What treatments are available for inability to achieve orgasm after a Transurethral Resection of the Prostate (TURP) procedure?

Inability to Achieve Orgasm After TURP

The inability to achieve orgasm after TURP is most commonly related to retrograde ejaculation (occurring in 42-84% of patients), which does not typically prevent orgasm itself but eliminates visible ejaculate; true anorgasmia after TURP is rare and should prompt evaluation for psychological factors, nerve injury, or other underlying causes. 1, 2, 3

Understanding the Problem

The sexual dysfunction following TURP needs careful characterization:

• Retrograde ejaculation occurs in 42-84% of sexually active patients after conventional TURP, where semen travels backward into the bladder rather than exiting through the urethra 1, 2, 3
• True anorgasmia (inability to experience orgasm) is distinctly different from retrograde ejaculation and is much less common after TURP 1
• TURP does not negatively impact erectile function in most patients, with studies showing no significant worsening of erections after the procedure 1, 2, 3
• Libido and overall sexual satisfaction may decline in some patients, often related to psychological factors rather than direct surgical effects 1

Initial Assessment

Determine the specific nature of the sexual dysfunction:

• Distinguish between retrograde ejaculation and anorgasmia: Patients with retrograde ejaculation can still experience orgasm but without visible ejaculate, while true anorgasmia means no orgasmic sensation occurs 1
• Evaluate for psychological factors including depression, anxiety, and performance concerns, which can significantly impact sexual function after surgery 1
• Assess for concurrent erectile dysfunction, as this may contribute to difficulty achieving orgasm and should be managed according to standard ED guidelines 4
• Review medications that may impair orgasm, including antidepressants, antihypertensives, and other agents 4

Treatment Approaches

For Retrograde Ejaculation (Not True Anorgasmia)

If the issue is retrograde ejaculation with preserved orgasmic sensation:

• Reassurance and education that orgasm can still occur without visible ejaculate is often the most important intervention 1, 3
• No specific medical treatment reliably reverses retrograde ejaculation after TURP 1, 2
• Alpha-adrenergic agonists (such as pseudoephedrine or imipramine) have been used off-label to restore antegrade ejaculation in some cases, though evidence is limited and this is not standard practice 4

For True Anorgasmia

If the patient cannot achieve orgasmic sensation:

• Referral to a mental health professional with expertise in sexual health should be considered, as psychological factors are often contributory 4
• Psychosexual counseling and behavioral therapy may help address performance anxiety, relationship issues, or other psychological barriers 4
• Treat any concurrent erectile dysfunction according to standard guidelines, as adequate erectile rigidity is necessary for orgasm 4
• Review and potentially adjust medications that may impair orgasm 4

Prevention Strategies

For future patients considering TURP:

• Ejaculation-sparing TURP techniques that preserve urethral mucosa around the verumontanum and prostatic apex can maintain antegrade ejaculation in up to 83% of patients, though this is not yet standard practice 5
• Modified "minimally invasive" TURP approaches with limited resection at the bladder neck (6 and 12 o'clock positions only) may preserve ejaculatory function in selected young patients with smaller prostates 6
• Patients should be counseled preoperatively that retrograde ejaculation is a common and expected outcome of conventional TURP 1, 2, 3

Important Caveats

• The vast majority of patients (73-74%) remain sexually active after TURP, and the procedure does not reduce this proportion 3
• While retrograde ejaculation causes considerable bother in some patients, overall sexual satisfaction rates remain stable (67-69%) before and after TURP 2
• Worsening of erectile function occurs in only 3.7-5.8% of patients with good preoperative function, suggesting that new-onset anorgasmia from nerve injury is uncommon 1
• Psychological factors, both before and after surgery, play a significant role in sexual dysfunction and should not be overlooked 1