Int Urol Nephrol (2015) 47:497–501 DOI 10.1007/s11255-015-0923-2

UROLOGY - ORIGINAL PAPER

Ejaculatory function after anastomotic urethroplasty for pelvic fracture urethral injuries Ahmed El-Assmy • Mohammed Benhassan Ahmed M. Harraz • Adel Nabeeh • El Housseiny I. Ibrahiem



Received: 5 January 2015 / Accepted: 27 January 2015 / Published online: 6 February 2015 Ó Springer Science+Business Media Dordrecht 2015

Abstract Purpose The effect of anastomotic urethroplasty for pelvic fracture urethral injuries (PFUIs) on ejaculatory profile is under-reported in the literature. There is controversy as regards the effect of bulbocavernous muscle splitting during surgery on ejaculatory function (EjF). We evaluated the effects of anastomotic urethroplasty on EjF using a validated questionnaire. Methods We retrospectively reviewed the computerized surgical records to identify patients who underwent anastomotic posterior urethroplasty for PFUIs from June 1998 to January 2014. Those patients were retrieved and evaluated for their EjF using the EjF component of the Male Sexual Health Questionnaire (MSHQ). Results Overall, 58 patients were included in the study with a mean age of 31.6 years. All patients except one have antegrade ejaculation, and according to the overall ejaculatory score, only 5 patients (8.6 %) reported ejaculatory dysfunction and the remaining 53 (91.4 %) had good or average EjF. Ten men (17.2 %) reported decreased volume and force of ejaculate. Decreased pleasure during ejaculation was the commonest ejaculatory disorder (39.6 %). The score of each of the seven ejaculatory questions among the study patients was in harmony to the previous study of anterior urethroplasty except that men in this study had higher ejaculatory frequency and latency. Conclusions Nearly all men maintained antegrade ejaculation after posterior urethroplasty for PFUIs. The risk of

A. El-Assmy (&)  M. Benhassan  A. M. Harraz  A. Nabeeh  E. H. I. Ibrahiem Urology Department, Urology and Nephrology Center, Mansoura University, Mansoura, Egypt e-mail: [email protected]

urethral reconstruction and splitting the bulbocavernous muscle on ejaculation seems to be minimal. Keywords Urethroplasty  Ejaculation  Pelvic fracture urethral injuries (PFUIs)  MSHQ

Introduction Ejaculation consists of two main phases: The first is emission which is defined as deposition of seminal fluid into the posterior urethra controlled by sympathetic pathway (T10-L2) leading to sequential contraction of the epididymis, vas deferens, seminal vesicle, and prostate, with closure of the bladder neck. The second phase is expulsion initiated somatically from the sacral spinal cord (S2–S4) via the pudendal nerve, causing rhythmic contractions of the bulbospongiosus and bulbocavernosus muscles, which force the ejaculation through the distal urethra [1]. The urethra has an essential role in ejaculation as it serves as a conduit, so men with urethral stricture often complain of ejaculatory dysfunction due to urethral obstruction caused by the stricture [2]. Pelvic fracture urethral injuries (PFUIs) often result from high-velocity injuries that are associated with disruption of the pelvic ring [3]. Anastomotic urethroplasty is highly effective approach for treating strictures disease. It aims to establish a normal caliber urethra through which semen and urine can be expelled with minimal resistance. Urethral injury in men with PFUIs is often complicated and located posteriorly at the membranous urethra [4] or more commonly at the bulbomembranous junction [3]. One of the most concerning issues of urethroplasty in men with PFUIs is disruption of the bulbocavernosus muscle, which aids in semen expulsion [1]. To date, few

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studies addressed the effect of anterior and posterior urethroplasty on ejaculatory function (EjF) [2, 5–7]. Also, there is controversy regarding the effect of splitting bulbocavernosus muscle on EjF. Barbagli et al. [8] hypothesized that muscle damage during surgery may have been the etiology of the 23 % ejaculatory dysfunction rate in that series. On the other hand, Erikson et al. [7] did not find similar results in their prospective study, and they concluded that splitting this muscle seems to have a minimal effect on EjF. To the best of our knowledge, only one study evaluated the effect of posterior urethroplasty on EjF [6]. That study suffered from some limitations as it contained small number of patients, and the authors used non-validated questionnaire. In the present study, we used the EjF component of the validated Male Sexual Health Questionnaire (MSHQ) [9] to determine the effect of anastomotic urethroplasty for PFUIs on EjF. Also, the results of this study were further compared with the single published study that used the same assessment tool for evaluation of EjF after anterior urethroplasty [7].

Materials and methods After institutional review board approval, the computerized surgical records were retrospectively reviewed to identify patients who underwent perineal anastomotic posterior urethroplasty for PFUIs from June 1998 to January 2014. Clinical presentation, investigations, and operative and postoperative details were reviewed from the patient charts.

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and if satisfactory, the suprapubic cystostomy catheter was removed 1 day later. Follow-up Patients were contacted by mail or phone and were reevaluated in the follow-up outpatient clinic. Assessment of the EjF was achieved using ejaculatory component of the MSHQ [9] which consists of seven questions including ejaculatory frequency, latency, volume, force, pain, pleasure, and dry ejaculation. Each question was scored from 1 (lowest/poor function) to 5 (highest/best function) for a maximum score of 35 (no dysfunction). The results of the overall MSHQ score was interpreted as good EjF if the score ranges from 28–35, and average and poor if the score ranges from 22–27 and 21 or less, respectively. Since there are no established clinical cutoffs for this questionnaire, these categories represent an average score of 4 or greater points on each question for good, 3 for average, and less than 3 for poor function. All the patients were interviewed during which a complete medical and sexual history was taken and particular attention was given to the patient’s EjF before pelvic fracture, immediately after trauma, and after urethroplasty. Statistical analysis Data were processed using SPSS-16 for Windows (SPSS, Inc., Chicago, IL). The results of this study were compared with previous study of Erickson et al. [7] using Student’s one-sample t test. A P value of \0.05 was considered significant.

Surgical repair Results All surgical repairs were approached through inverted U-shaped or midline perineal incisions, with the patient in an exaggerated lithotomy position. The bulbar urethra was dissected down to the distal end of the stenosed segment, which led to the apex of the prostate. After excising all scarred tissue, the distal urethral end was spatulated after mobilizing the anterior urethra and a tension-free mucosato-mucosa anastomosis was made with four to six sutures of 4/0 polyglycolic acid over a silicon Foley catheter. The operation was completed by inserting a suprapubic tube and closing the perineal wound with a drain. None of our patients required supracrural re-routing or symphysiotomy to complete the anastomosis. The silicon catheter and suprapubic cystostomy drainage were maintained for 21–28 days after surgery. After removing the urethral catheter, a gravity voiding film, with contrast medium infused through the suprapubic cystostomy tube, was taken to confirm the integrity of the repair,

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Overall, 58 patients were included in the study. The mean ± SD (range) age of the patients at the time of interview was 31.6 ± 12.2 (16–73) years, and the mean ± SD (range) time from the urethroplasty to the interview was 61.3 ± 46.7 (6–165) months. None of the patients had major medical illness, diabetes mellitus, neurological abnormalities, or psychological disorders that could affect ejaculation at time of interview. The mean ± SD (range) urethral stenosis length was 40 ± 13 (10–60) mm, and the cause of trauma was road traffic accident in all patients. Fifty-five patients (94.8 %) presented with indwelling suprapubic cystostomy tube due to complete urethral obstruction, and the remaining 3 presented with difficulty of micturition. Among the 58 patients, 36 (62 %) men were sexually active and the remaining 22 (38 %) were single, and all completed the EjF component of MSHQ. All patients

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Table 1 Results of ejaculatory component of MSHQ Question

Good (4–5) no (%)

Average (3) no (%)

Overall

34 (58.6)

19 (32.8)

Frequency

53 (89.7)

Latency

48 (82.8)

Force

23 (39.7)

25 (43.1)

Volume

31 (53.4)

Pain Pleasure Dry

Poor (\3) no (%)

Table 2 Comparison with men after anterior urethroplasty by Erickson et al. [7] Question

Erickson et al.’s mean

This study’s mean

P value

5 (8.6)

Overall

26.9

26.7

0.9

5(8.6)

1 (1.7)

Frequency

4.33

4.63

0.04

5 (8.6)

5 (8.6)

Latency

3.81

4.36

0.01

10 (17.2)

Force

3.56

3.25

0.17

17 (29.4)

10 (17.2)

Volume

3.88

3.5

0.1

53 (91.4)

3 (5.2)

2 (3.4)

Pain

4.40

3.94

0.055

6 (10.3) 55 (94.9)

29 (50.1) 2 (3.4)

23 (39.6) 1 (1.7)

Pleasure Dry

2.79 4.28

2.55 4.55

0.16 0.12

reported good EjF before initial pelvic trauma. At time of evaluation and according to the overall MSHQ score, only five patients (8.6 %) reported ejaculatory dysfunction and 53 patients (91.4 %) had good or average EjF. After repair of PFUIs, only one patient (1.7 %) exhibited impaired ejaculatory frequency and 5 (8.6 %) patients reported delayed ejaculation. Ten men (17.2 %) reported decreased volume and force of ejaculate. One (1.7 %) reported dry ejaculation, and decreased pleasure during ejaculation was the commonest ejaculatory disorder among our group (39.6 %). Patient with dry ejaculation had patent urethra on ascending urethrography. The details of patients in each of the 7 questions are listed in Table 1. We reviewed Medline and identified only 1 study that previously used the MSHQ to evaluate EjF in men after anterior urethroplasty by Erickson et al. [7]. The scores of the seven questions of EjF of MSHQ among men in our study were in harmony to those found in Erickson et al.’s study [7] with no statistically significant difference except that patients in this study had significantly higher ejaculatory frequency and latency, Table 2.

Discussion Urethral injuries associated with pelvic fracture were initially termed pelvic fracture urethral distraction defects (PFUDDs) by Turner-Warwick based on the assumption that they were usually complete injuries. However, the International Consultation on Urological Diseases recommended replacing PFUDD with PFUI, because these injuries are not complete disruptions in most cases, and that even when they are complete, they are not necessarily distracted [3]. Until recently, few studies evaluated the sexual function after urethroplasty and most of them have focused on erectile dysfunction (ED). These studies reported 18 to 72 % postoperative ED rate [2, 4, 10–14]. The theoretical risk of ED comes from the close relationship of the cavernous nerves with the proximal urethra when they emerge

from the pelvic floor [15], so nerves are liable to iatrogenic injury during urethral dissection leading to transient neuropraxia as the cause. Ejaculatory dysfunction after urethroplasty has been studied considerably less, and to the best of our knowledge, only four published studies addressed the issue of EjF after anterior and posterior urethroplasty [2, 5–7]. In an older study of 17 patients with scrotal island patch urethroplasty, the authors could not reconstruct the bulbocavernosus muscle over the bulb in three patients. This resulted in urethral pouching which did not interfere with micturition, but prevented forceful ejaculation, and the semen leaked slowly for several minutes after orgasm [5]. More recently, Erickson et al. [2] retrospectively evaluated 52 men with anterior urethroplasty using the 3 EjF questions from the Brief Male Sexual Function Inventory [16]. They found an overall increase in postoperative ejaculatory score (5.3–6.2 points, P = 0.04) and attributed this improvement due to relief of urethral obstruction. However, being a retrospective study, recall bias was a major concern. In addition, a retrospective study of 32 men with PFUIs treated by posterior urethroplasty showed that all had postoperative antegrade ejaculation, of whom only 5 (16 %) had decreased volume than before their injury and 1 (3 %) had delayed ejaculation [6]. Similarly, recall bias was again a concern and that study did not use a validated questionnaire. Lastly, the effect of anterior urethroplasty on the EjF was prospectively evaluated by Erickson et al. [7]. Their study included 43 men who underwent anterior urethroplasty and were asked to complete the EjF component of the MSHQ preoperatively and postoperatively after resuming sexual activity. Postoperatively, decreased and improved ejaculation was defined as an increase and a decrease of 5 or more points, respectively. The overall ejaculatory score did not change postoperatively at a mean follow-up of 8.1 months, but men with poor preoperative function had significant improvement. Overall ejaculatory force and volume did not change significantly. Postoperative EjF was stable in 30

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men (70 %), improved in 8 (19 %), and worse in 5 (11 %) patients. To our knowledge, this is the first study to evaluate the EjF after posterior urethroplasty for PFUIs using the MSHQ, which is a validated questionnaire developed in 2004 by Rosen et al. [9]. This questionnaire was specifically designed to thoroughly evaluate the EjF. In addition, the questionnaire-based assessment provides a reproducible method of gathering and comparing relevant information. Based on the fact that 94.8 % of our patients presented with indwelling suprapubic cystostomy catheter with no urine or semen comes through the urethra, the EjF could not be evaluated by MSHQ before urethroplasty. After urethroplasty, antegrade ejaculation returned in all men except one (1.7 %). Using the overall ejaculatory score, only 5 men (8.6 %) complained of ejaculatory dysfunction and the majority of patients (91.4 %) reported improved function after constructive surgery at a median follow-up of 61 months. In this study, the scores of the 7 questions of EjF for men with PFUIs repair were in agreement with those found in Erickson et al.’s study [7] with no statistically significant difference except that our men had significantly higher ejaculatory frequency and latency. Higher ejaculatory frequency could be explained by the fact that the mean age of our patients was lower than those of Erickson et al.’s [7]; 31.6 and 40.49 years, respectively. The reported results of splitting the bulbocavernosus muscle on EjF showed contradictory findings. Studies in which this muscle was purposely inhibited showed decreased EjF [17]. On the other hand, Erickson et al. [7] stated that splitting this muscle seems to have a minimal effect on EjF in men after anterior urethroplasty. In our study, 10 (17.2 %) men complained of decreased semen volume after posterior urethroplasty compared with before pelvic trauma. We were unable to determine whether PFUIs affected the ejaculatory volume in these men or not. In addition, many of these men had aged several years after the injury and the ejaculatory volume might have simply decreased with aging [18]. However, it seems that splitting bulbocavernosus muscle has minimal effect on its function and this finding is in concordance with that reported by Erickson et al. [7]. We acknowledge some limitations in our study: First, the limitations of retrospective recall of this study did not allow us to directly measure the effect of PFUIs on EjF. Secondly, the impact of PFUIs and associated pelvic injuries on patients’ long-term fertility was not assessed. Finally, to accurately estimate the actual effect of urethroplasty and splitting the bulbocavernous muscle on EjF, more objective tests are required such as bulbocavernous muscle contractile potential preoperatively and postoperatively and measuring the ejaculate volume.

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Conclusions Nearly all men maintained antegrade ejaculation after PFUIs repair. The risk of splitting the bulbocavernous muscle on ejaculation is minimal. However, objective testing is required to accurately estimate the effects of bulbocavernous muscle splitting on its contraction and EjF. Conflict of interest

No conflict of interest to declare.

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Ejaculatory function after anastomotic urethroplasty for pelvic fracture urethral injuries.

The effect of anastomotic urethroplasty for pelvic fracture urethral injuries (PFUIs) on ejaculatory profile is under-reported in the literature. Ther...
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