Not all men who undergo treatment for lower urinary tract symptoms (LUTS) should prioritize the preservation of ejaculation when choosing a treatment, said Thomas Hermanns, MD, from the University of Zurich. Some men would be better off prioritizing the outcome of treatment over the increased possibility of ejaculatory function.
The spectrum of adverse effects of the various treatments for LUTS runs from losing the ability to ejaculate, to reduced semen volume, to anejaculation during orgasm.
Although studies have shown that ejaculation-preservation procedures are successful in 60% to 100% of LUTS cases, they "should not be offered to sexually inactive men because it might impact functional outcome," Hermanns said during his presentation at the European Association of Urology 2020 Congress.
The procedures should also not be offered to sexually active men with an absolute indication for deobstruction, such as "patients who have kidney function impairment or recurrent infections," he added.
Still, "ejaculatory dysfunction is a major issue," he acknowledged. "Potency, ejaculation, and orgasm perception play an important role in the quality of life in our patients."
Patients need to have all the information before any shared decision-making takes place, he said. They need to consider whether the potential inferior relief of ejaculation-preservation procedures and a likelihood of secondary procedures are "worth the bother."
"Worth the Bother"
Many men might feel that the benefit outweighs the risk, said Laetitia de Kort, MD, from University Medical Centre Utrecht in the Netherlands, who spoke in support of ejaculation-preserving procedures during her presentation.
The main purpose of ejaculation — fertilization — is not a concern for many men older than 50 years, she said. The problem lies in the emotional consequences. Because ejaculation and orgasm occur simultaneously, there is a positive association between the two. Men might find that the absence of that association harms "their sense of masculinity," she explained.
Studies have shown that 40% to 100% of men experience a decrease in sexual satisfaction when they don't ejaculate.
This is true for female partners, too, she said. In a cross-sectional survey of 240 women, 50.43% reported that they consider it very important that their partner ejaculates during intercourse.
Once we have taken the Hippocratic Oath, "we have sworn a promise that we will not inflict any unnecessary harm to our patients," she said. In this context, "it is our duty to spare ejaculation, if possible."
But de Kort agrees with Hermanns that all patients need to be well informed before they can make a decision about personal treatment.
de Kort examined several systemic reviews of antegrade ejaculation outcomes after LUTS surgery.
Less than 30% of men who underwent surgery for LUTS and benign prostatic hyperplasia reported dysfunction after the procedure, according to a 2016 review. "That means 70% were spared," she said.
And the risk for ejaculatory dysfunction trended lower with GreenLight laser treatment (risk ratio [RR], 0.71) and with prostate artery embolization (RR, 0.73) than with the "classic" transurethral resection of the prostate (TURP) in a 2019 review, although those results did not achieve statistical significance.
Ejaculatory function was slightly better after prostatic urethral lift than after TURP in a second 2019 review that involved 297 men with benign prostatic hyperplasia, but there was a downside: "Prostatic urethral lift was less effective at relieving LUTS," de Kort reported.
Aquablation was shown to be better at preserving ejaculation than TURP in a third 2019 review, and was as effective in relieving LUTS as TURP.
Some of the newer techniques might preserve ejaculation, "but this may be at the expense of the degree of relief from LUTS," said de Kort.
Comparative studies with a control group are needed, said Hermanns. And follow-up needs to be longer than the 3 to 6 months commonly seen in many studies.
Patients should be also aware that surgery to preserve ejaculation does not come with a guarantee, he said, although "it works out in almost all procedures."
Hermanns has been an advisor for MSD, Bayer, and Janssen. de Kort has been a speaker for AstraZeneca, Astellas Pharma, and Boston Scientific.
European Association of Urology (EAU) 2020 Congress: Thematic Session 02. Presented July 17, 2020.
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Cite this: Preserving Ejaculation May Come at a Cost for LUTS Patients - Medscape - Jul 27, 2020.