The Link Between Prostate Enlargement and Sexual Dysfunction
Benign prostatic enlargement (BPE) is a common condition in aging men. As the prostate grows, it compresses the urethra, causing lower urinary tract symptoms (LUTS): weak stream, hesitancy, frequent urination, and nocturia. By age 60, more than half of men have some degree of BPE. By age 80, the number exceeds 80%.
For decades, the gold standard surgical treatment for BPE has been transurethral resection of the prostate (TURP). The procedure removes obstructing prostate tissue and reliably improves urinary symptoms. However, TURP has a significant downside: it frequently causes sexual dysfunction. Retrograde ejaculation (dry orgasm where semen goes into the bladder instead of out through the penis) occurs in up to 90% of men after TURP. De novo erectile dysfunction (ED) occurs in 10% to 30% of men.
These numbers matter because men with BPE are often sexually active. The condition itself is already associated with ED through shared biological mechanisms: reduced nitric oxide, pelvic hypoxia, and sympathetic overactivity. Adding a treatment that worsens sexual function creates a difficult trade-off.
In recent years, a new category of treatments has emerged: minimally invasive surgical treatments (MIST). These procedures aim to reduce prostate tissue or relieve obstruction while preserving normal ejaculation and erectile function. A review by Eric Chung (2025) provides an overview of these MIST technologies with a specific focus on sexual function outcomes. The full text is available here:review by Eric Chung on MIST for BPE and sexual function outcomes
What Are MIST?
Minimally invasive surgical treatments for BPE share a common goal: improve urinary flow with less tissue destruction and fewer side effects than TURP. The major commercially available MIST technologies include the following.
MIST technologies represent an evolving approach to balancing efficacy and preservation of sexual function.
- Prostatic arterial embolization (PAE). A radiologist injects small particles into the arteries supplying the prostate, causing the tissue to shrink. No cutting. No cautery.
- Aquablation. A robotically controlled water jet removes prostate tissue. Real-time ultrasound imaging guides the procedure, which spares the ejaculatory ducts.
- Rezūm (convective water vapor therapy). Steam injected into the prostate destroys excess tissue. The steam spreads through the tissue, causing cell death while preserving surrounding structures.
- UroLift. Permanent implants retract the prostate lobes, opening the urethra without removing tissue. The ejaculatory ducts remain intact.
- Laser enucleation (HoLEP, ThuLEP). A laser separates the entire prostate adenoma from the surgical capsule, similar to open surgery but through a scope. The tissue is then morcellated and removed.
- iTind (temporary implant). A nitinol device inserted into the urethra reshapes the prostate over several days, then is removed. No permanent implant remains.
Each technology has a different balance of efficacy, safety, and sexual function preservation.
Key Findings from the Chung Review
The Chung review summarizes published data on how MIST technologies affect urinary symptoms and sexual function. The collective evidence shows several consistent patterns.
Urinary outcomes. All MIST technologies improve LUTS. The International Prostate Symptom Score (IPSS, 0 to 35) typically drops by 50% to 70% within three to six months after treatment. Peak urinary flow rates increase by 50% to 100%. These improvements are durable for at least one to two years, with longer-term data still accumulating.
Ejaculatory function. This is where MIST differ most dramatically from TURP. While TURP causes retrograde ejaculation in approximately 90% of men, MIST technologies have much lower rates. UroLift preserves antegrade ejaculation in over 90% of men. Rezūm does so in 85% to 95%. PAE achieves about 90%. Aquablation preserves ejaculation in 70% to 80%, depending on the volume of tissue removed. Even laser enucleation, the most aggressive MIST, preserves antegrade ejaculation in 20% to 40% of men far better than TURP.
Erectile function. De novo erectile dysfunction after MIST is uncommon. Reported rates range from 0% to 15%, depending on the technology and study. This compares favorably to TURP, where 10% to 30% of men experience worsened erectile function. Men with pre-existing ED do not typically worsen after MIST, and some studies report improvement in erectile function following relief of LUTS, though this is not a consistent finding.
Comparison of MIST Technologies for Sexual Function Outcomes
| Technology | Preservation of antegrade ejaculation | De novo ED | Best for prostate size | Key limitation |
| TURP (standard) | ~10% | 10-30% | Any size | High retrograde ejaculation rate |
| UroLift | >90% | Low | Medium lobe (obstructing) | Does not reduce prostate volume |
| Rezūm | 85-95% | Low | Any size | May require multiple sessions |
| Aquablation | 70-80% | Low | Large (>50 mL) | Robotic, expensive, learning curve |
| PAE | ~90% | Low | Any size | Requires experienced interventional radiologist |
| HoLEP / ThuLEP | 20-40% | Low to moderate | Very large (>80 mL) | Learning curve, retrograde ejaculation common |
| iTind | >90% | Low | Small to moderate (30-80 mL) | Temporary, effect may diminish over time |
What the Review Does Not Say
The Chung review is a narrative review, not a systematic review or meta-analysis. This distinction matters. A systematic review follows a strict protocol, searches multiple databases comprehensively, and quantifies results. A narrative review summarizes the literature as the author interprets it. The level of evidence is lower.
Additionally, most studies cited in the review have follow-up of two years or less. Long-term data beyond five years are sparse, especially for newer technologies like Rezum and iTind. Durability of ejaculatory function preservation over a decade is unknown.
Finally, many studies are industry-sponsored. Device manufacturers fund a substantial portion of MIST research. While this does not invalidate the findings, it is a known source of potential bias.
Two Key Takeaways from the Chung Review
The review by Chung provides a clear summary of what is known about MIST and sexual function. Based on the evidence presented, two main conclusions emerge.
List 1: Two Key Takeaways from the Chung Review
- MIST significantly preserve antegrade ejaculation compared to TURP. The difference is substantial – up to 80 percentage points higher preservation rates with technologies like UroLift, water vapor therapy (Rezum), and PAE. For men who value normal ejaculation, this is a compelling advantage.
- De novo erectile dysfunction is less common after MIST than after TURP. The reported rates range from 0% to 15% for MIST, compared to 10% to 30% for TURP. However, the quality of evidence is lower, and some studies did not systematically assess erectile function using validated questionnaires.
Limitations of the Review
The Chung review is a valuable overview, but it has limitations that readers should understand. The author is transparent about the nature of the work – it is a narrative review, not a systematic review or meta-analysis. This means the evidence synthesis reflects the author’s selection and interpretation of studies, not a comprehensive, protocol-driven analysis.
Most studies cited in the review have follow-up of two years or less. Long-term data beyond five years are sparse for newer MIST technologies. Durability of ejaculatory function preservation over a decade is unknown.
Additionally, many studies are industry-sponsored. Device manufacturers fund a substantial portion of MIST research. While this does not invalidate the findings, it is a known source of potential bias. Few head-to-head comparisons between different MIST technologies exist. Most studies compare a MIST to TURP or to sham, making indirect comparisons imprecise.
Clinical Scenarios: Matching Patient to Procedure
Based on the evidence summarized by Chung, a thoughtful clinician can match patient characteristics and priorities to specific MIST technologies. The following scenarios illustrate this approach.
List 2: Three Clinical Scenarios for MIST Selection
- Younger, sexually active man for whom ejaculatory function is critical. For a man in his 50s or 60s with bothersome LUTS who wants to preserve normal ejaculation, UroLift or water vapor therapy (Rezum) are the best options. Both have preservation rates above 85% for antegrade ejaculation. The trade-off is that symptom improvement, while substantial, is slightly less than with tissue-removing procedures like TURP or HoLEP.
- Older man with large prostate (>80 mL) and severe symptoms. For a man with a very large prostate causing significant obstruction and retention, tissue removal is necessary. HoLEP, ThuLEP, or Aquablation provide excellent symptom relief comparable to open surgery but with shorter recovery. These procedures have higher rates of retrograde ejaculation (60-80%), but erectile function is generally preserved. The patient should understand that normal ejaculation is unlikely.
- Man at high bleeding risk on anticoagulation. For a man who cannot safely stop blood thinners due to atrial fibrillation, mechanical heart valve, or recent stent, PAE or iTind are attractive. Both can be performed without interrupting anticoagulation. Neither causes significant bleeding or retrograde ejaculation.
Comparison with TURP and Earlier Data
TURP remains the gold standard for surgical treatment of BPE in terms of symptom relief. However, the sexual side effects are substantial. Retrograde ejaculation is nearly universal. Erectile dysfunction affects a meaningful minority.
MIST technologies do not match TURP for maximal symptom reduction. On average, IPSS improvement is 50% to 70% still highly effective for most men, but less than TURP. The trade-off is better preservation of sexual function. For a man who finds retrograde ejaculation unacceptable, the slightly lower symptom improvement is a worthwhile compromise.
The Chung review adds value by focusing specifically on sexual function outcomes. Previous reviews emphasized urinary parameters. By synthesizing ejaculatory and erectile function data across MIST platforms, Chung provides a practical reference for clinicians counseling sexually active men with BPE.
Clinical Application
At Adult & Pediatric Urology (APUMN), we take the findings of this review into account when counseling men with lower urinary tract symptoms due to benign prostatic enlargement who are concerned about sexual function. The evidence confirms that for men who prioritize normal ejaculation, UroLift or water vapor therapy (Rezum) are reasonable options. For men with very large prostates who accept the likelihood of retrograde ejaculation, HoLEP or Aquablation provide excellent symptom relief with good erectile function preservation. For men on anticoagulation, PAE or iTind offer safe alternatives. The decision requires a conversation about the trade-off between symptom improvement and ejaculatory function.
Author
Gregory S. Parries, M.D., PhD
