Neurourology and Urodynamics
Effects of Bariatric Surgery on Male Lower Urinary Tract Symptoms and Sexual Function 1
Asnat Groutz,1* David Gordon,1 Pinhas Schachter,2 Hadar Amir,1 and Mordechai Shimonov2 Sackler Faculty of Medicine, Urogynecology and Pelvic Floor Unit, Tel Aviv Sourasky Medical Center, Lis Maternity Hospital, Tel Aviv University, Tel Aviv, Israel 2 Sackler Faculty of Medicine, Department of Surgery, E. Wolfson Medical Center, Tel Aviv University, Tel Aviv, Israel
Aim: To investigate the effect of bariatric surgery on male lower urinary tract symptoms (LUTS) and sexual function. Methods: Fifty-five consecutive obese men who underwent a laparoscopic sleeve gastrectomy were prospectively enrolled. Two validated questionnaires, the International Prostate Symptoms Score (IPSS) and the International Index of Erectile Function (IIEF) were used to assess LUTS and sexual function, before and 3 months after surgery. Fifty-three men (mean age 39 12.5 years) completed all pre and postoperative questionnaires. Mean body mass index (BMI) before and 3 months after surgery was 42.8 5.3 and 31.3 5.4 kg/m2; respectively. Results: Preoperatively, 41 (77%) men (mean age 40 12.9, mean BMI 42.2 5 kg/m2) had some degree of LUTS and 39 (74%) men (mean age 40.7 12.4, mean BMI 42.8 5.6 kg/m2) were sexually active. Postoperatively, the total IPSS score decreased significantly (5.5 4.4 vs. 2.7 2.6; P < 0.001), however this change was due to improvement in storage phase LUTS, measured by questions 2, 4, and 7 of the IPSS questionnaire. No statistically significant changes of voiding phase LUTS, measured by questions 1, 3, 5, 6 of the IPSS, were observed. Of the various aspects of sexual dysfunction, only erectile function, measured by questions 1–5 and 15 of the IIEF questionnaire was significantly improved (22.7 7.2 vs. 26.1 6.5, P ¼ 0.02). Postoperative overall intercourse satisfaction (9.5 4.2 vs. 11.5 3, P ¼ 0.01) and overall satisfaction (7.9 2.5 vs. 8.9 1.3, P ¼ 0.02) were significantly improved as well. Conclusion: Male storage phase LUTS and erectile function were significantly and rapidly improved following bariatric surgery. Larger and long-term studies are required to investigate these apparently beneficial effects. Neurourol. Urodynam. # 2016 Wiley Periodicals, Inc. Key words: bariatric surgery; lower urinary tract symptoms; male; sexual function; weight loss INTRODUCTION
Obesity is a major risk factor for life-threatening diseases, including diabetes mellitus, cardiovascular disease, hypertension, stroke, and certain forms of cancer. It affects both industrialized and developing populations, regardless age, gender, and socioeconomic class. Long-term adherence to behavioral weight-loss programs is usually poor, and currently bariatric surgery is the most effective treatment for significant and sustained weight loss.1,2 It is recommended for class 2 obesity associated with comorbidities and for class 3 obesity (body mass index [BMI] 35–39.9 kg/m2 and >40 kg/m2; respectively).3 Obesity is also an established and modifiable risk factor for female urinary incontinence, but comprehensive data regarding the association between obesity and male lower urinary tract symptoms (LUTS), as well as male sexual function are lacking. The present study was undertaken to assess the effect of significant rapid weight loss on LUTS and sexual function among obese men undergoing laparoscopic sleeve gastrectomy. METHODS
Fifty-five consecutive obese men, who underwent laparoscopic sleeve gastrectomy in a single university-affiliated medical center, were prospectively enrolled. This series represents preliminary results of a larger ongoing study to investigate the impacts of significant weight loss on LUTS and sexual function among morbidly obese men and women. Medical indications for bariatric surgery included class 2 obesity associated with comorbidities (BMI 35–39.9 kg/m2), class 3 obesity (BMI >40 kg/m2) and obese patients with BMI #
2016 Wiley Periodicals, Inc.
30–35 kg/m2 who previously failed bariatric surgery. Other criteria for inclusion in the study included age over 18 years and Hebrew as the primary language. Patients who did not meet these inclusion criteria (BMI, age and language) were excluded. The study protocol was approved by the local hospital Helsinki committee. Preoperative demographic data, comorbidities, BMI, physical examination, and laboratory tests were prospectively obtained and documented in a detailed computerized data base. Two validated questionnaires, the International Prostate Symptoms Score (IPSS)4 and the International Index of Erectile Function (IIEF)5 were used to assess male LUTS and sexual function, respectively. Eligible patients were prospectively evaluated before and 3 months after surgery. The IPSS, originally developed for patients suffering from benign prostatic hyperplasia (BPH), is commonly used to assess male LUTS.4,6 It comprises of eight questions: seven questions concerning urinary storage and voiding symptoms over the past month (feeling of incomplete bladder emptying, frequency, intermittency, urgency, weak stream, straining, and nocturia), and one question concerning the impact of urinary symptoms on quality of life (QOL). Each symptom question is Dr. John Heesakkers led the peer-review process as the Associate Editor responsible for the paper. Potential conflicts of interest: Nothing to disclose. Correspondence to: Asnat Groutz, MD, Urogynecology and Pelvic Floor Unit, Tel Aviv Sourasky Medical Center, Lis Maternity hospital, 6 Weizman Street, Tel Aviv, Israel. E-mail: [email protected] Received 7 November 2015; Accepted 31 January 2016 Published online in Wiley Online Library (wileyonlinelibrary.com). DOI 10.1002/nau.22980
2
Groutz et al.
scored from 0 to 5, the total score can therefore range from 0 (asymptomatic) to 35 (very symptomatic). The QOL question is scored from 0 to 6. The IIEF is a widely used self-administered questionnaire to assess male sexual function.5,7 The questionnaire comprises of 15 items, each scored from 0 to 5, allowing the assessment of the five main domains of male sexual function: erectile function (items 1–5, 15), orgasmic function (items 9,10), sexual desire (items 11,12), intercourse satisfaction (items 6–8), and overall satisfaction (items 13,14). Of the 55 patients, 53 (mean age 39 12.5 years; range 19–67) completed all pre and postoperative questionnaires. Mean BMI before and 3 months after surgery was 42.8 5.3 kg/m2 and 31.3 5.4 kg/m2; respectively. Comparison of the 53 responders versus the two non-responders, showed no statistically significant differences in terms of their mean age, BMI before and after surgery, or perioperative morbidity. Statistical analysis was performed using Student’s t-test for continuous data or Fisher exact test for categorical data. Further analysis of pre versus postoperative results was undertaken by using paired t-tests (cross over analysis). Data are summarized as mean standard deviation (SD), or percentage according to the variables. P < 0.05 was considered statistically significant. Statistical Package for Social Sciences (SPSS), version 15.0, was used for the analysis. RESULTS
Fifty-three men (mean age 39 12.5 years, range 19–67; mean BMI 42.8 5.3 kg/m2) who underwent laparoscopic sleeve gastrectomy completed all pre and postoperative questionnaires. Of the 53 patients, 7 (1.9%) had previously undergone bariatric surgery, 16 (30.2%) had diabetes mellitus, and 19 (35.8%) had hypertension. All patients were Israeli Jewish men, 43 (81%) of whom were born in Israel, and all but one reported at least a high school diploma. Preoperatively, 41 (77%) patients (mean age 40 12.9 years, mean BMI 42.2 5 kg/m2) had some degree of LUTS. Twelve other patients (mean age 36.2 10.4 years, mean BMI 45 5.6 kg/m2) did not report any LUTS. Pre and postoperative IPSS scores of the 41 preoperatively symptomatic patients are presented in Table I. Overall, surgically induced weight loss was associated with statistically significant improvement in storage phase LUTS (measured by questions 2, 4, and 7 of the IPSS questionnaire) and QOL (question 8). Specifically, the total score of the IPSS questionnaire decreased from 5.5 4.4 preoperatively to 2.7 2.6 postoperatively (P < 0.001). No statistically significant changes of voiding phase LUTS, measured by questions 1, 3, 5, 6 of the IPSS, were observed. Moreover, 10 (24.4%) patients reported complete resolution of LUTS following weight loss. Further paired t-test analysis for testing pre versus postoperative results of the IPSS questionnaire is presented in Table II. The paired t-test analysis also show a statistically significant improvement in storage phase LUTS (measured by questions 2, 4, and 7 of the IPSS questionnaire) as well as the total IPSS score. Sexual function was evaluated by using the IIEF questionnaire. Preoperatively, 39 (74%) patients (mean age 40.7 12.4 years, mean BMI 42.8 5.6 kg/m2) were sexually active. Fourteen other patients (mean age 30.7 14.3 years, mean BMI 43 4.6 kg/m2) were not sexually active. Pre and postoperative IIEF scores of the 39 sexually active patients are presented in Table III. Of the various aspects of sexual dysfunction, only erectile function, measured by questions 1–5 and 15 of the IIEF questionnaire was significantly improved (22.7 7.2 vs. 26.1 6.5, P ¼ 0.02). However, postoperative overall intercourse satisfaction (9.5 4.2 vs. 11.5 3, P ¼ 0.01), as well as overall satisfaction (7.9 2.5 vs. 8.9 1.3, Neurourology and Urodynamics DOI 10.1002/nau
P ¼ 0.02), were also significantly improved. Further paired t-test analysis for testing pre versus postoperative results of the IIEF questionnaire is presented in Table IV. Results show a significant improvement in all of the investigated categories, however, these results should be interpreted with caution because of the small series and the complexity of sexual function.
TABLE I. IPSS—Pre and Postoperative Analysis (N ¼ 41) Mean SD
Preoperative
BMI (kg/m2) IPSS items Incomplete emptying Frequency Intermittency Urgency Weak stream Straining Nocturia Total score Quality of life
42.2 5 0.73 1.39 0.41 0.78 0.41 0.36 1.4 5.5 1.5
P
Postoperative
1.4 1.5 1 1.3 1.1 0.8 1.1 4.4 1.8
31 5.8
Effects of Bariatric Surgery on Male Lower Urinary Tract Symptoms and Sexual Function 1
Asnat Groutz,1* David Gordon,1 Pinhas Schachter,2 Hadar Amir,1 and Mordechai Shimonov2 Sackler Faculty of Medicine, Urogynecology and Pelvic Floor Unit, Tel Aviv Sourasky Medical Center, Lis Maternity Hospital, Tel Aviv University, Tel Aviv, Israel 2 Sackler Faculty of Medicine, Department of Surgery, E. Wolfson Medical Center, Tel Aviv University, Tel Aviv, Israel
Aim: To investigate the effect of bariatric surgery on male lower urinary tract symptoms (LUTS) and sexual function. Methods: Fifty-five consecutive obese men who underwent a laparoscopic sleeve gastrectomy were prospectively enrolled. Two validated questionnaires, the International Prostate Symptoms Score (IPSS) and the International Index of Erectile Function (IIEF) were used to assess LUTS and sexual function, before and 3 months after surgery. Fifty-three men (mean age 39 12.5 years) completed all pre and postoperative questionnaires. Mean body mass index (BMI) before and 3 months after surgery was 42.8 5.3 and 31.3 5.4 kg/m2; respectively. Results: Preoperatively, 41 (77%) men (mean age 40 12.9, mean BMI 42.2 5 kg/m2) had some degree of LUTS and 39 (74%) men (mean age 40.7 12.4, mean BMI 42.8 5.6 kg/m2) were sexually active. Postoperatively, the total IPSS score decreased significantly (5.5 4.4 vs. 2.7 2.6; P < 0.001), however this change was due to improvement in storage phase LUTS, measured by questions 2, 4, and 7 of the IPSS questionnaire. No statistically significant changes of voiding phase LUTS, measured by questions 1, 3, 5, 6 of the IPSS, were observed. Of the various aspects of sexual dysfunction, only erectile function, measured by questions 1–5 and 15 of the IIEF questionnaire was significantly improved (22.7 7.2 vs. 26.1 6.5, P ¼ 0.02). Postoperative overall intercourse satisfaction (9.5 4.2 vs. 11.5 3, P ¼ 0.01) and overall satisfaction (7.9 2.5 vs. 8.9 1.3, P ¼ 0.02) were significantly improved as well. Conclusion: Male storage phase LUTS and erectile function were significantly and rapidly improved following bariatric surgery. Larger and long-term studies are required to investigate these apparently beneficial effects. Neurourol. Urodynam. # 2016 Wiley Periodicals, Inc. Key words: bariatric surgery; lower urinary tract symptoms; male; sexual function; weight loss INTRODUCTION
Obesity is a major risk factor for life-threatening diseases, including diabetes mellitus, cardiovascular disease, hypertension, stroke, and certain forms of cancer. It affects both industrialized and developing populations, regardless age, gender, and socioeconomic class. Long-term adherence to behavioral weight-loss programs is usually poor, and currently bariatric surgery is the most effective treatment for significant and sustained weight loss.1,2 It is recommended for class 2 obesity associated with comorbidities and for class 3 obesity (body mass index [BMI] 35–39.9 kg/m2 and >40 kg/m2; respectively).3 Obesity is also an established and modifiable risk factor for female urinary incontinence, but comprehensive data regarding the association between obesity and male lower urinary tract symptoms (LUTS), as well as male sexual function are lacking. The present study was undertaken to assess the effect of significant rapid weight loss on LUTS and sexual function among obese men undergoing laparoscopic sleeve gastrectomy. METHODS
Fifty-five consecutive obese men, who underwent laparoscopic sleeve gastrectomy in a single university-affiliated medical center, were prospectively enrolled. This series represents preliminary results of a larger ongoing study to investigate the impacts of significant weight loss on LUTS and sexual function among morbidly obese men and women. Medical indications for bariatric surgery included class 2 obesity associated with comorbidities (BMI 35–39.9 kg/m2), class 3 obesity (BMI >40 kg/m2) and obese patients with BMI #
2016 Wiley Periodicals, Inc.
30–35 kg/m2 who previously failed bariatric surgery. Other criteria for inclusion in the study included age over 18 years and Hebrew as the primary language. Patients who did not meet these inclusion criteria (BMI, age and language) were excluded. The study protocol was approved by the local hospital Helsinki committee. Preoperative demographic data, comorbidities, BMI, physical examination, and laboratory tests were prospectively obtained and documented in a detailed computerized data base. Two validated questionnaires, the International Prostate Symptoms Score (IPSS)4 and the International Index of Erectile Function (IIEF)5 were used to assess male LUTS and sexual function, respectively. Eligible patients were prospectively evaluated before and 3 months after surgery. The IPSS, originally developed for patients suffering from benign prostatic hyperplasia (BPH), is commonly used to assess male LUTS.4,6 It comprises of eight questions: seven questions concerning urinary storage and voiding symptoms over the past month (feeling of incomplete bladder emptying, frequency, intermittency, urgency, weak stream, straining, and nocturia), and one question concerning the impact of urinary symptoms on quality of life (QOL). Each symptom question is Dr. John Heesakkers led the peer-review process as the Associate Editor responsible for the paper. Potential conflicts of interest: Nothing to disclose. Correspondence to: Asnat Groutz, MD, Urogynecology and Pelvic Floor Unit, Tel Aviv Sourasky Medical Center, Lis Maternity hospital, 6 Weizman Street, Tel Aviv, Israel. E-mail: [email protected] Received 7 November 2015; Accepted 31 January 2016 Published online in Wiley Online Library (wileyonlinelibrary.com). DOI 10.1002/nau.22980
2
Groutz et al.
scored from 0 to 5, the total score can therefore range from 0 (asymptomatic) to 35 (very symptomatic). The QOL question is scored from 0 to 6. The IIEF is a widely used self-administered questionnaire to assess male sexual function.5,7 The questionnaire comprises of 15 items, each scored from 0 to 5, allowing the assessment of the five main domains of male sexual function: erectile function (items 1–5, 15), orgasmic function (items 9,10), sexual desire (items 11,12), intercourse satisfaction (items 6–8), and overall satisfaction (items 13,14). Of the 55 patients, 53 (mean age 39 12.5 years; range 19–67) completed all pre and postoperative questionnaires. Mean BMI before and 3 months after surgery was 42.8 5.3 kg/m2 and 31.3 5.4 kg/m2; respectively. Comparison of the 53 responders versus the two non-responders, showed no statistically significant differences in terms of their mean age, BMI before and after surgery, or perioperative morbidity. Statistical analysis was performed using Student’s t-test for continuous data or Fisher exact test for categorical data. Further analysis of pre versus postoperative results was undertaken by using paired t-tests (cross over analysis). Data are summarized as mean standard deviation (SD), or percentage according to the variables. P < 0.05 was considered statistically significant. Statistical Package for Social Sciences (SPSS), version 15.0, was used for the analysis. RESULTS
Fifty-three men (mean age 39 12.5 years, range 19–67; mean BMI 42.8 5.3 kg/m2) who underwent laparoscopic sleeve gastrectomy completed all pre and postoperative questionnaires. Of the 53 patients, 7 (1.9%) had previously undergone bariatric surgery, 16 (30.2%) had diabetes mellitus, and 19 (35.8%) had hypertension. All patients were Israeli Jewish men, 43 (81%) of whom were born in Israel, and all but one reported at least a high school diploma. Preoperatively, 41 (77%) patients (mean age 40 12.9 years, mean BMI 42.2 5 kg/m2) had some degree of LUTS. Twelve other patients (mean age 36.2 10.4 years, mean BMI 45 5.6 kg/m2) did not report any LUTS. Pre and postoperative IPSS scores of the 41 preoperatively symptomatic patients are presented in Table I. Overall, surgically induced weight loss was associated with statistically significant improvement in storage phase LUTS (measured by questions 2, 4, and 7 of the IPSS questionnaire) and QOL (question 8). Specifically, the total score of the IPSS questionnaire decreased from 5.5 4.4 preoperatively to 2.7 2.6 postoperatively (P < 0.001). No statistically significant changes of voiding phase LUTS, measured by questions 1, 3, 5, 6 of the IPSS, were observed. Moreover, 10 (24.4%) patients reported complete resolution of LUTS following weight loss. Further paired t-test analysis for testing pre versus postoperative results of the IPSS questionnaire is presented in Table II. The paired t-test analysis also show a statistically significant improvement in storage phase LUTS (measured by questions 2, 4, and 7 of the IPSS questionnaire) as well as the total IPSS score. Sexual function was evaluated by using the IIEF questionnaire. Preoperatively, 39 (74%) patients (mean age 40.7 12.4 years, mean BMI 42.8 5.6 kg/m2) were sexually active. Fourteen other patients (mean age 30.7 14.3 years, mean BMI 43 4.6 kg/m2) were not sexually active. Pre and postoperative IIEF scores of the 39 sexually active patients are presented in Table III. Of the various aspects of sexual dysfunction, only erectile function, measured by questions 1–5 and 15 of the IIEF questionnaire was significantly improved (22.7 7.2 vs. 26.1 6.5, P ¼ 0.02). However, postoperative overall intercourse satisfaction (9.5 4.2 vs. 11.5 3, P ¼ 0.01), as well as overall satisfaction (7.9 2.5 vs. 8.9 1.3, Neurourology and Urodynamics DOI 10.1002/nau
P ¼ 0.02), were also significantly improved. Further paired t-test analysis for testing pre versus postoperative results of the IIEF questionnaire is presented in Table IV. Results show a significant improvement in all of the investigated categories, however, these results should be interpreted with caution because of the small series and the complexity of sexual function.
TABLE I. IPSS—Pre and Postoperative Analysis (N ¼ 41) Mean SD
Preoperative
BMI (kg/m2) IPSS items Incomplete emptying Frequency Intermittency Urgency Weak stream Straining Nocturia Total score Quality of life
42.2 5 0.73 1.39 0.41 0.78 0.41 0.36 1.4 5.5 1.5
P
Postoperative
1.4 1.5 1 1.3 1.1 0.8 1.1 4.4 1.8
31 5.8
