How are sexual dysfunctions managed after end to end urethral anastomosis?

Management of Sexual Dysfunction After End-to-End Urethral Anastomosis

Sexual dysfunction after end-to-end urethral anastomosis should be managed with a stepwise approach beginning with PDE5 inhibitors for erectile dysfunction, followed by more invasive options, while addressing ejaculatory dysfunction, penile sensory changes, and psychological impacts through specialized referrals. 1, 2

Types of Sexual Dysfunction After Urethral Anastomosis

• Ejaculatory dysfunction is the most common sexual complication after end-to-end anastomosis, affecting approximately 23.3% of patients 3
• Decreased glans sensitivity occurs in about 18.3% of patients following the procedure 3
• Altered glans filling during erection (glans that is neither full nor swollen) affects approximately 11.6% of patients 3
• Cold glans sensation during erection is reported in approximately 1.6% of cases 3
• Erectile dysfunction can occur but is less common, with most studies showing minimal impact on erectile function directly attributable to the anastomotic procedure itself 4, 5

Evaluation of Sexual Dysfunction

• Use validated tools such as the Sexual Health Inventory for Men (SHIM) to monitor erectile function over time 6
• Assess for ejaculatory dysfunction, penile shortening, altered glans filling, and changes in penile sensation 7
• Evaluate for psychological factors that may contribute to sexual dysfunction, including anxiety about performance after surgery 6
• Consider the impact of the original trauma (in cases of traumatic strictures) versus the surgical intervention itself, as the trauma often causes more significant erectile dysfunction than the subsequent repair 5

Management Approach

Erectile Dysfunction Management

• First-line: Oral PDE5 inhibitors (sildenafil, tadalafil, vardenafil, avanafil) should be offered as initial therapy 1, 2
• Second-line options for those who fail PDE5 inhibitors:
  • Intracavernous injection therapy using vasodilator drugs 2
  • Intraurethral alprostadil suppositories 2
  • Vacuum erection devices 2
• Third-line: Penile prosthesis implantation for patients with refractory erectile dysfunction 2

Ejaculatory Dysfunction Management

• Pelvic floor physical therapy with Kegel exercises can help improve ejaculatory control 6
• Cognitive behavioral therapy may be beneficial for addressing ejaculatory concerns 6
• Referral to a urologist specializing in sexual medicine for persistent ejaculatory issues 6

Sensory Changes and Glans Filling Issues

• Patients should be counseled that sensory changes and altered glans filling may improve over time (6-12 months) 3
• For persistent sensory deficits, referral to a sexual health specialist for potential management strategies 6
• For altered glans filling, PDE5 inhibitors may help improve overall penile blood flow 1

Psychological Support

• Individual or couples counseling should be offered for those wishing to improve relationship or intimacy issues 6
• Sexual therapy with a mental health professional with expertise in sexual medicine can help address psychological aspects of sexual dysfunction 6
• Encourage couples to discuss their sexual intimacy concerns and provide appropriate referrals 6

Special Considerations

• The location and length of the stricture can impact the risk of sexual dysfunction, with more distal and longer strictures having higher risk of complications like penile shortening 4
• Patients with pre-existing vascular erectile dysfunction may have less noticeable changes in erectile function after surgery compared to those with non-vascular causes 5
• Partner involvement in treatment decisions is essential for improving outcomes 2
• For patients with significant distress about sexual function, assess for depression/anxiety using a simple screening tool like the Distress Thermometer 6

Prevention Strategies

• Consider using non-transecting techniques for longer and more distal bulbar strictures to minimize risk of penile shortening or angulation 4
• Meticulous surgical technique with careful dissection to preserve neurovascular structures 8
• Early intervention with erectile rehabilitation protocols may help preserve erectile function 1

Follow-up Recommendations

• Regular assessment of sexual function using validated questionnaires 6
• Adjustment of treatment approach based on response and patient preferences 2
• Referral to specialists (urologist, sexual medicine expert, psychotherapist) for persistent dysfunction 6