Rustamov M N, Galiullin O F, Vinarov A Z
Institute of Urology and Human Reproductive Health, FGAOU VO I.M. Sechenov First Moscow State Medical University, Moscow, Russia.
National Medical Research Center of Urology on Urology, Moscow, Russia.
Urologiia. 2023 Mar(1):46-52.
Ejaculation disorders occur in 62-75% of patients after surgical treatment for benign prostatic hyperplasia (BPH). Despite the development and widespread introduction into clinical practice of laser procedures, which have reduced the overall incidence of complications, the frequency of ejaculatory disorders is still high. This complication negatively affects the quality of life of patients.
To study the nature of ejaculation disorders in patients with BPH after surgical treatment. In this work, we did not compare the effect of various surgical methods and techniques in patients with BPH on ejaculation. At the same time, we selected the most widely used procedures in routine urological practice and assessed the presence and development of ejaculatory dysfunction prior to and after surgery. It should be emphasized that we determined the disorders that occurred in the same patients in whom ejaculatory function was evaluated prior to surgery.
A prospective study of the ejaculatory function of 224 sexually active men aged 49 to 84 years with LUTS/ BPH before and after surgical treatment was performed. From 2018 to 2021, thulium laser enucleation of prostatic hyperplasia (ThuLep) was done in 72 patients, conventional TURP in 136 patients, and 16 patients underwent open transvesical simple prostatectomy. Surgical treatment was carried out by certified urologists with extensive experience. ThuLep and conventional TURP were not ejaculatory-sparing. All patients underwent a standard examination for LUTS/ BPH pre- and postoperatively, including IPSS score, uroflowmetry to determine the maximum urine flow rate (Qmax), PSA, urinalysis, transrectal ultrasound examination with a calculation of prostate volume, postvoid residual. The erectile function was assessed according to the IIEF-5 score. Ejaculation function was evaluated according to the Male Sexual Health Questionnaire (MSHQ-EjD) preoperatively and at 3- and 6-months follow-up. For the diagnosis of premature ejaculation, CriPS questionnaire was used. For the differential diagnosis of retrograde ejaculation and anejaculation after surgical treatment, patients underwent an analysis of post-orgasmic urine for the presence and quantity of spermatozoa.
The average age of patients was 64 years. At baseline, various ejaculatory disorders were detected in 61.6% of cases. In 48.2% of patients (n=108) a decrease in the ejaculate volume was found, while 47.3% (n=106) noted a decrease in the intensity of ejaculation. In 15.2% of cases (n=34), acquired premature ejaculation was detected, and 17% (n=38) men reported pain or discomfort during ejaculation. In addition, 11.6% (n=26) had delayed ejaculation during intercourse. There were no patients with anejaculation at baseline. The average score on the IIEF-5 scale was 17.9, and on the IPSS scale 21.5 points. Three months after surgical treatment, the following disorders of ejaculation were documented: retrograde ejaculation in 78 (34.8%), anejaculation in 90 (40.2%) patients. In the remaining 56 (25%) men, antegrade ejaculation was preserved. Among those with antegrade ejaculation, an additional survey was carried out, which showed a decrease in ejaculate volume and in the intensity of ejaculation in 46 (20.5%) and 36 (16.1%) cases, respectively. Pain during ejaculation was noted by 4 (1.8%) men, however, there was neither premature nor delayed ejaculation after surgical treatment.
In patients with BPH, the predominate types of ejaculation disorders before surgical treatment were as following: a decrease in ejaculate volume (48.2%), a decrease in the speed (intensity) of ejaculation (47.3%), painful ejaculation (17%), premature ejaculation (15.2%), and delayed ejaculation (11.6%). After surgical treatment, retrograde ejaculation (34.8%, n=78) and anejaculation (40.2%, n=90) prevailed.
良性前列腺增生（BPH）手术治疗后，62%-75%的患者会出现射精功能障碍。尽管激光手术已得到发展并广泛应用于临床实践，且降低了总体并发症发生率，但射精功能障碍的发生率仍然很高。这种并发症对患者的生活质量产生负面影响。
研究BPH手术治疗后患者射精功能障碍的性质。在本研究中，我们未比较不同手术方法和技术对BPH患者射精功能的影响。同时，我们选择了泌尿外科常规实践中最常用的手术方式，并评估手术前后射精功能障碍的存在情况和发展变化。需要强调的是，我们确定的是在手术前评估过射精功能的同一批患者中出现的功能障碍。
对224例年龄在49至84岁、有下尿路症状/良性前列腺增生（LUTS/BPH）且性功能活跃的男性患者进行前瞻性研究，观察其手术治疗前后的射精功能。2018年至2021年期间，72例患者接受了前列腺增生铥激光剜除术（ThuLep），136例患者接受了传统经尿道前列腺电切术（TURP），16例患者接受了开放性经膀胱单纯前列腺切除术。手术由经验丰富的认证泌尿外科医生进行。ThuLep和传统TURP都不能保留射精功能。所有患者在手术前后均接受了LUTS/BPH的标准检查，包括国际前列腺症状评分（IPSS）、尿流率测定以确定最大尿流率（Qmax）、前列腺特异抗原（PSA）、尿液分析、经直肠超声检查并计算前列腺体积、残余尿量。根据国际勃起功能指数-5（IIEF-5）评分评估勃起功能。术前以及术后3个月和6个月随访时，根据男性性健康问卷（MSHQ-EjD）评估射精功能。对于早泄的诊断，使用早泄诊断问卷（CriPS）。为鉴别手术治疗后逆行射精和无射精，患者接受了射精后尿液分析，以检测精子的存在情况和数量。
患者的平均年龄为64岁。基线时，61.6%的病例检测到各种射精功能障碍。48.2%的患者（n = 108）精液量减少，而47.3%（n = 106）的患者射精强度降低。15.2%的病例（n = 34）检测到获得性早泄，17%（n = 38）的男性报告射精时疼痛或不适。此外，11.6%（n = 26）的患者性交时射精延迟。基线时没有无射精的患者。IIEF-5量表的平均评分为17.9分，IPSS量表平均评分为21.5分。手术治疗3个月后，记录到以下射精功能障碍：逆行射精78例（34.8%），无射精90例（40.2%）。其余56例（25%）男性保留了顺行射精。在保留顺行射精的患者中，进行了进一步调查，结果显示分别有46例（20.5%）和36例（16.1%）精液量和射精强度下降。4例（1.8%）男性报告射精时疼痛，然而，手术治疗后既没有早泄也没有射精延迟。
在BPH患者中，手术治疗前射精功能障碍的主要类型如下：精液量减少（48.2%）、射精速度（强度）降低（47.3%）、射精疼痛（17%）、早泄（15.2%）和射精延迟（11.6%）。手术治疗后，逆行射精（34.8%，n = 78）和无射精（40.2%，n = 90）最为常见。
