Male Sexual Dysfunction

Erectile Dysfunction After

Anterior Urethroplasty: A Prospective
Analysis of Incidence and Probability
of Recovery—Single-center Experience
Prem N. Dogra, Ashish Kumar Saini, Amlesh Seth
OBJECTIVE To evaluate the incidence and probability of recovery of erectile dysfunction after different types
of one-stage urethroplasties for anterior urethral stricture disease.
METHODS Seventy-eight men undergoing single-stage anterior urethroplasty from January 1, 2008 to March
31, 2010 were followed prospectively. Patients were divided into 3 groups: group 1 (n ⫽
25)—penile substitution urethroplasty; group 2 (n ⫽ 32)—primary excision anastomotic bulbar
urethroplasty; and group 3 (n ⫽ 21)— bulbar substitution urethroplasty. Patients willing to
participate completed the International Index of Erectile Function (IIEF) preoperatively and
then on subsequent follow-up visits at 3, 6, 9, 12, and 15 months after urethroplasty. Pre- and
post-urethroplasty erectile functions were compared.
RESULTS Our mean follow-up period was 15.50 ⫹ 2.389 months. The mean age (years) was similar among
groups. The mean stricture length (cm) was 4.78 ⫾ 0.747, 2.95 ⫾ 0.658, and 6.13 ⫾ 0.981
in-groups 1, 2, and 3, respectively (P ⫽ .001). Mean preoperative IIEF score was 24.60 ⫾ 2.365
(similar among groups). Erectile dysfunction (ED) was found in 15 (20%) patients: 4/25 (16%),
9/32 (28%), and 2/21 (10%) in groups 1, 2, and 3, respectively. Mean postoperative decline (3
months) in IIEF score was 22.54 ⫾ 4.823. Overall, the decline was not significant among groups
(P ⫽ .502.) Recovery of erectile function was seen in 75/78 (96%) men at a mean follow-up time
of 5.63 ⫾ 2.59 months.
CONCLUSIONS Anterior urethroplasty has a probability of causing ED in as much as 20% of patients. The type
of urethroplasty has no significant effect on ED. Recovery of erectile function occurs within 6
months of urethroplasty. UROLOGY 78: 78 – 81, 2011. © 2011 Published by Elsevier Inc.

T
here has been a paradigm shift in managing ure- after different types of anterior urethroplasty using a
thral stricture disease during the past 2 decades, validated questionnaire (International Index of Erectile
with a shift toward performing more urethroplas- Function [IIEF]-5) was conducted at our center and we
ties rather than endoscopic management because the report our findings here.
long-term follow-up and literature review have shown
superior results.1 As the number and types of urethroplas- MATERIAL AND METHODS
ties being performed worldwide is on a rise, so are their
inadvertent complications. ED risk after urethroplasty From January 1, 2008 to March 31, 2010, 89 patients underwent
single-stage anterior urethroplasty by senior consultant urolo-
stems from the close proximity of cavernosal nerves with
gists in our department. All patients were evaluated with de-
the proximal urethra as they emerge from the pelvic tailed clinical history, physical examination, urine culture, ul-
floor.2-4 Once the patient is voiding well, the emphasis trasonography with residual urine measurement, uroflowmetry,
turns to erectile function (ED).5 Still now, there is scar- and retrograde and voiding cystourethrography. Exclusion cri-
city of long-term prospective studies specifically evaluat- teria include patients undergoing staged repair, sexually inac-
ing the effect of different types of anterior urethroplasties tive, pelvic fracture, history of trauma, or unwilling to partici-
on ED.5-7 A prospective study specifically evaluating ED pate. Patients not completing both a preoperative and at least
2 postoperative questionnaires and not engaged in sexual ac-
tivity were excluded from the analysis. Seventy-eight patients
From the Department of Urology, All India Institute of Medical Sciences, New Delhi, were included in the study. All patients completed a preoper-
India ative IIEF-5 questionnaire to ascertain baseline sexual function
Reprint requests: Dr. Prem N. Dogra, Professor and Head, Department of Urology,
All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029, India.
and a repeat IIEF was given to all patients on consequent
E-mail: [email protected] postoperative visits at 3, 6, 9, 12, and 15 months, respectively.
Submitted: September 16, 2010, accepted (with revisions): January 11, 2011 IIEF is a validated multidimensional questionnaire used ex-

78 © 2011 Published by Elsevier Inc. 0090-4295/11/$36.00

doi:10.1016/j.urology.2011.01.019
Table 1. Patient characteristics, stricture site, length, ED, and follow-up
Group 2 Group 3
Group 1 Bulbar (Excision and Bulbar Substitution
Penile Urethroplasty Primary Anastomosis) Urethroplasty
Parameters (n ⫽ 25) (n ⫽ 32) (n ⫽ 21) P Value
Age (y), mean (range) 38.12 ⫾ 13.075 (22-64) 37.66 ⫾ 12.167 (21-64) 38.10 ⫾ 11.322 (23-71) .987
Mean stricture length (cm) 4.78 ⫾ 0.747 (3-6) 2.95 ⫾ 0.658 (2-4) 6.13 ⫾ 0.981 .001
Etiology inflammatory 06 (24%) 21 (65.6%) 9 (42.9%)
Catheter-induced 09 (36%) 04 (12.5%) 5 (23.8%)
Failed hypospadias repair 02 (8%) 0 0
Idiopathic 08 (32%) 07 (21.9%) 07 (33.3%)
Mean previous 2.48 ⫾ 0.875 2.28 ⫾ 0.958 2.29 ⫾ 0.644 .324
interventions
Mean follow-up (mo) 16.08 ⫾ 2.581 (12-21) 15.19 ⫾ 2.402 (12-21) 15.29 ⫾ 2.101 (12-18) .339
ED after repair 4 (16%) 9 (28%) 2 (10%)

Table 2. Mean IIEF score preoperatively, postoperatively, and at the end of the study
Group 2 Group 3
Group 1 Bulbar (Excision and Bulbar Substitution
Penile Urethroplasty Primary Anastomosis) Urethroplasty
Parameters (n ⫽ 25) (n ⫽ 32) (n ⫽ 21) P Value
Mean preop IIEF score 24.88 ⫾ 2.205 (20-27) 25.03 ⫾ 2.348 (20-27) 23.62 ⫾ 2.397 (16-27) .080
Mean IIEF score (3 mo) 22.68 ⫾ 4.616 (11-27) 21.84 ⫾ 5.903 (9-27) 23.43 ⫾ 2.891 (16-27) .502
Mean IIEF score (6 mo) 24.52 ⫾ 2.383 (20-27) 24.22 ⫾ 4.427 (9-27) 23.48 ⫾ 2.522 (16-27) .573
Mean difference in IIEF 2.20 (P ⫽ .011) 3.188 (P ⫽ .002) 0.190 (P ⫽ .446) .039
score (postop 3 mo)
Mean IIEF score (15 mo) 24.38 ⫾ 2.459 (n ⫽ 21) 24.11 ⫾ 4.022 (n ⫽ 27) 23.59 ⫾ 2.647 (n ⫽ 17) .392

tensively for evaluating male sexual function and severity of The severity of ED was measured in all 3 groups pre- and
ED.8 IIEF consists of 5 domains of sexual function, including post-operatively. The data were analyzed using SPSS 16 (SPSS,
erectile function (EF), orgasmic function (OF), intercourse Inc., Chicago, IL). The data were compared among groups using
satisfaction (IS), sexual desire (SD), and overall satisfaction analysis of variance, Pearson chi-square test, and then within
(OS). The severity of ED is measured by subdividing the EF the groups using paired t-test. Multivariate analysis was done
domain by level of severity: 26-30 no ED, 22-25 mild ED, using Pillai’s trace, Wilks’ lambda, Hotelling’s trace, and Roy’s
17-21 mild to moderate ED, 11-16 moderate ED, and 6-10 largest root tests. The power of the study was 0.813. The level
severe ED.9,10 of significance was set at P ⬍.05.

Surgical Techniques RESULTS

In group 1 (penile urethroplasty, n ⫽ 25), 14 underwent ventral
longitudinal penile flap urethroplasty and 11 dorsal inlay graft Seventy-eight men were included in the analysis. The
urethroplasty (buccal mucosa in 6, lingual mucosa in 2, and stricture site was bulbar in 53 and penile in 25. Of 11
penile skin in 3). In group 2 (bulbar urethral strictures up to 4 men not included, 4 failed repair, 3 had not engaged in
cm, n ⫽ 32), all underwent end-to-end anastomotic urethro- sexual activity, and 4 were lost to follow-up. The etiology
plasty. In group 3 (bulbar urethral stricture length of ⬎4 cm, of strictures were inflammatory in 36, catheter-induced in
n ⫽ 21), all patients underwent dorsal buccal mucosal substi- 18, failed hypospadias repair in 2, and unknown cause in
tution graft urethroplasty by a ventral sagittal urethrotomy and 22. The mean age (years) was 38.12 ⫾ 13.07, 37.66 ⫾
minimal-access perineal approach as described by us previously 12.167, and 38.10 ⫾ 11.322, respectively, in groups 1, 2,
(Table 1).11 and 3 (P ⫽ .987). The mean stricture length (cm) was
4.78 ⫾ 0.747, 2.95 ⫾ 0.658, and 6.13 ⫾ 0.981 in groups
Follow-Up 1, 2, and 3, respectively (P ⫽ .001). The mean duration
After removal of the catheter at 3 weeks, patients were seen at
since onset of symptoms was 3.4 years (1-14) (Table 1).
regular follow-ups. Three monthly visits consisted of filling out
the IIEF-5 questionnaire and evaluation of erectile function
Mean preoperative IIEF score was 24.60 ⫾ 2.365,
during each visit. Mean follow-up was 15.50 ⫹ 2.389 (12-21) which was similar among the three groups: group
months (Table 1). 1—24.88 ⫾ 2.205; group 2—25.03 ⫾ 2.348; and group
3—23.62 ⫾ 2.397. ED after urethroplasty was found in
Data Analysis 4/25 (16%), 9/32 (28%), and 2/21 (10%) in groups 1, 2,
Preoperative EF scores were compared with immediate post-op and 3, respectively. Mean postoperative decline (3
scores at 3 months and then subsequently at 3-month intervals months) in IIEF score was 22.54 ⫾ 4.823. Overall, the
to evaluate EF. decline was not significant among groups: group 1—22.68 ⫾

UROLOGY 78 (1), 2011 79

 statistically significant in this group. In group 2, all 3 men
with ED were evaluated using a penile Doppler, which
did not reveal a vascular anomaly. We believe that neu-
rogenic (perineal nerve), arteriogenic (bulbar artery),
and psychosomatic factors play a synergistic, yet ill-de-
fined role in this subgroup. The perineal nerve, which
sends fine branches that penetrate the corpus spongiosum
mainly in the bulbar area, may be injured during bulbar
urethroplasty.2,3,16 During dissection of the central ten-
don of the perineum, the perineal nerves are most likely
to be damaged upon surfacing from the ischiorectal fossa.
They may also be damaged when the bulbospongiosum
muscle is fully divided along the midline as in conven-
tional bulbar anastomotic urethroplasty.2,3,16 At the ter-
mination of bulbospongiosus muscle, the perineal and
dorsal nerves are in close proximity, which may lead to
their damage during urethroplasty as proposed by Yucel et
al.2,3 The perineal nerves play an important role in bul-
bospongiosum muscle contractions.4 Ejaculatory dysfunc-
Figure 1. Severity of ED domain preoperatively, postoperatively,
and at 12 months of follow-up (color figure available online).
tions mainly in form of decrease in force of semen expul-
sions might result from disruption of the reflex pathways
providing innervations of the bulbospongiosum muscle.4
4.616; group 2—21.84 ⫾ 5.903; and group 3—23.43 ⫾ We did not find any decline in ejaculatory function in
2.891 (P ⫽ .502). However, the mean difference in IIEF this subgroup and we believe that the removal of rigid,
score at 3 months within group 2 was 3.188, which was stenosed, fibrotic urethra and the reestablishment of ure-
statistically significant (P ⫽ .002) compared with groups thral continuity might obviate the negative impact of
1 (2.20, P ⫽ .011) and 3 (0.190; P ⫽ .446) (Table 2). neurogenic and arteriogenic factors. In group 3 (substi-
Overall, the age and length of stricture were not found to tution urethroplasty), only mild to moderate ED was seen
be statistically significant with occurrence of ED. How- in 2 (10%) patients. We believe that our minimally
ever, patients who were older (⬎55) had a lower pre-op invasive approach of substitution urethroplasty12 could
IIEF score and greater decline postoperatively. The mean be a possible factor for a minimal change in IIEF score in
duration of being free of ED was 5.63 ⫾ 2.59 months. this subgroup of patients. The original dorsal onlay graft
Improvement of total mean IIEF score of 24.12 ⫾ 3.388 technique, using circumferential mobilization of the ure-
was seen at 6 months in groups 1 (24.52 ⫾ 2.383) and 2 thra, can lead to tearing of vascular connections between
(24.22 ⫾ 4.427). In group 3, although patients had a long spongiosum and tunica albuginea, as well as the lateral
stricture length, compare from groups 1 and 2 then to the vascular connection between the urethra and the super-
postop decline was insignificant. The recovery in EF was ficial perineal tissue.16
consistent on further follow-up, with no patient showing Our findings suggest that the minimally invasive ure-
deterioration in IIEF score. There were statistically no throplasties have a promising role in the future as, well as
differences in ED after different types of repair in multi- a better outcome in terms of erectile function. Interest-
variate analysis. Three patients in group 2 continued to ingly, nearly all patients (96% [75/78]) had recovery of
have ED (severe in 1, moderate in 2) at the end of the
EF within 6 months of surgery and only 3 patients in
study (Figure 1).
group 2 (bulbar anastomotic urethroplasty) had persistent
ED. These 3 patients were older in age and had a preop-
COMMENT erative mild to moderate ED, so to suspect the urethro-
In our study, we found that 16% of patients undergoing plasty as a culprit would be inappropriate. We believe
penile urethroplasty (group 1) reported ED after surgery, that ED, which is transient, is multifactorial. Psychoso-
which was mild to moderate in 4% and moderate in 12%. matic healing and neural regeneration fortunately lead to
All patients in this group had recovery of EF within 6 the recovery in a majority of cases. In all of the groups,
months of surgery. We believe that physical (decrease the maximum improvement was seen until 6 months,
tissue swelling) and psychosomatic healing occurring dur- after which there was an area of little variation. We
ing this period might relate to recovery of penile sensi- believe that there may be a role of early use of phospho-
tivity and EF. In group 2 (bulbar anastomotic urethro- diesterase inhibitor-5 inhibitors in those who have ED
plasty), 28% of patients reported ED: 25% moderate and and thus it is a matter of further study for us. The efficacy
3% severe. In this group, 3% (2 with moderate ED and 1 of the use of antiinflammatory drugs and similar other
with severe ED) did not improve after a mean follow-up agents can be proved only by further randomized, con-
of 15 months. The mean difference in IIEF score was also trolled trials. There have been conflicting views regard-

80 UROLOGY 78 (1), 2011

ing whether urethroplasty affects erectile function. References
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UROLOGY 78 (1), 2011 81