Treatment of Retrograde Ejaculation in Men on BPH Treatment
The first-line pharmacologic treatment for retrograde ejaculation in men on BPH therapy is pseudoephedrine (an alpha-adrenergic agonist), typically dosed at 60 mg every 6 hours starting the day before anticipated ejaculation, with two additional doses on the day of ejaculation. 1
Understanding the Problem
Retrograde ejaculation is a common adverse effect of BPH treatments, particularly:
- Alpha-blockers (tamsulosin, alfuzosin, doxazosin, terazosin) used for BPH cause ejaculatory dysfunction more frequently than other side effects 2
- Surgical interventions for BPH (TURP, laser procedures) have high rates of retrograde ejaculation postoperatively 3
- The mechanism involves relaxation of the bladder neck, allowing semen to flow backward into the bladder rather than antegrade through the urethra 4
Treatment Algorithm
Step 1: Confirm the Diagnosis
- Obtain post-ejaculatory urinalysis to document presence of sperm in urine 1, 4
- Classify as complete (no antegrade ejaculate) versus partial (reduced antegrade volume with sperm in urine) 1
- Identify the etiology: medication-induced (alpha-blockers), post-surgical, diabetic neuropathy, or idiopathic 1
Step 2: First-Line Pharmacologic Management
Pseudoephedrine protocol (alpha-adrenergic agonist that increases bladder neck tone):
- Dosing regimen: 60 mg every 6 hours starting the day before planned ejaculation, plus two 60 mg doses on the day of ejaculation 1
- Expected efficacy: 58-70% of patients show improvement in seminal parameters 1
- For complete retrograde ejaculation: 58% recover sperm in antegrade ejaculate (mean 273.5 million total sperm count) 1
- For partial retrograde ejaculation: 62.5% achieve ≥50% increase in antegrade sperm count (from 26.9 to 84.2 million) 1
Step 3: Alternative Pharmacologic Options
If pseudoephedrine fails or is contraindicated:
- Anticholinergic medications may be considered, though evidence is limited 5
- Other sympathomimetics have been studied but with less robust data than pseudoephedrine 5
Step 4: Non-Pharmacologic Approaches for Fertility
When medications fail and fertility is the goal:
- Urinary sperm retrieval: Alkalinize urine with oral medications or add sperm wash media into bladder prior to ejaculation to preserve sperm viability 4, 5
- Surgical techniques or electroejaculation are options but have limited data 5
Critical Clinical Pitfalls
Medication Management
- Do not discontinue BPH alpha-blocker therapy without considering the trade-off between urinary symptoms and ejaculatory function 6
- If the patient is on tamsulosin specifically for BPH and ejaculatory dysfunction is intolerable, consider switching to a 5-alpha reductase inhibitor (finasteride or dutasteride) which does not cause retrograde ejaculation, though these take 3-6 months to work 2
Surgical Considerations
- Counsel patients preoperatively about high risk of retrograde ejaculation with standard BPH surgeries (TURP, laser enucleation) 6, 3
- Consider ejaculation-sparing procedures such as prostatic urethral lift (PUL) for eligible patients (prostate <80g, no obstructive middle lobe) who prioritize preservation of ejaculatory function 6
- Water vapor thermal therapy also preserves ejaculatory function better than TURP 6
Fertility Counseling
- Address fertility concerns proactively before initiating BPH treatment in men of reproductive age 5
- Pseudoephedrine treatment can achieve antegrade total sperm counts >39 million in 38.5% of patients, which is sufficient for natural conception 1
- For men with persistent retrograde ejaculation despite treatment, assisted reproductive techniques using retrieved sperm remain viable options 4, 5