If you have BPH (Enlarged Prostate) You Might Experience Erectile Dysfunction.
By Dr. Alex Shteynshlyuger MD – Board Certified Urologist specializing in the treatment of ED and BPH.
The link between BPH and ED is probably more complex than we appreciate.
It has been noted that men who have enlarged prostate and BPH are more likely to have ED. The question is why?
BPH is a significant health issue for men. It has a greater impact on health than is generally appreciated. The direct effect of BPH is to cause urinary symptoms, slow urinary stream, and frequent urination. It causes numerous quality of life issues such as poor sleep, social restrictions on travel because of the constant need to void. It can lead to urinary incontinence and depression.
It appears that the relationship is due to a common risk factor, age as well as the effect of BPH on sleep and hormonal milieu. Aging is associated with increased risk for ED such as hypertension, obesity, and diabetes. These conditions tend to have onset around the age when BPH becomes symptomatic – close to age 50-60.
Sleep, BPH, and ED Link
Frequent urination at night caused by BPH has been shown to disturb normal sleep patterns and leads to chronic day-time tiredness and poor-quality sleep. This been shown in numerous studies. Abnormal hormonal function caused by inadequate sleep and tiredness can certainly cause and contribute to ED.
It has been shown in numerous studies that poor sleep patterns can also cause numerous hormonal abnormalities including low testosterone, increased stress hormone levels such as cortisol, lower thyroid levels. This is probably the underlying mechanism for the reported association between BPH and ED.
In addition, many symptoms that can result from BPH can cause ED: tiredness, loss of vigor due to poor sleep patterns; depression and withdrawal from partners due to urinary incontinence.
Fortunately, a number of effective treatment options are available for men with BPH and ED including medical and surgical treatment.
Do Current Recommendations for Treatment of BPH Make Sense?
This brings into question the current management recommendations for BPH. Many men adapt to their urinary symptoms and are not bothered by them even when their AUA symptom score index (a measure of how BPH affects the quality of life) is pretty significant. There is significant reticence among men about taking medications. Many would rather wake up 2-3 times per night than be treated.
The question becomes whether we should proactively recommend treatment to prevent secondary health effects of BPH. The current treatment recommendation for BPH based on the presumption that BPH is mostly a quality of life issue is probably outdated. There is accumulating evidence that BPH has a significant health effect on men that extends beyond urinary function.
BPH Treatment with Minimal or No Sexual Side Effects
BPH is a significant medical problem and can have many negative repercussions. While some treatments for BPH have significant sexual side effects, men should not avoid getting urological care for BPH. We have a range of treatment options that have minimal or no sexual side effects. BPH itself can have a negative effect on sexual function and in particular ejaculation.
Natural Treatment for ED and BPH
Many men may actually experience improved sexual function after treatment for BPH. Certainly, while medical treatment is important, it is a good idea to integrate other modalities into the care plan. We know for a fact that weight loss and exercise can boost sexual function and improve libido and can help urinary function as well.
Good Mediterranean diet can actually prevent ED over long-term; general medical care such as good control of blood pressure, cholesterol and diabetes are important. Men with BPH should also see a primary care doctor for a general check-up. Some men may have low testosterone levels and may benefit from supplemental testosterone if they are symptomatic.
Side Effects of Medications for ED
Medications used for the treatment of BPH infrequently cause ED but they do affect ejaculation. The risk of ED from taking medications such as Proscar and Avodart is less than 10% but they can cause decreased production (volume) of semen, “dry up”. Alpha blockers such as Flomax and Uroxatral can cause retrograde ejaculation but curiously on rare occasions can cause priapism (unwanted prolonged erection) as a side effect.
Side Effects You Might Like
One of the newer medical treatment options for BPH which is FDA approved is Cialis which is also used for the treatment of ED. Viagra, Levitra, and Staxyn work in a similar way. This is certainly of interest to men who have problems with both BPH and ED – “kill two birds with one pill”.
Treatment Options with Minimal Side Effects
Another new and exciting FDA-approved treatment for BPH is Urolift. It’s an effective treatment option for BPH which involves an office-based insertion of a urethral transprostatic implant. Analysis of a randomized control trial revealed that there are no ejaculatory side effects and no erectile side effects; many men actually experienced a slight improvement in sexual function.
Other good treatment options for men who are concerned about sexual dysfunction from the treatment of BPH are minimally-invasive treatments that include Microwave therapy and TUNA. These treatments have fewer side effects than TURP, in particular, the risk of retrograde ejaculation is much lower with Prostiva than with TURP; it is also lower with TUMT than with TURP. About 30% of men will need another treatment within 5 years; in comparison, fewer men need to be re-treated after Laser or TURP procedures.
Does TURP Cause ED?
Traditionally, it was noted that TURP was associated with sexual side effects including retrograde ejaculation (semen goes into the bladder during orgasm instead of leaving the body) as well as ED. In fact, it’s one of the risk factors that is often discussed. However, it should be noted that men with BPH are at increased risk for ED. Many men undergoing TURP have significant problems with ED to start with.
During the surgery (TURP), we remove the obstructive tissue which is confluent with the muscle fibers that propel semen forward during ejaculation. As a result, around 70% of men experience retrograde ejaculation after TURP or similar procedures (various lasers of the prostate). For procedures such as TURP and lasers of the prostate, retrograde ejaculation is an unavoidable side effect.
A procedure called transurethral incision of the prostate (TUIP) is an option for men with smaller prostate – it has lower retrograde ejaculation risk. Other minimally invasive procedures such as Targis and Prolieve (TUMT – transurethral microwave therapy) and Prostiva (TUNA) also associated with fewer sexual side effects (<10% risk of retrograde ejaculation) but lower efficacy in the long term.
TURP is also associated with ED. Whether TURP causes ED is not clear as some randomized controlled studies actually show improvement in erectile function after TURP and others show slightly worsened function (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC104331/).
Mechanisms of ED after TURP
There are two mechanisms for ED after TURP: (1) as men age, the rate of ED increases so for some men it’s incidental that they have TURP and their ED ‘flares up”; (2) the heat generated during TURP especially if the resection is thorough or the prostate is small can damage the nerve fibers that run alongside the prostate gland and innervate the penis. This can lead to ED. The risk of ED attributable to TURP as distinct to aging is somewhere in the range of 15% based on data from randomized controlled studies.
Randomized studies show that after TURP some men experience worsening of erectile function and some experience improvement.
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