There is a paucity of published literature on the andrological consequences of urethral repair. Until recently authors have focused mainly on technical aspects and objective results. Reported outcomes of urethral reconstruction surgery have traditionally focused only on urodynamic parameters such as flow rates. Patient reported outcome measures have largely been neglected and there is a scarcity of well conducted systematic studies on the subject. For these reasons whether the different components of sexual life are more or less affected by different types of urethral reconstruction remains largely unknown. In an attempt to clarify the available scientific evidence, the authors make a critical review of available literature, systematizing it by sexual domain and study type. Brief pathophysiological correlations are discussed.
Urethral stenosis, although relatively uncommon in the universe of urologic diseases, is by no means a rare condition. It accounts for about 52% of urethral and 1.8% of urologic pathology, respectively, and presents an estimated prevalence of 0.6% [
At present, there is no doubt that reconstructive surgery in the form of different types of urethroplasty represents the “gold standard” in the treatment of these patients. Urethroplasty is associated with reproductively high success rates, when properly employed. There is enough data in the literature regarding the results obtained with several techniques, anastomotic or substitution. When objective variables such as flow rates are considered, several authors describe success rates that exceed in many cases 80% whether for anterior urethra, bulbar [
These data reflect however only one aspect of results, as patients carry out a substantially different perception of success than physicians, not only taking into account flow rates and radiological or endoscopic data. It is well known that there is a significant mismatch between what is considered a urethral reconstruction failure/success between treatment physicians and patients [
Although in recent years there has been a growing interest in relation to urethral stricture’s andrologic implications, the relationship between urethroplasty and erectile dysfunction, for example, remains controversial up to the present day. The existence of few specific studies, heterogeneous study populations, differing methodologies, and diversity of procedures analyzed makes it very difficult to provide definitive answers.
Consequences in aesthetics and change of body image, mostly related to the distal urethroplasties, have obvious potential impact in terms of self-esteem and possibly sexual behavior. Although of subjective nature, these aspects are particularly noticeable in multioperated hypospadias patients, a group of patients of increasing importance in percentage terms that pose a particularly difficult approach.
Concerning erectile and ejaculatory dysfunction, potentially injured structures in the course of urethroplasty include several arterial structures, nerve branches (autonomic and/or somatic), and eventually myogenic components.
There is a recognized potential for injury of branches of the Common Penile Artery, essential in the hemodynamics of erection in posterior urethroplasties, and of more distal vessels, of smaller and questionable practical importance, in anterior urethroplasties.
Equally important are neurogenic autonomic lesions due to the proximity of the neurovascular bundles to the membranous urethra, potentially damaged in instrumentation of the posterior urethra [
Of potential functional importance, though debatable and still practically in the field of scientific curiosity, are the neuronal connections identified between autonomic and somatic pelvic, perineal, and even genital nerve terminals, making the latter capable of nitrergic activity. Authors like Yucel and Baskin [
Finally, section and aggressive mobilization or denervation of the bulbospongiosus muscle to expose the bulbar urethra may result in more or less subtle changes in ejaculation dynamics, since the rhythmic contractions of the muscle during the expulsion phase are fundamental in seminal fluid expulsion [
A systematic review of several databases including PubMed, Cochrane Library, Embase, and Google Scholar was conducted. Systematic searches of these databases used terms as “urethroplasty,” “urethral reconstruction,” “urethral anastomosis,” “urethral stricture,” “urethral stenosis,” and “urethral obstruction,” and terms such as “erectile dysfunction,” “impotence,” “sexual dysfunction,” “ejaculatory dysfunction,” and “orgasmic dysfunction.” The search strategy used both keywords and MeSH terms and was limited to human studies.
The purpose of this study was to review the existing literature about the impact of urethroplasty in all domains of sexual function and to analyze it.
Literature is absolutely lacking in terms of evaluation of the aesthetic consequences of urethroplasties performed in adulthood for urethral strictures. We can only infer conclusions based on findings from literature in the context of hypospadiology, a study population with necessarily different and very particular characteristics.
Despite all the limitations pointed out, there are a few studies that looked specifically at the cosmetic aspect of the reconstruction of the penile urethra in this context that allow us at least some critical reflections.
Authors as Bubanj et al. [
Even et al. [
Although subject to wide variation in individual perception, these aspects must of course be considered in addressing these patients and integrated with the other facets of the pathology/treatment strategy.
There are few prospective studies with correct methodology, making use of fully validated questionnaires such as the IIEF (International Index of Erectile Function) or the BMSFI (Brief Male Sexual Function Inventory) specifically dealing with anterior urethroplasties. Table
Anterior urethra, erectile dysfunction: prospective studies.
Authors, year |
|
Questionnaire | Follow-up (months) | Age (median) | Results |
---|---|---|---|---|---|
Sharma et al., 2011 [ |
34 | BMSFI | 3 | 34,6 | Preop BMSFI: 10,21; postop: 10,34 |
|
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Anger et al., 2007 [ |
25 | IIEF | 6,2 | 39 | Preop IIEF: 62,6; postop: 59,6 |
|
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Dogra et al., 2011 [ |
78 | IIEF-5 | 15,5 | 38,1 | 38% of postop ED |
|
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Raber et al., 2005 [ |
30 | IIEF | 51 | 42 | Preop IIEF5: 24 |
|
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Erickson et al., 2010 [ |
52 | IIEF | 7,2 | 40,6 | Preop IIEF5: 18,7; postop:12,6 |
IIEF: International Index of Erectile Function; BMSFI: Brief Male Sexual Function Inventory; NSD: no statistical difference; SSD: statistically significant difference.
The only discordant study is from Erickson et al. [
Table
Anterior urethra, erectile dysfunction: retrospective studies.
Authors, year |
|
Questionnaire | Follow-up (months) | Age (median) | Results |
---|---|---|---|---|---|
Singh et al., 2010 [ |
150 | BMSFI | >3 | 40 | Mean preop BMSFI EF: 9,1; postop: 8,8 |
|
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Erickson et al., 2007 [ |
52 | BMSFI | 22,3 | 41,7 | Mean preop BMSFI EF: 9,2; postop: 8,8 |
|
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Coursey et al., 2001 [ |
174 | NVQ | 36 | 43,8 | 69,1% no difference in erectile function |
|
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Nelson et al., 2005 [ |
11 | IIEF | 56,4 | 30,6 | 0% ED |
|
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Morey and Kizer, 2006 [ |
22 | NVQ | 26,1 | 39,95 | No difference between end-to-end and extended anastomotic techniques or other types of penile surgery |
|
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Welk and Kodama, 2012 [ |
44 | NVQ | 40 | 27,6 | No difference between nontransecting APA and dorsal graft |
|
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Ekerhult et al., 2013 [ |
169 | NVQ | 12–132 | 16–75 | No difference between anastomotic repair and onlay |
IIEF: International Index of Erectile Function; ED: erectile dysfunction; BMSFI: Brief Male Sexual Function Inventory; NSD: no statistical difference; NVQ: nonvalidated questionnaire.
Other studies [
Concerning the studies included in Table
There are 3 additional prospective studies, presented in Table
Anterior and posterior urethra, erectile dysfunction: other prospective studies.
Authors, year |
|
Study type | Questionnaire | Follow-up (months) | Age (median) | Results |
---|---|---|---|---|---|---|
Lumen et al., 2011 [ |
20 | P | IIEF-5 | 6 | 48 | Mean preop IIEF5: 15; postop: 11,62 |
|
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Xie et al., 2009 [ |
125 | P |
IIEF-5 |
27,3 | ? |
Mean preop IIEF5: 16,57; postop: 17,22 |
|
||||||
Johnson and Latini, 2011 [ |
37 | P | IIEF-5 | 9 | 45 | Mean preop IIEF5: 15; postop: 10 |
IIEF: International Index of Erectile Function; SLQQ: Sexual Life Quality Questionnaire; ED: erectile dysfunction; BMSFI: Brief Male Sexual Function Inventory; NSD: no statistical difference; P: prospective.
Lesions of the posterior urethra, associated with the overwhelming majority of cases to traumatic injuries of the pelvic ring, are unequivocally linked to erectile dysfunction, either by direct damage to neurovascular structures or by indirect action of edema, inflammation, and fibrosis. Presence of urethral trauma in pelvic fractures is a widely documented risk factor of erectile dysfunction. 42% of patients with pelvic fracture and urethral lesions had ED compared with only 5% of patients with fractures and without urethral injury [
Table
Posterior urethra, erectile dysfunction.
Authors, year |
|
Study type | Questionnaire | Follow-up (years) | Age (median) | Results |
---|---|---|---|---|---|---|
Anger et al., 2009 [ |
26 | R | IIEF | 4,4 | 40,2 | 54% ED |
|
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Corriere, 2001 [ |
60 | R | ? | 27,3 | 35 | 33% “complete” ED |
|
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Shenfeld et al., 2003 [ |
25 | D | — | <3 | 28,6 | 72% preoperative ED |
|
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Koraitim, 2005 [ |
155 | R | — | 1–22 | 21 | 34% “definitive” ED |
|
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Mundy, 1996 [ |
82 | R | ? | >5 | ? | 7% “permanent” ED |
|
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Yin et al., 2011 [ |
76 | R | — | 42,5 | 34,5 | 95% remained potent |
|
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Lumen et al., 2009 [ |
61 | R | — | 5,58 | 34 | 32,8% ED previous to surgery |
|
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Onen et al., 2005 [ |
49 | R | NVQ | 12 | 20 | 18,4% ED at last follow-up |
|
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Mouraviev et al., 2005 [ |
96 | R | — | 8,8 | ? | 34% after realignment |
|
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Tunç et al., 2000 [ |
58 | R | — | 3,9 | 24,2 | 16,2% |
|
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Aboutaieb et al., 2000 [ |
35 | R | — | ? | 25 | 18,3% ED early repair |
|
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Morey and Mcaninch, 1997 [ |
82 | R | — | >1 | ? | 54% ED previous to repair |
|
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Corriere et al., 1994 [ |
50 | R | — | >1 | ? | 48% ED previous to repair |
IIEF: International Index of Erectile Function; NVQ: nonvalidated questionnaire; ED: erectile dysfunction; P: prospective; R: retrospective; D: descriptive.
Koraitim [
Analyzing 76 patients with a follow-up ranging from 14 to 74 months, Yin et al. [
Tunç et al. [
Morey and Mcaninch [
Finally, we can make use of a subanalysis of six studies specifically dealing with posterior urethroplasties, analyzing erectile function before and after urethroplasty, encompassed in a broader meta-analysis, discussed later [
With the limitations already mentioned, posterior urethroplasty does not seem to play a significant deleterious effect
Two fairly recent meta-analysis sought to systematize the available studies and shed some light on the subject (Table
Meta-analyses, erectile dysfunction.
Meta-analyses | Studies |
|
Urethroplasty | Results |
---|---|---|---|---|
Feng et al. [ |
23 | 1729 | Anterior and posterior urethroplasty | No significant difference before or after urethroplasty [OR 0,85; 95% CI (0,52–1,40); |
|
||||
Blaschko et al. [ |
36 | 2323 | Anterior urethroplasty | 1% incidence of |
Feng et al. [
In turn Blaschko et al. [
In summary, the limitations already mentioned obviously make it impossible to provide complete definitive answers regarding the relationship between urethroplasty and erectile dysfunction. Although it is unwise to assume that there is no relationship (in particular when dealing with any individual patient), globally, the evidence accumulated to date, encompassing progressive methodological and statistical quality, seems to point only to a small deleterious role for either anterior or posterior urethroplasty.
Table
Ejaculation.
Authors, year |
|
Study type | Questionnaire | Follow-up (months) | Urethroplasty | Age (median) | Results |
---|---|---|---|---|---|---|---|
Singh et al., 2010 [ |
150 | R | BMSFI | >3 | AU | 40 | Mean preop BMSFI Ej: 4,7; postop: 6,3 |
|
|||||||
Sharma et al., 2011 [ |
34 | P | BMSFI | 3 | AU | 34,6 | Mean preop BMSFI Ej: 4,68; postop: 6,71 |
|
|||||||
Erickson et al., 2007 [ |
52 | R | BMSFI | 4 | AU | 41,7 | Mean preop BMSFI Ej: 5,3; postop: 6,2 |
|
|||||||
Barbagli et al., 2008 [ |
60 | R | N. Valid. | 68 | AU |
39 | 23% ejaculatory dysfunction |
|
|||||||
Erickson et al., 2010 [ |
43 | P | MSHQ | 6,8 | AU | 40,4 | Mean preop MSHQ Ej: 25,54; postop: 26,94 |
|
|||||||
El-Assmy et al., 2015 [ |
58 | R | MSHQ | 61,3 | PU | 31,6 | 8,6 ejaculatory dysfunction |
|
|||||||
Anger et al., 2008 [ |
32 | R | N. Valid. | 58,8 | PU | 38,6 | 100% antegrade ejaculation |
BMSFI: Brief Male Sexual Function Inventory; MSHQ: Male Sexual Health Questionnaire; AU: anterior urethroplasty;
Most authors comparing pre- and postoperative scores report significant improvement in ejaculatory function [
Authors as Barbagli et al. [
In order to minimize this potential problem, several authors have proposed some minimally invasive procedures in an attempt to maximally preserve structures involved in ejaculatory mechanics. Authors like Barbagli and Kulkarni [
Two studies evaluated this component of sexuality in the context of urethroplasty (Table
Orgasm.
Authors, year |
|
Study type | Questionnaire | Follow-up (months) | Urethroplasty | Age (median) | Results |
---|---|---|---|---|---|---|---|
Anger et al., 2007 [ |
25 | P | IIEF | >3 | AU | 39 | Mean preop IIEF (orgasmic domain): 8,6; postop: 8,3 |
|
|||||||
Nelson et al., 2005 [ |
11 | R | IIEF | 56,4 | Hypospadias | 30,6 | No change |
IIEF: International Index of Erectile Function; AU: anterior urethroplasty; NSD: no statistical difference.
Although a virtual absence of literature on the subject makes it difficult to draw any critical analysis on the subject, a lack of influence of urethral surgery on orgasm is not surprising, since orgasm is essentially considered a neurophysiological phenomenon [
There are some specific articles that address fertility in the context of urethroplasty (Table
Fertility.
Authors, year |
|
Study type | Follow-up (months) | Urethroplasty | Age (median) | Results |
---|---|---|---|---|---|---|
Anger et al., 2008 [ |
13 | D | >3 | PU | 38,6 | 46% normal (WHO) |
|
||||||
Iwamoto et al., 1992 [ |
14 | D | 56,4 | PU | ? | 50% normal (WHO) |
|
||||||
Onen et al., 2005 [ |
19 | D | 144 | PU | 20 | 26,3% abnormal semen parameters (WHO) |
D: descriptive; R: retrospective; PU: posterior urethroplasty.
Although there are a lot of series describing the results achieved with various types of urethroplasties, the andrological aspects of this pathology and its treatment(s) are clearly insufficiently studied. The available literature is confusing, dispersed, not systematized, and often containing methodological deficits. Although we have been assisting in recent efforts in an attempt to obtain more and better data, there are still obvious gaps that prevent valid conclusions on the subject. Large scale, prospective investigations using standardized validated questionnaires are needed to reliably elucidate the real impact of urethroplasty on the different domains of sexual function.
The author declares that there is no conflict of interests regarding the publication of this paper.