Background
Urinary stone is a common disease with a prevalence rate varying from 1 to 20% [
1]. Endourological procedures (EP), including percutaneous nephrolithotomy (PCNL) and ureteroscopy (URS), are strongly recommended to remove stones according to guidelines [
1,
2]. However, these transurethral procedures may have adverse effects on sexual function [
3]. In 2003, Joshi et al. firstly found that indwelling double-J stent resulted in sexual problems in 35% of sexually active patients [
4,
5]. Increasing concerns were raised about the impact of indwelling double-J stent or EP on sexual function. Sofer et al. utilized a validated questionnaire, the International Index of Erectile Function (IIEF) including five evaluating items, and demonstrated sexual dysfunction after EP regardless of whether double-J stent was applied [
3]. It posed the question-is it double-J stent or EP itself that affected sexual function? With accumulated evidence, a pooled analysis is required to address the issue.
Sexual function depends on several functional domains. The International Consultation on Sexual Medicine (ICSM) recommended IIEF and Female Sexual Function Index (FSFI) as sexual dysfunction questionnaire for general population with level of evidence 1A [
6]. They assess functions by different sexual feature in both sexes. The IIEF questionnaire for men includes five items: erectile function, orgasmic function, sexual desire, intercourse satisfaction and overall satisfaction; while the female FSFI questionnaire includes five items: desire, arousal, lubrication, orgasm, satisfaction and pain [
7,
8]. The two questionnaires were widely used to evaluate sexual function related to surgeries like abdominal aortic aneurysm surgical repair and bariatric surgery [
9,
10]. To address sexual dysfunction after EP, IIEF and FSFI are also the optimal tools.
Sexual activity and fulfillment are essential to maintain emotional well-being and quality of life [
11]. Therefore, we conducted the first systematic review to assess the impact of the EP and double-J stent on sexual health, and to provide information for patients counseling when endourological interventions are under consideration. This result is also helpful for urologists to have a comprehensive understanding of the complications of transurethral surgery. Accordingly, optimized surgical strategy could be developed to reduce complications and promote fast recovery after surgery.
Discussion
Based on current evidence, the indwelling double-J stent negatively correlated with sexual function in all domains. Non-stent procedures had no impact on general sexual function in both sexes even though one or two domains of the administered questionnaires were mildly impaired, including erectile function and orgasmic function in men and sexual desire in women. One study reported that sexual deterioration in women recovered 1 month after stent removal [
19]. In another study, the IIEF score remained unchanged on the 10th day after stent removal when compared with the preoperative baseline value [
16]. These results suggest that sexual function was impaired after employing a stent but recovered soon following stent removal.
Sexual activity is an important aspect of individual life. The World Health Organization (WHO) describes sexual health as “a state of physical, emotional, mental, and social well-being in relation to sexuality.” [
20] Moreover, sexuality is also a way of experiencing pleasure and physical release, facilitating quality of life and longevity [
21]. Regular sexual activity varies from 71.3% in old people to 96% in young people. However, the prevalence of erectile dysfunction (ED) ranges from 2.3 to 53.4% according to age [
22]. Women appear to be more vulnerable to sexual problems. As many as 40–45% of women have experienced sexual dysfunction during their lifetimes [
23]. Unexpected deterioration of sexual function has a significant impact on patients after having undergone certain surgeries. Ureteroscopy preoperatively increases anxiety in patients because of its surgical approach. The passage of rigid material, urethral expansion, and stent placement are new and fear-inducing events for some patients. Patients frequently inquire about the effect these procedures have on sexual function. However, urologists often only provide a simple explanation in accordance with their clinical experience. This systematic literature review provides more accurate evidence for preoperative patient consulting.
Factors that increase the rate of sexual dysfunction after EP are quite complex. EP primarily refers to ureteroscopy, cystoscopy, and percutaneous nephrolithotomy. Upper urinary stones and urinary strictures are considered for EP because malignant diseases such as prostate cancer are often accompanied by nerve injury after radiotherapy or surgery [
24]. Surgical injury from ureteroscopy does not directly involve nerves; however, bladder or urethral mucosa may be irritated during the procedure. This depends on the nature of the ureteroscope, its diameter, and rigidity. Two included studies reported detailed information regarding the endoscope. One utilized an 8-Fr semi-rigid ureteroscope, and the other used a 7.5-Fr rigid ureteroscope or cystoscope. No significant change in sexual function was found at the fourth week compared with that at the preoperative baseline. Patients were reported to have had a more comfortable experience after flexible ureteroscopy with decreased pain and anxiety [
25]. Nevertheless, in general, sexual dysfunction rarely occurs, even after rigid endoscopy.
The double-J stent is used for drainage and to decrease the incidence of renal colic and ureteral obstruction. Stent-related complications follow the benefits, especially lower urinary tract symptoms (LUTS). A meta-analysis of RCTs compared stent and non-stent procedures to treat ureteral stones [
26]. Dysuria, irritation, hematuria, urinary infection, and pain were the top five common complications. The stent group had the highest incidence of flank or voiding pain (31.4% stent vs. 19.7% non-stent), dysuria (51.2% stent vs. 23.0% non-stent), and irritation (45.0% stent vs. 24.2% non-stent). LUTS such as dysuria and irritation are strongly related to sexual dysfunction. A large population-based study reported that odds ratios for ED were 3.0 (storage LUTS vs. no LUTS), 2.6 (voiding LUTS vs. no LUTS) and 4.0 (combined LUTS vs. no LUTS) [
27]. The results are similar to those of previous studies. Joshi et al. validated a ureteral stent symptom questionnaire (USSQ) that was widely used to assess stent-associated disturbances [
4,
5]. The post-stent LUTS were urgency (57.5%), urge incontinence (18.5%), incomplete emptying (27.5%), and dysuria (18.5%). Two primary complications, LUTS and pain, led to secondary complications described in USSQ: worse general health, impaired work performance, and sexual problems. Apart from LUTS and pain, the evidence showed that the double-J stent also provoked unfavorable mental changes such as anxiety and depression [
5,
28]. All stent-associated disturbances (LUTS, pain, mental disorder) may impair sexual health. Included studies in our review utilized specific questionnaires (IIEF and FSFI) to evaluate sexual function. We found a significant decrease of sexual function in stent patients. The parameters of the stent (rigidity, diameter, material, and length) may also affect the degree of complications. Nevertheless, to our knowledge, current studies have not concentrated on whether and how stent technology affects sexual function.
USSQ is utilized to assess the safety of a new stent or medications that can relieve symptoms after placement of a stent. Zhu et al. and Giannarini et al. showed impairment in sexual health in patients compared to that in healthy individuals at four weeks after stent placement [
29,
30]. By contrast, some studies showed no significant difference when comparing sexual health at the fourth week after placement with that at the fourth week after removal [
30,
31]. A slight improvement of symptoms after stent removal may account for these results. The authors concluded that patients tended to suffer sharp declines in sexual function after stent insertion and sexual function slowly recovered with indwelling time. After the stents were removed, sexual function returned to that at baseline. In addition, medications such as α-blockers and antimuscarinics are effective in relieving stent-related LUTS, pain, and sexual problems [
32,
33].
There are several limitations about the systematic review. The primary limitation is the small number of eligible studies and sample sizes. The ROBINS-I tool shows significant bias for the studies. In addition, the sexual function assessment questionnaires were various and the heterogeneity was high in the male groups. Addressing the effect of EP or stent on sexual function still demands well-designed and large sample studies with a standard assessment tool.
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