Retrograde Ejaculation and Anejaculation

Normal forward (antegrade) ejaculation only occurs if a number of conditions are met. Normally, sperm from the testes, seminal fluids and prostatic secretions mix within the prostatic fossa before being ejaculated through the urethra and out through the end of the penis via the meatus. This requires:

1. Closure of the bladder neck (internal sphincter) and the external sphincter

2. Contraction of the prostate muscle to pressurize the semen in the prostatic fossa

3. Opening of the external sphincter but continued closure of the bladder neck 

The pressurized semen preferentially travels out through the urethra because it is the pathway of least resistance. If there is a problem with any of these steps, the semen may not exit via the urethra.

Retrograde ejaculation is a condition where the seminal fluid is redirected from the prostatic fossa backwards into the bladder rather than forwards to the urethra and out the penis. 

Anejaculation: a condition distinct from retrograde ejaculation. In anejacuation, there is no production of semen at all into the urethra. The symptom is the same and differentiating the 2 conditions requires a POST-EJACULATE URINE ANALYSIS.

• In both retrograde ejaculation AND anejaculation there no production of fluid with orgasm. That is, they are symptomatically identical.

• In retrograde ejaculation, post-ejaculate urine analysis will reveal sperm

• In anejaculation, post-ejaculate urine analysis will not reveal sperm.

If anejaculation is present, sperm retrieval from upstream in the reproductive tract (PESA, TESE) may be possible and in some cases ejaculation can be stimulated using a special electrical stimulator.

How to do a post-ejaculate urine analysis to check for sperm.

This is the critical test to differentiate retrograde ejaculation from anejaculation. You will be provided with a lab requisition to obtain a "Post-Ejaculate Urineanalysis (PEU)"

1. Set up an appointment with Life Labs (or lab at infertility centre) to receive the specimen

2. Abstain from ejaculating for minimum 4 days prior to the date of collection

3. Masturbate at home - MAKE SURE YOU URINATE AND EMPTY THE BLADDER JUST BEFORE DOING THIS

4. Every 30 minutes after masturbation, try to urinate into the supplied specimen container. The goal is to have some urine, but as little as possible so as to avoid overflowing the specimen cup but at the same time emptying the bladder to completion

5. Take the specimen into the lab. It is NOT so important that the specimen is taken in immediately - the same days is fine. The idea is to see if there are ANY sperm. The number, motility and morphology are unimportant.

Causes of Retrograde Ejaculation

1. Neurological: problems with coordination of the nervous system may cause problems, especially patients with spinal cord injury. Also includes men with diabetes or retroperitoneal lymph node dissection

2. Surgical and post-operative defunctionalization of the internal sphincter which can occur with transurethral resection of the prostate.

Medications including those that are used to treat prostate problems (e.g tamsulosin/Flomax, finasteride/Proscar, dutasteride/Avodart) which can cause this and are usually reversible. Other types of medications include antihypertensives, major teanquilizers, antidepressants and recreational drugs (alcohol, cocaine and amphetamines)

Drugs Which Disrupt Emission and Ejaculation

From Center for Disease Control and Prevention. Reproduction Technilogy Success Rate. 1998-9-32.

Management 

If stopping offending medications is not effective there are a couple of approaches which can be helpful. Use of a vibrating device, such as the FertiCare device, can stimulate the proper neural reflexes for antegrade ejaculation. There are some situations (especially with neurological causes) where medication has little chance of success. 

There are 3 main options for obtaining sperm in the setting of retrograde ejaculation or anejaculation:

1. Medications to restore antegrade ejaculation

2. Post-ejaculation retrieval of sperm for the urine

3. Artificial stimulation of emission and ejaculation

If all else fails or in select circumstances (e.g. where expediency is required or a general anesthetic for electroejaculation would like to be avoided), sperm can almost always be retrieved quickly and with minimal risk from the testis itself with a minor surgical procedure - a Testicular Sperm Extraction. Any sperm retrieved by TESE require IVF. Sperm retrieved by other methods can sometimes be used for insemination, but often the quality of the sperm is diminished and IVF is required.

Medications to Restore Antegrade Ejaculation

These medications are probably best taken on a continuous basis the can be taken only for the day where ejaculation is hoped for. Options:

1. Pseudoephedrine (Sudafed) 120 mg twice daily

2. Imipramine 25 mg twice to three times daily

3. Midodrine 2.5-10 mg three times per day

Post-ejaculation Sperm Retrieval

Instructions for collecting sperm.

• Take Sudafed 120 mg twice daily for 3 days prior to your appointment - this may be enough to induce antegrade ejaculation

Option 1 - Alka-Seltzer

• Take 2 Alka-Seltzer tablets the night before your appointment

• Take another 2 Alka-Seltzer tablets the morning of your appointment

Option 2 - Sodium Bicarbonate

• Take sodium bicarbonate 650 mg four times daily starting the day prior to your appointment

Option 3 - Baking Soda

• Take 2 table spoons of baking soda before bed for the night before the appointment

• Take and additional 2 table spoons 2 hours before your sample

Collecting the Specimen

• Empty your bladder prior to masturbation

• Masturbate and collect any fluid that comes out and milk the penis to collect any more fluid

• Urinate into a second container as soon as possible

• Take both specimens to the Andrology lab

In some cases, catheterization of the bladder and instillation of a small volume of sperm preservation solution followed by masturbation and repeat catheterization for collection will be used.

Artificial Stimulation of Emission and Ejaculation

1. Penile vibratory stimulation: very effective for spinal cord injury (especially lesions above T10). Not very effective for low spinal cord injuries of post-retroperitoneal lymph node dissection (for testis cancer). FertiCare manufactures a device for this purpose,

   1. The Viberect X3 (SCI Model) is a less expensive alternative. A google search will provide several purchasing options.

2. Electroejaculation. Requires anesthesia. Uses a rectal probe to deliver an electrical current to the pelvic plexus of nerves.