Retrograde Ejaculation (RE) is the misdirected propulsion of semen from the posterior urethra into the bladder instead of antegrade through the anterior urethra and out the urethral meatus. RE can either be complete, with a total absence of ejaculate, or partial, with preservation of a minimal amount of antegrade ejaculate. Patients will often present to a urologist with infertility or azospermia. Among all patients presenting for infertility, RE is found as the underlying cause in less than 2 percent of the cases, but is more frequent in patients with azospermia, accounting for 18 percent of the latter.
For antegrade ejaculation to occur, the prostate, bladder neck, external sphincter, seminal vesicles, vas deferens, and perineal musculature must all be anatomically and functionally intact and follow a coordinated series of events to propel semen through the urethral meatus. Common causes of RE can be categorized as anatomic, neurogenic, pharmacological, or idiopathic in origin (Table I). Many of the underlying processes have the ability to cause either anejaculation (AE) or RE.
For the patient with orgasm but no ejaculation, RE appears very similar to AE, and the diagnosis is left to the urologist; the two conditions, in fact, share many common causes. Like most diseases in medicine, a thorough history and physical examination is the foundation for diagnosis. Patients will report a history, of aspermia, and any chronic medical conditions, medications, or previous surgeries must be elucidated. The physical examination includes a digital rectal examination and a complete neurological examination. Postejaculate urinalysis revealing greater than five to ten spermatozoa per high-powered field after centrifugation confirms the diagnosis.
Surgical procedures involving the bladder neck that lead to a compromise of its ability to close and remain closed throughout the expulsion phase of ejaculation are the most common anatomic and iatrogenic causes of RE. TURP procedures for treatment of benign prostatic hyperplasia cause RE in up to 75% of patients; transurethral incision of the prostate has lower rates but still must be considered as a potential etiology. Urethral trauma, bladder neck surgery, ureterocele excision, urethral stricture repair, and open prostatectomy are other surgical causes of anatomic RE. Congenital anatomic anomalies include posterior urethral valves, ectopic ejaculatory duct openings,epispadias, or utricle cysts and may also cause RE.
Similar to AE, both neuropathies and surgical disruption of sympathetic ganglia and hypogastric plexus and nerves can reduce neural tone to the bladder neck, leading to incompetence and RE. Attempts to preserve nerves during RPLND have led to decreased rates of RE following surgical treatments of testicular tumors.
When no offending medication, anatomic abnormality, or neurological cause can be found as the cause of RE, it is considered idiopathic, possibly psychogenic, in nature and accounts for a large percentage of all cases. Fortunately, idiopathic RE responds well to treatment, with medical therapy alone leading to success rates of 78%.
Treatment: Treatment of RE can be aimed either at simply restoring antegrade ejaculation or allowing for fertility and reproduction. Restoring antegrade ejaculation focuses on increasing sympathetic tone of the bladder neck or decreasing parasympathetic activity. If successful, the return of antegrade ejaculation may be sufficient to allow for natural conception or may provide enough good quality sperm to use with assisted reproductive techniques. Imipramine, given as a daily dose of 25-50 mg for seven days prior to planned intercourse, has been successfully used to treat RE, with a return of antegrade ejaculation in 65-100% of patients and a 40% rate of spontaneous pregnancy. Anticholinergics, alpha-adrenergic agonists, or similar combinations may be used to modulate bladder neck activity but are not as effective as imipramine, which should be considered the first-line therapeutic agent for RE.
If medical management fails to return antegrade ejaculation, then attempts can be made to harvest sperm from urine for later use with ART. Since the acidity and high osmolarity or urine is detrimental to spermatozoa motility and viability, two different techniques are commonly employed to adjust the urine within the bladder. The first involves drainage of the bladder by urethral catheter and instillation of isotonic buffer solution that will prevent damage to the sperm. The patient masturbates, and then voids to recover sperm. A less invasive method involves alkalinization of the urine by drinking sodium bicarbonate solutions until the urine has a pH of 7.68.1 and an osmolarity of 300-500 mOsm/l. Once again, the patient masturbates and the urine is collected for sperm harvesting.
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