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BPH and Erectile Dysfunction: What is the Link?

BPH and ED

What is BPH?

Benign prostatic hyperplasia is a noncancerous (benign) condition that affects more than 6 million men older than 50 years old in the United States. In benign prostatic hyperplasia, or BPH, the prostate becomes enlarged, which can cause it to squeeze or press against the urethra. This pressure on the urethra can reduce the flow of urine from the bladder and result in lower urinary tract symptoms, such as decreased urine stream, frequent urination, difficulty starting urine flow, having to strain to empty the bladder, and, in severe cases, an inability to urinate. Just how large a prostate has to be before it will put pressure on the urethra and cause symptoms varies from man to man. Generally, however, the prostate weighs about 20 grams in a young man, and by around age 40 years the gland has already begun to grow as part of aging. Men with a prostate of 40 grams or larger are three times as likely to experience urinary symptoms.

BPH, Urinary Tract Symptoms, and ED

At one time, the relationship between BPH and erectile dysfunction was believed to be based solely on age: as men age, their chances of having BPH increases, and thus so does the risk of erectile dysfunction. Older men are also more likely to have other risk factors for erectile dysfunction, including high blood pressure, diabetes, and cardiovascular disease, or to have undergone a procedure for prostate cancer. However, several studies have indicated that BPH and the lower urinary tract symptoms that accompany it are associated with an increased incidence of erectile dysfunction.

One of the most important was the Male Cologne Survey, in which 4,489 men aged 30 to 80 were questioned about their sexual activities and related factors. The researchers discovered a high percentage of men who had lower urinary tract symptoms due to BPH also had erectile dysfunction: 38 percent among men ages 30 to 39; 43 percent in those 40 to 49; 72 percent in those 50 to 59; 79 percent among those 60 to 69; and 75 percent among those aged 70 to 80. The percentage of men without urinary symptoms who had erectile dysfunction was much lower in each age group. (Braun)

More evidence of a link between BPH and lower urinary tract symptoms and erectile dysfunction come from two other large studies. One was conducted in 3,230 men in Europe, Russia, the Middle East, Latin America, and Asia. Investigators found that men with severe urinary symptoms were about twice as likely to experience erectile dysfunction. (Macfarlene)

In the Multinational Survey of the Aging Male (MSAM-7), a survey or more than 14,000 men ages 50 to 80 years, the high prevalence of BPH associated with lower urinary tract symptoms in aging men was confirmed. Most of the men surveyed had urinary tract symptoms ranging from mild to severe, with about one-third of them in the moderate-to-severe range. Approximately 60 percent of the men in the study also experienced erectile dysfunction, and the study’s authors also noted that ejaculatory problems were nearly as common as erection difficulties. (Rosen) Overall, the increased risk of erectile dysfunction among men who have BPH with associated lower urinary tract symptoms is twofold to 11-fold.

Does BPH Cause Erectile Dysfunction?

Scientists are still uncertain why BPH and its lower urinary tract symptoms are associated with erectile dysfunction. One idea concerns the sympathetic nervous system, which studies show is hyperactive in animals and men with BPH-associated urinary tract symptoms. Nerve fibers in the sympathetic nervous system transmit signals that have an impact on stress and stress-related symptoms. An increase in these signals may lead to overactivity in the sympathetic nervous system, which is associated with erectile problems.

Do Treatments for BPH Cause Erectile Dysfunction/Impotence?

BPH can be treated with either medications or a variety of medical procedures, including surgery; either of which can potentially be a cause of erectile dysfunction. Medications used for BPH treatment include alpha-blockers (e.g., Flomax), 5-alpha reductase inhibitors (Avodart) and finasteride (Proscar), anticholinergics, and the phosphodiesterase 5 inhibitor (see erectile dysfunction treatment pills) tadalafil (Cialis).

Alpha-blockers

Alpha-blockers are medications used to relax the muscles where the bladder narrows toward the urethra, as well as to improve blood flow and lower blood pressure. Drugs in this category include alfuzosin (Uroxatral), doxazosin (Cardura), prazosin (Minipress), tamsulosin (Flomax), and terazosin (Hytrin).

Alpha-blockers generally are not one of the causes of erectile dysfunction. In fact, some studies suggest use of alpha-blockers may actually improve erectile function. For example, in one small study, some of the men reported a 100 percent improvement in erectile dysfunction after taking the alpha-blocker Cardura for two years. (WebMD) In another study, 53 men with BPH were given the alpha-blocker doxazosin to take daily for six weeks. Some men had erectile dysfunction and others did not. At the end of the trial, the men who had erectile dysfunction had improved urinary tract symptoms and erectile function, while the men who did not have erectile dysfunction experienced even better improvement in urinary symptoms. (Demir)

In yet one more study of alpha-blockers and erectile dysfunction, a total of 1,724 men (average age, 57 years) who had urinary tract symptoms were evaluated. Of this group, 263 men were taking alpha-blockers. The researchers found a decreased risk of sexual dysfunction among the men taking alpha-blockers. They also reported that the improvement in sexual function correlated with the improvement in urinary tract symptoms more strongly among men who were using alpha-blockers. (Kumar)

However, at least one study has shown that use of tamsulosin/Flomax may cause erectile dysfunction. In a 12-week study, a total of 177 men who had benign prostatic hyperplasia with lower urinary tract symptoms were given tamsulosin. The authors reported that although the incidence of erectile dysfunction was small, it was not negligible and was more apt to occur in men who had a smaller prostate and fewer lower urinary tract symptoms. (Song 2011)

Phosphodiesterase inhibitor

The phosphodiesterase 5 inhibitor tadalafil (Cialis), which has been approved for erectile dysfunction treatment since 2003, was approved for treatment of BPH symptoms in October 2011 by the FDA. In studies leading up to FDA approval of Cialis for BPH, men who took 5 mg of tadalafil experienced statistically significant improvement in their BPH symptoms compared with men who took a placebo. Among men who had both erectile dysfunction and BPH, those who took 5 mg of tadalafil reported a significant improvement in symptoms of both erectile dysfunction and BPH, while men who took placebo did not.

5-alpha reductase inhibitors

The 5-alpha reductase inhibitor drugs work by shrinking the size of the prostate. The two main drugs in this category are dutasteride (Avodart) and finasteride (Proscar). Men who take these drugs typically do not notice any improvement in BPH symptoms for several months, so the impact of side effects also occurs later. A literature review published in the Journal of Sexual Medicine explored the effect of 5-alpha reductase inhibitors on erectile dysfunction. The investigators reported that sexual side effects were found in 2.1 percent to 38 percent of clinical trials, with the most common side effect associated with the drugs for BPH being erectile dysfunction. They attributed the development of erectile dysfunction to a decrease in nitric oxide activity related to a decline in dihydrotestosterone (DHT) levels. (Erdemir)

On April 11, 2012, the Food and Drug Administration (FDA) announced that because research suggested use of finasteride was linked to various sexual side effects, manufacturers of finasteride 5 mg (Proscar) and finasteride 1 mg (Propecia, for hair loss) had to add warnings to their labels. The new changes were in addition to another modification made in 2011, when makers of finasteride added a warning that the drug might cause erectile dysfunction after men stopped using it. The additional warnings include libido disorders, ejaculation disorders, and orgasms disorders after discontinuing Propecia; reduced libido after stopping Proscar; and male infertility and/or poor semen quality that improved after stopping either drug. (FDA)

Subsequent to the FDA announcement, a study from George Washington University reported in July 2012 that finasteride caused sexual side effects, including erectile dysfunction, changes in genital sensation, and quality of ejaculate. In fact, in the study 96% of men who took finasteride still suffered sexual side effects as long as 14 months after they stopped taking the drug. (Irwig 2012)

Anticholinergics

Anticholinergics block the action of acetylcholine, a chemical that sends messages to the bladder that trigger contractions, which can make you want to urinate even when your bladder is not full. Thus anticholinergics can delay the urge to urinate. Drugs in this category include darifenacin (Enablex), fesoterodine (Toviaz), oxybutynin (Ditropan), and tolterodine (Detrol). Use of anticholinergics increases the risk of erectile dysfunction, as reported by the Merck Manual and several other sources, including a study published in the International Journal of Impotence Research, although no statistics are provided. (Merck; Ricci)

Other Procedures to Treat BPH can Cause Erectile Dysfunction

In addition to drugs, some other BPH treatments can impact erectile function. One of the long-term complications of transurethral resection of the prostate (TURP) is erectile dysfunction, which reportedly occurs in less than 5 percent of men. (Cornell) However, men who chose the laser treatment known as photo-selective vaporization of the prostate (PVP) will find that there is no risk of erectile dysfunction associated with this procedure. A transurethral incision of the prostate  (TUIP), in which an electrical current or laser beam is used to treat the prostate tissue, also reportedly is one of the causes of erectile dysfunction in 4 to 25 percent of men. (Fitzpatrick)

Among men who undergo transurethral microwave thermotherapy (TUMT) for BPH, the risk of erectile dysfunction appears to be related to the dose administered, with lower-energy TUMT procedures resulted in a lower incidence of erectile dysfunction compared with higher-energy procedures. One study found no change in erectile function after low-energy TUMT, (Francisca) while another reported an 18.2 percent rate of erectile dysfunction after a high-energy TUMT procedure. (Arai)

The relatively new procedure called high-intensity focused ultrasound (HIFU) is also sometimes used to treat BPH, but the only reports on its impact on erectile dysfunction thus far are related to its use in prostate cancer, where a 20 to 49.8 percent incidence of erectile dysfunction has been reported. (Mearini) The most radical treatment option for BPH, prostatectomy or prostate surgery, is also a cause of erectile dysfunction.

See also

BPH Drugs May Contribute to Sexual Dysfunction

Finasteride (Proscar) May Reduce Libido, Cause Erectile Dysfunction

Can ED Drugs Help with BPH?

Researchers had suspected for some time that the erectile dysfunction drug tadalafil (Cialis) may be helpful in reducing lower urinary tract symptoms experienced by men who have BPH. After reviewing the results of numerous studies, the Food and Drug Administration (FDA) agreed and in October 2011, it approved the use of tadalafil for treatment of BPH symptoms.

Among the many studies leading up to approval of tadalafil (Cialis) for treatment of BPH symptoms was one presented at the Annual Scientific Meeting of the American Urological Association in Chicago. Researchers reported on the results of a study in which 200 men who had had BPH symptoms for at least six months were given either 20 mg of tadalafil once daily or a placebo for three months. At the end of the study period, the men who had taken tadalafil experienced an improvement in urinary flow, peak flow, bladder capacity, and the ability to empty their bladder. The researchers also noted that by the end of the study, the proportion of men with urethral obstruction increased in the placebo group and declined in the tadalafil group. (Johns Hopkins)

In another study, investigators at the University of Texas Southwestern Medical Center in Dallas enrolled 1,058 men who had BPH symptoms. The men were randomly assigned to receive once daily treatment with placebo or tadalafil (2.5, 5, 10, or 20 mg) for 12 weeks. At the end of the study, men who had taken tadalafil had an improved urinary flow compared with those in the placebo group, with the most improvements seen in the men who took the highest dose of tadalafil.

The results of these studies suggest that erectile dysfunction drugs may be beneficial in treating BPH symptoms. Reasons for this benefit are not clear, but experts have some theories. One is associated with the fact that the bladder muscles and prostate both have high activity levels of phosphodiesterase 5 (PDE-5), which is the enzyme erectile dysfunction drugs block. When erectile dysfunction drugs relax the arteries and allow blood to flow into the penis, they may also cause small blood vessels in the prostate and bladder to open up, which could improve urinary symptoms. Another possibility is that in older men who have lower urinary tract symptoms, the nerve signals to the brain, prostate, and bladder may not operate properly. Drugs for erectile dysfunction may block those signals and thus improve BPH symptoms.

Natural Remedies for BPH

Along with conventional BPH treatment approaches, you may want to explore natural remedies for BPH. The benefits of natural remedies are that they can be incorporated into your daily lifestyle and gradually become healthful habits that not only help manage BPH symptoms but also promote prostate health as well, without the side effects of drugs and other medications.

At the top of the list of natural remedies for BPH is diet, but not just any diet: The Prostate Diet provides the nutritious foods and beverages necessary to support and promote a healthy prostate as well as help prevent BPH. Such a diet focuses on natural, whole foods along with natural cancer killers (e.g., green tea, turmeric, lycopene, among others), all of which can go a long way toward preventing and treating BPH.

A healthy diet should be combined with several other positive lifestyle choices that can help boost the immune system and manage the actions that can contribute to an enlarged prostate.

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References

Arai Y et al. Impact of interventional therapy for benign prostatic hyperplasia on quality of life and sexual function: a prospective study. J Urol 2000 Oct; 164(4): 1206-11

Braun M, et al. Epidemiology of erectile dysfunction: results of the ‘Cologne Male Survey.’ Int J Impot Res 2000; 12:305–11.

Cornell Physicians: http://www.cornellurology.com/BPH/treatments/surgical.shtml

Demir O et al. The effect of alpha-blocker therapy on erectile functions in patients with lower urinary tract symptoms due to benign prostate hyperplasia. Asian J Androl 2009 Nov; 11(6): 716-22

Erdemir F et al. 5-alpha reductase inhibitors and erectile dysfunction: the connection. J Sex Med I 2008 Dec; 5(12): 2917-24

Fitzpatrick JM. Minimally invasive and endoscopic management of benign prostatic hyperplasia. In AJ Wein, ed., Campbell-Walsh Urology, 9th ed., vol. 3. pp. 2803–44. Philadelphia: Saunders Elsevier, 2007.

Food and Drug Administration announcement regarding finasteride: http://www.fda.gov/Drugs/DrugSafety/InformationbyDrugClass/ucm299754.htm

Francisca EA et al. Quality of life assessment in patients treated with lower energy thermotherapy (Prostasoft 2.0): results of a randomized transurethral microwave thermotherapy versus sham study. J Urol 1997 Nov; 158(5): 1839-44

Irwig MS. Persistent sexual side effects of finasteride; could they be permanent? Journal of Sexual Medicine July 2012.

Johns Hopkins. The Best Treatment Strategies for BPH.

Kumar R et al. Alpha-blocker use is associated with decreased risk of sexual dysfunction. Urology 2009 Jul; 74(1): 82-87

Macfarlane GJ, et al. The relationship between sexual life and urinary condition in the French community. J Clin Epidemiol 1996; 49:1171–76.

Mearini L, Porena M. Transrectal high-intensity focused ultrasound for the treatment of prostate cancer: past, present, and future. Indian J Urol 2010 Jan-Mar; 26(1): 4-11

Merck Manual.
http://www.merckmanuals.com/professional/print/sec17/ch227/ch227c.html

Ricci E et al. Current drug use as risk factor for erectile dysfunction: results from an Italian epidemiological study. Int J Impot Res 2003 Jun; 15(3): 221-24

Roehrborn CG et al. Changes in peak urinary flow and voiding efficiency in men with signs and symptoms of benign prostatic hyperplasia during once daily tadalafil treatment. BJU Int 2010 Feb; 105(4): 502-7

Rosen R, et al. Lower urinary tract symptoms and male sexual dysfunction: The Multinational Survey of the Aging Male (MSAM-7) Eur Urol 2003; 44:637–49.

Song SH et al. Effect of tamsulosin on ejaculatory function in BPH/LUTS. Asian J Androl 2011 Nov; 13(6): 846-50

WebMD: http://www.webmd.com/sexual-conditions/medicine-ed

 

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Created: November 23, 2010
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Site last updated 17 April, 2014

  
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