What is the treatment for retrograde ejaculation and benign prostatic hyperplasia (BPH) or bladder outlet obstruction (BOO)?

Treatment of Retrograde Ejaculation in Patients with BPH/BOO

For patients with retrograde ejaculation related to BPH treatment, alpha-blocker selection should prioritize agents with lower ejaculatory dysfunction rates, and when retrograde ejaculation occurs, first-line medical management with sympathomimetic agents (pseudoephedrine or imipramine) should be attempted before considering surgical alternatives or sperm retrieval techniques.

Understanding the Problem

Alpha-Blocker-Induced Retrograde Ejaculation

• Silodosin has the highest probability of causing ejaculatory dysfunction among alpha-blockers, while tamsulosin also carries elevated risk compared to alfuzosin, doxazosin, and terazosin 1, 2
• When prescribing alpha-blockers for LUTS/BPH, the choice should be based on patient age, comorbidities, and different adverse event profiles including ejaculatory dysfunction 1
• Surgical therapy for BPH (open surgery or TURP) is associated with retrograde ejaculation in nearly 100% of cases due to the bladder neck remaining open 3

Mechanism and Risk Factors

• Retrograde ejaculation occurs when sympathetic nerve function is disrupted, either pharmacologically (alpha-blockers) or anatomically (post-surgical) 3
• Diabetes is the most common etiology for complete retrograde ejaculation (60% of cases), while idiopathic causes predominate in partial retrograde ejaculation (82%) 4

Medical Management Algorithm

First-Line: Sympathomimetic Therapy

Pseudoephedrine is the preferred first-line agent, with a 58-70% success rate in improving seminal parameters:

• Short-course protocol: 60 mg pseudoephedrine every 6 hours on the day before planned conception attempt, plus two additional 60 mg doses on the day of ejaculation 4
• In complete retrograde ejaculation, 58.3% of patients recovered spermatozoa in antegrade ejaculate with mean total sperm count of 273.5 million 4
• In partial retrograde ejaculation, 62.5% achieved ≥50% increase in antegrade sperm count (from 26.9 million to 84.2 million) 4

Alternative Medical Options

• Imipramine and chlorpheniramine + phenylpropanolamine show significantly higher reversal rates than ephedrine alone 5
• For anejaculation specifically, midodrine demonstrates superior efficacy compared to imipramine, pseudoephedrine, and ephedrine 5
• Medical treatment for retrograde ejaculation offers realistic chances of natural conception and should be first-choice therapy 5, 6

Surgical Management Considerations

Minimizing Ejaculatory Dysfunction Risk

When surgical intervention is necessary for BPH:

• Prostatic urethral lift (PUL) preserves ejaculatory function with no evidence of de novo ejaculatory dysfunction, making it the preferred option for sexually active men concerned about ejaculation 1
• Ejaculatory function scores (MSHQ-EjD) significantly improved at 12 and 36 months following PUL treatment 1
• Water vapor thermal therapy reported no de novo erectile dysfunction and only 1% dysuria at 36 months, with improved ejaculatory bother and function scores 1

High-Risk Procedures

• TURP and open prostatectomy carry nearly 100% risk of retrograde ejaculation 3
• Transurethral needle ablation (TUNA) has the lowest risk of retrograde ejaculation among endoscopic BPH treatments, though TUNA is no longer recommended by current guidelines 1, 3

Prevention Strategy for BPH Patients

Alpha-Blocker Selection

For sexually active men requiring alpha-blocker therapy:

1. Choose alfuzosin, doxazosin, or terazosin over tamsulosin or silodosin 1, 2
2. All alpha-blockers have similar efficacy (4-7 point IPSS improvement), but differ in ejaculatory dysfunction rates 1
3. Tamsulosin has lower orthostatic hypotension risk but higher ejaculatory dysfunction probability 1, 2

Combination Therapy Considerations

• When adding 5-alpha reductase inhibitors (finasteride/dutasteride) to alpha-blockers, counsel patients that 5-ARIs independently cause ejaculatory disorders and decreased libido 1, 2
• The combination increases overall sexual side effect burden but provides superior long-term outcomes for disease progression 2

Sperm Retrieval as Alternative

When Medical Management Fails

• Urinary sperm retrieval remains an option when sympathomimetic therapy fails to restore antegrade ejaculation 6, 7
• Electroejaculation and electrovibration stimulation show low overall success rates and should be reserved for refractory cases 5, 7
• Assisted reproductive techniques can successfully utilize retrieved sperm despite often-impaired sperm quality in retrograde ejaculation patients 6, 7

Critical Clinical Pitfalls

• Do not assume all alpha-blockers carry equal ejaculatory dysfunction risk—silodosin and tamsulosin have significantly higher rates 1, 2
• Counsel patients about retrograde ejaculation risk BEFORE initiating alpha-blocker therapy, especially in men desiring fertility 1
• For men planning conception, consider PUL or water vapor thermal therapy over TURP to preserve ejaculatory function 1
• Medical treatment success rates are higher for retrograde ejaculation (58-70%) than for complete anejaculation, where success rates are lower 4, 5