Is terazosin (alpha-blocker) best for treating dry ejaculation?

Terazosin Is Not Recommended for Treating Dry Ejaculation

Terazosin is not recommended for treating dry ejaculation as alpha-blockers like terazosin can actually cause ejaculatory dysfunction rather than treat it. 1

Understanding Dry Ejaculation

Dry ejaculation (aspermia) can occur due to:

• Anejaculation (inability to transport semen)
• Retrograde ejaculation (ejaculation into the bladder rather than antegrade)

Alpha-blockers like terazosin are known to cause ejaculatory problems as a side effect rather than treat them. According to the AUA guidelines, ejaculatory problems are among the primary adverse events reported with alpha-blocker therapy 1.

Recommended Treatments for Dry Ejaculation

First-Line Options:

1. SSRIs (Selective Serotonin Reuptake Inhibitors):

   • Paroxetine (10-40 mg/day or 20 mg 3-4 hours pre-intercourse)
   • Sertraline (25-200 mg/day or 50 mg 4-8 hours pre-intercourse)
   • Fluoxetine (5-20 mg/day)
   • Clomipramine (25-50 mg/day or 25 mg 4-24 hours pre-intercourse) 1

2. For retrograde ejaculation specifically:

   • Sympathomimetics like pseudoephedrine (60 mg every 6 hours) have shown efficacy in 70% of patients with retrograde ejaculation 2

Why Alpha-Blockers Like Terazosin Are Contraindicated

Alpha-blockers work by blocking alpha-1-adrenergic receptors, which:

• Reduces prostatic smooth muscle tone (beneficial for BPH)
• Disrupts the normal ejaculatory process by affecting bladder neck closure during ejaculation

Multiple guidelines and studies confirm that alpha-blockers can cause ejaculatory dysfunction:

1. The AUA guidelines specifically note that ejaculatory problems are among the primary adverse events of alpha-blocker therapy 1

2. The European Association of Urology guidelines indicate that alpha-blockers, especially selective ones like tamsulosin and silodosin, significantly increase ejaculatory dysfunction compared to placebo 1

3. Research shows that drugs that antagonize alpha-1-adrenergic receptors (including iloperidone and alpha-blockers like terazosin) can cause retrograde ejaculation 3

Mechanism of Alpha-Blocker Induced Ejaculatory Dysfunction

Alpha-blockers cause ejaculatory dysfunction by:

• Preventing contraction of the bladder neck during ejaculation
• Allowing semen to flow into the bladder (retrograde ejaculation) rather than out through the urethra
• Reducing seminal fluid volume

Treatment Algorithm for Dry Ejaculation

1. Determine the type and cause of dry ejaculation:

   • Post-ejaculatory urinalysis to check for sperm (indicates retrograde ejaculation)
   • Assess for neurological conditions, diabetes, or medication effects

2. For retrograde ejaculation:

   • First-line: Sympathomimetics (pseudoephedrine)
   • Second-line: Consider urinary sperm retrieval for fertility purposes

3. For other forms of ejaculatory dysfunction:

   • SSRIs for premature ejaculation with dry orgasm
   • Psychological evaluation for psychogenic causes
   • Testosterone therapy if morning testosterone <300 ng/dL 1

Important Caveats

• If the patient is currently taking an alpha-blocker like terazosin for BPH, consider that this medication may be causing the dry ejaculation
• If both erectile dysfunction and ejaculatory problems are present, treat the erectile dysfunction first, as this may improve ejaculatory function 4
• Avoid alpha-blockers in patients concerned about preserving ejaculatory function

While one small study suggested terazosin might help with premature ejaculation 5, this is not the same as treating dry ejaculation, and the evidence is limited compared to the substantial evidence showing alpha-blockers cause ejaculatory dysfunction.