Does a Transurethral Resection of the Prostate (TURP) worsen erectile dysfunction?

Does TURP Worsen Erectile Dysfunction?

TURP does not significantly worsen erectile dysfunction in most patients, with the most recent high-quality guideline evidence showing that erectile function measured by IIEF-5 remains similar at 12 months after both monopolar and bipolar TURP. 1

Evidence from Current Guidelines

The 2023 European Association of Urology guidelines provide the most definitive evidence on this question:

• Comparative evaluations of overall sexual function using IIEF-15 showed no differences between bipolar TURP and monopolar TURP at 12-month follow-up 1
• Erectile function measured by IIEF-5 appears similar at 12 months for both TURP techniques 1
• The guidelines acknowledge that some patients consciously choose alternative procedures over TURP specifically to preserve sexual function, but this reflects patient preference rather than evidence of significant erectile dysfunction risk 1

Incidence of New-Onset Erectile Dysfunction

When new erectile dysfunction does occur after TURP, the rates are relatively low:

• Research studies report new-onset erectile dysfunction in 5.8-14% of patients who had normal erectile function before surgery 2, 3, 4
• One large center study with over 500 patients found a 12% incidence of newly reported erectile dysfunction after TURP 4
• The majority of patients (approximately 85-95%) maintain their preoperative erectile function status 2, 3

Specific Risk Factors for Post-TURP Erectile Dysfunction

Diabetes mellitus is the most consistently identified independent risk factor for developing erectile dysfunction after TURP 2, 4:

• Patients with diabetes have significantly higher risk (P = 0.003) 4
• Metabolic syndrome is associated with worse erectile function outcomes after TURP 5

Intraoperative capsular perforation increases risk of postoperative erectile dysfunction (P = 0.02) 4

Lower preoperative erectile function scores predict higher risk of postoperative decline 2:

• Patients who develop erectile dysfunction postoperatively had significantly lower IIEF-5 scores and nocturnal penile tumescence parameters preoperatively (P < 0.0001) 2

Important Distinction: Ejaculatory vs. Erectile Function

TURP has a clear negative impact on ejaculatory function but not on erectile function 3:

• Retrograde ejaculation occurs in approximately 47-65% of sexually active patients after TURP 6, 3
• This is a well-established side effect distinct from erectile dysfunction 1, 3
• Patients must be counseled preoperatively that retrograde ejaculation is expected, while erectile dysfunction is not 1, 3

Potential for Improvement in Erectile Function

Some patients with preoperative erectile dysfunction actually experience improvement after TURP 7, 3:

• Among patients with mild-to-moderate erectile dysfunction before TURP, 16.2% reported improvement after surgery 3
• One study found significant improvement in erectile function at 3 months post-TURP in patients who had preoperative erectile dysfunction 7
• This improvement likely reflects relief of lower urinary tract symptoms and associated psychological factors 7, 3

Clinical Pitfalls to Avoid

Do not attribute all postoperative sexual dysfunction to the surgical procedure itself 1, 3:

• Many men undergoing TURP are older with baseline erectile dysfunction 1
• Psychological factors play an important role both before and after surgery 3
• The natural progression of age-related erectile dysfunction may coincide with the postoperative period 1

Distinguish between TURP for benign prostatic hyperplasia and radical prostatectomy for cancer 1:

• The evidence cited here applies to TURP for BPH, not radical prostatectomy 1
• Radical prostatectomy has much higher rates of erectile dysfunction (variable but often >50%) 1

Consider the impact of prior TURP when planning other treatments 1:

• Patients with prior TURP have increased risk of urethral stricture with subsequent radiation therapy (up to 2%) 1
• Prior TURP increases risk of incontinence with brachytherapy 1

Preoperative Counseling Recommendations

Inform patients that TURP does not typically worsen erectile function but retrograde ejaculation is expected 1, 6:

• Set realistic expectations about the 47-65% risk of retrograde ejaculation 6, 3
• Explain that erectile function preservation rates are approximately 85-95% 2, 3, 4
• Identify high-risk patients (diabetes, metabolic syndrome, capsular perforation risk) who may benefit from closer monitoring 2, 4, 5

For patients who prioritize sexual function above all else, alternative procedures may be considered 1:

• Transurethral incision of the prostate (TUIP) has significantly lower retrograde ejaculation rates but higher reoperation rates (18.4% vs 7.2%) 1
• Alternative ablative or nonablative techniques may be chosen despite potentially inferior relief of bladder outlet obstruction 1