What is the treatment for dry ejaculation caused by an enlarged prostate (Benign Prostatic Hyperplasia)?

Treatment for Dry Ejaculation Caused by Enlarged Prostate

For patients with dry ejaculation caused by benign prostatic hyperplasia (BPH), the most effective treatment approach is surgical intervention, particularly transurethral incision of the prostate (TUIP) for smaller prostates (≤30g) or modified surgical techniques that preserve the bladder neck and periurethral tissue. 1

Understanding Dry Ejaculation in BPH

Dry ejaculation (aspermia) in BPH patients typically occurs due to:

• Retrograde ejaculation (RE) - ejaculate flows backward into the bladder rather than out through the urethra 2
• Anejaculation - complete absence of ejaculate 3
• Decreased volume of semen - partial ejaculatory dysfunction 4

Treatment Options Based on Prostate Size

For Small Prostates (≤30g)

• TUIP (Transurethral Incision of the Prostate) is recommended as first-line surgical treatment with significantly lower rates of retrograde ejaculation (18.2%) compared to TURP (65.4%) 1
• TUIP preserves more of the bladder neck function while still relieving obstruction 1

For Larger Prostates (>30g)

• Modified surgical approaches that preserve the periurethral tissue (7.5 mm laterally; 10 mm proximally from the verumontanum) can minimize post-operative retrograde ejaculation 2
• Newer minimally invasive techniques like Rezum, Aquablation, or Urolift show promising results for ejaculatory function preservation 2, 5
• Prostate artery embolization (PAE) limits retrograde ejaculation rates but has a 10% re-intervention rate at 12 months 2

Medical Therapy Options

• Alpha-blockers - Some selective alpha-blockers (particularly alfuzosin) have shown lower rates of ejaculatory dysfunction compared to other medications 4
• 5-alpha-reductase inhibitors (finasteride, dutasteride):
  • Can cause ejaculatory dysfunction in 4-18% of patients 2
  • Sexual side effects include decreased libido, ejaculatory dysfunction, and erectile dysfunction 1, 6
  • These side effects are typically reversible and become less common after the first year of therapy 6

Treatment Algorithm

1. Assess prostate size through imaging to determine appropriate intervention 6
2. For patients with mild symptoms and small-to-moderate prostate enlargement:
   • Consider alpha-blockers with lower ejaculatory dysfunction profiles (e.g., alfuzosin) 4
3. For patients with moderate-to-severe symptoms:
   • Small prostate (≤30g): TUIP is recommended for preservation of ejaculatory function 1
   • Larger prostate (>30g): Consider newer minimally invasive techniques or modified surgical approaches that preserve the bladder neck and periurethral tissue 2, 5
4. For patients who have already developed retrograde ejaculation:
   • Medical therapy with sympathomimetics
   • Urinary sperm retrieval (if fertility is desired)
   • Bladder neck reconstruction in select cases 3

Important Considerations

• Ejaculatory dysfunction affects approximately 46% of men with BPH-related LUTS 2
• The severity of ejaculatory dysfunction correlates strongly with LUTS severity - 64.1% of men with severe LUTS report ejaculatory problems 4
• Surgical treatments have varying impacts on ejaculatory function:
  • TURP: 50-70% retrograde ejaculation rate 2
  • TUIP: 21-35% retrograde ejaculation rate 2
  • Open prostatectomy: High RE rates, but can be reduced with robotic approaches and urethral-sparing techniques 2

Common Pitfalls to Avoid

• Failure to discuss ejaculatory function before initiating BPH treatment - this should be part of the initial evaluation 2, 4
• Assuming all surgical approaches have similar effects on ejaculatory function - techniques vary significantly in their preservation of ejaculatory function 2
• Overlooking the relationship between ejaculatory dysfunction and treatment efficacy - interestingly, some studies suggest that ejaculation disorder caused by selective alpha-1A blockers may be associated with larger symptomatic improvements in BPH 7