Physician perceptions of sexual dysfunction related to benign prostatic hyperplasia (BPH) symptoms and sexual side effects related to BPH medications

Abstract

In a large-scale epidemiology study, 50% of aging men reported erectile dysfunction (ED) or ejaculatory dysfunction (EjD), with lower urinary tract symptoms (LUTS) an independent risk factor for each of these conditions. In light of the shift from urologists (UROs) to primary care/internal medicine physicians (PCPs) for the initial management of men with LUTS associated with benign prostatic hyperplasia (BPH), a survey was conducted to assess the perceptions of UROs and PCPs regarding sexual dysfunction (SD) in men with LUTS/BPH and the effects of BPH treatments (α1-adrenergic receptor antagonists (α-blockers) and 5α-reductase inhibitors (5ARIs)) on sexual function. The survey was mailed to 7500 UROs and 2500 PCPs, with 1275 (13%) surveys returned (1087 by UROs, 177 by PCPs and 11 by other specialty). α-Blocker monotherapy was the most common medication prescribed by both UROs (56%) and PCPs (47%). UROs estimated that 19% of their patients with LUTS/BPH experienced SD owing to their symptoms compared with the estimate of 27% by PCPs. UROs estimated that 19% of their patients experienced SD owing to their BPH medication compared with the PCP estimate of 24%. The incidence of EjD owing to BPH medications estimated by UROs (32%) was higher than that estimated by PCPs (22%); the rate of ED estimated by PCPs (34%) was higher than that estimated by UROs (23%). UROs were more aware than PCPs of the specific sexual side effects caused by α-blockers versus 5ARIs. These results suggest that physicians are underestimating the prevalence of SD in men with LUTS/BPH. As men with LUTS/BPH are at increased risk for SD, physicians should be especially cognizant of BPH treatment-related sexual side effects.

Introduction

Benign prostatic hyperplasia (BPH) is a common and often progressive condition in aging men, affecting 50% of men in their 6th decade and 90% of men in their 9th decade.1 BPH is often associated with bothersome lower urinary tract symptoms (LUTS) that can negatively impact quality of life.2, 3, 4 Recent epidemiology studies have established an association between LUTS and sexual dysfunction (SD), both erectile dysfunction (ED) and ejaculatory dysfunction (EjD), in community-based samples of aging men5, 6, 7 and in aging men with LUTS/BPH.8, 9, 10 Importantly, LUTS is an independent risk factor for ED and EjD after controlling for age and other comorbidites.6, 7, 10 Population-based data also indicate that most aging men continue sexual activity and that sexuality is an important quality of life component regardless of age.7, 11 On the other hand, male SD has a significant negative effect on quality of life.12, 13, 14, 15 As a result of the strong association between LUTS and male SD, men presenting with LUTS should be assessed for ED and EjD and men presenting with ED or EjD should be assessed for LUTS.

The goals of treatment for men with bothersome LUTS/BPH are to relieve symptoms, improve quality of life and prevent serious complications (e.g., acute urinary retention and BPH-related surgery). In some countries, urologists (UROs) remain the initial provider contacted by men with LUTS. In the US, however, men with LUTS/BPH are managed initially by primary care/internal medicine physicians (PCPs) (49%) rather than UROs (37%).16 In France, approximately 70% of men with symptomatic LUTS initially contact a general practitioner and approximately 30% contact a URO.17 The increasing role of PCPs stems in part from the shift from surgery to pharmacological treatments for the first-line management of LUTS/BPH. Unfortunately, some pharmacological treatments for LUTS/BPH (i.e., α1-adrenergic receptor antagonists (α-blockers) and 5α-reductase inhibitors (5ARIs)) are associated with sexual side effects (i.e., ED, EjD and hypoactive sexual desire [HSD]).18, 19 For example, in two US clinical trials in men with LUTS/BPH, treatment with tamsulosin resulted in a higher incidence of EjD (8.4% for tamsulosin 0.4 mg; 18.1% for tamsulosin 0.8 mg) than placebo (0.2%).20 Furthermore, treatment with a 5ARI, finasteride or dutasteride, is associated with higher incidences of ED, EjD and HSD in men with LUTS/BPH than placebo.21, 22

Although men with LUTS/BPH have a high prevalence of SD and may experience sexual side effects from BPH treatments, many do not discuss these conditions or side effects with their healthcare provider.7, 23, 24, 25, 26 In light of the association between LUTS and male SD and the roles of UROs and PCPs in the initial management of men with LUTS, the present survey was conducted to assess and compare the perceptions of UROs and PCPs regarding SD in men with LUTS/BPH and the effects of BPH treatments on sexual function.

Methods

The physician survey, which included 12 questions (see Appendix A), was developed to gain an understanding of how physicians treat patients with LUTS/BPH and of the occurrence of SD both with and without medical therapy in these patients. The survey, which was sponsored by The American Foundation for Urologic Disease (AFUD) and funded through an unrestricted educational grant from sanofi-aventis, was mailed to 7500 US UROs and 2500 PCPs who treat a large number of patients with LUTS/BPH. Physicians were informed that their individual responses would be kept confidential and that only aggregate responses would be reported. The survey was conducted in 2003.

Results

Of 10 000 surveys mailed to physicians, 1275 (13%) surveys were returned by September 2003. Of the 1275 physicians, 1087 (85%) indicated that they were UROs, 177 (14%) indicated that they were PCPs, and 11 (<1%) reported another specialty. Only the data from the 1264 UROs and PCPs were analyzed. The majority (70%) of UROs saw 400 or fewer patients each month, whereas 71% of PCPs saw more than 400 patients each month (Table 1). The overall age distribution of patients seen by UROs and PCPs was generally comparable, with 43 to 44% of patients aged 65 years or older. Among the UROs surveyed, 79% saw more than 40 patients with BPH/LUTS each month, whereas the majority (60%) of PCPs saw 40 or fewer patients with BPH/LUTS each month.

Table 1 Age distribution and number of patients seen each month

The distribution of patients treated with watchful waiting, prescription medications (α-blockers and/or 5ARIs), surgery, and other methods was similar for UROs and PCPs, with the majority of patients treated with α-blockers and/or 5ARIs (Figure 1). Among the medications prescribed for the treatment of LUTS/BPH, α-blocker monotherapy was the most common for both UROs and PCPs, but a greater percentage of the patients managed by UROs were prescribed α-blockers (56%) than were those managed by PCPs (47%; Figure 2). In contrast, 5ARI monotherapy was prescribed to a greater percentage of patients with LUTS/BPH seen by PCPs (21%) than those seen by UROs (13%).

Figure 1
figure1

Current treatment of patients with LUTS/BPH. AB, α-blocker; 5ARI, 5α-reductase inhibitor.

Figure 2
figure2

Current treatment of patients with LUTS/BPH who receive prescription medications. AB, α-blocker; 5ARI, 5α-reductase inhibitor.

UROs estimated that 19% of their patients with LUTS/BPH experienced SD as a result of their LUTS and not solely because of their age or other comorbidities (e.g., diabetes, hypertension) compared with the PCP estimate of 27% of patients. PCPs also reported a slightly higher incidence of SD as a result of BPH medications in their patients (24%) than did UROs (19%). Interestingly, the incidence rate of EjD resulting from BPH medications that was estimated by UROs (32%) was higher than that estimated by PCPs (22%), whereas the incidence rates of ED and HSD estimated by PCPs (34 and 26%, respectively) were higher than those estimated by UROs (23 and 17%, respectively; Figure 3).

Figure 3
figure3

Estimated percentage of patients with LUTS/BPH exhibiting SD as a result of BPH medications. ED, erectile dysfunction; EjD, ejaculatory dysfunction; HSD, hypoactive sexual desire.

When asked specifically about the sexual side effects of α-blockers, PCPs again perceived a higher incidence of ED and HSD in their BPH patients than did UROs, and UROs perceived a higher rate of EjD in their BPH patients than did PCPs (Figure 4a). Regarding the perceived sexual side effects of 5ARIs, UROs and PCPs reported similar rates for EjD, ED, and HSD (Figure 4b). UROs estimated a higher rate of EjD with α-blocker therapy than with 5ARI therapy, similar rates of ED with α-blockers and 5ARIs, and lower rates of HSD with α-blockers than with 5ARIs (Figure 4a and b). In contrast, PCPs reported similar rates of EjD, ED, and HSD with α-blockers and 5ARIs.

Figure 4
figure4

Estimated percentage of patients with sexual side effects when treated with ABs (a) and 5ARIs (b). ED, erectile dysfunction; EjD, ejaculatory dysfunction; HSD, hypoactive sexual desire.

When asked to choose the term they preferred to use when discussing ejaculation abnormalities with their patients, UROs most frequently selected the terms retrograde ejaculation (34%) and abnormal ejaculation (21%), whereas PCPs selected abnormal ejaculation (46%) and EjD (29%).

Discussion

In the last few years, important information has been published in the medical literature on the relationship between LUTS/BPH and SD in aging men. A large, population-based epidemiological study conducted in 14 000 aging men from Europe and the US demonstrated that the prevalence of LUTS of any severity was 90% and that the prevalence rates of ED and EjD were approximately 50%.7 The reported rates of ED and EjD have been as high as 70% in clinic-based samples of men with LUTS/BPH.27 Furthermore, during the last decade, both UROs and PCPs have been involved in the initial management of patients with LUTS/BPH, thereby creating a need for broader educational initiatives on sexual function in these patients. The data from the present survey suggest that both UROs and PCPs identify BPH-related and BPH treatment-related SD at a lower rate than has been observed in both population-based and clinic-based epidemiological studies. Possible reasons for physician underestimation of SD in patients with LUTS/BPH may be patients' under-reporting of SD to their physicians, hesitancy on the part of physicians to initiate discussions about SD with their patients, and an inadequate awareness by physicians and patients about the link between LUTS and different types of male SD. Data from the present survey suggested that PCP estimates of the incidence of ED and HSD as side effects of α-blocker and 5ARI therapy were higher than those of UROs. This finding may have been owing to a PCP sampling bias, as discussed below, and/or to the extent that men discuss ED and HSD with different healthcare providers. In the multinational Men's Attitudes to Life Events and Sexuality (MALES) survey, men with ED were significantly less likely to discuss ED and its treatment with a specialist (e.g., URO) than with their regular general practitioner/family physician (odds ratio=0.592; 95% CI: 0.491−0.715).28

Possible limitations of the survey should also be mentioned. The sample size in the present study was small and, therefore, may not provide a true representation of UROs and PCPs in the US. In addition, because the survey sampled PCPs who treated a large number of men with LUTS/BPH, the respondents may have greater knowledge of BPH treatments and their sexual side effects than US PCPs in general. Furthermore, the larger number of UROs versus PCPs responding to the survey may skew the data. Finally, the data were collected retrospectively based on physician perceptions and overall estimates of patient percentages. However, the qualitative data from this survey are useful for providing hypotheses for future studies in this area. For example, the qualitative data obtained in this pilot survey were useful in designing the first large-scale, observational, disease registry of US men with LUTS/BPH, the BPH Registry & Patient Survey, in which actual clinical practice patterns and patient outcomes are being prospectively documented.29

In 2003, the American Urological Association (AUA) guideline on the management of BPH was issued to provide up-to-date information to physicians on BPH diagnosis, treatments and patient outcomes, together with recommendations for future research.18 Data from the AUA Panel's review suggested that the α-blockers alfuzosin, doxazosin, tamsulosin and terazosin have comparable clinical efficacy in alleviating the symptoms of BPH, but have different side effect profiles.18 Although adequate comparator trials are lacking, trials comparing each α-blocker with placebo have suggested that tamsulosin is associated with a higher incidence of EjD as a side effect of treatment than alfuzosin, doxazosin or terazosin.18 Data also indicate that the 5ARI finasteride is less effective at alleviating the urinary symptoms of BPH than is an α-blocker.18, 30 5ARI treatment is associated with mainly sexual side effects, including ED, EjD and HSD.18 Although combined therapy with an α-blocker and a 5ARI is no more effective in alleviating BPH symptoms than α-blocker monotherapy in studies of less than 1 year of treatment,30, 31 a 5-year study, published in December 2003 after the completion of the present survey, suggests greater symptom relief and decreased overall BPH progression with combination therapy.32 The incidence of sexual side effects from combination therapy with an α-blocker and a 5ARI is generally the sum of the rates for each medication alone.18 The AUA guideline on BPH management18 provides useful information for physicians who are trying to advise BPH patients about their treatment options. This information, together with assessments of the patient's sexual function and medication-related sexual side effects, should help physicians in the successful management of their patients with LUTS/BPH.

When concomitant LUTS/BPH and SD are identified, the management approach should consider the effects of treatments on each of these conditions. Additional studies are needed to evaluate the best treatment options in these cases. However, preliminary data suggest that treatment of the symptoms of BPH with some α-blockers may also improve ED and EjD.33, 34, 35, 36, 37 Finally, data from a study of sildenafil suggested an improvement in LUTS in men being treated for ED.38 As additional knowledge is gained on the mechanisms involved in the association between LUTS and SD, as well as other age-related diseases (e.g., hypertension, hyperlipidemia, diabetes mellitus and depression),39 and as existing and new treatment options are evaluated, evidence-based management guidelines for these concomitant conditions should evolve. In the meantime, it is important for both UROs and PCPs to assess both LUTS and sexual function in their aging male patients and to monitor BPH medication-related sexual side effects in their patients with LUTS/BPH.

In conclusion, the results of this qualitative survey of UROs and PCPs suggest that physicians are underestimating the prevalence of SD in their male patients with LUTS/BPH. A second survey of UROs and PCPs, conducted 1 year after the present survey, will be used to determine whether physician perceptions of LUTS/BPH and SD remain the same or change. The ongoing prospective BPH Registry & Patient Survey also will provide valuable information on management practices and patient outcomes in a real-world, physician office-based population of US men with LUTS/BPH.

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Acknowledgements

This survey was sponsored by The American Foundation for Urologic Disease (AFUD) and funded through an unrestricted educational grant from sanofi-aventis. Patricia B Leinen, PhD, (Tri-Med Communications, Media, PA, USA) contributed to the preparation of the manuscript.

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Correspondence to A Seftel.

Appendix A

Appendix A

Table a1 The questions included in the physician survey were:

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Seftel, A., Rosen, R. & Kuritzky, L. Physician perceptions of sexual dysfunction related to benign prostatic hyperplasia (BPH) symptoms and sexual side effects related to BPH medications. Int J Impot Res 19, 386–392 (2007). https://doi.org/10.1038/sj.ijir.3901540

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Keywords

  • benign prostatic hyperplasia
  • lower urinary tract symptoms
  • ejaculatory dysfunction
  • impotence
  • prevalence
  • sexual dysfunction
  • drug therapy
  • physician survey
  • physician specialty

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