If you are experiencing complete urinary retention (inability to empty the bladder), fever/chills, heavy bleeding, or severe pain, contact emergency or urgent care immediately.

Key facts

  • Across randomized surgical trials, a standard erectile-function score did not change significantly on average after TURP, laser procedures, or minimally invasive procedures, while retrograde ejaculation was common after TURP and other electrosurgical or laser procedures1.
  • In one randomized trial comparing PAE with TURP, complete loss of ejaculation happened in 16% of men after PAE versus 52% after TURP, while a reduced amount of ejaculate was more common after PAE, in 40%2.
  • In that same trial, some change in ejaculation (counting any change, not only complete loss) affected 56% of men after PAE and 84% after TURP, among the 25 men in each group whose ejaculation could be assessed3.
  • In a randomized trial of Aquablation versus TURP, complete loss of ejaculation happened in 10% of men after Aquablation versus 36% after TURP, among sexually active men4.
  • The pivotal randomized trial of the prostatic urethral lift (UroLift) reported no new cases of erectile or ejaculatory dysfunction; the pivotal trial of water vapor thermal therapy (Rezum) reported no new erection problems, and its authors concluded that ejaculatory function was preserved5,6.
  • A meta-analysis of alpha-blocker trials found higher odds of ejaculatory disorders than with placebo, with no significant difference in erectile dysfunction7.
  • A meta-analysis of 5-alpha-reductase inhibitor trials in BPH found a higher risk of sexual dysfunction, erectile dysfunction, and decreased libido than with placebo8.
  • Talk with your doctor before you decide. This information does not replace personal medical advice.

Ejaculation, erection, and libido: three different things

Trials measure these with different tools: a standard erectile-function questionnaire and a separate ejaculation-function questionnaire, and some also ask about bother separately from function1. A treatment can leave one domain unchanged while clearly affecting another, and a man can feel bothered by a change even when a validated score says his function did not change1. Grouping all three together as "sexual side effects" can hide which one actually changed for a given option.

Why this matters: If a side effect worries you, ask specifically about ejaculation, about erections, and about desire, rather than asking only whether an option has "sexual side effects."

Questions to ask

  • Which of ejaculation, erections, and libido does the evidence for this option actually cover?
  • Was that measured with a validated questionnaire, or only asked informally?
  • If function scores do not change, could I still feel more bothered?

Medicines: alpha-blockers, 5-alpha-reductase inhibitors, and combinations

Alpha-blockers, such as tamsulosin, alfuzosin, and silodosin, are used to treat BPH symptoms7. A meta-analysis of randomized trials found higher odds of ejaculatory disorders with alpha-blockers than with placebo, and found that uroselective alpha-blockers carried higher odds than non-selective ones; the same meta-analysis found no significant difference in erectile dysfunction across trials of alpha-blockers compared with placebo7. Within that class, silodosin carried higher odds of ejaculatory dysfunction than tamsulosin7. In a 9-month extension study of silodosin, ejaculation dysfunction was the most common side effect, reported by about 9% of men, and rarely led to stopping the medicine9. 5-alpha-reductase inhibitors, such as finasteride and dutasteride, are another class of BPH medicines. A meta-analysis of randomized trials in BPH found a higher risk of sexual dysfunction overall, of erectile dysfunction, and of decreased libido with 5-alpha-reductase inhibitors than with placebo8. Combination therapy, or adding a bladder medicine or a PDE5 inhibitor such as tadalafil, changes the mix of medicines you are taking. Ask your doctor whether that combination changes these risks for you.

Questions to ask

  • For this specific medicine, how often is reduced ejaculation reported, versus no ejaculation at all, versus a change in erections?
  • If I notice a change, would it likely improve if I stopped or switched medicines?
  • How does combining medicines change these risks compared with either one alone?

Office procedures: UroLift and Rezum

The pivotal randomized trial of the prostatic urethral lift (UroLift) reported no new cases of erectile or ejaculatory dysfunction over the first year, and described the procedure as preserving sexual function5. In a separate network meta-analysis of randomized trials comparing surgical options for BPH, the prostatic urethral lift ranked highest for erectile-function scores compared with TURP at 24 months, though direct head-to-head evidence for that comparison was limited10. The pivotal randomized trial of water vapor thermal therapy (Rezum) also reported no new erectile dysfunction and described the treatment as preserving both erectile and ejaculatory function6.

Questions to ask

  • How many men in the trials for this option were followed for ejaculation and erections, and for how long?
  • Is my prostate size and shape within the range these trials studied?
  • What would recovery and retreatment look like if I chose this instead of surgery?

Prostate artery embolization (PAE)

In a randomized trial comparing PAE with TURP, some change in ejaculation, counting both reduced and absent ejaculation, affected 56% of men after PAE and 84% after TURP, among the 25 men in each group whose ejaculation could be assessed before and after3. A closer analysis of the same trial found that complete loss of ejaculation was less common after PAE than after TURP, 16% versus 52%, but a reduced amount of ejaculate was more common after PAE, in 40%2. In 5 men who had PAE before prostate-cancer surgery as part of a related proof-of-concept study, tissue examined afterward showed changes in structures involved in ejaculation, including the prostate glands, seminal vesicles, and ejaculatory ducts, which may help explain these findings2. See PAE vs TURP for the wider comparison.

Questions to ask

  • Based on these trial numbers, what is a realistic range for me, not just an average?
  • If my ejaculate decreases rather than stops completely, is that the more likely outcome for me?
  • How would we know if a change was from PAE rather than from something else?

Surgery: TURP, laser enucleation, and Aquablation

Retrograde ejaculation is a well-known risk of TURP and similar electrosurgical procedures. A pooled analysis of randomized trials found a much higher rate of retrograde ejaculation after TURP and other electrosurgical procedures than before surgery, and a similarly higher rate after laser procedures as a group; most minimally invasive procedures did not show a significant increase1. Erectile function, measured on a standard questionnaire, did not change significantly on average after TURP, laser procedures, or minimally invasive procedures in that same pooled analysis1. A separate meta-analysis comparing enucleation procedures such as holmium laser enucleation with TURP found no significant difference in the rate of retrograde ejaculation between the two, but slightly higher erectile-function (IIEF-5) scores with enucleation, about 1 point higher at 4 or more years of follow-up, a small difference11. In a randomized trial of Aquablation versus TURP, complete loss of ejaculation happened in 10% of men after Aquablation versus 36% after TURP, among sexually active men4.

Questions to ask

  • For the surgery you suggest, how often do men have reduced ejaculation, no ejaculation, or a change in erections?
  • How does that compare with the figures reported for PAE or an office procedure, for someone with my prostate size?
  • How long were the men in these trials followed before erections and ejaculation were checked?

Comparison table

These ranges come from the trials and meta-analyses cited on this page. They are reported findings, not guarantees for any one person. "Reported in trials" marks a figure from the specific study cited, not a site-wide estimate.

Sexual side effects by BPH treatment, by source
OptionEjaculationErectionsEvidence
Alpha-blockers More likely than placebo; varies by drug, reported in trials7 No significant difference vs placebo across trials of alpha-blockers7 Meta-analysis of randomized trials
5-alpha-reductase inhibitors More likely than placebo, reported in trials8 More likely than placebo, reported in trials8 Meta-analysis of randomized trials in BPH
UroLift No new cases in the pivotal trial, reported in trials5 No new cases in the pivotal trial, reported in trials5 1 randomized trial
Rezum Described as preserved by trial authors6 No new cases in the pivotal trial, reported in trials6 1 randomized trial
PAE Some change in 56%; complete loss in 16%, vs 84% and 52% after TURP, reported in trials2,3 Not given a verified rate on this page 1 randomized trial plus a secondary analysis
TURP Common; higher than before surgery in pooled trials, reported in trials1 No significant change on average in a pooled analysis, reported in trials1 Pooled analysis of randomized trials
Laser enucleation (e.g., HoLEP) Similar to TURP in one meta-analysis, reported in trials11 About 1 point higher (IIEF-5) than TURP at 4+ years, a small difference11 Meta-analysis of randomized trials
Aquablation Less complete loss than TURP, 10% vs 36%, reported in trials4 Not given a verified rate on this page 1 randomized trial

Questions to ask before you decide

The figures on this page come from specific trials and meta-analyses, and your own case may differ from the patients studied. Compare the broader choices in BPH treatment options and BPH treatment options comparison, review BPH medication if a medicine is on your list, and bring questions to ask before PAE if PAE is on yours. If you are weighing PAE against an office procedure, see PAE vs Rezum vs UroLift.

Questions to ask a urologist

  • Of the options you would offer me, which has the best evidence on ejaculation and erections for someone with my size and symptoms?
  • How would we find out if a change happened, and when would we check?
  • If a medicine affects me, what would switching or stopping look like?

Questions to ask an interventional radiologist

  • How does PAE's reported ejaculation data compare with the office procedures and surgery options I am also considering?
  • What follow-up would we use to track any change after PAE?
  • What is still unknown about PAE's effect on erections?

Common questions

Does PAE cause retrograde ejaculation?

PAE can change ejaculation, but not always in the same way, and the studies cited here measured anejaculation and diminished ejaculate rather than retrograde ejaculation specifically; ask your clinician which term applies to you. In one randomized trial, complete loss of ejaculation (anejaculation) was less common after PAE than after TURP, 16% versus 52%, while a reduced amount of ejaculate was more common after PAE, in 40%2. Counting any change in ejaculation, not just complete loss, 56% of men were affected after PAE and 84% after TURP, among the 25 men in each group whose ejaculation could be assessed3. Ask your interventional radiologist how these numbers might apply to you.

Does Rezum or UroLift affect ejaculation?

The pivotal trial of UroLift reported no new cases of erectile or ejaculatory dysfunction over the first year, while the pivotal trial of Rezum reported no new erection problems and its authors concluded that ejaculatory function was preserved5,6. A separate pooled analysis of several trials found that men who had the prostatic urethral lift (UroLift) reported more bother about ejaculation afterward, even though a validated ejaculation-function score did not change1. Ask how bothered you might feel, not only whether a number changed.

Can BPH treatment cause erectile dysfunction?

It depends on the treatment. In a pooled analysis of randomized surgical trials, a standard erectile-function score did not change significantly on average after TURP, laser procedures, or minimally invasive procedures1. Among medicines, a meta-analysis found no significant difference in erectile dysfunction across trials of alpha-blockers compared with placebo7, while a separate meta-analysis found a higher risk of erectile dysfunction with 5-alpha-reductase inhibitors (finasteride, dutasteride) than with placebo8. A meta-analysis comparing laser enucleation with TURP found slightly higher erectile-function (IIEF-5) scores with laser enucleation, about 1 point higher at 4 or more years, a small difference11. Ask which option you are considering, since the answer differs by treatment.

Can an enlarged prostate itself cause ED?

Possibly, though this page cannot prove cause and effect. In one study of men aged 40 to 60 with BPH symptoms, men with worse urinary symptom scores tended to have worse erectile-function scores12. BPH symptoms are not likely the only explanation for a change in erections; ask your doctor whether age or other health conditions should also be checked.

Do BPH medicines cause sexual side effects?

Yes, for some medicines. Alpha-blockers are more likely than placebo to affect ejaculation, with silodosin more likely than tamsulosin, but a meta-analysis found no significant difference in erectile dysfunction across trials of alpha-blockers compared with placebo7. In one extension study, about 9% of men taking silodosin reported an ejaculation problem9. 5-alpha-reductase inhibitors (finasteride, dutasteride) were linked to a higher risk of sexual dysfunction overall, erectile dysfunction, and decreased libido than placebo in a meta-analysis of randomized trials8. Ask your doctor which medicine you are taking and what its specific risks are.

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Talk with your doctor before you decide. This information does not replace personal medical advice. Read the medical disclaimer.

Sources

  1. Manfredi et al., impact of BPH surgery on erectile and ejaculatory function, meta-analysis, Eur Urol Focus 2022, PMID 35803852 ↩︎
  2. Müllhaupt et al., ejaculatory disorders after prostatic artery embolization, World J Urol 2020, PMID 31813028 ↩︎
  3. Abt et al., PAE vs TURP randomized trial, BMJ 2018, PMID 29921613 (56% and 84% figures: full text, PMC6006990) ↩︎
  4. Gilling et al., WATER trial (Aquablation vs TURP), J Urol 2018, PMID 29360529 ↩︎
  5. Roehrborn et al., L.I.F.T. study (prostatic urethral lift / UroLift RCT), J Urol 2013, PMID 23764081 ↩︎
  6. McVary et al., Rezūm water vapor thermal therapy RCT, J Urol 2016, PMID 26614889 ↩︎
  7. Bapir et al., alpha-adrenoceptor antagonists and sexual function, systematic review and meta-analysis, Arch Ital Urol Androl 2022, PMID 35775356 ↩︎
  8. Liu et al., 5-alpha-reductase inhibitors and sexual function, meta-analysis, J Sex Med 2016, PMID 27475241 ↩︎
  9. Osman et al., silodosin 9-month open-label extension study, World J Urol 2015, PMID 25712312 ↩︎
  10. Light et al., erectile function after surgery for benign prostatic obstruction, network meta-analysis, Eur Urol 2021, PMID 34127315 ↩︎
  11. Liu et al., endoscopic enucleation vs TURP, impact on sexual function, systematic review and meta-analysis, J Endourol 2020, PMID 32242462 ↩︎
  12. Kardasevic & Milicevic, correlation of BPH symptoms and erectile dysfunction, Med Arch 2017, PMID 28428671 ↩︎