The conventional opinion held by most urologists is that there is no significant relationship between LUTS and sexual dysfunction (SD). Even the well accepted AHCPR Consensus statements on BPH claim that erectile dysfunction (ED) and LUTS have no relationship other than the increased occurrence in the ageing man [1]. That dogmatic concept is in contention with new information addressing the relationship between SD and LUTS. However, even if such an association were present, why should urologists be concerned about SD in men with LUTS in the first place? This relationship is important because: (i) additional information on risk factors for either disease could be important for patient screening; (ii) there is an increasing pool of affected men, given the age demographics in many Western societies; (iii) sexual problems related to LUTS are not necessarily limited to ED; and (iv) many currently available treatments for LUTS (medical and surgical) affect sexual function.

Are men with LUTS/BPH at greater risk of sexual problems? The answer to this requires that SD be regarded as more than just an erection issue, but should be assessed from several different aspects or ‘domains’ of overall sexual function. Male SD may manifest as problems such as decreased libido, ejaculation, erectile function, or combinations of all three. An interesting and early investigation of this comes from France, where MacFarlane et al.[2] investigated sexual function and LUTS in a community-based survey. In this early-1990s study, ≈ 2000 men aged 50–80 years were evaluated using a questionnaire. Sexual satisfaction negatively correlated with increasing age and LUTS. Also, urinary symptoms adversely affected the general sense of well-being and self-esteem (i.e. perception of sexual life satisfaction). The relative risk (RR) of ED stratified by the IPSS ranged from 0 at an IPSS of 1.0 to 3.3 for an IPSS of> 19 (Table 1).

Table 1.  The relationship between satisfaction and the IPSS
IPSSRR (95% CI) of being
0 (reference)
1–71.50 (1.09–2.05)1.29 (0.75–2.21)
8–192.07 (1.25–3.07)2.19 (1.13–4.23)
≥  192.38 (0.70–8.08)3.34 (0.79–14.12)

The Krimpen study [3] of erectile and ejaculation dysfunction assessed the RR for ED in a community cohort based on various clinical attributes. In this study, LUTS had a linear relationship with increasing risk of ED. The authors reported an increased RR for ED, from 1.8 to 7.5, depending on the degree of urinary complaints. This increased RR of ED based on the severity of LUTS was greater than that found with cardiac symptoms, pulmonary problems and a history of smoking. This suggests that ED is a worthwhile symptom to query in patients who present with LUTS.

LUTS diminish the quality of a patients’ life; Girman et al.[4] reported a similar linear relationship between LUTS and the Bother index, also showing that interference with daily activities and overall general health were directly related to the worsening LUTS. Of note, sexual satisfaction is also significantly associated with LUTS, in that the more severe the LUTS the more likely that poor sexual satisfaction was reported. In a follow-up report, Girman et al.[5] showed a similar relationship between prostate volume and sexual dissatisfaction.

Most recently, Rosen et al.[6] reported on the Multinational Survey of the Ageing Male (MSAM-7); this important study revealed a very strong association between the level of sexual intercourse and patients’ IPSS. The International Index of Erectile Function score was also significantly associated with the severity of LUTS. Importantly, this association between LUTS and SD persisted when controlled for age and other comorbidities which are known to affect sexual function. Measures of ejaculatory dysfunction, reduced ejaculate and ejaculation pain were also strongly associated with LUTS. The results of the MSAM-7 suggest that older men still have an active sex life and that the severity of LUTS affects sexual disorders independently of other risk factors.

The NIH-sponsored MTOPS Trial addressing the effect of finasteride and/or doxazosin on the progression of BPH was recently reported at the ISIR (Montreal 2002). A secondary aim of this important study addressed the relationship between sexual function and the severity of LUTS in 3000 men. Assessing the prevalence of SD and LUTS in a cross-sectional analysis of baseline data, McVary et al.[7] reported a strong association between baseline AUA Symptom Index and the various domains of sexual function, including libido, erectile capability, ejaculation, problem assessment, and overall satisfaction with sexual life (P < 0.001 for each domain). There was also a significant association of the sexual function domains and maximum urinary flow rate (P < 0.001). This latest report is important because the comorbidities which are frequently associated with ED (including age, partner status, marital status, hypertension, lipid disorders, and diabetes) were controlled in a multivariate analysis, and the patients were exceedingly well characterized clinically. Also, the duration of LUTS was associated very strongly with erectile function, problem assessment and the overall satisfaction with sexual life (P < 0.01). These results support an association of LUTS and SD that is independent of the usual comorbidities.

What is clear from the most recent reports is that there is a strong and consistent association between LUTS and SD. Significantly many ageing men are concerned about ejaculatory dysfunction in addition to their ED. Urologists would do well to address these issues prospectively with their patients when they discuss the choice of treatments for LUTS.


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  • 1
    McConnell JD, Barry MJ, Bruskewitz RC et al. Benign prostatic hyperplasia: diagnosis and treatment. US Department of Health and Human Services Public Health Service, AHCPR Publication no. 94-0582. 1994
  • 2
    Macfarlane GJ, Botto H, Sagnier PP, Teillac P, Richard F, Boyle P. The relationship between sexual life and urinary condition in the French community. J Clin Epidemiol 1996; 49: 11716
  • 3
    Blanker MH, Bohnen AM, Groeneveld FPMJ et al. Correlates for erectile and ejaculatory dysfunction in older Dutch men: a community-based study. J Am Geriatrics Soc 2001; 49: 43642
  • 4
    Girman CJ, Jacobsen SJ, Tsukamoto T et al. Health-related quality of life associated with lower urinary tract symptoms in four countries. Urology 1998; 51: 42836
  • 5
    Girman CJ, Jacobsen SJ, Rhodes T, Guess HA, Roberts RO, Lieber MM. Association of health-related quality of life and benign prostatic enlargement. Eur Urol 1999; 35: 27784)
  • 6
    Rosen R, O'Leary M, Altwein J et al. LUTS and male sexuality: Findings of the MSAM-7. Int J Impot Res 2002; 14 (Suppl.): AC3.8
  • 7
    McVary KT, Foster H, Kusek J, Ramsdell J, Bautista O and the MTOPS Study Group. Self-reported sexual function in men with symptoms of BPH – a MTOPS Study report. Int J Impot Res 2002; 14 (Suppl.): ACP1.32