Retrograde ejaculation is a condition in which semen travels up into the bladder rather than down through the penis during ejaculation.
In this article, we discuss the causes of retrograde ejaculation as well as the associated symptoms and available treatment options.
What is Retrograde Ejaculation?
Ejaculation is a complex process that occurs at the spinal level. It is triggered by specialized receptors that are present within the penis. Ejaculation consists of two phases – emission and expulsion.
Emission occurs when there is a response from the epididymis, vas deferens and seminal vesicles and prostatic gland.
First, the bladder neck closes. The nervous system stimulates this response (also known as the ‘fight or flight response’ which activates during stress, exercise as well as sexual arousal).
Second, the seminal vesicles, prostate and Cowper’s glands secretions deposit into the part of the urethra (urinary tube) that surrounded by the prostate gland. This mixture comprises of sperm from the vas deferens, and fructose (sugar) from the seminal vesicles.
The fructose is essential for providing energy to the sperm for their motility. Motile sperm reach the ovaries for fertilization. Prostatic secretions contain proteases that liquify the semen within the female reproductive tract.
After emission, expulsion occurs. Expulsion involves the coordinated action of the neck of the bladder as well as the muscles of the penis.
The neck of the bladder contains a ring of muscle known as a sphincter.
This sphincter must contract for semen to expel in the correct direction (i.e., through and out of the penis).
This sphincter is like a physical “gate.” When this gate is not closed, semen refluxes into the bladder instead of through the penis.
Men who suffer from retrograde ejaculation experience a low volume of ejaculate as well as a low or even absent sperm count. This can result in infertility.
Symptoms of Retrograde ejaculation
Retrograde ejaculation doesn’t affect your ability to get an erection or orgasm — but when you climax, it can result in dry orgasms. Retrograde ejaculation symptoms include:
- Orgasms in which you ejaculate very little semen (dry orgasms)
- Cloudy urine after orgasm containing semen
- Male infertility
Men with retrograde ejaculation may have reduced or even absent ejaculate. The lower reference limit for semen volume is about 1.5ml. This is the World Health Organization definition.
We want to emphasize in this article that retrograde ejaculation is not the same as aspermia (a lack of sperm).
Retrograde ejaculation is associated with the reduced volume and backward flow of ejaculate. Aspermia is associated with a reduced amount of healthy sperm within the ejaculate.
Causes of Retrograde Ejaculation
Ejaculation is important for normal human reproduction. Failure can occur during emission or expulsion.
This can lead to retrograde flow of semen and infertility. Most ejaculatory disorders in men are categorized into psychological (inorganic) and organic causes.
Organic causes almost always cause retrograde ejaculation. Although retrograde ejaculation is common, it is only responsible for up to 2% of all causes of infertility in men. Outside of fertility, retrograde ejaculation can be distressing to men and their partners because of a “dry orgasm.”
- Drug-related
Commonly prescribed drugs such as alpha-blockers and psychotropic medications can cause retrograde ejaculation.
Men who are receiving treatment for hypertension, erectile dysfunction, or an enlarged prostate gland should review their medications.
- Nervous system
Nervous system causes include spinal cord injuries, which result from trauma and surgery in the abdomen or pelvis.
These are uncommon and irrelevant to most men who have not had major abdominal surgery.
Diabetic neuropathy and stroke can also be causes of retrograde ejaculation. Diabetes mellitus arises from insulin resistance and an elevated glucose level.
Diabetes is an increasingly prevalent silent disease in the United States. Chronic diabetes leads to neuropathy (nerve damage). It can also lead to a weak nervous system, resulting in ineffective contraction of the bladder neck during ejaculation.
Multiple sclerosis is a less common cause of neuropathy. Men who have had a stroke may suffer from retrograde ejaculation.
- Surgery
Anatomical causes of retrograde ejaculation include deficits at birth and acquired deficits (e.g., from a previous surgery of the genital tract). Of these, acquired anatomical structural deficits are more common. This is especially so for older men who have had surgery of the urogenital tract.
Surgery, such as bladder neck surgery and surgery for testicular cancer or prostate surgery.
Older men who may have had a removal of an enlarged prostate gland (Transurethral resection of the prostate (TURP) are susceptible to retrograde ejaculation.
Treatment of Retrograde Ejaculation
The goal of treatment in retrograde ejaculation is to establish antegrade (normal) flow. Selecting the optimal treatment option can only occur after the exact cause is diagnosed.
Medication
For example, men on alpha-blocker drugs or psychotropic drugs should be discontinued. We recommend this if the benefit of reversing retrograde ejaculation outweighs the cost of discontinuing or switching the offending drug.
Drugs that work to enhance the sympathetic nervous system have had success in the treatment of retrograde ejaculation.
They work by increasing the contractile force of the bladder neck during the expulsive phase of ejaculation.
Examples of these drugs include ephedrine sulfate, imipramine, midodrine, and pseudoephedrine. Of these, imipramine is the preferred drug of choice.
A survey of the latest evidence reveals that treatment with these drugs results in the restoration of antegrade ejaculation in about 30% of patients.
Of note, these drugs are not without their side-effects, including:
- Elevated heart rate.
- Anxiety.
- Dry mouth.
- High blood pressure.
- Headache.
Surgery
Men who have tried and failed medical management have other options available to them.
These options are surgical interventions. Two surgical techniques pioneered in 1998 are still performed today with variable degrees of success.
The first involves the injection of collagen into the neck of the bladder.
The second involves dilating obstructions of the urethra with a scope designed for the exploration of the urethra. This technique is only indicated for some anatomical causes of retrograde ejaculation.
The third and more recent technique is bladder neck reconstruction. This involves surgical manipulation of the bladder neck. This strengthens the contraction of the bladder neck during the expulsion phase of ejaculation.
The surgical techniques described above are viable options for men who have tried and failed medical treatment.
We recommend selecting a urologist who has significant experience.
The surgical technique, as well as the training and expertise of the urologist, are essential considerations.
This is because they influence the success rate of the procedure. Indeed, surgery is associated with its own set of risks, such as bleeding, infection, and damage to nearby anatomical structures.
Men who are considering surgical options should practice due diligence. This involves meticulous research on potential surgeons.
Additionally, many surgical interventions are preceded with computed tomography (CT), and magnetic resonance imaging (MRI) scans.
Managing Infertility in Men with Retrograde Ejaculation
There are a variety of assisted ejaculation procedures that harvest sperm for reproduction.
Of these, harvesting sperm from urine is one technique that has reported decent success rates.
Before the harvest of sperm from urine, sodium bicarbonate is administered to men to increase the pH level of the urine.
This reduces the toxic effect of acid (naturally present in the urine) on sperm quality. Men have to empty their bladders before orgasm to reduce the volume of urine.
After orgasm, the patient is asked to empty his bladder again. The collected urine is then sent to a laboratory that processes the specimen for assisted reproductive techniques.
Another popular technique utilized by fertility medicine specialists is the Hotchkiss method.
This method involves emptying the bladder before ejaculation by using a catheter. The bladder is washed out, and the patient ejaculates shortly after.
The ejaculate, which is present in the bladder (due to retrograde flow), is then collected via the same catheter. Pregnancy rates have been reported to be about 25% when using this technique.
The third technique involves a post-ejaculate voiding into a specialized solution. This causes the semen within the urine to be suspended at the top, which allows for separation.
This technique has higher success rates in pregnancy (about 60%). This success rate has been documented based on a minimal sample size of just five patients in the literature.
Conclusion
Retrograde ejaculation is a distressing condition that affects men and couples who are trying to conceive.
Dry orgasms can lead to dissatisfying sexual intercourse and strain relationships. Fortunately, treatment options exist in the form of drugs.
Couples who are experiencing male infertility and are trying to conceive can also consider fertility techniques.
