Urinary symptoms, quality of life and sexual function in patients with benign prostatic hypertrophy before and after prostatectomy: a prospective study
M. Gacci, Department of Urology, University of Florence, V. Masaccio N°102, 50132, Firenze, Italy
To evaluate urinary symptoms, sexual dysfunction and quality of life in patients with benign prostatic hypertrophy (BPH) before and after open prostatectomy, using the International Prostate Symptom Score (IPSS), the International Continence Society (ICS)-‘BPH’ (ICS-male, ICS-sex and ICS-QoL) and International Index of Erectile Function (IIEF) questionnaires.
PATIENTS AND METHODS
Sixty men with BPH (mean age 68 years) underwent a digital rectal examination, transurethral ultrasonography, measurement of total prostatic specific antigen serum level and uroflowmetry. Their urinary symptoms, sexual function and quality of life were fully evaluated using the IPSS, ICS-‘BPH’ and IIEF before and 6 months after suprapubic prostatectomy. The body mass index (BMI) was also calculated for each patient. Univariate analysis was used to examine the relationship between symptom scores and age, tobacco use, alcohol intake and BMI.
In a univariate analysis, age was the most important prognostic factor for both urinary and sexual symptoms. Prostatectomy resulted in a significant improvement in obstructive (mean 9.68 to 3.38) and irritative symptom (6.70 to 3.06), and quality-of-life scores (3.41 to 1.34). ICS-male scores were both significantly decreased, the mean voiding score from 13.72 to 10.28 and the incontinence score from 10.43 to 7.81. There was also a significant decrease in the ICS-QoL symptom score (from 9.20 to 7.27). Comparative results between IIEF and ICS-sex showed no improvement in sexual scores after open surgery, but there was a significant increase in sexual desire and overall satisfaction (both P = 0.035).
The combined use of the IPSS, ICS-‘BPH’ and IIEF allows an evaluation of the relationship between age, prostatic symptoms and sexual dysfunction. Age may be considered both a direct and indirect (BPH-related) prognostic factor for sexual activity. Suprapubic prostatectomy resolves obstructive symptoms, and maintains sexual desire, overall sexual satisfaction and an improvement in quality of life. However, irritative symptoms, erection, orgasm and sexual intercourse satisfaction are not significantly altered.
BPH is a common condition in middle-aged and elderly men  but it is unclear whether sexual dysfunction in older men is related to prostatic enlargement or is merely a consequence of ageing. Both urinary and sexual symptoms are usually related, with a subjective decrease in quality of life . A surgical approach, when indicated, may reduce urinary and sexual symptoms, thus restoring a good quality of life.
During the last 50 years TURP has been the reference standard for the surgical treatment of BPH, except for patients with large adenomas. Suprapubic prostatectomy, an easy, safe and effective surgical technique, has become increasingly less common as TURP has gained popularity . Currently, the most common clinical methods used for evaluating men for the surgical treatment of BPH include ultrasonography  and urodynamic variables , e.g. maximum flow rate (Qmax) and postvoid residual urine volume (PVR). In addition, there are several self-administered questionnaires [6–8] which assess urinary and sexual symptoms and quality of life before and after treatment.
We used the IPSS, the International Continence Society ‘BPH’ (including the ICS-male, ICS-sex, and ICS-QoL) and the International Index of Erectile Function (IIEF) to systematically analyse urinary symptoms, quality of life and sexual dysfunction in patients with BPH, and to evaluate the changes after suprapubic prostatectomy.
PATIENTS AND METHODS
Between 1999 and 2000, 60 men with BPH (mean age 68 years, sd 8.2) were selected for this study; only patients with prostatic adenoma of> 60 mL (estimated by TRUS) were enrolled. The inclusion criterion was an ability to communicate, understand and comply with study requirements, while exclusion criteria were other coexistent urinary disorders (e.g. prostatic carcinoma, neuropathic bladder, urethral stricture) or presence of penile induration (Peyronie's disease). All patients gave their approval by informed consent.
Fifty patients (83%) presented with complaints of moderate to severe urinary symptoms (dysuria, nocturia, polyuria), while 10 (17%) presented to our institution for a periodic prostatic evaluation or cancer prevention. Thirty-seven (62%) had previously been diagnosed with BPH, while for 23 (38%) it was the first diagnosis. Of the patients who had been previously diagnosed, six had been treated with α-blockers and two with finasteride; none of these patients had reported any improvement in sexual function with medical therapy.
All patients had a routine prostatic evaluation, including a DRE, TRUS and measurement of serum total PSA level, to exclude the presence of prostatic carcinoma. TRUS was also used to measure the adenoma volume, using the ellipsoidal formula. The PVR was calculated by the same technique and a free flow rate measured, at voided volumes of> 150 mL, using a Urodyn 1000 system (Dantec, Denmark).
Each patient included in the study was asked to complete the IPSS, ICS-‘BPH’ and IIEF questionnaires (Appendix), and answer questions about tobacco and alcohol use. The body mass index (BMI) of each patient was calculated. A univariate analysis was used to identify the most important prognostic factors for urinary symptoms and sexual dysfunction; four different items were evaluated using the Wilcoxon test, i.e. age (≤ 65 vs> 65 years), tobacco (smokers vs non-smokers), alcohol (daily intake vs abstention), BMI (≤ 25 vs> 25 kg/m2). A Wilcoxon test (between IPSS ≤ 12 vs> 12) and a linear regression analysis were used to evaluate the clinical effect of BPH on sexual dysfunction.
The men underwent open prostatectomy after giving informed consent; 6 months afterward the TRUS and uroflowmetry were repeated, and the patients asked to repeat the questionnaires. Suprapubic transvesical prostatectomy was performed under general or spinal anaesthesia using a modified Freyer technique, comprising anterior bladder access, enucleation of the adenoma through a circular bladder neck incision, urethral section and #0 catgut (cylindrical 5/8 needle) suturing of the prostatic groove. A Foley catheter balloon was positioned and inflated in the prostatic groove for 2 days, to provide compression and avoid bleeding. An interrupted #0 polyglycolic suture was used for bladder wall closure, while an extraperitoneal drainage tube was placed for several days. After 6–7 days, the Foley catheter was removed.
The IPSS and ICS-BPH (ICS-male and ICS-QoL) scores were used to evaluate urinary symptoms and quality of life; the ICS-sex questions about erection and ejaculation, and each group of the IIEF questions, were also analysed to assess sexual activity in patients before and 6 months after surgery. Student's t-test was used to assess the changes in scores. Using the IIEF and ICS-sex results the accuracy of both questionnaires was evaluated for assessing sexual function, using the Spearman and Pearson tests; linear regression analysis was also used.
None of the patients had a prostatic nodule or solid lesion suspicious for prostatic cancer on the DRE. TRUS showed no hypo- or hyperechoic lesions of the prostate. The mean (range) PSA level was 3.6 (2.1–4.5) ng/mL, Qmax 8.2 (5.5–12.2) mL/s and PVR 101 (0–400) mL. The mean (range) size of the enucleated adenoma was 63 (45–95) g and all specimens showed benign adenomatous tissue. The mean operative duration was 50 (40–75) min, the hospitalization time 6 (4–7) days, the indwelling catheter time 5.5 (3–7) days and the intraoperative blood loss 200 (50–350) mL. There were no complications during or after surgery.
All patients completed the three questionnaires; the results are shown in Table 1. Linear regression analysis detected no relationship between the IIEF scores and IPSS or ICS-‘BPH’ scores (P = 0.121 and 0.116, respectively) but there was a nearly significant trend using the Wilcoxon test for patients categorised by IPSS (P = 0.061), whereby patients with an IPSS of < 12 had a higher IIEF score (mean 55.23) than those with an IPSS of> 12 (mean 46.08).
Table 1. The overall urinary and sexual symptom scores of the 60 patients before and after surgery
|Irritative|| 6.71 (3.56, 0–15)|| 3.06 (2.49)||< 0.001|
|Obstructive|| 9.69 (5.02, 0–20)|| 3.38 (3.04)||< 0.001|
|QoL|| 3.41 (1.61, 0–7)|| 1.34 (1.21)||< 0.001|
|Overall||19.50 (8.75, 2–41)|| 7.57 (5.82)||< 0.001|
|ICS-male||49.16 (10.92, 33–76)||36.84 (8.39)||< 0.001|
|ICS-sex|| 7.18 (2.76, 4–15)|| 7.66 (2.62)||0.161|
|ICS-QoL|| 9.20 (2.67, 5–15)|| 7.27 (2.77)||< 0.001|
|Overall||66.62 (14.65, 41–101)||49.97 (9.02)||< 0.001|
|Erectile function||18.96 (8.12, 0–30)||19.08 (9.14)|| 0.250|
|Intercourse satisfaction|| 9.25 (3.79, 0–15)|| 8.51 (4.60)|| 0.035|
|Orgasm function|| 6.89 (3.02, 0–10)|| 6.55 (3.35)|| 0.511|
|Sexual desire|| 6.30 (1.83, 2–10)|| 6.73 (2.75)|| 0.035|
|Overall satisfaction|| 6.11 (2.66, 2–10)|| 6.85 (2.65)|| 0.035|
|Overall score||47.49 (17.95, 0–72)||45.32 (21.12)|| 0.893|
The univariate analysis of IPSS using the clinical variables of age, tobacco use, alcohol and BMI showed a significant difference with age (Table 2) but not for the other factors. A similar analysis for the IIEF scores showed that men aged < 65 years had significantly higher scores than those> 65 years old and that non-smokers had higher scores than smokers (Table 2). Patients with a daily alcohol intake had higher IIEF scores than those abstaining. There was also a statistically significant difference between patients with a normal BMI (≤ 25) and those considered overweight (> 25).
Table 2. Univariate analysis of the IPSS and IIEF scores, considering age, smoking habit, alcohol and BMI, using the Wilcoxon test
| ≤ 65 (18)||17.64||55.12|
|> 65 (42)||23.17||43.22|
|P|| 0.023|| 0.034|
|P|| 0.741|| 0.541|
|Daily intake (44)||19.64||45.75|
|P|| 0.892|| 0.352|
| ≤ 25 (27)||20.64||47.89|
|> 25 (33)||18.41||46.58|
|P|| 0.866|| 0.320|
| ≤ 12 (20)||55.23|| |
|> 12 (40)||46.08|| |
|P|| 0.06*|| |
Prostatectomy caused a significant change in Qmax, the mean (range) Qmax being 26.1 (14.5–41.2) mL/s and the mean PVR 9 (0–50) mL. The mean (sd) improvement in Qmax was 17.9 (8) mL/s and the reduction in PVR 92 (111) mL, with 39 patients having no detectable PVR at the 6-month follow-up.
There was a significant correlation between the IPSS obstructive score and Qmax at baseline (P = 0.0046), while correlations at 6 months were insignificant. There was also a significant correlation between IPSS obstructive scores and PVR, but only at 6 months (P = 0.0020). There was no significant correlation between the changes in IPSS obstructive score and Qmax or PVR.
After surgery the IPSS and ICS-BPH scores showed significant improvements in urinary symptoms, with the IPSS showing more significant changes for obstructive symptoms than for irritative symptoms or quality of life (Table 1). The changes in sexual function after surgery as assessed by the IIEF and ICS-sex are also shown in Table 1; there was a significant decrease in the ICS-male score for both voiding and incontinence, and a significant decrease in ICS-QoL symptom score.
Comparing the IIEF and ICS-sex showed no evidence of changes in sexual scores after surgery. Both scores before surgery were similar to those afterward. The IIEF single-item analysis showed no significant changes for ‘erectile function’, ‘intercourse satisfaction’ and ‘orgasmic function’ (Table 1) before and after surgery. However, there was a significant increase after prostatectomy in ‘sexual desire’ and ‘overall satisfaction’. The IIEF and ICS-sex overall scores were significantly different before (P = 0.0024, Spearman, and 0.0016, Pearson) and after surgery (both P < 0.001). Linear regression analysis between the IIEF and ICS-sex before and after treatment confirmed these results, with P = 0.002 and < 0.001.
LUTS  and sexual dysfunction are common in middle-aged and elderly men; the prevalence of ‘clinical BPH’ is about 50% in 50–70-year-old men . Since Freyer  first described suprapubic prostatectomy, many other surgical approaches have been developed to increase the safety and efficacy of the technique. Over the last century, antibiotic and antithrombotic treatments have been used. Blood loss and catheterization times for the procedure have decreased, but with the advent of the transurethral approach, the role of open surgery has been limited to treating large adenomas only. More recently, several ‘mini-invasive’ techniques have been developed to increase patient compliance (by reducing complications, e.g. incontinence or sexual changes) and the cost-effectiveness ratio [12,13].
However, the endpoint of any treatment for BPH remains the relief of urinary symptoms and the subsequent improvement in the patients’ quality of life. To this end, self-administered questionnaires have been used to compare symptoms before and after treatment; we used two validated instruments, the IPSS and ICS-BPH.
All patients recruited for the study were candidates for prostatectomy, as the obstructive symptoms were more relevant than irritative ones (Table 1). Furthermore, several of the patients were previously treated with α-blockers or finasteride, with no significant improvement in urinary symptoms or quality of life.
The ICS-‘BPH’ questionnaire  initially assessed the prevalence of five urinary symptoms in patients 60–69 years old and in those> 70 years old (terminal dribble, hesitancy, intermittency, weak stream and incomplete emptying). In the present study, three predominant symptoms were identified, i.e. weak stream (questions 12 and 14), incomplete emptying (question 17) and terminal dribble (question 18). These questions showed poor scores in the present patients, although maximum scores were obtained by evaluating urinary symptoms such as polyuria, nocturia and urgency. Question 33 asks patients to answer ‘how they feel if they had to spend the rest of their life with these symptoms as they are now.’ For this question, the present patients had a high mean score of 4.2, i.e. ‘mixed feelings’, ranging from 1 (perfectly happy) to 7 (desperate), showing the importance of living a life conditioned by obstructive symptoms.
Ansong et al. reported a prevalence of erectile dysfunction (ED) in elderly patients of 21.3–46.3%. Considering this result, and the voiding symptoms of BPH already noted, we hypothesized that changes in sexual function might be associated with urinary disorders, and used the IIEF questionnaire to evaluate sexual function before and after surgery.
Rosen et al. compared 148 patients with ED of different causes with 130 control patients (mean age 55 years) to validate the IIEF scores . Comparison with the present analysis showed that patients with BPH had greater sexual dysfunction than the controls, but less than patients diagnosed with ED.
There was a relationship between prostatic symptoms and sexual dysfunction but it was not statistically significant. Patients with slight urinary symptoms (IPSS ≤ 12) had less sexual dysfunction than those with more severe urinary symptoms (IPSS> 12; P = 0.061). Analysis of single IIEF items showed that sexual desire and overall satisfaction were significantly lower in patients with more severe symptoms, while for other variables (erectile function, orgasmic function and intercourse satisfaction) patients reported similar results, independent of the IPSS. This suggests that both sexual desire and overall satisfaction are relevant only in patients with no severe urinary symptoms, when quality of life is preserved.
The IPSS and IIEF scores were also analysed according to age, tobacco use, alcohol intake and BMI; there were significant differences in urinary symptoms between younger and elderly patients, suggesting that over time the obstructive symptoms progress more quickly than irritative symptoms. As previously reported , age is also the main prognostic factor for ED in patients with BPH. The present study showed significant differences in IIEF scores for patients above and below 65 years old. Differences in IIEF scores between younger and older patients were similar to those in IIEF scores between slightly and severely symptomatic patients. Therefore, these data confirm that age is both a direct and indirect (BPH-related) prognostic factor for sexual changes. Tobacco and alcohol use might also moderately increase irritative urinary symptoms and decrease quality of life and sexual desire in patients with BPH. Finally, BMI was not related to urinary symptoms or sexual function.
There was a significant improvement in Qmax and PVR in all patients after surgery, and the overall IPSS and ICS-‘BPH’ scores were significantly lower. There was a remarkable reduction in the IPSS obstructive (mean − 65.2%) and irritative symptoms (− 54.3%), and quality of life (− 60.6%). Similarly the mean ICS-‘BPH’ scores decreased significantly for urinary symptoms and quality of life, all by ≈ 25% (Table 1). Therefore, while the IPSS was reduced more significantly for obstructive than irritative symptoms, the ICSmale voiding score and incontinence score had analogous reductions in symptom score.
A thorough evaluation of urinary symptoms is helpful before surgery for predicting the outcome . Suprapubic prostatectomy resolves obstructive symptoms and significantly improves quality of life; irritative symptoms are only marginally reduced by surgery, and the IIEF and ICS-sex scores did not change significantly after surgery.
All patients reported small changes in the IIEF questions about erection, orgasm or intercourse satisfaction. For ejaculation (question 9), all patients reported scores of 1 or 2, but loss of ejaculation did not influence orgasm (question 10), as each patient was previously informed that even if ejaculation was lost, orgasmic sensation would be preserved.
For all patients there was an unexpected increase in scores for two items, ‘sexual desire’ and ‘overall satisfaction’. Reducing ‘prostatism’ and improving quality of life could induce an increase in ‘overall satisfaction’ in patients who have undergone suprapubic prostatectomy. We also suggest that a better social and physical performance could improve ‘sexual desire’. Differences between the IIEF scores before and after surgery were similar to the discrepancies before surgery between the IIEF scores of patients with slight (IPSS ≤ 12) and severe (IPSS> 12) prostatic symptoms. Therefore, we suggest that as slightly symptomatic patients have a better sexual life than their severely affected counterparts, the resolution of urinary symptoms by removing prostatic tissue may restore a good quality of life and improve sexual activity.
The use of both the IIEF and ICS-sex appeared to be useful for evaluating the internal agreement of the answers. The combined use of these tests provides a valid method for evaluating patients with BPH treated by both medical and surgical therapy; while the IIEF evaluates all aspects of sexuality, ICS-sex can be used to check the answers in the overall scores.
Sexual activity is a complex area; ICS-sex, with only four questions, may not be sufficient to thoroughly evaluate more significant changes in sexual function. However, it might be considered as a first-line investigation for sexual disorders, with the more specific IIEF used to gain more detailed information
In conclusion, the IPSS, ICS-‘BPH’ and IIEF are useful instruments for examining all aspect of urinary symptoms, quality of life and sexual changes, both in research and clinical practice; the combined use of these self-administered questionnaires allows an evaluation of the relationships between age, prostatic symptoms and sexual changes. Patients with severe urinary symptoms (IPSS> 12) show less sexual desire and overall satisfaction than those with only slight symptoms (IPSS < 12). The same is true for patients aged> or < 65 years, and thus age may be considered both a direct and indirect (BPH-related) prognostic factor for sexual activity.
We thank Prof Jenny Donovan for her substantial contribution in suggesting improvements in the quality and methods of presentation of this manuscript, and for the accurate final review.
maximum urinary flow rate
postvoid residual urine volume
International Continence Society
International Index of Erectile Function
body mass index
The IPSS, recommended by the International Consensus Committee, is a self-administered questionnaire based on seven questions about urinary symptoms and one about QoL. The answers are assigned a score of 0–5; therefore, the final score is 0–35 points. Patients can be classified as mildly (0–7), moderately (8–19) or severely symptomatic (20–35).
The ICS-‘BPH’ is used to evaluate urinary symptoms (ICSmale, 22 questions), quality of life (ICSQoL, six questions) and sexual function (ICSsex, four questions) in patients with BPH. Many questions have a bothersome index ranging from 0 (‘no problem’) to 4 (‘severe problem’). It is a complete instrument for identifying treatment-related changes in patients with BPH.
The IIEF is a brief, reliable, self-administered scale for assessing erectile function. It is a useful instrument for both research and clinical settings, with high sensitivity for detecting changes in patients with ED. It is based on 15 questions in five domains (erectile function, orgasmic function, sexual desire, intercourse satisfaction and overall satisfaction).