Benign prostatic hyperplasia, or BPH, is the noncancerous enlargement of the prostate due to the proliferation of cells within the prostate. BPH is as normal as aging, and this is why approximately 90% of men will have an enlarged prostate by the time they reach the age of 80.
How Does BPH Cause Urinary Symptoms?
The prostate is a walnut-shaped gland around the urethra or the tube that carries urine from the bladder through the penis and out of the body. It is responsible for producing seminal fluid needed during ejaculation. As the prostate enlarges, it begins to squeeze on the urethra, potentially causing urinary symptoms including urinary incontinence, the need to urinate at night, a feeling of not being able to empty the bladder, slow or weak stream, and in severe cases, if BPH is left untreated, urinary retention, which can be an emergency.
Importantly, because the lower urinary tract symptoms associated with BPH often come on relatively slowly, many men find themselves modifying their lifestyle to accommodate the prostatic enlargement rather than getting treated in its earliest stages. Eventually, these compromises and lifestyle changes become so significant that a man inadvertently changes their life such that their social activities and hobbies are curtailed or revolve around the ability to get to a bathroom.
With the ubiquitous nature of BPH, it is no wonder that there are treatment options ranging from medication to minimally invasive outpatient office procedures and procedures performed in surgery centers. Each procedure has pros and cons; thus, treatment is tailored to a patient’s prostatic and anatomical particulars. However, in this article, we will discuss the concept of retrograde ejaculation. Retrograde ejaculation occurs when the urethra becomes damaged and, rather than semen exiting the body through the penis, is forced backward into the bladder.
This is a significant concern in patients who undergo surgical and heat-based BPH treatments, including simple prostatectomy, transurethral resection of the prostate TURP, Green Light Therapy, and, less often, a side effect of Rezum, which uses targeted steam therapy to destroy prosthetic tissue. While not inherently dangerous, retrograde ejaculation can cause fertility concerns in men who are still looking to conceive naturally.
Because many men who develop BPH and ultimately get treatment for it have passed the typical age of conceiving a child, this is a concern that we primarily have with patients in their 40s and 50s. Of course, anyone who is concerned with a dry orgasm, as it is sometimes called, should discuss this possibility with Dr. Kapadia during their consultation.
BPH Procedures That Cause Retrograde Ejaculation
Some urologists may offer procedures that carry a risk for retrograde ejaculation simply because they are effective in selected patients.
- First is the gold standard in BPH treatment, known as transurethral resection of the prostate, or TURP. This is a procedure during which bipolar electrical current is used to mechanically cut away excess prostatic tissue and carve out the prostate. This has traditionally been the procedure of choice for a significantly enlarged prostate in the past, but newer, less invasive procedures have become more popular, addressing these and other concerns. TURP carries a 40 to 60% chance of retrograde ejaculation, so patients should expect this as a potential side effect. Remember that the nerves and blood supply needed for an erection and pleasurable sex are not affected, only seminal fluid.
- Another very effective and popular procedure that comes with an approximately 4 to 6% risk of retrograde ejaculation is Rezum therapy. This procedure uses bursts of targeted steam to heat and destroy prostatic tissue. This is an excellent option for many men with a normal bladder neck and an uncomplicated enlarged prostate. The procedure is performed in about five minutes and done in the office, and the patients are back to their everyday lives quickly. While the risk of retrograde ejaculation is there, most patients are pleased by the speed and minimal invasiveness of the procedure.
- A simple prostatectomy is also an option for larger prostates over 80 grams. This procedure, performed robotically, hollows out the prostate. It can be likened to removing the pulp of an orange but keeping the skin. Over 80% of patients will experience retrograde ejaculation after this procedure.
- Green Light therapy, which uses a laser to destroy excess prostatic tissue, again using thermal therapy, can cause retrograde ejaculation in upwards of 80% of patients.
Procedures That Do Not Cause Retrograde Ejaculation
As mentioned above, not all BPH procedures cause retrograde ejaculation, and newer options that do not use heat-based ablative techniques have reduced this risk dramatically. These include:
- Urolift, which uses sutures to pull apart the prostatic lobes and take pressure off the urethra. Urolift does not involve any cutting away or destruction of prostatic tissue, and consequently, retrograde ejaculation is not a concern.
- Aquablation is another newer therapy that uses a targeted, high-intensity water jet to remove prostatic tissue mechanically. In not using thermal energy, retrograde ejaculation is virtually eliminated.
The Bottom Line
Once again, the decision on the BPH procedure that is best for you ultimately comes down to a consultation with Dr. Kapadia and an understanding of the various risks and considerations, including retrograde ejaculation.