felt that their erection ability improved.
Meanwhile, 70% of the patients were often troubled by retrograde
ejaculation after the HOLEP treatment, but their satisfaction with their
orgasm remain unchanged. The major reason is that the internal sphincter in
the neck of the bladder was injured and could not block semen flowing into the
bladder (Libman and Fichten,
1987; Dunsmuir et al,
1996; Tuhkanen et al,
2004).
In summary, HOLEP did not affect the sexual functions of the patient
significantly but did improve the ability to achieve early morning erection,
while causing retrograde ejaculation, which has no particular effect on
orgasm.
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Acknowledgments
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Financial support was provided by the Department of Urology of Qilu
Hospital of Shandong University.
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Abstract
Materials and Methods
