V. How Does BPH/LUTS Affect Erectile Function?
BPH is a very common condition, with more than six million men over 50 years of age suffering from it and symptoms associated with it. The estimate is that these figures are going to double over the next 20 years, largely related to the aging of our population and the increased risk of BPH as we age. As previously mentioned, age is the number one factor associated with the incidence of BPH. Patients between 60 and 69 years of age have a two-fold increased risk of acute urinary retention, and that jumps to a four-fold risk of urinary retention for men over 70 years of age. When the International Prostate Symptoms Score is 8 or greater, there is a two-fold risk of acute urinary retention. Score yourself at the end of this chapter. Men with prostate sizes over 40 grams are three times as likely to have moderate to severe symptoms, twice as likely to be bothered by these symptoms and twice as likely to experience interference with normal daily activities.
In a very large study known as the MTOPS (Medical Treatment of Prostate Symptoms) study, finasteride was associated with a 34% reduction in risk for progression of BPH, doxazosin, an alpha-blocker, was associated with a 39% reduction in risk of BPH progression, and the combination of doxazosin and finasteride was associated with 67% reduction in risk for BPH progression. Previously it was thought that men with BPH/LUTS had erectile dysfunction because BPH typically occurred in older men, and older men are likely to have conditions such as high blood pressure, high cholesterol and coronary artery disease, or to have undergone radical prostate surgery, and therefore, it was believed that age was the real link. However, it has now been shown in several medical studies that LUTS is an age-independent risk factor for the development of erectile dysfunction.
Table 4 • Incidence Of ED in men with and without LUTS (Modified after Braun, et. al.)
A large study from Cologne, Germany, showed that for each decade of life over 30 years of age, men who had LUTS had a two-fold higher incidence of erectile dysfunction than men who did not have LUTS (Table 4). Another very large study called the MSAM-7 study demonstrated that there was both an age and severity of LUTS relationship. That is, that the older men were and the more severe their lower urinary tract symptoms, the more likely they were to have erectile problems.
It is not fully understood exactly why lower urinary tract symptoms are associated with the development of erectile dysfunction. There is no doubt that men who have severe LUTS have a significant interference with their quality of life. Imagine a man who has to get out of bed five times every night. His sleep deprivation will be such that he will have a significant reduction in his quality of his sleep. It is well known that anything that reduces life satisfaction may, in fact, impact negatively upon erectile function. Much animal and human research is ongoing at the moment which demonstrates that BPH-associated LUTS is a cause for sympathetic nervous system hyperactivity. The autonomic (involuntary) nerves are combined sympathetic and parasympathetic. Sympathetic nerve fibers transmit signals which result in a variety of bodily functions including stress-related symptoms.This increased sympathetic nerve discharge may be a factor in why men have urgency and frequency of urination during the day time. If a state of sympathetic over-activity is present, this is well known to be associated with erection problems as sympathetic nerve fibers are anti-erection. While other theories exist, it is not yet fully understood how LUTS results in erectile dysfunction.
So for the 45–year-old man who has no medical conditions other than BPH and the LUTS associated with it, he is at increased risk for the development of erectile dysfunction. In men with LUTS, the increased risk of erection problems developing is somewhere in the range of 2– to 11–fold, depending on the severity of the lower urinary tract symptoms. Interestingly, it is now understood that the enzyme PDE5 (see later for the story about PDE5 inhibitors) is present within the prostate. PDE5 inhibitors are a class of drugs that includes Viagra, Levitra and Cialis, and it has now been shown that all three drugs not only result in improved erections in many men, but also improved urinary function in men with BPH/LUTS. While these drugs are not yet approved for the treatment of LUTS, it is likely that sometime in the future, one of these drugs will be or that the newer PDE5 inhibitors coming down the road will be used as a medical treatment for BPH.
It is my practice in men who present with the complaint of erectile dysfunction who also have an elevated International Prostate Symptom Scores to inform them that they may not only see improvement in their erectile function but also in their urinary symptoms when using a Viagra-like medication. There are now some physicians in the country who are exploring the use of Viagra, Levitra and Cialis in patients with LUTS without erectile problems, for the purpose of urinary symptom improvement.
CHAPTER 3
DECIDING ON A TREATMENT
| I.Deciding on a Treatment II.Impact of Prostate Cancer Diagnosis on Sexual Function III.Complications of Treatment: Overview IV.Factors to Consider when Deciding on Treatment V.Information You Should Give Your Doctor VI.Questions You Should Ask Your Doctor |
I. Deciding on a Treatment
After the initial shock of being given a diagnosis of cancer, you will need to start grappling with decisions regarding treatment. The treatments outlined in this book include watchful waiting (where no specific therapy is undertaken), radical prostatectomy surgery and radiation therapy, either in the form of implantable seeds (brachytherapy) or external beam radiation in a number of forms.
It is prudent to take your time when making decisions about prostate cancer treatment. While patients are understandably stressed and distressed by their diagnoses, the good news is that prostate cancer is a relatively slow-growing cancer in the vast majority of cases. Once you have been biopsied, your surgeon will be able to tell you how many of the cores on the biopsy were positive and what the volume of cancer is within each core and in the entire set of specimens.
The pathologist will also grade the cancer. The grading system most frequently used is the Gleason grading system, which identifies the major and the minor patterns and is scored from 1 to 5, where 5 is the most aggressive cancer and 1 is the least aggressive cancer. The majority of men are in the Gleason 6 (3+3) range, a large number are 7 (3+4 or 4+3), very uncommonly we see Gleason 8, 9 and 10, and likewise, rarely do we see Gleason 5 or 4. Gleason cancers that are 5 or 6 are moderately differentiated. Gleason 7 cancers are deemed to be of intermediate aggressiveness, and Gleason 8, 9 and 10 are highly aggressive cancers. In general, the higher the Gleason grade, the greater the concern the physician will have about the prostate cancer growth.
It is important to understand that the vast majority of men who have prostate cancer are curable and may go on to live many years after treatment. These men may also live with the complications of their treatments. The literature comparing radiation, surgery and watchful waiting is largely murky. There is evidence from a large Swedish study that shows that there is a survival advantage to men undergoing radical prostatectomy. There is also evidence that seed implantation is less effective for patients with intermediate-or high-grade cancers, Gleason grades 7 through 10.
Only you and your partner, should you have one, can make the final decision. It is likely that a good physician will give you options and you will have to make decisions regarding these based on a risk-benefit analysis. Risk benefit analysis means that you will review the extent and the aggressiveness of the cancer and compare it to the side effects of the respective treatments.