Collaborative Review – Sexual Medicine – LUTS Critical Analysis of the Relationship Between Sexual Dysfunctions and Lower Urinary Tract Symptoms Due to Benign Prostatic Hyperplasia Mauro Gacci a, *, Ian Eardley b , Francois Giuliano c , Dimitris Hatzichristou d , Steven A. Kaplan e , Mario Maggi f , Kevin T. McVary g , Vincenzo Mirone h , Hartmut Porst i , Claus G. Roehrborn j a Department of Urology, University of Florence, Italy; b Department of Urology, St James University Hospital, Leeds, England; c Raymond Poincare ´ Hospital, Department of Physical Medicine and Rehabilitation, Garches, France; d Centre for Sexual and Reproductive Health, Aristotle University of Thessaloniki, Thessaloniki, Greece; e Department of Urology, Weill Cornell Medical College, Cornell University, New York, USA; f Sexual Medicine & Andrology Unit, Department of Clinical Physiopathology, University of Florence, Florence, Italy; g Department of Urology, Northwestern University, Feinberg School of Medicine, Chicago, IL, USA; h Department of Urology, University Federico II of Naples, Naples, Italy; i Private Practice of Urology and Andrology, Hamburg, Germany; j Department of Urology, UT Southwestern Medical Center, 5323 Harry Hines Boulevard, J8 142, Dallas, TX, USA EUROPEAN UROLOGY 60 (2011) 809–825 available at www.sciencedirect.com journal homepage: www.europeanurology.com Article info Article history: Accepted June 20, 2011 Published online ahead of print on June 29, 2011 Keywords: LUTS ED BPH PDE5 PDE5-i Prostate Benign prostatic hyperplasia EjD IPSS IIEF Age Abstract Context: This review focuses on the relationship among sexual dysfunction (SD), lower urinary tract symptoms (LUTS) due to benign prostatic hyperplasia (BPH), and related therapies. Objective: We reviewed the current literature to provide an overview of current data regarding epidemiology and pathophysiology of SD and LUTS. Moreover, we analysed the impact of currently available therapies of LUTS/BPH on both erectile dysfunction (ED) and ejaculatory dysfunction and the effect of phosphodiesterase type 5 inhibitors (PDE5-Is) in patients with ED and LUTS. Evidence acquisition: We conducted a Medline search to identify original articles, reviews, editorials, and international scientific congress abstracts by combining the following terms: benign prostatic hyperplasia, lower urinary tract symptoms, sexual dysfunction, erectile dysfunction, and ejaculatory dysfunction. Evidence synthesis: We conducted a comprehensive analysis of more relevant general population–based and BPH/LUTS or SD clinic-based trials and evaluated the common patho- physiologic mechanisms related to both conditions. In a further step, the overall impact of current BPH/LUTS therapies on sexual life, including phytotherapies, novel drugs, and surgical procedures, was scrutinized. Finally, the usefulness of PDE5-Is in LUTS/BPH was critically analysed, including preclinical and clinical research data as well as possible mechanisms of action that may contribute to the efficacy of PDE5-Is with LUTS/BPH. Conclusions: Community-based and clinical data demonstrate a strong and consistent association between LUTS and ED, suggesting that elderly men with LUTS should be evaluated for SD and vice versa. Pathophysiologic hypotheses regarding common basics of LUTS and SD as discussed in the literature are (1) alteration of the nitric oxide (NO)–cyclic guanosine monophosphate (cGMP) pathway, (2) enhancement of RhoA–Rho-kinase (ROCK) contractile signalling, (3) autonomic adrenergic hyperactivity, and (4) pelvic atherosclerosis. The most important sexual adverse effects of medical therapies are ejaculation disorders after the use of some a-blockers and sexual desire impairment, ED, and ejaculatory disorders after the use of a-reductase inhibitors. Minimally invasive, conventional, and innovative surgical treat- ments for BPH may induce both retrograde ejaculation and ED. PDE5-Is have demonstrated significant improvements in both LUTS and ED in men with BPH; combination therapy with PDE5-Is and a1-adrenergic blockers seems superior to PDE5-I monotherapy. # 2011 European Association of Urology. Published by Elsevier B.V. All rights reserved. * Corresponding author. University of Florence, Department of Urology, Viale A. Gramsci 7, FI 50121, Italy. Tel. +39 0557949402; Fax: +39 0554377755. E-mail address: maurogacci@yahoo.it (M. Gacci). 0302-2838/$ – see back matter # 2011 European Association of Urology. Published by Elsevier B.V. All rights reserved. doi:10.1016/j.eururo.2011.06.037