Lower urinary tract symptoms (LUTS) secondary to benign prostatic hyperplasia (BPH) are common in men over age 50 and significantly impact quality of life.  Medical and surgical treatments for BPH offer varying degrees of symptom relief but can come with sexual side-effects such as loss of libido, erectile dysfunction and ejaculatory dysfunction.  Since BPH is a quality of life issue, the aim of treatment should be to provide symptom relief without introducing new issues such as sexual dysfunction that impair quality of life. While the effects of loss of libido and erectile dysfunction are readily understood, retrograde ejaculation has often been accepted as a common but harmless side-effect of surgical BPH treatments. The objective of this study was to determine the level of bother in BPH patients who experienced de novo anejaculation after undergoing transurethral resection of the prostate (TURP).

80 subjects (45 PUL, 35 TURP) with symptomatic BPH were enrolled in a prospective, randomized, controlled trial across 10 centers in Europe (BPH6 study).    During PUL, small permanent UroLift® implants were placed transurethrally to retract the obstructing prostatic lobes.  TURP was conducted in standard fashion. Sexual function was evaluated at baseline through 12 months post-procedure using the Sexual Health Inventory for Men (SHIM) questionnaire and the Male Sexual Health Questionnaire for Ejaculatory Function (MSHQ -EjD function).  Data from the TURP arm were analyzed to determine the level of patient bother from de novo anejaculation.  Subjects who answered 1-5 to MSHQ-EjD function question 3 (“How would you rate the amount or volume of semen or fluid when you ejaculate”) were defined as having volume from ejaculation.  Men who answered 0 “Could not ejaculate” to the same question were defined as having anejaculation.  The amount of bother from ejaculatory difficulties was evaluated using the MSHQ-EjD bother question. At the earliest follow up time in which anejaculation was reported, the corresponding response to the MSHQ-EjD bother question was assessed and results were compared to subjects who did not report anejaculation.  To determine if any increased bother from anejaculation was sustained, the same assessment was performed at the last follow up visit through 12 months in which anejaculation was reported and compared to subjects with ejaculatory volume.  SHIM and MSHQ-EjD outcomes through 12 months after TURP and PUL were compared.

All 35 subjects who were enrolled in the TURP arm of the BPH6 study had ejaculatory volume at baseline prior to surgery.  66% (23/35) subjects experienced anejaculation during the follow up period.  At the earliest and latest assessment in which anejaculation was reported, the MSHQ-EjD bother score was significantly better (p 0.03) for those TURP subjects who maintained ejaculatory volume compared to those who lost function (Table 1).  Further, average MSHQ-EjD function for TURP declined over time and was significantly worse compared to PUL subjects at all follow up times (7.7 TURP vs 12.3 PUL at 1 month, p=0.03; 5.6 TURP vs 11.9 PUL at 12 months, p<0.0001).  In PUL subjects, the MSHQ-EjD bother associated with ejaculatory function decreased from baseline throughout follow up (1.8 ± 1.8 baseline vs 1.0 ± 1.3 at 1 month, p=0.02; 1.7 ± 1.8 baseline vs 1.2 ± 1.1 at 12 months, p=0.2).  SHIM remained stable for both TURP and PUL subjects with similar results between groups at all follow up times (17.2 TURP vs 20.9 PUL at 1 month, p=0.3; 17.7 TURP vs 20.7 PUL at 12 months, p=0.5).

This study demonstrates that subjects who completely lose the ability to ejaculate after TURP are significantly more bothered than subjects who still have some ejaculatory volume after surgery.  At the earliest time that anejaculation was reported, the MSHQ-EjD bother score was significantly higher in subjects with anejaculation compared to those with ejaculatory volume.  These results were sustained with similar results at the latest time anejaculation was reported, demonstrating that a complete loss of ejaculation is bothersome to patients early on and almost a year after surgery.  In contrast, PUL subjects experienced MSHQ-EjD function and bother improvement from baseline at 1 month that was sustained through 12 months.  For both TURP and PUL subjects, erectile function was maintained.  However, the loss of ejaculation was reflected in declining MSHQ-EjD function scores for TURP that were significantly worse compared to PUL where subjects maintained stable ejaculatory function.

Completely losing the ability to ejaculate after TURP is bothersome to patients, especially compared to patients who maintain some ejaculatory volume.  These patients are bothered by the loss shortly after surgery and remain bothered almost a year after surgery.  When counseling patients on treatment options for BPH, clinicians may want to consider the patients’ perspective on ejaculatory dysfunction and discuss the potential effects of TURP and more invasive therapies.