Can surgical treatment for benign prostatic hyperplasia improve sexual function? A systematic review

Abstract

Introduction

Erectile dysfunction is an established, well known risk of any operative management of benign prostatic hyperplasia (BPH). However, there are some cases reported in which surgical treatment has paradoxically improved erectile function. Here, we present a systematic review of the literature pertaining to the effect of surgery on sexual function, focusing on reports of improvement in erectile function following surgery.

Materials and methods

We searched PUBMED, EMBASE, Web of Knowledge, and SCOPUS databases for the following keywords: ((“sexual function” OR “erectile function”) AND “improvement” AND “benign prostatic hyperplasia” AND “surgery”).

Results

Sixteen studies (total n = 2087) were reviewed which reported a significant improvement in any aspect of erectile function. Ten of these studies had a follow-up period of 12 months or more while five had a follow up less than 12 months. Various surgical methods were included in the 16 studies; however, five reported TURP outcomes specifically. Eleven studies reported outcomes using the International Index of Erectile Function (IIEF). Overall, a further 87 studies showed no significant change and 8 studies showed a significant reduction.

Conclusions

The majority of studies report no change in erectile function following surgical intervention for BPH. There seems to be no obvious correlating factor between the studies reporting an improvement in erectile function. Further research is needed to guide us in how to consent our patients for erectile function outcomes for BPH surgery.

Keywords:

• Erectile dysfunction
• benign prostatic hyperplasia
• transurethral resection of prostate
• lower urinary tract symptoms

Introduction

Patients with benign prostatic hyperplasia (BPH) often present with varying severity of lower urinary tract symptoms (LUTS), due to the anatomical obstruction of the urethra and/or bladder neck by the prostate. These features include frequency, urgency, nocturia, hesitancy, reduced urinary flow rate, incomplete emptying and the need to double void. Prevalence of BPH is estimated as 50% of men in their 50s, and reaches 80% for men over 80 years [1]. However, not all men who have radiological BPH show clinical signs of LUTS. It is estimated that 18% of men aged 40–49 years old, and 56% of men aged 70–79 years old are symptomatic of BPH, as shown by the validated International Prostate Symptom Score (IPSS) being >8 [2]. The primary aim of operative management of BPH is to reduce LUTS, which ultimately improves quality of life (QoL).

It is widely accepted that surgical procedures for bladder outflow obstruction pose a significant risk of erectile dysfunction. However, a less well-researched area is the potential improvement that surgical procedures can have on sexual function. While, LUTS have a significant negative impact on QoL for patients, sexual function can also have an important role to play in a patient’s well-being and sexual dysfunction is associated with poor mood and a negative impact on relationship quality [3,4].

There are many surgical options and various techniques now available to treat BPH including, transurethral resection of the prostate (TURP), photoevaporisation (PVP) prostatic urethral lift (PUL). The operative method and modality of energy used may be a factor in determining whether erectile function is affected. While surgical factors must be considered, patient factors should also be considered. Initial severity of LUTS is regarded as an independent risk factor that correlates with erectile dysfunction [5]. A study conducted by Ozayar et al. [6] reported that in men scheduled for BPH surgery, 36% of those with moderate LUTS and 94% with severe LUTS were found to have coexisting erectile dysfunction [5], with other studies quoting similar finding [7]. Age has also been shown to be a significant factor in predicting erectile dysfunction, with prevalence of erectile dysfunction gradually increasing from 6.5% in men aged 20–39 years old, to 77.5% in those aged 75 years and above [8]. While these factors are risks for developing erectile dysfunction, they may also be predictors of those patients likely to improve sexual function following surgical treatment of BPH.

This review evaluates the reported potential improvements in erectile function after operative management of BPH. We hope to assess whether there are any factors, which may determine these improvements.

Materials and methods

This review was conducted in accordance to PRISMA guidelines using the MEDLINE, EMBASE and Web of Science database from January 1 1900 to November 9 2017.

The keywords used in the selection were (“sexual function” [All Fields] OR “erectile function” [All Fields]) AND (“improvement” [All Fields]) AND (“benign prostatic hyperplasia” [All Fields]) AND (“surgery” [All Fields]). For the purposes of this review, although sexual function is searched as a keyword, erectile function is classified as a separate attribute to sexual function as ejaculatory function.

All duplicates and non-English studies were excluded during this review. Only original studies that had evidence of a statistically significant improvement in any aspect of erectile function after surgical intervention were included. Non-relevant studies and studies with insufficient reporting of erectile function symptoms were excluded. Studies which showed no significant change in sexual function and those that showed, at least in some aspect, a significant reduction in sexual function were included. The included studies presented validated scoring systems for erectile function such as the IIEF or a suitable equivalent system devised by the authors (Table 1).

Table 1. Studies that showed significant improvement in sexual function after intervention.

Study	Study design	Study aim	Inclusion/exclusion criteria	Follow-up	Arm(s)	Erectile function scoring system	Improvement in erectile function	Other comments on sexual function	Other significant outcomes
Gilling et al. 2017 [9]	Prospective, single arm, multicentre trial at 3 centres in Australia and New Zealand 21 participants	Establish the safety and effectiveness of aquablation, a novel, image guided, robotic assisted, water jet tissue ablation technology, for the treatment of BPH	Between 50 and 80 years old IPSS >12 Qmax ≤12 mL/s Schafer scale 2 or greater Prostate volume 25 to 80 mL Excluded for active UTI, urinary retention or PVR 400 mL or greater, abnormal renal function, elevated PSA, history or suspected prostate or bladder cancer	1, 3, 6, and 12 months	Aquablation	IIEF-15	In 11 sexually active subjects, intercourse satisfaction significantly improved (p<.01)	No reported ejaculatory dysfunction. All other sexual function domains improved but not statistically significant	IPSS improved significantly by 16.2 points at 12 months (p<.01) QOL improved by 3.3 points (p<.01) Qmax improved by 9.7 mL/s (p<.01) PVR improved by 89 mL (p<.01)
Giulianelli et al. 2015 [10]	Prospective study 50 participants	Evaluate the safety and efficacy of bipolar button electrode transurethral enucleation of the prostate (B-TUEP) in saline	IPSS >12 Qmax < 15 mL/s ≥45 years old Prostate volume >20 g Drug therapy non-responders	3, 6, and 24 months	B-TUEP group	IIEF-5	IIEF-5 showed statistically significant improvement compared to baseline values (p<.01)	None	Qmax – 82% at 3 months, 80% at 6 months and 83.3% at 12 months showed significant improvement of >15 mL/s and <25 mL/s IPSS – improved significantly at 12 months (p<.05)
McVary et al. 2014 [11]	Prospective, randomised, controlled, blinded study 206 participants	Determine whether the prosthetic Urolift (PUL) treatment demonstrated significant improvement in LUTS and urinary flow rate while preserving sexual function	≥50 years old No prior BPH surgery A 30–80 cm^3 prostate IPSS >12 Qmax – ≤12 mL/s on a voided volume of 125 mL No obstructive median lobe	3, 6, and 12 months	PUL (n = 140) Sham (n = 66)	Sexual health inventory for men (SHIM) (IIEF-5) Male sexual health questionnaire ejaculatory disease (MHSQ-EjD)	Those entering the study with severe ED had significantly improved SHIM scores (p=.016)	No de novo sustained anejaculation or erectile dysfunction. Ejaculatory function significantly improved overall by 1.3 points at 12 months(p<.001)	IPSS was greatly improved in PUL group with 88% greater than that of sham control at 3 months (p=.003) Qmax improvement of 4.3 mL/s was significantly greater than control (p=.005) QOL and BPHII was significantly improved over control (p<.001)
Zhang et al. 2013 [12]	Prospective, non-randomised (patients chose surgical option) 384 participants	Study the effects of plasma kinetic resection of the prostate on erectile function and compare with TURP	8–35 IPSS Failure to respond to medical treatment. Reported sexual activity over the past 6 months. No suspected or known prostate cancer. No previous prostatic surgery. No concomitant diseases.	12 months	PKRP (n = 288) Monopolar TURP (n = 96)	IIEF-5	IIEF-5 scores significantly improved for both PKRP and TURP groups (p<.001)	PKRP had a higher postoperative IIEF-5 than those in the TURP group after controlling for baseline IIEF-5(p<.001)	The IPSS significantly decreased from baseline to 12 months in both groups (p<.001). No statistically significant difference between groups. Qmax significantly improved from baseline to 12 months in both groups but the Qmax was significantly higher in the PKRP group than in the TURP (p<.001)
Giulianelli et al. 2013 [36]	Prospective, randomised controlled study 160 participants	Evaluate the efficacy and safety of plasma kinetic energy (Gyrus electro surgical system), which produces vaporisation of tissue immersed in isotonic saline against standard monopolar TURP	Patients excluded due to suspected prostate cancer, bladder calculus, neurogenic bladder, previous prostate surgery, renal impairment, associated hydronephrosis and urethral stricture	1, 3, 6, 12, 18, 24, 30, and 36 months	Monopolar TURP (n = 80) Bipolar TURP (n = 80)	IIEF-5	IIEF-5 significantly improved in both groups at all intervals (p<.0001)	No statistically significant difference in IIEF-5 scores between groups	IPSS, QOL, PSA, Qmax and PVR all improved significantly in both groups at all intervals (p<.0001)
Pisco et al. 2013 [13]	Prospective, non-randomised (patients chose interventional option) 89 participants	To prospectively evaluate the safety, morbidity and short and intermediate term results of PAE for BPH after failure of medical treatment.	>50 years old IPSS > 18 QOL > 3 Qmax <12 mL/s Prostate size > 40 g No malignancy No advanced atherosclerosis or tortuosity of the iliac arteries	1, 3, 6, 12, 18, and 24 months	Prostatic arterial embolisation	IIEF	IIEF score significantly improved (p=.003)	IIEF scores improved in 31 patients while the remaining patient’s scores remained stable from baseline	IPSS significantly decreased (p<.0001) QOL score decreased (p<.0001) Postvoid residual volume (PVR) significantly decreased (p=.002) PSA level significantly decreased (p<.0001) Qmax significantly increased (p<.0001)
Terrasa et al. 2013 [14]	Prospective, single arm study from a single centre of patients between August 2007 and November 2011 102 participants	To comprehensively evaluate the impact of PVP on sexual function	Patients who needed surgical relief of bladder outlet obstruction due to benign prostatic obstruction and who described themselves as being sexually active.	12 months	PVP with the GreenLight^TM HPS 120 W device	Danish prostate symptom score and sexual function DAN-PSSsex 7 item Likert scale assessing sexual satisfaction	Global sexual satisfaction score improve (p=.047) All bother scores (questions 1B, 2B, and 3B) improved after surgery (p=.019, p=.0006, and p=.044)	Erection symptoms and pain during ejaculation symptom scores were globally unchanged (p=.36 and .91, respectively) Through a multivariable model, the global improvement of sexual satisfaction was shown to be explained only by I-PSS variation (p=.006)	IPSS, Qmax and PVR all significantly improved at 12 months (p<.0001)
Elshal et al. 2012 [15]	Longitudinal study of the prostate unit database (2 randomised controlled trials and another 27 patients) 191 participants	To assess the change and predictors of sexual-related outcomes after laser prostate surgery	Inclusion criteria not stated	1, 6, and 12 months	HOLEP (n = 99) HOLAP (n = 34) GreenLight PVP (n = 58)	IIEF-15	Significant improvement in mean overall score, erectile function, desire, and intercourse satisfaction domains of IIEF in the HOLEP group (p<.05)	Significant difference among the three groups in overall IIEF-15 at 1 year: unchanged in 22.2%, 24.4%, and 29.3%, improvement in 60.6%, 29.4%, and 41.4% and decline in 17.2%, 41.2%, and 29.3% in the HOLEP, HOLAP, and PVP groups, respectively (p<.05)	All groups showed significant improvement in IPPS, Qmax and post voiding residual urine reduction (p<.05)
Woo et al. 2012 [16]	Prospective, multicentre, single-arm study. 64 participants	Determine the effect of the PUL procedure on erectile and ejaculatory function	≥55 years IPSS > 13 Qmax of 5–12 mL/s PRV of <250 mL Serum PSA of <10 ng/mL	6 weeks, 3, 6 and 12 months	PUL	SHIM (IIEF-5) MSHQ-EjD MSHQ-EjD Bother	Significant improvement in SHIM at 3 and 12 months as compared to baseline (p=.01)	No reported reduction in erectile function. Analysis showed erectile function was preserved through 12 months independently of initial ED condition. No reported retrograde ejaculation at any follow-up visit. MSHQ-EjD significantly improved at 6 weeks and 3 months (p<.001)	IPSS statistically improved at all time points (to be presented in further detail in a future report)
Jaidane et al. 2010 [17]	Prospective, controlled study 100 participants	To assess the effects of TURP on erectile function	TURP group – BPH with LUTS and/or PVR and reporting sexual activity over the last 6 months No cancer, previous prostatic surgery TURBT group – superficial tumour, reporting sexual activity No other cancers, bladder outlet obstruction due to BPH, previous prostatic surgery.	3 and 6 months	TURP (n = 50) TURBT (n = 50)	IIEF-15	TURP group had a statistically significant improvement in mean IIEF-15 global score at 3 months (p<.0001) Statistically significant improvement in mean score in four of five subdomains of IIEF-15 (erectile function, orgasmic function, intercourse satisfaction and overall satisfaction)	No significant change in the sexual desire subdomain score. No statistically significant changes between 3 months and 6 months scores. The TURP group was statistically inferior to the mean IIEF-15 global score in the TURBT group. 70% incidence of retrograde ejaculation	Hospital Anxiety and Depression Scale improved significantly IPSS significantly improved.
Paick et al. 2007 [18]	Retrospective study. 57 participants	Evaluate the impact of high-power KTP photoselective laser vaporisation of the prostate on erectile function in men with LUTS/BPH	Failed previous medical therapy with alpha-blockers Patients who underwent KTP laser vaporisation of the prostate from December 2005 to June 2006 In a stable and heterosexual relationship within 4 weeks of the procedure and during follow up Not on 5 alpha reductase inhibitors, no indwelling catheter, no previous prostatic surgery, no urethral stricture, no malignancy	4 weeks, 6 months	KTP photoselective vaporisation	IIEF-15	Total IIEF significantly increased after KTP photoselective vaporisation of the prostate (p=.010) Erectile function domain significantly improved after KTP photoselective vaporisation (p=.015) All other IIEF domains improved 6 months after surgery (p<.05)	6 patients reported retrograde ejaculation (13.3%)	IPSS, mean QoL, Qmax and PVR all significantly improved after treatment (p<.001)
Meng et al. 2007 [19]	Prospective, single arm 108 participants	Evaluate the effect of Ho:YAG laser enucleation of the prostate (HoLEP) to the sexual function of patients with BPH	Patients with BPH for at least 2 years	6 months	HOLEP	DANPSS sex	Significant change was observed for early morning erections, which increased from 45% to 62% (p<.01)	No other statistically significant changes to erectile function. 70% of patients reported retrograde ejaculation	PVR, Qmax, nocturia frequency and IPSS all improved significantly after 6 months (p<.01)
Gacci et al. 2003 [37]	Prospective, single arm study. 60 participants	Evaluate urinary symptoms, sexual dysfunction and quality of life in patients with BPH before and after open transvesical prostatectomy (modified Freyer technique)	Prostatic adenoma of >60 mL Coexistent urinary disorders were excluded Peyronie’s disease excluded	6 months	Open Prostatectomy	IIEF	Significant increase in “sexual desire” and “overall satisfaction” domains of the IIEF (p=.0024)	No significant changes for “erectile function”, “intercourse satisfaction” and “orgasmic function” domains. Slight but not significant improvement in “erectile function” domain (p=.25)	IPSS, ICS-BPH, Qmax and PVR all improved significantly following open prostatectomy (p<.001)
Brookes et al. 2002 [20]	Multicentre pragmatic randomised controlled trial 340 participants	Examine the impact on sexual function of treatments for LUTS in men	IPSS ≥8 Qmax < 15 mL/s Excluded those with a life expectancy less than 6 months, evidence of prostate cancer, previous prostatic surgery, neuropathic bladder function, serum creatinine concentration >250 µmol/l, or prostate size >120 cm^3	7.5 months follow up	TURP group (n = 117) Non-contact laser therapy group (n = 117) Conservative management (n = 106)	International continence and sexual functional score (ICSsex)	Significant improvement in erectile function of the TURP (p=.012) and significant reduction in pain or discomfort (p=.0064)	Ejaculatory function was significantly worse after all three treatment methods (p<.005)	No data given
Francisca et al. [21]	Prospective randomised trail Level 1b A total of 147 patients recruited and randomized to undergo either TUMT or TURP 122 patients out of 147 were evaluated and assessed.	We evaluate changes in sexual function in patients treated with high energy transurethral microwave thermotherapy (TUMT) compared to transurethral resection of the prostate (TURP)		Pre-op, at 3 and 12 months after treatment	Group 1, 66 (54%) patients were randomized to TUMT vs. group 2, 56 (46%) to TURP	A self-administered questionnaire which evaluated sexual function. Questionnaire dealt with domains, such as social status, libido, erection, intercourse, ejaculation and overall satisfaction. Assessment also included medical history, symptom score, digital rectal examination, prostate specific antigen, urinalysis, transrectal ultrasonography of the prostate, uroflowmetry, post-voided residual measurement and urodynamic investigations with pressure flow studies.	In group 2, more patients had morning erections at 3 months (p=.025)	Significantly more patients undergoing TURP (36%) had changes in sexual function compared to TUMT group (17%). The TUMT group was more satisfied with the sex life. Of these patients 55% graded sex as very satisfying compared to 21% in TURP. In general, older patients had sexual dysfunction more often, while younger patients had pain during sexual activities more frequently.
Kunelius et al. 1998 [22]	Prospective, single arm Study 155 participants	Evaluate the sexual function of patients with benign prostatic hyperplasia before and after TURP	Patients who had been referred for elective electroresection of the prostate in a period of 1 year at the University of Oulu.	6 and 12 months	TURP	Authors Own Questionnaire – 22 points pertaining to various aspects of sexual function	A significant increase in the number of patients reporting early morning erections – 53% before TURP and 83% after (p<.01)	No statistically significant difference in other aspects including overall satisfaction with sex life, successful intercourse, coital frequency, libido, erection quality and orgasm.

Results

Six hundred and ninety-two studies were found from the initial search of PUBMED, EMBASE, WEB of SCIENCE, and SCOPUS databases. Two hundred and ninety-six duplicate studies were found. Thirty-seven non-English studies were excluded consisting of 11 French, 10 Chinese, five German, four Russian, three Japanese, three Italian, and one Spanish study. Eighty-eight review articles were then removed, but relevant reviews were searched for original studies and were discussed. Fifty-nine conference abstracts and one book were also removed. Fifty-eight studies which were non-relevant and 38 studies that had poor data on sexual function were then removed. Of these non-relevant studies to this review, the majority were assessing pharmacological treatment of BPH. We were unable to access the full text of four studies.

Studies were then divided into those that showed; statistically significant improvement in at least some aspect of sexual function (16 studies), no significant change in sexual function (87 studies) and those that showed a significant reduction in at least some aspect of sexual function (eight studies). The 16 studies that showed a significant improvement in at least some aspect of sexual function were mainly focused on in the discussion.

Discussion

Of the 111 original English articles which were relevant and had reliable data; 87 showed no significant change in any aspect of sexual function; eight showed a significant reduction and 16 studies showed significant improvement in some aspect of sexual function. This is interesting in light of the consensus being that surgical treatment of LUTS/BPH poses a significant risk of erectile dysfunction, hence this often features as a risk which is addressed as part of the consent process. Bearing this in mind, still the majority of these studies (87) showed no statistically significant change in erectile function following treatment, which would suggest while there is a risk of erectile dysfunction, this is relatively low and actually patients have more chance of having improvement in erectile function than reduction. Interestingly, a study conducted by Bardoli et al., focused on specific surgical technique used to treat symptomatic BPH and concluded that patients that underwent the Prostatic Urolift procedure did not suffer any sexual dysfunction side effects [23].

Of the 16 studies, the techniques which showed improvement in sexual function (see Figure 1) were: Aquablation, Transurethral Enucleation of the Prostate, Prostatic Urethral Lift, Monopolar/Bipolar/Unspecified TURP, Plasmakinetic Resection of the Prostate, Prostatic Arterial Embolisation (PAE), Photovaporisation of Prostate (Greenlight PVP), Holmium Laser Enucleation of the Prostate (HoLEP), KTP photoselective vaporisation, open prostatectomy. Interestingly, although TURP is the technique mostly associated with sexual dysfunction, in this review it was the technique with the most studies showing improvement in sexual function with seven out of the 16 studies quoting this in their series.

Figure 1. Results.

Throughout the studies reviewed, the International Index of Erectile Function (IIEF) was the most popular method of assessing erectile function in participants, whether that be the short version (IIEF-5) or the non-altered version (IIEF-15). Eleven out of the 16 studies used IIEF-15, which in general is good as there is consistency within the community so research is more standardised making it easy to compare. Interestingly, McVary et al. [11] found that participants entering with severe erectile dysfunction had significantly improved IIEF-5 scores following transurethral prostate convective water vapor thermal energy (Rezum). Henceforth, it is reasonable to deduce there could exist an indirect predictive variable between severe erectile dysfunction prior to surgery, that is the worse the erectile function prior to surgical treatment, the more the patient has to gain in erectile function due to treatment. A study conducted by Pavone et al. [24] had reported a similar finding, this time using TURP. In their study, they found that no patients who had good erectile function before TURP improved their erectile function. On the other hand, 16.2% (22 out of 136 participants) of the cohort who had mild or moderate erectile dysfunction before TURP improved their erectile function; although, these results were not statistically significant.

Furthermore, it is important to note and counsel patients accordingly, that patients with normal or good erectile function initially are at more risk of having a reduction in erectile function following treatment. Bruyère et al. [25] examined the effect of photoselective vaporization (PVP) of the prostate on sexual function and found that one subgroup, patients with normal preoperative erectile function, showed a significant decrease after treatment. Overall, it is safe to argue that patients with normal/good preoperative erectile function have more to lose and those with severe erectile dysfunction preoperatively have more to gain with regards to postoperative erectile function, and this is essentially could be a factor to consider when counselling patients prior to surgery.

Furthermore, although the articles which showed no statistically significant improvement in erectile function of their candidates did note that individuals or groups within their cohort in-fact improved their erectile function post-intervention. Choi et al. [26] found that although overall their cohort of patients had a reduced IIEF score 3 months after TURP, which did improve to no significant change at 6 months. In addition, it was found that patients who had better voiding symptoms after TURP had improved erectile function the reasons for which remain unknown. Kim et al. [27] also found a correlation where sexual satisfaction scores improved significantly with the improvements in LUTS and QoL following HoLEP. In addition to this, more novel laser techniques have been utilised in the treatment of symptomatic BPH such as Thulium Laser Enucleation of Prostate (ThuLEP); however, the long-term effects of this technique have not been fully investigated such as its effect on sexual function, rather more emphasis has been placed on the short-term outcomes such as post-operative bleeding and failed trial without a catheter (TWOC) [28]. One study compared TURP, transurethral microwave thermotherapy (TUMT), interstitial laser coagulation of the prostate (ILC), and transurethral needle ablation TUNA and did report a 20.4%, 15.2%, 7.9%, and 17.1% increase in erectile function scores following the respective treatments; although, these were not statistically significant [29].

Some of the excluded studies which showed no change or a reduction in erectile function could have had subgroups or a number of participants who did have an improvement in erectile function like the studies discussed above; however, they did not state this. Data on individual patient improvements would be beneficial to see any factors which would give patients a better chance of improving erectile function following treatment.

Although the 111 studies focus on assessing erectile function and of these 111, 16 showed improvement following surgical treatment, the other benefits and risks still need to be assessed for each treatment to weigh up whether overall it is suitable for the individual patient. The majority of studies did assess other outcomes such as peak urinary flow, post voidal residual volume, LUTS and QoL and in general these all did significantly improve after treatment. However, only a few studies reported on adverse effects such as retrograde ejaculation [9,11,17] and incidence reported is between 0 and 70%. This can have impacts on patients’ fertility and is a factor of sexual function, hence again must be addressed appropriately during the consent process.

More recently, a number of studies evaluating the effectiveness of the PUL method to treat BPH showed significant improvements in ejaculatory function [30–35], although they did not show any significant changes in erectile function. Importance must also be given to ejaculatory function as this may be an important factor for the patient’s psychological well-being and could be potentially considered for individual patients.

Limitations of the review

We acknowledge limitations of this review, for instance there is no single uniform definition of “sexual dysfunction”, which is used as a point of reference in the papers. In addition, throughout the review there is a variation in the use of the IIEF score. Although IIEF was the most popular method of assessing erectile function in participants, both the short version (IIEF-5) and the non-altered longer version (IIEF-15) were employed by some authors in this series. In this respect, both are validated scoring systems; however, it may affect the direct comparability of the cohorts.

Thirty-seven articles were excluded, as they were not in English with no translation available. Although unlikely, it is possible that there could have been some important data in these articles that may have changed the overall conclusion of this review.

Finally, the studies in general had good data on their participants’ baselines which included age, prostate volume, urinary flow and baseline erectile function. However, upon closer inspection other patient factors such as ethnicity, patient co-morbidities and concomitant medications were not mentioned. It would have been interesting to see if there was any correlation as to whether any patient factors had an impact on improving erectile function.

Conclusions

Although surgical intervention for BPH is assumed to have a negative impact on erectile function, this may appear to be an exaggeration of the true extent of harm and deterioration, as the majority of studies show no significant change in erectile function, with the converse of more of studies reporting an improvement. Overall, it is imperative that surgeons counsel their patients appropriately with regards to a potential risk of decline in erectile function and gain fully informed consent.

Disclosure statement

No potential conflict of interest was reported by the authors.