Retrograde Ejaculation

Retrograde ejaculation is the passage of semen backward into the bladder during orgasm, because the bladder neck fails to close. Orgasm is usually preserved, but little or no semen is expelled. It causes male infertility, and is harmless otherwise.

It is found in up to about 2% of men with infertility. After transurethral prostate surgery it is very common, in about 65 to 90%.

Pathophysiology. Ejaculation needs sympathetic closure of the bladder neck, contraction of the vas, seminal vesicles and prostate, and relaxation of the external sphincter. Failure of bladder neck closure sends semen along the path of least resistance into the bladder.

Causes:

• Surgery: transurethral resection or incision of the prostate, bladder neck incision, radical prostatectomy, retroperitoneal lymph node dissection, colorectal and aortic surgery.
• Neurological: diabetic autonomic neuropathy, multiple sclerosis, spinal cord injury.
• Drugs: alpha blockers (silodosin most, tamsulosin often), antipsychotics, tricyclic antidepressants and thioridazine.
• Congenital: bladder neck anomalies, hypospadias repair, and ectopic ureteric orifice.

Orgasm with little or no semen (dry orgasm), cloudy urine after orgasm, and difficulty in conceiving. Onset follows surgery, a new drug, or long standing diabetes. Sexual desire and erection are normal. Bladder neck surgery history, back or pelvic trauma and neurological symptoms may be present.

• Semen analysis: low or absent volume (under 1.4 mL), without azoospermia on repeat.
• Post-ejaculatory urine: centrifuged urine after orgasm shows sperm. Over 10 to 15 sperm in each high power field supports the diagnosis, with any sperm in a man with absent ejaculate being significant.
• HbA1c, neurological examination, medication review, and testosterone when libido is low.
• Cystoscopy or uroflowmetry for bladder neck abnormalities. Ejaculatory duct obstruction is excluded when semen volume is low and fructose is absent.

Differential diagnosis.

• Anejaculation
• Ejaculatory duct obstruction
• Hypogonadism with low volume
• Congenital absence of the vas deferens
• Drug induced reduced ejaculation
• Incomplete collection of the sample
• Anorgasmia

• Men not wanting children: reassurance, with no treatment. Review drugs.
• Stop or switch the causative drug when possible, for example a different alpha blocker or tadalafil 5 mg daily for lower urinary tract symptoms, and optimise glycaemic control.
• Sympathomimetic drugs to improve bladder neck closure (response varies, about 25 to 50%):
  • Pseudoephedrine 60 mg orally 1 to 2 hours before intercourse, or 60 mg every 6 hours for several days around ovulation.
  • Imipramine 25 mg orally once or twice daily (maximum 75 mg daily).
  • Contraindications: hypertension, ischaemic heart disease, arrhythmia, hyperthyroidism, glaucoma, urinary retention from prostatic obstruction, and use of monoamine oxidase inhibitors. Imipramine adds a risk of QT prolongation and anticholinergic effects.
• Sperm recovery for assisted conception when drugs fail:
  • Alkalinise the urine with sodium bicarbonate 1 to 2 g orally the night before and on the morning of collection, aiming for urine pH over 7.0.
  • The man empties his bladder, ejaculates by masturbation, and passes urine immediately into a sperm friendly culture medium. Spermatozoa are processed for intrauterine insemination or intracytoplasmic sperm injection. Catheter based bladder collection is an alternative.
• Sperm banking before prostate surgery, retroperitoneal lymph node dissection or other planned treatment in men wanting children.
• Surgical bladder neck reconstruction has been tried but results are poor.

Monitoring. Review at 3 months for response and drug adverse effects. Repeat semen analysis when pregnancy is wanted.

Referral and escalation. Refer to urology or a fertility clinic when pregnancy is wanted. Urgent referral is rarely needed, except for adverse cardiac effects of sympathomimetics.