Objective: To evaluate the pre- and postoperative aspects of sexual life (SL) in patients with bulbar urethral stricture who underwent ventral oral graft urethroplasty.
Methods: Between 2009 and 2010, men undergoing ventral oral graft bulbar urethroplasty were enrolled in a prospective study to ascertain sexual disorders before and after surgery. The validated Male Sexual Health Questionnaire-Long Form (MSHQ-LF) was completed pre- and postoperatively; the unvalidated but adapted Post-Urethroplasty Sexual Questionnaire (PUSQ) was completed postoperatively. Data were compared using the non parametric Wilcoxon test.
Results: A total of 52 patients were included in the study. Before urethroplasty, most of the patients reported sexual disorders, in particular reduced ejaculatory stream (84.6%); many of them (34.6%) feared the risk of a postoperative worsening in the quality of SL. Following urethroplasty, nobody reported a worsened erection, whilst most of the patients noticed a significant improvement in terms of erection, ejaculation, relationship with partner, sexual activity and desire. Modifications in the sensitivity of the scroto-perineal area were reported by 42.4% and 15.4% noticed aesthetic changes, but without impact on SL. All patients reported an improvement in quality of life (QoL) and were satisfied with the outcome of urethroplasty.
Conclusions: Urethral stricture disease determines sexual disorders which have a significant impact on SL. Patients confessed a marked anxiety tackling urethroplasty and declared that one of their deepest fears regarded a potential further deterioration in the quality of SL. The minimally-invasive ventral graft urethroplasty showed to improve SL in all its aspects.
As there is an increasingly widespread use of urethroplasty for urethral stricture treatment [ 1 ], the potential complications of the surgery need to be better understood in order to reduce their probability of occurrence and enable the specialist to provide the right information during counseling.
With the aim of studying sexual complications following urethroplasty, some Authors have recently used different validated questionnaires such as IIEF, IIEF-5, MSHQ-EjD Short Form, BMSFI, Sexual Life Quality Questionnaire or Coursey’s questionnaire [ 2 – 10 ]. Others used adapted but non validated questionnaires [ 11, 12 ]. However, most of the studies mix repairs of different urethral segments and different reconstructive techniques making interpretation of results difficult. Literature has supposed that bulbar urethroplasty has the potential to adversely affect sexual life, potentially involving different anatomical structures concerned with sexual function [ 2 – 6 ] , but to date it is lacking an exhaustive analysis of several pre- and postoperative aspects of SL in selected series of patients undergoing bulbar reconstruction.
We evaluated the effect of the ventral oral graft urethroplasty in patients with bulbar stricture disease using the MSHQ-Long Form (LF) and the unvalidated Post-Urethroplasty Sexual Questionnaire (PUSQ) to ascertain various sexual complications, particularly with regard to ejaculatory dysfunctions, genital sensitivity disorders and impact on SL. To our knowledge this is the first study reporting the effect of graft bulbar urethroplasty on SL by means of the MSHQ-LF.
Material and Methods
Between 2009 and 2010 a consecutive series of 105 patients treated with a ventral oral graft bulbar urethroplasty were offered enrollment in a prospective study evaluating sexual disorders before and after surgery. The study was approved by our Ethics committee.
All patients were evaluated and surgically treated by the same urologist (E.P.) at our referral Center for Urethral Surgery.
Regarding the urethral stricture disease, pre-operative investigations included detailed clinical history, uroflowmetry, retrograde and voiding cystourethrography, and urethroscopy. Postoperative assessment included uroflowmetry and urine culture every 4 months in the first year and annually thereafter. Urethrography and urethroscopy were performed in patients presenting obstructive symptoms or peak flow rate < 14 mL/s. Urethral reconstruction was considered a failure when any postoperative procedure was needed, including dilatation.
Exclusion criteria for the enrollment in the study included several aspects potentially impacting on sexual function: patients 60 years old; patients sexually inactive or with concomitant pathologies such as obesity, diabetes, hypertension, cardiovascular diseases, neurological diseases; smoking patients; patients with genital disorders such as lichen sclerosus, failed hypospadias repair, and penile curvature; patients with a history of previous urethroplasty or penile surgery; patients in which our urethral reconstruction had an unsuccessful outcome.
All enrolled patients completed pre-operatively (1 month before surgery) and postoperatively (1 year after the surgery) the validated MSHQ-LF [ 13 ]. One year after the surgery, they also completed an unvalidated but adapted Post-Urethroplasty Sexual Questionnaire (PUSQ) developed by our group of reconstructive urologists to ascertain several pre- and postoperative changes.
Through an Y-inverted incision the bulbocavernous muscles were gently divided, exposing the bulbar urethra minimally and without its mobilization. All urethroplasties were performed without sectioning the central tendon of perineum, including those for the repair of proximal bulbar strictures. The strictured tract was opened by the ventral-sagittal urethrotomy approach and the oral graft was sutured to the mucosal margins of the exposed urethral plate. A few stitches fixed the ventral spongiosum to the graft. Finally, the adventitia of the spongiosum was closed over the graft.
Description of Questionnaires
The MSHQ-LF [ 13 ] was developed and validated to assess several aspects regarding male sexual dysfunctions. It is a 25-item self-administered questionnaire that comprises three core domains (erection, ejaculation, satisfaction with SL) and additional items related to sexual activity, desire and bother concerning sexual dysfunction. Every question scores from 5 (best situation) to 0 (worst situation): Erection score 0-15 (Q1 – Q3); Erection bother score 1-5 (Q4); Ejaculation score 1-35 (Q5 – Q11); Ejaculation bother score 1-5 (Q12); Satisfaction score 6-30 (Q13 – Q18); Sexual activity and desire score 1-35 (Q19 – Q25).
The PUSQ was designed to ascertain pre- and postoperative changes in SL. It is a 32-item self-administered questionnaire comprising eight core domains: Sexual disorders before urethroplasty; Changes in Erection, Ejaculation, genital Cosmesis and genital Sensitivity following Urethroplasty; degree of Satisfaction after urethroplasty and Impact on SL; Importance of Counseling. The questionnaire was designed by the group of experts who work in our referral Centre for Urethral Surgery, and it is based on their long experience in managing patients with urethral stricture disease.
Statistical analysis was performed using the S-PSS 12.0 software. Pre- and postoperative scores of the MSHQ were compared using the non parametric Wilcoxon test. Data are presented as median (range). An alpha value of 5% was considered as threshold for significance.
A total of 52 (49.5%) patients completed the study. Fifty-three men were excluded from the study because they did not fulfill our inclusion criteria or because they did not complete the questionnaires postoperatively.
Mean patient age was 36 years (range 19-60). Etiology of stricture was catheter in 8 patients, unknown in 44. Average stricture length was 2.2 cm (range 1-5).
Table 1 and table 2 show, respectively, the mean pre- and postoperative scores for total score, principal domains and single question of the MSHQ-LF. Data demonstrated a post-urethroplasty improvement both in total score (p=0.001) and in each of the principal domains; particularly, there has been a significant improvement in Erection score and Erection bother score (p=0.0001, p=0.008), Ejaculation score and Ejaculation bother score (both p=0.0001) and Sexual activity and Desire score (p=0.0001), as well as in each of the single questions of these domains.
Table 3 shows the results of the PUSQ. Regarding the pre-operative disorders related to the urethral stricture, 44 patients (84.6%) reported reduced ejaculatory stream, 14 (26.9%) painful ejaculation, 14 (26.9%) ejaculation failure, 10 (19.2%) infections or burning after sexual intercourse. These sexual disorders have persisted for a long time (>5 yrs in 30 pts, 57.7%) and influenced enough or markedly (24 pts, 46.2%) the QoL.
With regard to the changes in erection following urethroplasty, none of the patients complained of a worsened erection, while 18 patients (34.6%) reported an improved erection. Only 2 patients (3.8%) reported a small penile curvature associated with a slight shortening. All (100%) reported a completely swollen glans during erection.
In what concerns the changes in ejaculation following urethroplasty, 34 patients (65.4%) had an improved ejaculation due to a stronger/non-obstructed stream or because the burning/pain during ejaculation had disappeared. Only 10 pts (19.2%) reported a worsened ejaculation because of post-ejaculation dribbling or reduced stream.
Regarding the postoperative sensitivity genital disorders, 22 pts (42.4%) localized them in the scroto-perineum, and 4 (7.6%) in the glans. Only 2 (3.8%) pts felt their glans cold during erection. Nobody reported problems in the sexual activity due to these sensitivity disorders. As regards the changes in genital cosmesis, only 8 pts (15.4%) noticed aesthetic changes, mainly located in the scrotum and/or in the perineum. Nobody experienced problems in the sexual activity due to these aesthetic changes.
No patient reported problems in the sexual activity due to oral harvesting.
In what concerns the surgery impact on SL, 14 pts (27%) reported an increased frequency of intercourses, while only 4 (7.6%) a decreased frequency. Nobody reported a decreased sexual desire, while 36 patients (69.2%) reported an improved desire. The quality of SL improved in 34 patients (65.4%). The sentimental relationship with partner resulted improved in 12 patients (23%). This improvement was confirmed by 38.5% of partners.
As regards the satisfaction degree with urethroplasty, none of the patients complained of a worsening in the QoL; on the contrary all (100%) reported an improved QoL and were satisfied with the final result of urethroplasty.
In relation to the importance of Counseling, 38 patients (73.2%) declared a medium/high anxiety degree tackling urethroplasty and 50 patients (96.2%) declared that it is important to be informed in detail about the various surgical techniques that could be used during urethroplasty. Thirty-eight patients (73%) declared they have been provided with all the necessary information regarding possible sexual complications following urethroplasty, while 14 (27%) denied having been adequately information.
With regard to the most significant fears prior to undergoing urethroplasty, 44 patients (84.6%) declared to be afraid that surgery might not be resolutive, 18 (34.6%) to be afraid of a postoperative worsening in the quality of SL and 16 (30.8%) to be afraid of the postoperative genital scars.
Urethral stricture is a long-term pathology in which the impact on QoL and SL has hardly been studied. Our study has shown that the disease has a significant impact on SL, particularly in relation to the ejaculatory function: reduced stream, painful ejaculation, ejaculation failure, and infections or burning after sexual intercourse.
Also the urethral reconstruction has a potential impact on sexual life as it involves several anatomical structures concerning the sexual function. From this point of view, it should be noted that post-urethroplasty sexual disorders represent an increasingly acknowledged complication in literature, but most of the studies mix either anterior with posterior strictures or different surgical techniques. Mundy was the first to comment on sexual complications after urethroplasty, reporting a permanent erectyle dysfunction (ED) rate of 5% after anastomotic repairs and 0.9% after graft urethroplasty [ 14 ]. Coursey et al reported 30% of ED in patients undergoing anterior urethroplasty [ 9 ]. Erickson et al have shown that anterior urethroplasty caused ED in 38% of patients; bulbar urethroplasty appeared to affect erectile function to a greater extent than penile urethroplasty (76% vs 38%) [ 5 ].
Various authors suggest that the higher sexual complication rate after bulbar urethroplasty versus penile urethroplasty may be explained by the proximity of the bulbar urethra to the nerves responsible for erection [ 2 – 5 ]. Cavernous nerves are located at the convergence of the crura; some fibers pass through the tunica albuginea to supply the corpus spongiosum but most cavernous fibers remain outside the urethra at the 1 and 11 o’clock positions. Therefore, dissection of the urethra near the intercrural space is more likely to expose erectile nerves to risk of damaging [ 9, 15 – 17 ]. In this regard Barbagli and other warned that dorsal urethrotomy approach might impair erection when dissection of the bulbar urethra from the corpora is very proximal [ 3, 4, 18 ].
Excision and primary anastomosis repairs (EPA) were more likely to result in ED than graft-augmented anastomotic repairs (50% vs 26%): this is explained with the more extensive urethral resection and mobilization for EPA [ 5 ]. Other sexual complications such as cold glans and decreased penile sensitivity may be related to vascular injury in the spongiosum distally to the urethral transection [ 12 ]. Overall, several studies suggest that anastomotic repairs have a more important impact on SL when compared to the impact of graft techniques [ 3, 9 – 11, 14, 19 – 21 ]. By using a ventral graft urethroplasty without the need for urethral mobilization from the corpora or for urethral transection, our study has shown protection from postoperative ED and other sexual disorders such as penile shortening. Eighteen patients (34.6%) reported an improved erection, probably due to a simple restoration of the urethral function and a reducing of stenosis-related disorders.
Both MSHQ-LF and PUSQ showed that after surgery, most of our patients had an improved ejaculation in terms of force, volume and pleasure, due to a non-obstructed stream and to the disappearance of the burning/pain during ejaculation. Only 19.2% of pts reported a worsened ejaculation because of post-ejaculation dribbling or reduced stream. This could be explained by the weakening of the ventral graft causing pseudodiverticula. Some authors have supposed that ejaculatory disorders may be due to the disruption during the surgery of the perineal nerves or of the bulbospongiosus muscle, which are involved in semen expulsion [ 3, 6 ]. Using the MSHQ-Short Form questionnaire Erickson et al reported that postoperative ejaculatory function was stable in 70% of patients, improved in 19% and worse in 11%, and stated that urethroplasty has a minimal effect on ejaculatory function [ 6 ]. To reduce risk of ejaculatory disorders we followed some surgical principles: carefully midline opening of the bulbospongiosus muscles, avoiding the damaging of the nerve branches positioned more laterally; no sectioning of the perineal central tendon which takes part to the ejaculatory mechanism; good coverage of the graft with the spongiosum; reconstructing the bulbospongiosus muscles.
Our adapted PUSQ showed its usefulness in ascertaining other pre- and postoperative previously undetected changes. A percentage of 42.4 of patients complained of sensitivity genital disorders localized in the scroto-perineum, probably consequent to the sectioning of some branches of the perineal nerves. Only 3.8% of patients reported cold glans during erection, unlike the series with transecting techniques which report this complication in 11% of the cases [ 12 ]. However, nobody experienced problems in the sexual activity due to these sensitivity disorders. These data seem to refute the hypothesis that perineal nerves play a role in the erection [ 16 ].
Only 15.4% of pts noticed scrotal aesthetic changes but without impact on SL. For the first time it was investigated the impact of the oral harvesting on SL: nobody reported problems.
Generally, the quality of SL was improved in terms of frequency of intercourses, sexual desire and sentimental relationship with partner. Overall QoL resulted improved in all our patients and they were satisfied with the result of urethroplasty; conversely, studies on anastomotic procedures report an overall dissatisfaction with SL of 45% [ 19 ]. We can say that the ventral oral grafting techniques seem to be exempt of sexual complications, apart from the post-ejaculation dribbling. This is due to its being a minimally-invasive surgery in which the urethra is not mobilized, transected or shortened.
Our study highlights the importance of Counseling as 73.2% of pts confessed a marked anxiety tackling urethroplasty and 96.2% declared that it is important to know in detail the different techniques that could be used during urethroplasty. Some of the most important fears before urethroplasty regarded the risk of a worsening in the quality of SL and genital scars. However, we were surprised to discover that, despite our efforts during counseling, 27% of patients declared they have not been adequately informed about the possible postoperative sexual complications: all this says a lot about the paramount importance that the risk of sexual complications has for the patients.
We are aware that MSHQ-LF and other sexual validated questionnaires used in different studies [ 2 – 10 ] have not been specifically designed to evaluate patients after urethroplasty, but currently the only validated questionnaire for urethral stricture surgery does not include a sexual assessment [ 22 ]. Furthermore, our unvalidated questionnaire confirmed the data obtained by the MSHQ-LF, and provided further precious information on SL following urethroplasty.
The limitation of our series is that it involves only ventral oral graft bulbar urethroplasty. Thorough studies should be conducted in the future, comparing different techniques (transecting versus non transecting, dorsal versus ventral urethral approach and grafting) through the use of validated and adapted questionnaires which cover all aspects of SL.
Many are the anatomical structures involved in urethroplasty that might impair sexual function. We need to understand better the role of each structure involved in every aspect of SL with the aim of sparing it during surgery and perform a sexuality-preserving urethroplasty.
Urethral stricture disease determines sexual disorders, in particularly ejaculatory dysfunction, which have a significant impact on SL. Patients confessed a marked anxiety tackling urethroplasty and declared that one of their deepest fears regarded a potential further deterioration in the quality of SL. The minimally-invasive ventral graft urethroplasty does not cause sexual complications, on the contrary it showed to improve SL in all its aspects.