Last updated: March 2026
It is the question that concerns men most when considering prostate surgery. More than pain, more than anaesthesia, more than the hospital stay. "Doctor, will I still be able to have sex?" And the second question, often asked with more hesitation: "Will I still ejaculate?"
I will answer with complete honesty, because I believe a patient about to make a decision about his body deserves clear information — neither sugarcoated nor dramatised.
First and foremost: HoLEP does not affect erections
This needs to be said clearly from the start. Erections depend on two nerves — the cavernous or erectile nerves — that run along the back and sides of the prostate, outside the capsule. Prostatic enucleation works inside the capsule, peeling the adenoma away without touching these nerves at any point.
If a patient had normal erections before surgery, he will continue to have them afterwards. In fact, some patients report an improvement in their sex life after the operation, simply because the urinary symptoms that were limiting it — getting up four times a night, urgency, constant dribbling — have disappeared. When those problems go away, confidence and comfort improve, and with them, intimacy.
If a patient already had erectile dysfunction before surgery (which is common at this age and with conditions such as diabetes or hypertension), the operation will not make it worse, but it will not cure it either — they are separate problems.
Retrograde ejaculation: what it is and why it happens
This is where I need to be completely transparent. After a complete prostatic enucleation — whether HoLEP, TURP, open surgery, or any other technique that removes the adenoma — most patients experience what we call retrograde ejaculation.
What does that actually mean?
During orgasm, the semen instead of coming out through the penis flows backwards, into the bladder. The orgasm is felt, the sensation of pleasure is there, but there is no expulsion of semen. When the patient urinates after orgasm, the urine comes out slightly cloudy — that is the semen mixed with urine. It is completely harmless.
Why does it happen?
The ejaculatory mechanism depends on a closure that occurs at the prostatic urethra during orgasm. This closure prevents semen from going towards the bladder and directs it outward. When the prostatic adenoma is removed, this closure mechanism is disrupted. This is an inherent consequence of all techniques that completely remove the adenoma — it is not specific to HoLEP.
How common is it?
In the published literature, the rate of retrograde ejaculation after HoLEP ranges from 70 to 90%. It is similar with TURP (75–80%) and with open surgery. In other words: it is the norm, not the exception.
Is it dangerous?
No. Retrograde ejaculation has no health consequences whatsoever. The semen is eliminated naturally with urine. It is painless, does not cause infections, and creates no problems.
Does it affect fertility?
Yes. If a man wishes to father children and preserving antegrade ejaculation is a priority, this must be discussed before surgery. Options exist for sperm banking before the procedure, and assisted reproduction techniques can use semen recovered from urine after orgasm. But if future fertility is important, it is a factor that may tip the balance toward a more conservative treatment.
What patients actually tell me
After thousands of enucleations and asking my patients directly about their experience, I can share what they convey:
When I ask whether they miss ejaculation, they often say yes. It is a different sensation — something is missing.
When I ask about orgasm, the answers vary. Some tell me it is more intense and satisfying than before. Others notice no significant difference. And others tell me, with some regret, that it has become a mild "tingle" — not as good as before.
But when I ask whether they would have the same operation again, the answer is almost unanimous: yes. They tell me that their life, overall, has improved enormously despite the retrograde ejaculation, and that they would do it again without hesitation.
Can ejaculation be preserved with prostate surgery?
Yes, but with important caveats that the patient must understand before deciding.
Minimally invasive treatments (Rezum, UroLift, iTIND)
These procedures have been commercially positioned as ejaculation-preserving options. And it is true that they preserve ejaculation in most cases. However, the improvement in urinary flow is significantly less than with enucleation, durability is limited, and many patients will eventually require retreatment.
Laser-based options that preserve ejaculation
In our practice, we have two minimally invasive laser-based options for carefully selected patients who prioritise ejaculatory preservation:
The first is bilateral bladder neck incision with laser, in younger patients with an elevated, narrow bladder neck. If the incisions are kept half a centimetre to one centimetre above the verumontanum, ejaculation is preserved consistently. In my personal experience, I have had only one case of antegrade ejaculation loss with this technique, and we perform it virtually every week. It is done under sedation, takes 3–4 minutes, and the patient goes home the same day with a catheter for removal the following day.
The second is isolated middle lobe enucleation in patients whose obstruction is mainly caused by middle lobe growth. If the tissue around the verumontanum is preserved, ejaculation is consistently maintained and there is a very significant improvement in urinary symptoms.
These two options strike me as quite competitive compared to other minimally invasive treatments, but not every patient is a candidate. Selection is crucial, and we perform a prior cystoscopy to confirm that the patient's anatomy is suitable.
Ejaculation-sparing HoLEP
Attempts have been published to perform complete enucleation while preserving tissue around the verumontanum to maintain ejaculation. Results to date are modest — success rates of around 50%. And there remains uncertainty about whether leaving adenomatous tissue behind compromises the procedure's durability, with the risk that this residual tissue may grow and cause obstruction again.
Putting things in perspective
When I advise my patients on this topic, I often share something I believe is important: most of the men we operate on are 55–65 years old or older. Over time, the importance of antegrade ejaculation tends to diminish, but being able to urinate properly will become increasingly important. I have seen too many patients who at 75–80 are admitted for a hip fracture and develop urinary retention because a conservative approach was chosen decades earlier.
The medical device industry has invested enormous sums in shifting our perception of the relative importance of ejaculation versus bladder function. And they have been extraordinarily effective in that marketing effort. But as urologists, we should be advisors to our patients, not sales representatives for any company.
The decision always belongs to the patient. But for it to be a truly informed decision, he needs to know all the facts — not just the ones the advertising highlights.
- Erections: not affected. The erectile nerves are not touched during surgery.
- Ejaculation: in 70–90% of cases it will be retrograde (dry). Orgasm persists.
- Overall satisfaction: over 96% of patients are satisfied and would have the surgery again.
- Ejaculation-preserving options exist for selected patients, but with lower efficacy or durability.
At ICUA we will explain all the options honestly and personally.
📞 +34 91 435 28 44 · ✉ icua@icua.es
Scientific references
- Iscaife A, Rodríguez Socarrás M, Talizin TB, et al. Contemporary results of En Bloc HoLEP for large prostates. World J Urol. 2025;43:401. PubMed
- Kim M, Song SH, Ku JH, et al. Pilot study of the clinical efficacy of ejaculatory hood sparing technique for ejaculation preservation in HoLEP. Int J Impot Res. 2015;27:20-24. PubMed
- Lee SW, Choi JB, Lee KS, et al. Satisfaction and quality of life after holmium laser enucleation of the prostate. Investig Clin Urol. 2017;58:35-41. DOI
- Saitta G, Becerra JEA, Del Álamo JF, et al. 'En Bloc' HoLEP with early apical release. World J Urol. 2019;37:2451-2458. PubMed
- Gauhar V, Gómez Sancha F, Enikeev D, et al. Results from a global multicenter registry of 6193 patients (REAP). World J Urol. 2023;41:3033-3040. PubMed
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