Retrograde ejaculation

Retrograde ejaculation (RE) occurs when the semen passes into the bladder rather than along the urethra.

Retrograde ejaculation is common in the following situations:

• after most transurethral resections of the prostate
• after 40% of bladder neck incisions

RE is a common type of ejaculatory dysfunction, but accounts for only 0.3%-2% of male infertility

• this condition is marked by substantial retrograde propulsion of seminal fluid into the bladder
  • in the normal physiological state, the bladder neck closes with high pressure during ejaculation, forcing semen deposited into the posterior urethra to flow antegrade through the urethra and out the urethral meatus
    • with impaired or absent bladder neck closure, however, semen in the proximal urethra may be propelled along the path of least resistance into the bladder
      
      
• presumptive diagnosis of RE is often reached by taking a careful patient history with attention to coexisting medical conditions, medications and surgical history
  • in men who present with absent or low-volume ejaculate, RE and ejaculatory duct obstruction comprise the differential diagnosis
  • patients with RE frequently describe a cloudy appearance of postorgasmic urine
  • diagnosis of RE is confirmed by a post-ejaculatory voided urine that reveals spermatozoa, seminal fluid or fructose
    
    
• aetiology:
  • underlying causes of RE may be divided into pharmacological, neurogenic and anatomic causes
    • pharmacologically-induced RE, as previously discussed, is largely attributable to psychotropic medications and alpha-adrenergic blockers
    • neurogenic causes include spinal cord lesions, surgical causes (including lumbar sympathectomy, retroperitoneal lymph node dissection(RPLND), aortoiliac vascular surgery and abdomino-perineal resection), and neuropathies (such as diabetic autonomic neuropathy and multiple sclerosis)
    • anatomic etiologies can be subdivided into:
      • congenital (posterior urethral valves, utricular cysts and exstrophy)
      • acquired conditions
        • far more common and usually result from mechanical disruption of the bladder neck and/or prostate
          • 30% -41% of men report new-onset RE following transurethral vaporization of the prostate and transurethral resection of the prostate, respectively (4)
    • four causes collectively account for more than 80% of cases. These factors are DM, prior history of RPLND, bladder neck surgery and transurethral resection of the prostate (1)
      
      
• management:
  • neurological causes of RE, such as spinal cord injury, are often refractory to medical therapy
    • however, in some patients with partial neurological injuries (i.e. in the early stages of progressive neurological diseases or with incomplete peripheral lesions following surgery or trauma) several classes of medications have been used to successfully induce antegrade ejaculation
      • include alpha adrenergic agonists, anticholinergics and antihistaminic drugs which function either by increasing the sympathetic or decreasing the parasympathetic tone of the bladder neck
        • these agents facilitate antegrade propulsion of semen by increasing bladder neck tone
          • imipramine
            • argued that 25-75 mg per day of oral imipramine should be applied as a first-line agent in patients with RE (5)
          • several alpha adrenergic agonists have also been widely used for the treatment of both RE
            • these sympathomimetics include pseudoephedrine, ephedrine and midodrine; are alternative pharmacological choices to imipramine
              • midodrine is an alpha adrenergic receptor agonist primarily used to treat orthostatic hypotension. It has also been shown to stimulate sympathetically innervated structures, including the vasa deferentia, prostate and seminal vesicles, and to promote the rhythmic muscle contraction required during ejaculation

Reference:

• 1) Yavetz H, Yogev L, Hauser R, Lessing JB, Paz G et al. Retrograde ejaculation. Hum Reprod 1994; 9: 381-6.
• 2) Kamischke A, Nieschlag E. Update on medical treatment of ejaculatory disorders. Int J Androl 2002; 25: 333-44.
• 3) Jefferys A, Siassakos D, Wardle P. The management of retrograde ejaculation: a systematic review and update. Fertil Steril 2011; 97: 306-12.
• 4) Hill B, Belville W, Bruskewitz R, Issa M, Perez-Marrero R et al. Transurethral needle ablation versus transurethral resection of the profstate for the treatment of symptomatic benign prostatic hyperplasia: 5-year results of a prospective, randomized, multicenter clinical trial. J Urol 2004; 171: 2336.
• 5) Schmidt HM et al. Management of sexual dysfunction due to antipsychotic drug therapy. Cochrane Database Syst Rev. 2012 Nov 14;11:CD003546.