Andrologic Sequelae in Prostatitis Patients



Fig. 12.1
Endocrine abnormalities leading to prostatic inflammation (Adopted from Pontari et al. [2] and Meng et al. [4])





12.3 Treatment of Low Testosterone in Patients with CP/ CPPS


Men with low testosterone may display symptoms of fatigue, sexual dysfunction, and decreased libido in addition to the common symptoms produced by CP/CPPS. These men will benefit from serum testosterone analysis and replacement therapy if a deficiency is found. While there is a paucity of literature on testosterone replacement therapy for hypogonadal patients with CP/CPPS, a recent study by Pang et al. has shown promising data [5]. Their study involved 48 patients, all of whom had a CP/CPPS history for at least 1 year, a score of at least 15 on the NIH-Chronic Prostatitis Symptom Index (NIH-CPSI), and a serum total testosterone concentration of less than 300 ng/dl [5]. Patients were treated with testosterone undecanoate 80 mg orally twice a day for 12 weeks [5]. After 12 weeks follow-up patients had significant improvements in NIH-CPSI totals and testosterone levels. Patients also experienced a benefit in terms of anxiety and depressive symptoms [5]. This initial study illustrates the various symptomatic benefits testosterone replacement therapy may offer to hypogonadal patients with CP/CPPS.


12.4 Sexual Dysfunction


Sexual dysfunction as a sequela of prostatitis is an umbrella term which encompasses a number of impairments. This includes erectile dysfunction (ED), premature ejaculation (PE), and painful ejaculation. Whether symptoms are actually caused by a primary or secondary process is still up for debate. Some argue that the urinary symptoms experienced by patients and the resultant impact on quality of life contribute to the sexual dysfunction seen. Nonetheless, there is a growing body of evidence on the prevalence of sexual dysfunction in patients with CP/CPPS. A study done in Turkey of 96 patients with microscopic evidence of prostatic inflammation revealed sexual dysfunction in 84 % of patients [6]. In a study done in China of 1786 men with chronic prostatitis, the overall prevalence of sexual dysfunction was found to be 49 %, with 7.7 % having both premature ejaculation and erectile dysfunction [7]. In another study from Turkey, 15.2 % of patients were found to have premature ejaculation and erectile dysfunction together [8]. Men who report both ED and ejaculatory difficulty also experience worse NIH-Chronic Prostatitis Symptom Index scores [9, 10]. It is important to note that when discussing the prevalence of the various sexual dysfunctions experienced by men with CP/CPPS, the statistics provided must be taken with a grain of salt. It has been recognized that the vast majority of evidence is based on questionnaire studies. This may limit the generalizability to practice; nonetheless the evidence is still compelling and can illuminate likely trends [11].


12.5 Erectile Dysfunction


Erectile dysfunction is defined as the consistent inability to achieve or maintain an erection for successful intercourse. Investigations on the prevalence of ED in men with CP/CPPS have reported varying numbers. One Chinese study estimated that the prevalence of ED in patients as assessed by the International Index of Erectile Function (IIEF-5) was 35.1 % [12]. A study performed in Italy of 399 men with symptoms of CP/CPPS found ED in 34 % [10]. A study of 296 patients in Malaysia found a component of ED either as a single symptom or in combination with ejaculatory dysfunction in 67 % of their study population [9]. A link between ED and a previous diagnosis of CP/CPPS has also been found. One case-control study reported that men with ED were more than three times more likely to have had previous CP/CPPS [13]. In terms of describing the underlying mechanism of ED in men with CP/CPPS, the research is scarce. There are, however, a few leading theories that should be discussed. Firstly, some patients may experience ED secondary to a low androgen status. Testosterone is hypothesized to exert its action on erectile function through peripheral and central mechanisms [14]. The frequency of sexual dysfunction increases as serum testosterone decreases and especially occurs with concentrations less than 225 ng/dl [10]. Other theories point to a vascular cause of ED. Prostatic inflammation may impair smooth muscle relaxation and vascularization of the prostate leading to suboptimal penile engorgement [13]. Additionally, it has been shown that men with CP/CPPS may have increased arterial stiffness resulting in a decreased filling of penile tissue with blood [15]. Afferent arterioles may also be externally compressed secondary to pelvic floor spasm exacerbating symptoms of ED [16]. Finally, there is an established association of CP/CPPS with psychogenic stress. Mood alterations secondary to pain and voiding dysfunction tend to reduce the frequency of sexual intercourse and contribute to a functional rather than an organic cause of ED. Any one of these mechanisms may contribute to ED in this patient population; however, a combination of physical and psychologic stress is likely responsible. The biologic rationale supported with the evidence of a high prevalence suggests that screening for ED among individuals with CP/CPPS is warranted.


12.6 Premature Ejaculation (PE)


PE is a poorly understood form of sexual dysfunction that is found to be commonly experienced by many healthy men. The definition has been established to encompass three main scenarios: ejaculation which occurs in a short time of vaginal penetration, usually within 1–3 min, the inability to delay ejaculation on nearly all vaginal penetrations, or a latency time that causes negative personal consequences such as distress or the avoidance of sexual intimacy in either the patient or partner. In line with the normal population of men, the actual prevalence of PE in men with CP/CPPS has not been established. There have, however, been a number of estimates cited in literature. One study from Turkey of 66 patients with CP/CPPS reported a 77.3 % PE rate [8]. An Italian study found a prevalence of premature ejaculation in their patient group to be 61.5 % [17]. A Chinese study of 600 men with CP/CPPS reported a PE prevalence of 30 % [18]. The differences in ethnicities and cultural attitudes toward sex may be an explanation for the spread of prevalence rates reported by these studies. Nonetheless, patients should be screened for symptoms of PE as the correlation with CP/CPPS has been consistently demonstrated. While the mechanism underlying the association of PE with CP/CPPS has not been clearly defined, two theories may explain the link. The first is the concept that prostatic inflammation alters sensation and the ejaculatory reflex. The resultant impairment of sensory feedback occurs prior to orgasm and may explain the mechanism of PE seen in patients with CP/CPPS [17]. A second theory is that patients with CP/CPPS may experience a significant amount of stress, depression, or anxiety. As a result of these psychologic factors, PE may develop. Ultimately, it is likely a combination of both biologic and social stressors plays a role in the development of PE.


12.7 Painful Ejaculation


Painful ejaculation is a pelviperineal pain caused by ejaculation or orgasm, and its prevalence rate is varied between 1 and 4 % in the general population [19]. Painful ejaculation is frequently seen in patients with CP/CPPS and has its own question within the NIH-CPSI [19]. The prevalence of painful ejaculation in CP/CPPS patients may range from 38 to 54 % based on reports from different studies [6, 9]. Men with painful ejaculation are more likely to be afflicted with additional symptoms. One multicenter study of 3700 patients found that of patients with painful ejaculation, 72 % also experienced erectile dysfunction. CP/CPPS patients with painful ejaculation also reported worse NIH-CPSI and quality of life scores [20]. The pathophysiologic explanation of painful ejaculation in patients with CP/CPPS is largely based on the inflammatory milieu seen in the prostate of these patients. With ejaculation, the contraction of an inflamed and irritated prostate gland can lead to severe pain and in many instances cause the patient to abstain from sexual activities [19].

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Jul 17, 2017 | Posted by in UROLOGY | Comments Off on Andrologic Sequelae in Prostatitis Patients

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