Lower Urinary Tract Symptoms and Male Sexual Dysfunction: The Multinational Survey of the Aging Male (MSAM-7)

Abstract

Objectives: Lower urinary tract symptoms (LUTS), which are often caused by benign prostatic hypertrophy (BPH), and sexual dysfunction are common in older men, with an overall prevalence of >50% in men aged ≥50 years. Men with LUTS have been reported to experience sexual dysfunction, including ejaculatory loss, painful ejaculation, and erectile dysfunction. This study was conducted to investigate the relationship between LUTS and sexual problems in aging men.

Methods: A large-scale, multinational survey was conducted in the US and six European countries to systematically investigate the relationship between LUTS and sexual dysfunction in older men. Detailed questionnaires were mailed to a national representative sample of men aged 50 to 80 years in each country. Selection was made on the basis of age, occupation, geographic region, and population density. LUTS and sexual function were assessed by validated symptom scales, including the International Prostate Symptom Score, the Danish Prostatic Symptom Score, and the International Index of Erectile Function. Subjects also completed a health and demographics questionnaire.

Results: A total of 34,800 surveys were mailed out, 14,254 were completed and returned, and 12,815 were deemed evaluable and included in the analysis. Results were consistent from one country to another. Although 90% of the men had LUTS, only 19% had sought medical help for urinary problems and only 11% were medically treated. Sexual activity was reported by 83% of the sample, with 71% reporting at least one episode of sexual activity during the previous 4 weeks. Sexual disorders and their bothersomeness were strongly related to both age and severity of LUTS. The relationship between sexual problems and LUTS is independent of comorbidities such as diabetes, hypertension, cardiac disease, and hypercholesterolemia.

Conclusions: Sexual activity is common in a majority of men over age 50 and is an important component of overall quality of life. The presence and severity of LUTS are independent risk factors for sexual dysfunction in older men. These results highlight the clinical importance of evaluating LUTS in patients with sexual dysfunction, and the need to consider sexual issues in the management of patients with benign prostatic hypertrophy.

Introduction

Lower urinary tract symptoms (LUTS) are a common, age-related condition in men. They are usually caused by benign prostatic hypertrophy (BPH), which is characterized by urinary frequency, urgency, decreased force of stream, and nocturia [1], [2]. Recent epidemiologic studies using validated symptom scales, such as the International Prostate Symptom Score (IPSS), have shown an overall prevalence rate of >50% in men aged ≥50 years [3], [4], [5]. Most cases of LUTS remain unmanaged; as a result, the disorder significantly affects quality of life (QoL) in many aging men and may progress to acute urinary retention [3], [6], [7]. A variety of invasive and noninvasive treatments provide symptomatic relief, but also result in side-effects in the majority of patients; this has to be taken into account when choice of treatment is considered [8], [9].

Traditionally, little attention has been given to the association between LUTS and sexual dysfunction, despite the high prevalence of both conditions in aging men. The widely cited Massachusetts Male Aging Study (MMAS) showed that 34.8% of men aged 40–70 years had moderate to complete erectile dysfunction (ED), which was strongly related to age, diabetes, depression, and cardiovascular disease [10]. LUTS were not considered a potential risk factor for ED in this study. However, more recent studies, examining clinic as well as community samples, have shown a significant association between LUTS and male sexual dysfunction [10], [11], [12], [13], [14]. Of note, both erectile and ejaculatory problems were reported more frequently in men with moderate-to-severe LUTS [15].

The specific mechanisms by which LUTS affect sexual function in aging men have not been elucidated, nor have previous studies controlled adequately for the confounding effects of age or common comorbidities such as hypertension and hypercholesterolemia [16]. Sexual problems may be exacerbated by surgical or nonsurgical treatments for LUTS, although results have varied from study to study [17], [18], [19], [20]. Surprisingly, a recent study showed improvement in LUTS symptoms following the management of ED with sildenafil [21].

The Multinational Survey of the Aging Male (MSAM-7), a large-scale, multinational survey, was conducted to systematically investigate the relationship between LUTS and sexual problems in aging men. Approximately 14,000 men aged 50–80 years were surveyed in the US and six European countries—the UK, France, Germany, the Netherlands, Italy, and Spain.