What are the treatment options for retrograde ejaculation after Transurethral Resection of the Prostate (TURP)?

Treatment Options for Retrograde Ejaculation After TURP

For patients with retrograde ejaculation after TURP, medical management with sympathomimetics or urinary sperm retrieval techniques are the primary treatment options, as the anatomical changes from TURP are typically permanent.

Understanding Retrograde Ejaculation After TURP

Retrograde ejaculation is a common complication following transurethral resection of the prostate (TURP), occurring in a significant percentage of patients. This condition results from damage to the bladder neck mechanism during surgery, causing semen to flow backward into the bladder rather than forward through the urethra during ejaculation.

Incidence and Risk Factors

• Retrograde ejaculation occurs in approximately 65.4% of patients following TURP 1
• The risk is significantly lower with alternative procedures like Transurethral Incision of the Prostate (TUIP), which has only an 18.2% risk 1

Treatment Options

1. Medical Management

• Sympathomimetic medications: These drugs can help increase bladder neck tone and potentially restore antegrade ejaculation
  • Options include pseudoephedrine, ephedrine, and imipramine
  • Most effective in partial retrograde ejaculation cases
  • Less effective when anatomical changes from TURP are significant

2. Sperm Retrieval Techniques for Fertility

For men concerned with fertility rather than the sensation of ejaculation:

• Post-ejaculatory urine collection:

  • Alkalinize urine before ejaculation (sodium bicarbonate)
  • Collect urine immediately after ejaculation
  • Process the urine to retrieve sperm for assisted reproduction 2, 3

• Pre-ejaculation bladder preparation:

  • Emptying bladder before sexual activity
  • Instilling sperm wash media into the bladder to create a more sperm-friendly environment 2

3. Surgical Alternatives for Future Patients

For patients who have not yet undergone TURP but are concerned about retrograde ejaculation:

• Transurethral Incision of the Prostate (TUIP):

  • Recommended for patients with prostates ≤30g 1
  • Significantly lower risk of retrograde ejaculation (18.2% vs 65.4% with TURP) 1
  • Provides equivalent symptomatic improvement to TURP in appropriately selected patients 4

• Modified TURP techniques:

  • "Minimally Invasive Nonexpensive TURP" with selective resection at 6 and 12 o'clock positions
  • Can preserve antegrade ejaculation in younger patients with smaller prostates 5

Algorithm for Management

1. Confirm diagnosis: Absence of antegrade ejaculate and presence of sperm in post-ejaculatory urine

2. Determine patient's primary concern:

   • If sensation of ejaculation is the primary concern:

     • Trial of sympathomimetic medications (pseudoephedrine, ephedrine)
     • Manage expectations regarding limited success rates with permanent anatomical changes

   • If fertility is the primary concern:

     • Urinary sperm retrieval techniques
     • Referral to reproductive specialist for intrauterine insemination or other assisted reproductive techniques

Important Considerations and Pitfalls

• Permanent nature: The anatomical changes from TURP are typically permanent, making complete restoration of antegrade ejaculation unlikely
• Fertility preservation: For younger men planning future fertility, consider TUIP or modified TURP techniques if appropriate for their prostate size 4, 5
• Medication limitations: Medical management has limited efficacy for complete retrograde ejaculation after TURP
• Psychological impact: Address the psychological aspects of altered sexual function

Prevention for Future Patients

For patients who have not yet undergone prostate surgery but are concerned about preserving ejaculatory function:

• Consider TUIP for prostates ≤30g 1, 4
• Discuss modified surgical techniques with urologist 5
• Consider newer technologies like Prostatic Urethral Lift (PUL) which may have lower rates of ejaculatory dysfunction 1