RETROGRADE EJACULATION

Retrograde ejaculation
Definition
Failure of adequate bladder neck contraction resulting in the propulsion of sperm back into the bladder on ejaculation.

Aetiology
Secondary to damage or dysfunction of the bladder neck sphincter mechanism. Underlying causes may be neurological (spinal cord injury; neuropathy associated with diabetes mellitus; nerve damage after retroperitoneal surgery) or anatomical disruption following transurethral resection of ejaculatory ducts (for obstruction); bladder neck incision (BNI); transurethral resection of the prostate (TURP); or open prostatectomy.

Incidence
Retrograde ejaculation following TURP or open prostatectomy occurs in 9 out of 10 men and after BNI, in 1 - 5 in 10.

Presentation
Dry ejaculation (failure to expel ejaculate fluid from the urethral meatus) and cloudy urine (containing sperm) in the first void after intercourse.

Investigation
The presence of >10 - 15 sperm per high-powered field in a post-ejaculate mid-stream urine specimen confirms the diagnosis of retrograde ejaculation.

Treatment
Medical therapy is initiated in men wishing to preserve fertility, and is only effective in patients who have not had bladder neck surgery. Oral adrenergic drugs may be used to increase the sympathetic tone of the bladder neck smooth muscle sphincter mechanism. Drugs include ephedrine sulphate (25 - 50mg QDS), pseudoephedrine (60mg QDS) or imipramine (25mg BD). Therapy is often given for 7 - 10 days prior to a planned ejaculation (co-ordinated with the partner's ovulation). Alternatively, sperm retrieval may be attempted. Oral sodium bicarbonate and adjustment of fluid intake is initiated to optimize urine osmolarity and pH, and enhance sperm survival. Sperm are collected by gentle urine centrifuge and washed in insemination media in preparation for intrauterine insemination (IUI) or in vitro fertilization (IVF) treatments.