Pleasurable ways to spontaneously expulse distal ureteral stones: A systematic review and meta-analysis of randomized controlled trials

Abstract

ABSTRACT Introduction Numerous non-invasive ways of managing distal ureteral stones have been recommended, such as administering treatments to inhibit receptors responsible for ureteral tone and peristaltic movement frequency. Nitric oxide, which is released during penile erection, causes smooth muscle relaxation by inhibiting the non-adrenergic non-cholinergic (NANC) nerves of the distal ureter and ureterovesical junction. Bladder neck contraction followed by relaxation, occurring during orgasm and ejaculation could also facilitate the passage of stones. However, the exact role of sexual activities involving these mechanisms has yet to be established. Objective This review aimed to evaluate the efficacy of sexual acts, including sexual intercourse and masturbation, to promote distal ureteral stones expulsion based on the findings of relevant randomized controlled trials (RCT)s. Methods A systematic search adhering to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist was performed in the Embase, Scopus, and Medline databases in July 2021. The initial search generated 50 articles. The articles were screened based on the eligibility criteria. Their quality was assessed using the Cochrane Risk of Bias (RoB) tool 2 for randomized trials. Measured outcomes included stone expulsion rate, expulsion time, analgesic injections frequency, and the need for a ureteroscopic (URS) lithotripsy. A fixed effects model was used for analyzing parameters with homogeneity among studies, whereas a random effects model was used for heterogenous studies. The odds ratio (OR) and mean difference (MD) among studies were displayed in forest plots using the Review Manager software version 5.4.1. Results A total of five RCTs with an overall low risk of bias, consisting of 406 subjects, were included in this review. Four studies evaluated sexual intercourse and one study evaluated masturbation. Both interventions were instructed to be performed for three to four times a week. The stone expulsion rate was higher in the sexual activity group compared to the control group at the two-week follow-up (OR 5.77 95%CI 3.70 - 9.01, p<0.00001) and four-week follow-up (OR 4.44 95%CI 2.73 - 7.23, p<0.00001) with a significantly lower expulsion time of the sexual activity group (MD -3.79 95% CI -6.38 - -1.20, p=0.004). The number of subjects requiring additional analgesic injections (MD -0.62 95% CI -1.03 - -0.21, p=0.003) and URS lithotripsy (OR 0.22 95% CI 0.13 – 0.37, p<0.00001) was also lower in the sexual activity group compared to the control group. Conclusions Performing sexual intercourse or masturbation for three to four times a week is beneficial for promoting spontaneous expulsion of distal ureteral stones. It could also reduce the use of analgesic injections and the need for a URS lithotripsy.