Anejaculation

Anejaculation is the complete absence of antegrade and retrograde ejaculation. Orgasm may or may not be preserved. It is a cause of male infertility and distress.

It is lifelong or acquired, and organic or psychogenic. Spinal cord injury is the largest single organic cause, affecting about 90% of men with complete injuries at levels higher than the sacral segments.

Pathophysiology. Ejaculation is a spinal reflex, with emission driven by sympathetic outflow from T10 to L2 and expulsion by somatic pudendal nerves from S2 to S4. Disruption at any point impairs the process.

Causes:

• Spinal cord injury, multiple sclerosis, and spinal surgery.
• Retroperitoneal lymph node dissection, aortoiliac, colorectal and pelvic surgery that damage sympathetic nerves.
• Diabetic autonomic neuropathy.
• Drugs: antidepressants (selective serotonin reuptake inhibitors), antipsychotics, alpha blockers and opioids.
• Hypogonadism, and bilateral ejaculatory duct obstruction (low semen).
• Psychogenic causes: anxiety, conditioning, trauma, rigid beliefs and relationship issues. Men may ejaculate in sleep or with a different stimulus.

No semen during intercourse or masturbation, with or without orgasm. Nocturnal emissions may be preserved in psychogenic disease. Neurological features (bladder or bowel dysfunction, lower limb weakness) and a history of surgery, diabetes, drugs and spinal injury point to an organic cause.

Men with spinal cord injury at or above T6 are at risk of autonomic dysreflexia during sexual stimulation, with sudden severe hypertension, headache, flushing and bradycardia.

• History distinguishing lifelong from acquired, global from situational, and noting nocturnal emissions and masturbation findings.
• Examination: genital and secondary sexual characteristics, perianal sensation, bulbocavernosus reflex, anal tone, lower limb neurology.
• Post-orgasmic urinalysis to exclude retrograde ejaculation.
• HbA1c, morning testosterone, prolactin and thyroid function.
• Penile vibratory stimulation as a diagnostic and treatment test.
• Spinal MRI when a neurological lesion is suspected. Transrectal ultrasound when ejaculatory duct obstruction is suspected.

Differential diagnosis.

• Retrograde ejaculation
• Ejaculatory duct obstruction
• Anorgasmia
• Hypogonadism
• Drug induced ejaculatory failure
• Congenital absence of the vas deferens
• Delayed ejaculation

• Stop or substitute causative drugs where possible, and correct hypogonadism.
• Psychogenic anejaculation: sex therapy, sensate focus, desensitisation to higher stimulation, and couple counselling.
• Drug treatment for neurogenic or partial disease: midodrine 7.5 to 15 mg orally 30 to 60 minutes before the attempt, or pseudoephedrine 60 mg orally, or imipramine 25 mg once or twice daily. Midodrine causes supine hypertension and is avoided in men with severe heart disease. Response is variable.
• Penile vibratory stimulation: vibrator applied to the glans (frequency about 100 Hz, amplitude 2.5 mm) for up to 2 to 3 minutes for each attempt, with rest between. Success is about 50 to 80% in men with spinal cord injury and an intact reflex arc. Men at or above T6 need blood pressure monitoring.
• Electroejaculation under general or regional anaesthesia, when vibratory stimulation fails, with a rectal probe delivering graded current. Retrograde sperm can be retrieved from the bladder.
• Autonomic dysreflexia prevention: nifedipine 10 to 20 mg orally 30 to 60 minutes before the procedure, with blood pressure monitoring, and stopping the procedure if systolic pressure rises by 20 to 40 mmHg or reaches over 150 mmHg. Treat a hypertensive crisis by sitting the patient up, loosening tight clothing, emptying the bladder, and giving antihypertensive treatment.
• Surgical sperm retrieval (testicular or epididymal) with intracytoplasmic sperm injection, when vibratory stimulation and electroejaculation fail.
• Sperm banking before retroperitoneal lymph node dissection or chemotherapy, with nerve sparing techniques where possible.

Monitoring. Review at 3 months for response and adverse effects, with repeat semen quality and cryopreservation planning where needed. Men with spinal cord injury need urinary tract and bladder surveillance.

Referral and escalation. Refer to urology, a fertility clinic or a spinal injury unit. Urgent referral for autonomic dysreflexia.