Pravin K. Rao, MD
BASICS
DESCRIPTION
• Expulsion of semen from posterior urethra into bladder with low- or zero-volume antegrade ejaculate.
• Suspected in men with symptoms or semen analysis findings suggesting low or absent ejaculate volume.
• Primary implications are for infertility.
– Also: Sexual function/satisfaction.
• No other known medical health effects.
• Men with failure of emissions are often labeled as having “retrograde ejaculation.”
– Failed deposition of ejaculate contents into posterior urethra before expulsion.
EPIDEMIOLOGY
Incidence
• 74–78% incidence after transurethral prostate surgery (1)[B]
• 4–26% incidence with α-blocker tamsulosin (2,3)[A]
• As low as 14% incidence after bilateral nerve-sparing retroperitoneal lymph node dissection (RPLND) (4)[B]
Prevalence
N/A
RISK FACTORS
• Bladder neck/prostate procedures
– Transurethral resection of the prostate
– Transurethral incision of the prostate (TUIP)
– Bladder neck incision (BNI)
• Surgical/traumatic/congenital neuropathy
– Retroperitoneal surgery
eg, RPLND
– Pelvic surgery
eg, abdominoperineal resection
– Spinal cord injury (SCI)/surgery
– Spina bifida/myelomeningocele
• Medical neuropathy
– Diabetes mellitus (DM)
– Multiple sclerosis (MS)
• Iatrogenic from medications
– α-blockers
Reduce bladder neck muscle tone
Reduce seminal emissions
Tamsulosin, terazosin, doxazosin
– Antipsychotic and psychotropic medications
Risperidone
– Antidepressants
Selective serotonin reuptake inhibitors
Genetics
N/A
PATHOPHYSIOLOGY
• Normal ejaculation requires:
– Seminal emission
– Bladder neck closure
– Antegrade expulsion from urethra
• Neurologic control:
– Central control in multiple brain regions
Can promote or inhibit ejaculation
– Sympathetic (T12–L3):
Hypogastric nerve (thoracolumbar)
Seminal “emission” into posterior urethra by contraction of epididymis, vas deferens/ampulla, seminal vesicle (SV), and prostate smooth muscle
Bladder neck closure preventing retrograde ejaculation
– Parasympathetic (S2–S4):
Pelvic nerve
Gland secretions of prostate SV
– Somatic (S2–S4):
Pudendal nerve
Efferents from sacral cord
Contraction of bulbocavernosal and ischiocavernosal muscles
Relaxation of external urethral sphincter
Projectile expulsion of ejaculate
– Sensory
Pudendal nerve
Tactile stimulation of penis can activate ejaculatory reflex
• Retrograde ejaculation occurs from impaired bladder neck closure due to various causes
– Poor coaptation of bladder neck
Medication side effect
Prostate surgery
Idiopathic
– Neural disruption
Spinal cord injury (SCI)
Diabetes mellitus (DM)
Retroperitoneal lymphnode dissection (RPLND)
Pelvic surgery
ASSOCIATED CONDITIONS
• See risks factors
• Benign prostatic hyperplasia (BPH)
• Bladder neck dysfunction
• Diabetes mellitus (DM)
• Multiple sclerosis (MS)
• Rectal cancer
• Testicular cancer
GENERAL PREVENTION
• Avoidance of iatrogenic causes
• Nerve sparing during RPLND
DIAGNOSIS
HISTORY
• Absence or presence of orgasm
• Presence of erectile dysfunction
• Cloudy urine after sex/orgasm
• Symptoms of hypogonadism
• Medical history (see risk factors)
• Surgical history (see risk factors)
• Medications (see risk factors)
• Accuracy of semen analysis findings:
– Low measured volume may be due to spillage
– Some patients report subjective low volume only at time of sample collection
Anxiety due to lab/atmosphere
Anxiety related to medical condition
PHYSICAL EXAM
• Usually normal physical exam findings
• Absent vasa suggests congenital absence of the vas deferens
• Small testes may suggest hypogonadism
• Seminal vesical (SV) dilation may suggest ejaculatory duct obstruction (EDO)
• Muscle weakness or focal neurologic deficit may suggest primary neurologic cause
DIAGNOSTIC TESTS & INTERPRETATION
Lab
• If ejaculate volume <1.5 cc, consider postejaculatory urinalysis (PEU)
• PEU
– >10–15 sperm/HPF is diagnostic for retrograde ejaculation
– Small number of sperm may be normal
– Technique:
Abstain from ejaculation 2–3 days
Empty bladder
Collect/attempt antegrade ejaculate
Collect urine by void or catheter
• Endocrine evaluation if clinical suspicion for hypogonadism
Imaging
Only performed for concurrent medical conditions
Diagnostic Procedures/Surgery
N/A
Pathologic Findings
N/A
DIFFERENTIAL DIAGNOSIS
• Anejaculation
• Anorgasmia (inability to reach orgasm)
• Aspermia due to failure of emission
• Congenital bilateral/unilateral absence of the vas deferens
• EDO
• Erectile dysfunction
– Failure to reach orgasm
– Poor expulsion of ejaculate through flaccid penile urethra
• Hypogonadism
• Semen spillage in lab
• Poor semen collection technique
TREATMENT
GENERAL MEASURES
• Treatment typically reserved for fertility purposes
• Treat reversible causes
• Modify causative medications
– Change or discontinue causative medications
– Some clinicians favor alfuzosin for BPH (possibly less RE than other α-blockers)
MEDICATION
First Line
• α-adrenergic agents
– Dosing structure highly variable:
Pseudoephedrine 60 mg
Ephedrine 25–50 mg
Imipramine 25–50 mg (may cause dizziness and nausea)
Frequency ranges from QD to QID
Duration ranges from 2–14 days
Side effects: HTN, tachycardia
• Author recommendation: Pseudoephedrine 60 mg QID × 2–7 days prior to ejaculation (titrate to effectiveness)
• Medical therapy less likely to be effective after bladder neck injury or surgery
Second Line
N/A
SURGERY/OTHER PROCEDURES
• Sperm retrieval
– For use with assisted reproductive techniques
IUI (intrauterine insemination)
IVF In vitro fertilization
ICSI Intracytoplasmic sperm injection
• Sperm retrieval technique
– Prior to collection, alkalinize urine to pH 7
Sodium bicarbonate 650 mg QID or 1–3 tablespoons of baking soda, 12–48 hr before collection
– Catheterize or void for collection
• Sperm retrieval from the testis and epididymis, an option for unsuccessful retrograde collection
– Adoption and use of donor sperm can prevent the need for IVF/ICSI
ADDITIONAL TREATMENT
Radiation Therapy
N/A
Additional Therapies
N/A
Complementary & Alternative Therapies
N/A
ONGOING CARE
PROGNOSIS
• Success rates with assisted reproductive techniques largely dependent on female factors
• 44% pregnancy rates with intrauterine insemination (5)[C]
COMPLICATIONS
• Main issue is infertility
• Emotional distress
FOLLOW-UP
Patient Monitoring
Follow up semen analysis to determine effectiveness of medical therapy
Patient Resources
MedlinePlus: Retrograde Ejaculation http://www.nlm.nih.gov/medlineplus/ency/article/001282.htm
REFERENCES
1. Briganti A, Naspro R, Gallina A, et al. Impact on sexual function of holmium laser enucleation versus transurethral resection of the prostate: Results of a prospective, 2-center, randomized trial. J Urol. 2006;175(5):1817–1821.
2. Wilt TJ, Mac Donald R, Rutks I. Tamsulosin for benign prostatic hyperplasia. Cochrane Database Syst Rev. 2003;(1):CD002081.
3. Lepor H. Long-term evaluation of tamsulosin in benign prostatic hyperplasia: Placebo-controlled, double-blind extension of phase III trial. Tamsulosin Investigator Group. Urology. 1998;51:901–906.
4. Steiner H, Zangerl F, Stöhr B, et al. Results of bilateral nerve sparing laparoscopic retroperitoneal lymph node dissection for testicular cancer. J Urol. 2008;180(4):1348–1352.
5. van der Linden PJ, Nan PM, te Velde ER, et al. Retrograde ejaculation: Successful treatment with artificial insemination. Obstet Gynecol. 1992;79:126–128.
ADDITIONAL READING
Ohl DA, Quallich SA, Sønksen J, et al. Anejaculation and retrograde ejaculation. Urol Clin North Am. 2008;35:211–220.
See Also (Topic, Algorithm, Media)
• Anorgasmia/Dysorgasmia
• Ejaculatory Disturbances
• Infertility, Urologic Considerations
• Semen Analysis, Abnormal Findings and Terminology
• Semen Analysis, Technical and Normal Value
CODES
ICD9
• 355.9 Mononeuritis of unspecified site
• 608.87 Retrograde ejaculation
• 606.9 Male infertility, unspecified
ICD10
• G62.9 Polyneuropathy, unspecified
• N46.8 Other male infertility
• N53.14 Retrograde ejaculation
CLINICAL/SURGICAL PEARLS
In men with spinal cord injury (SCI) or history of retroperitoneal surgery, men may have failure of seminal emission, so sperm retrieval from the bladder may not be feasible.