Getting to know ED

Published: Sunday November 24, 2013 MYT 12:00:00 AM
Updated: Sunday November 24, 2013 MYT 9:21:38 AM

Getting to know ED

BY ASSOC PROF DR CHRISTOPHER HO CHEE KONG

In normal men, erection occurs automatically, not.

  

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Facts and fallacies about erectile dysfunction (ED).

ERECTILE dysfunction (ED) is the inability to achieve or maintain an erection of the penis, which is satisfactory for sexual intercourse. Being a taboo subject, there are many myths circulating around that are worsened by men not talking openly about it with their doctors.

Here are some of the common misconceptions about this condition.

ED affects only elderly men

Although the majority of men affected by ED are elderly, younger men are not exclusively exempted. In Malaysia, data collected to date are for men above 40 years of age, and it showed a higher prevalence among men above 60 years of age.

However, in a study done in Brazil, the prevalence rate was 35% in men 18-40 years of age.

So if you are young and have ED, do not fret. You are not alone.

If you are above 40 years, up to 50% of men in Malaysia share your problem. In fact, in a recent local study, the prevalence of ED in those above 40 years of age was 69.5%.

ED is not dangerous or life-threatening

While it is true that ED on its own does not lead to death, it is actually an indicator of other underlying diseases that can shorten your life.

It has been proven that ED predicts coronary artery disease, with a lead time of two to five years. In other words, if you have ED, you are at risk of a heart attack in two to five years.

Therefore, if you have ED, you should be examined for the health of your heart as well. Both are equally important to men.

The presentation of ED by men in the clinic is an opportunity for doctors to screen for other diseases associated with it, and these include diabetes mellitus, testosterone deficiency syndrome, hypertension and high cholesterol levels (hyperlipidaemia).

ED is the partner’s fault

ED is not to be blamed on the partner for not being attractive anymore. Although psychological factors do affect ED, there are other physiological or organic factors involved as well. These include diseases affecting the blood vessels and/or the nerves supplying the penis.

Often, men shy away from sex when they are unable to perform, and this can construed by their partners that they are not attractive any more. This misconception can lead to relationships breaking down.

Men with ED have no sexual desire

This is not entirely true. Men with ED usually do have the desire, but due to the underlying disease affecting the blood vessels or nerves, they are unable to perform.

There are men with ED who lack desire. These men either have low levels of testosterone or are affected psychologically by stress or emotion.

Masturbation causes ED

There is no concrete evidence for this.

In normal men, erection is automatic

This is not true. Men need stimulation for sexual erection. Non-stimulated erection may occur during sleep or on awakening in the morning, but this is not related to sex.

There is also a refractory period before men can have an erection again, and this can last from minutes in younger men to days in older men. This is not ED.

An erection means men want sex

Again, this is not true. Men may experience a normal physiological erection during sleep or on getting up in the morning. It is not always related to sexual activity.

ED needs extensive investigations and treatment is usually delayed

ED is diagnosed through doctors asking you some simple questions (taking a history). A questionnaire known as the International Index of Erectile Function (IIEF) may be used.

A physical examination and some blood tests will follow to detect any other associated diseases. Treatment will usually then be given.

Only in certain complex cases, and this is very rare, will further tests like a Duplex ultrasound, cavernosogram or nocturnal penile tumescence test, be needed.

The first step in treatment is lifestyle modification, and this includes maintaining an ideal body weight, cessation of smoking, moderate exercise and a balanced diet.

This on its own may improve ED. Needless to say, blood pressure, sugar and cholesterol needs to be controlled. Any psychological factors such as stress need to be tackled as well.

The next step is oral medication (tablets to be swallowed). Phosphodiesterase-5 (PDE-5) inhibitors such as sildenafil, vardenafil and tadalafil, are effective in 80% of cases.

Often, men shy away from sex when they are unable to perform, and this can construed by their partners
that they are not attractive any more. – AFP

Caution is needed for those with heart problems. They will need to be assessed carefully by the doctor. If the heart disease is deemed mild, they can be given PDE-5 inhibitors.

In moderately severe cases, further tests will be required, while those who have severe disease should not be taking such drugs.

Those on nitrate medications also cannot be given PDE-5 inhibitors.

The other treatment options are injection of medication (like prostaglandin) directly into the penis using a small needle and syringe, using a vacuum pump device or inserting a penile prosthesis (requiring surgery).

Treatment is only temporary and the condition can be cured

This is another misconception where some people think that taking just one magical pill will solve it all. If lifestyle modification does not help and taking medication is required, you will probably need to continue taking the medication as long as you want to have erections.

The only exception is if it is solely psychological in nature, where counselling or behavioural therapy may cure the problem, and further treatment may not be required.

Circumcision reduces ED

There is no evidence that circumcision reduces ED.

ED treatment increases the size of the penis

This is another misconception. ED treatment solves erection, i.e. rigidity and hardness. It does not increase the length or size of the penis.

Traditional treatment is cheaper and much better than seeing a doctor

Unapproved medications are risky and may contain substances that are detrimental to health. It is not worth the risk. Most of these medications have not undergone stringent tests, and unlike conventional medication prescribed by doctors, have not been proven effective by robust trials.

In a review by Ho et al., most of the herbal treatments for ED were tested in animals, and only yohimbine, ginseng and butea superba were tested in humans.

ED can be helped. An open discussion with the doctor, especially a urologist, would be beneficial. Do not be embarrassed.

References:

1. Martins FG et al. J Sex Med 2009; 7(6):2166-73

2. Ho CCK et al. Curr Urol Rep 2011;12(6):470-8

3. Tong SF et al. Asia Pac J Public Health 2012;24(4):543-55

4. Tan HM et al. J Sex Med 2012;9(3):663-71

> This article is contributed by The Star Health & Ageing Panel, which comprises a group of panellists who are not just opinion leaders in their respective fields of medical expertise, but have wide experience in medical health education for the public. The members of the panel include: Datuk Prof Dr Tan Hui Meng, consultant urologist; Dr Yap Piang Kian, consultant endocrinologist; Datuk Dr Azhari Rosman, consultant cardiologist; A/Prof Dr Philip Poi, consultant geriatrician; Dr Hew Fen Lee, consultant endocrinologist; Prof Dr Low Wah Yun, psychologist; Datuk Dr Nor Ashikin Mokhtar, consultant obstetrician and gynaecologist; Dr Lee Moon Keen, consultant neurologist; Dr Ting Hoon Chin, consultant dermatologist; Prof Khoo Ee Ming, primary care physician; Dr Ng Soo Chin, consultant haematologist. 

For more information, e-mail starhealth@thestar.com.my. The Star Health & Ageing Advisory Panel provides this information for educational and communication purposes only and it should not be construed as personal medical advice. Information published in this article is not intended to replace, supplant or augment a consultation with a health professional regarding the reader’s own medical care. The Star Health & Ageing Advisory Panel disclaims any and all liability for injury or other damages that could result from use of the information obtained from this article.

I have blood in my urine

Health

Published: Sunday September 15, 2013 MYT 12:00:00 AM
Updated: Sunday September 15, 2013 MYT 7:31:06 AM

I have blood in my urine!

AGE WELL
BY ASSOC PROF DR CHRISTOPHER HO CHEE KONG

Microscopic haematuria means the presence of red blood cells in the urine that can only be detected microscopically. – Filepic

  

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The presence of blood or red blood cells in the urine needs to be investigated promptly.

THIS can be quite alarming if it occurs to you. The medical term for blood in the urine is haematuria. If you actually see blood in your urine, this is known as macroscopic haematuria.

On the other hand, if it is detected by your doctor using laboratory tests, it is known as microscopic haematuria. This is usually carried out during a medical check-up, and the blood in the urine is incidentally picked up.

Macroscopic or gross haematuria is more worrying as about one in five adults are subsequently found to have bladder cancer, as opposed to microscopic haematuria, where about one in 12 had bladder cancer.

In fact, roughly 50% of those with visible blood in the urine will have an underlying cause identified. In microscopic haematuria, only about 10% will have an identifiable cause.

However, not all red-coloured urine is caused by blood. There are certain medications, such as rifampicin for tuberculosis, as well as food like beetroot, which can cause reddish urine.

Porphyria, a rare disease, can also make the urine appear dark red in colour.

What are the causes?

There are various causes of haematuria. It could be due to infection, stones, cancer, trauma, inflammation, or surgery affecting the urinary organs, which include the kidney, ureter (tube-like structure connecting the kidney and bladder), bladder and urethra (passage from the bladder to the external environment).

Besides that, certain diseases like leukaemia, as well as medications like warfarin, can cause spontaneous bleeding.

In men, enlargement of the prostate (benign prostate hyperplasia) is a common cause of blood in the urine. Glomerulonephritis, a disorder affecting the kidneys, may also lead to blood appearing in the urine.

Surprisingly, strenuous exercise like long-distance running, rowing, swimming, cycling, football and boxing, have also been documented to give rise to haematuria, but this usually resolves spontaneously with rest.

In other cases, despite extensive investigation, no cause can be found. This is termed idiopathic.

What needs to be done?

The doctor will first assess to ensure that not too much blood has been lost. If there is significant blood loss, a blood transfusion may be needed and further procedures to stop the bleed may be required.

Otherwise, the doctor will take a full history, and this includes asking about smoking habits, exposure to industrial chemicals and any current medications.

If there is burning pain around the penis or vagina when passing urine, it could be infection. Pain elsewhere in the abdomen or back could be due to stones.

Painless gross haematuria is usually a sinister sign as it could be due to a tumour.

Next would be a physical examination, which includes examination of the abdomen, the vagina for women, and rectum to assess the prostate in men. Following that, further investigations will be ordered, and this includes:

1. Urine – urine will be analysed under the microscope to confirm red blood cells, as well as to look for infection and cancer cells (urine cytology).

For microscopic haematuria to be significant, there must be persistent detection of three or more red blood cells per high-power field in two out of three urine specimens examined under the microscope. Further tests will be needed only if there is persistent significant haematuria.

2. Blood – a blood test (haemoglobin) will be done to ensure that not too much blood has been lost, as well as to confirm that there are no problems with the clotting of blood (coagulation profile and platelets level).

3. Imaging – an ultrasound, and if necessary, a computerised tomography (CT) scan or intravenous urogram (IVU) will be done to obtain images of the urinary tract/organs to look for stones, tumours or other abnormalities.

4. Flexible cystoscope – this is a soft, tube-like instrument, which has a camera at one end. It is inserted through the urethra into the bladder to enable the doctor to have a look at the bladder. It is done under local anaesthesia, where gels containing medication (lignocaine) are inserted into the urethra to numb the area.

It is a quick procedure, usually taking less than 10 minutes.

If all these tests are normal and microscopic haematuria still persists, a renal biopsy may be needed if there is also protein detected in the urine and the function of the kidney is impaired.

In this procedure, a small piece of kidney tissue is removed via a needle, guided by ultrasound or CT scan, to be examined under the microscope. This is to detect diseases of the kidney.

How is it treated?

This would depend on the cause. If there is gross blood in the urine, a catheter may be inserted into the bladder to irrigate the bladder and wash out the blood and clots.

Approximately 80% of haematuria resolves by itself. If the bleeding persists, a cystoscopy may be done under anaesthesia to remove blood clots and “burn” (diathermise) the areas in the bladder that are bleeding.

If it is due to the prostate, a resection of the prostate may need to be done. Likewise, if it is tumour in the bladder, resection of the tumour needs to be done.

If it is due to infection, a course of antibiotics will usually solve the problem. Medications that may affect blood-clotting need to be stopped, and if there is a medical disorder affecting the clotting of blood, this will need to be treated with blood products (like platelets and fresh frozen plasma).

If it is due to a tumour or injury to the kidney, removal of the kidney (nephrectomy) or angioembolisation (occluding the blood vessel, which is bleeding, with substances such as coils) may be required.

Any blood in the urine which is visible to the naked eye needs to be investigated. Persistent, significant microscopic haematuria (as defined earlier on) should be investigated as well.

The main worry is an underlying cancer. A urologist is the specialist who will be the best person to consult with regarding this matter.

This article is contributed by The Star Health & Ageing Panel, which comprises a group of panellists who are not just opinion leaders in their respective fields of medical expertise, but have wide experience in medical health education for the public. The members of the panel include: Datuk Prof Dr Tan Hui Meng, consultant urologist; Dr Yap Piang Kian, consultant endocrinologist; Datuk Dr Azhari Rosman, consultant cardiologist; A/Prof Dr Philip Poi, consultant geriatrician; Dr Hew Fen Lee, consultant endocrinologist; Prof Dr Low Wah Yun, psychologist; Datuk Dr Nor Ashikin Mokhtar, consultant obstetrician and gynaecologist; Dr Lee Moon Keen, consultant neurologist; Dr Ting Hoon Chin, consultant dermatologist; Prof Khoo Ee Ming, primary care physician; Dr Ng Soo Chin, consultant haematologist. For more information, e-mailstarhealth@thestar.com.my. The Star Health & Ageing Advisory Panel provides this information for educational and communication purposes only and it should not be construed as personal medical advice. Information published in this article is not intended to replace, supplant or augment a consultation with a health professional regarding the reader’s own medical care. The Star Health & Ageing Advisory Panel disclaims any and all liability for injury or other damages that could result from use of the information obtained from this article.

Sunday May 12, 2013

Sex and the elderly male

AGE WELL
By Assoc Prof Dr CHRISTOPHER HO CHEE KONG

The need for love and sexual intimacy does not decrease with age. Nevertheless, with ageing, the body undergoes certain changes that may have significant effects on sexual health.

THE World Health Organization (WHO) has defined sexual health as the state of physical, mental and social well-being in relation to sexuality. It requires a positive and respectful approach to sexuality and sexual relationships, as well as the possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination and violence.

Sexual activity has its benefits. This includes improved mood by increasing endorphins in the body, which in turn will boost self esteem and prevent depression. It also strengthens the immune system, and coupled with the aerobic benefits, promotes longevity and enhances quality of life.

Due to advances in science and medicine, the average lifespan of men and women have increased. With increasing age, there is a misconception that sex dies a “natural” death. This was dispelled by a study conducted by the National Council of Aging in the United States, where it was reported that 71% of men in their 60s and 57% of men in their 70s engaged in sexual activity at least once a month.

The need for love and sexual intimacy does not decrease with age. Nevertheless, with ageing, the body undergoes certain changes that may have some effects on sexual health.

Sexual problems in elderly men

Erectile dysfunction

Diseases like diabetes and high cholesterol may cause clogging of the blood vessels supplying the penis. This will decrease blood flow and result in poor rigidity.

Diabetes may also affect the nerves innervating the penis and cause poor erection.

Besides the nerve and blood vessels, hormones (testosterone) also play an important role in maintaining a good erection.

Testosterone deficiency syndrome

Testosterone hormone production reduces with age. The decline is at an average rate of 1% per year after the age of 30. When there is low testosterone levels in the body, a man will inadvertently have poor libido, desire, as well as poor erection.

Ejaculatory disorders

Testosterone deficiency may also affect sperm production, resulting in low semen volume. Other ejaculatory disorders include retrograde ejaculation, anejaculation and painful ejaculation.

Retrograde ejaculation occurs when semen, which would normally be ejaculated via the urethra, is redirected to the urinary bladder. Diseases like diabetes, which may affect the nerve supply, as well as weak pelvic floor muscles (due to ageing), may cause these ejaculatory disorders.

Premature ejaculation (ejaculating too fast) may also be seen among the elderly, but the incidence is almost the same as younger men.

Slower response to stimulation, shorter orgasm and longer refractory period

The time needed for the body to rest before it is able to achieve orgasm again (refractory period) is longer. Young men may be able to achieve orgasm within minutes after the last ejaculation, but for elderly men, the waiting period may be a few days.

Treatment matters

As it is with all other health matters, lifestyle and behavioural modifications are important. Exercise, cessation of smoking, eating a balanced diet and maintaining a healthy weight are important measures to take.

Diseases like diabetes, hypertension and high cholesterol will need to be well controlled as well.

For erectile dysfunction, the options of treatment include phosphodiesterase-5 inhibitors, intracavernosal prostaglandin (injection of medication into the penis), vacuum erection devices and penile prosthesis (implanting rods or inflatable cylinders into the penis).

In testosterone deficiency syndrome, replacement of testosterone will be able to restore libido, desire as well as erection. Testosterone replacement can come in the form of tablets, gels, patches, and injections. Besides sexual health, the overall well being of the man will also improve with such treatment.

Treatment for ejaculatory disorder is a lot harder as the outcome is not so good. For retrograde ejaculation, medications like pseudoephedrine may help. Certain medications like tamsulosin, which may cause retrograde ejaculation or anejaculation, should also be stopped.

For anejaculation, electroejaculation and electrovibration stimulation devices may help. Whatever it’s worth, retrograde ejaculation and anejaculation are harmless and does not prevent one from achieving orgasm.

Finally, good open communication lines with the spouse or partner will do wonders. If there is slow response to stimulation, there is no need to rush. Focus on foreplay instead. If one has climaxed, but the partner isn’t ready for the sexual experience to end just yet, the focus should be on meeting the partner’s needs or on activities that don’t require an erection.

Although elderly men may face sexual health issues, these can be treated effectively. Continued sexual enjoyment into later life requires a degree of adjustment to changes in the body, mind, relationships and life circumstances.

A positive attitude towards older people’s sexuality and relationships is a vital part of promoting positive sexual health throughout people’s lives and ensuring that people of all ages are able to access appropriate sexual health advice, support and services.

> Assoc Prof Dr Christopher Ho Chee Kong is a urologist/sexual medicine physician. This article is contributed by The Star Health & Ageing Panel, which comprises a group of panellists who are not just opinion leaders in their respective fields of medical expertise, but have wide experience in medical health education for the public. The members of the panel include: Datuk Prof Dr Tan Hui Meng, consultant urologist; Dr Yap Piang Kian, consultant endocrinologist; Datuk Dr Azhari Rosman, consultant cardiologist; A/Prof Dr Philip Poi, consultant geriatrician; Dr Hew Fen Lee, consultant endocrinologist; Prof Dr Low Wah Yun, psychologist; Datuk Dr Nor Ashikin Mokhtar, consultant obstetrician and gynaecologist; Dr Lee Moon Keen, consultant neurologist; Dr Ting Hoon Chin, consultant dermatologist; Prof Khoo Ee Ming, primary care physician; Dr Ng Soo Chin, consultant haematologist. For more information, e-mail starhealth@thestar.com.my. The Star Health & Ageing Advisory Panel provides this information for educational and communication purposes only and it should not be construed as personal medical advice. Information published in this article is not intended to replace, supplant or augment a consultation with a health professional regarding the reader’s own medical care.

Passport renewal at Putrajaya

Passport renewal is now so easy. Just go to the new office at presint 15, bangunan chancery place, jalan diplomatik 2/2. Proceed to groundfloor, turn left and you will see an entrance on the left to a room where thr KiPPas kiosk is. You will need a photocopy of your ic, old passport and rm300 for a 5 year renewal. Insert your passport and ic into the slots and follow the instructions including paying rm300 cash. You will not need to insert photo and ic copy into machine. At the end after payment, get the receipt and proceed to the small desk beside the kiosk which is manned by an officer. Give her the receipt, a copy of the passport photo, a copy of your ic and your old passport. She will give you a number. Do not fret if you forgot to photostat your ic and do not have a photo. beside the kiosk there is a counter to photostat and take your photo. 30cents for ic photostat. photo rm15.
Proceed then out of this room, turn left and you will see sign boards directing to the main office for passport about 10metres away. Wait for your number to be called, ususally about an hour. When your number is called, sign your passpsort and the form, and lo behold, your new passport is in your hands.

Problems of a large prostate

AGE WELL
By Assoc Prof Dr CHRISTOPHER C.K. HO

Aside from urinary problems, benign prostate hyperplasia can also affect a man’s sex life.

BENIGN prostate hyperplasia (BPH) is a common condition seen in middle-aged and elderly men. It is an enlargement of the prostate gland, which — although not cancerous — may cause problems, as it may impede the flow of urine out of the bladder.

It may also cause bleeding during urination, and predispose to infection of the urine.

If urine is totally obstructed from passing out of the bladder, it will cause a build-up of pressure and urine in the bladder, which when severe, may cause back-pressure, as well as reflux of urine into the kidney. This will eventually cause renal failure.

BPH and sex

Aside from all the problems described above, BPH may also affect a man’s sexual life.

Multiple studies have shown that BPH and sexual dysfunction are inter-related.

Sexual dysfunction refers to sexual problems, such as erectile dysfunction (unable to maintain satisfactory erection of the penis for sexual intercourse), ejaculatory dysfunction (failure to expel semen), and low sexual desire.

BPH has been found to be a risk factor for erectile dysfunction, independent of age.

BPH has also been found to be a stronger predictor of sexual dysfunction compared to diabetes, heart disease or hypertension. In fact, erectile function has been shown to deteriorate in tandem with worsening symptoms of BPH.

How does BPH cause worsening of sexual function?

There are a few theories, which include the nitric oxide/cyclic guanosine monophosphate pathway, rhokinase, overactivity of the autonomic pathway, and pelvic organ atherosclerosis.

All these theories have one thing in common — failure of relaxation of the smooth muscle.

Relaxation of the smooth muscle in the erectile tissue of the penis is needed for engorgement of the penis with blood.

Similarly, relaxation of the smooth muscle in the prostate and bladder neck is needed for urine to pass out of the bladder through the penis.

When there is failure of relaxation of the smooth muscle in the penis, this leads to erection difficulties; while in the prostate and bladder neck, urination difficulties occur.

Treating BPH

Treatment of BPH consists of medical, as well as surgical interventions.

So, does treating BPH improve the symptoms of BPH?

It depends on the medication given. There are basically two groups of medication for BPH, ie alpha blockers and the 5α reductase inhibitors.

Examples of alpha blockers include terazosin, doxazosin, alfuzosin, tamsulosin and silodosin.

There are only two types of 5α reductase inhibitor in the market, ie finasteride and dutasteride.

Alpha blockers have been shown to improve erectile function. Those with worse erectile function had better improvement with alpha blockers.

However, not all the alpha blocker drugs have similar effects on ejaculation. Alpha blockers that act more specifically on the prostate (uroselective), like silodosin, have been shown to have detrimental effects on ejaculation. There is no effect on sexual desire.

The 5α reductase inhibitors act by inhibiting the conversion of testosterone to dihydrotestosterone.

Dihydrotestosterone is the potent hormone that causes growth of the prostate. It is also commonly known as the male hormone responsible for male characteristics.

Therefore, it is no surprise that 5α reductase inhibitors are associated with a decrease in sexual desire and erectile dysfunction. It is also detrimental to ejaculatory function as well.

However, these sexual dysfunctions are seen mainly during the first year of treatment. The incidence of these problems decreases with longer duration of therapy.

Sometimes, both the alpha blockers and 5α reductase inhibitors are used in combination to treat BPH.

Although symptoms of BPH show better improvement with combination therapy, the incidence of sexual dysfunction increases as well. In fact, the incidence of sexual dysfunction is much worse compared to using either medication alone.

What about surgical treatment?

The gold standard for treatment of BPH is still transurethral resection of the prostate (TURP).

The evidence for sexual dysfunction after TURP is debatable. There are studies which show that it worsens sexual function, but conversely, there are also other studies that show otherwise.

However, what is consistent is the evidence that minimally-invasive treatment of BPH like transurethral microwave therapy (TUMT) and transurethral needle ablation (TUNA), is less detrimental to sexual function compared to TURP.

Unfortunately, the long-term success rate for treatment of BPH symptoms with these minimally-invasive therapies are not well established, and may be lower than TURP.

Restoring sexual ability

All is not lost if sexual dysfunction occurs as a result of BPH or its treatment.

If erectile dysfunction occurs, phosphodiestaerase-5 inhibitor medications like vardenafil, tadalafil and sildenafil, can be used.

However, there is a higher risk of postural hypotension (drop in blood pressure) when it is taken together with alpha blockers.

In this situation, the alpha blocker used should be a more uroselective drug (like tamsulosin), which has less complications of hypotension.

Other treatments include intracavernosal prostaglandin injections (injecting a medication known as prostaglandin into the penis), vacuum pump devices, as well as penile prostheses (implanting a medical device into the penis).

If ejaculation is a problem, the alpha blocker can be switched to one that has been proven to have less ejaculatory side effects (like alfuzosin).

There are also other modalities of treatment. However, all these problems are best managed by urologists.

BPH may cause sex-related problems. Similarly, its treatment may also cause sexual dysfunction.

There are treatments available to help alleviate these sexual problems. Consultation with a urologist would be the best step to take.

References:

1. Braun MH, Sommer F, Haupt G, Mathers MJ, Reifenrath B, Engelmann UH. Lower urinary tract symptoms and erectile dysfunction: co-morbidity or typical ‘Aging Male’ symptoms? Results of the ‘Cologne Male Survey’. Eur Urol 2003; 44: 588–94.

2. Rosen R, Altwein J, Boyle P 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.

3. Mirone V, Sessa A, Giuliano F, Berges R, Kirby M, Moncada I. Current benign prostatic hyperplasia treatment: impact on sexual function and management of related sexual adverse events. Int J Clin Pract. 2011;65(9):1005-13

4. AUA Practice Guidelines Committee. AUA guideline on management of benign prostatic hyperplasia (2003). Chapter 1: Diagnosis and treatment recommendations. J Urol 2003;170:530-47.

5. Mebust WK, Holtgrewe HL, Cockett AT, Peters PC. Transurethral prostatectomy: immediate and postoperative complications. A cooperative study of 13 participating institutions evaluating 3,885 patients. J Urol 2002; 167: 999–1003

6. Jadaine M et al. Effect of TURP on Erectile Function: A Prospective Comparative Study. Int J Impot Res 2010; 22: 146-51

7. Mishriki SF et al. TURP and sex: patient and partner prospective 12 years follow up study. BJU Int 2011; 109: 745-50

8. Hoffman RM, Monga M, Elliot SP, Macdonald R, Wilt TJ. Microwave thermotherapy for benign prostatic hyperplasia. Cochrane Database Syst Rev 2007; CD004135

9. Bouza C, López T, Magro A, Navalpotro L, Amate JM. Systematic review and meta-analysis of transurethral needle ablation in symptomatic benign prostatic hyperplasia. BMC Urol 2006; 6: 14