What is retrograde ejaculation

Retrograde ejaculation is a rarer type of ejaculation problem when semen travels backwards into the urinary bladder instead of through the urethra (the tube that urine passes through). The semen later leaves your body during urination. Retrograde ejaculation is uncommon. It most often occurs when the opening of the bladder (bladder neck) does not close. This causes semen to go backward into the bladder rather than forward out of the penis. Normally, semen moves forward and out of your penis through the urethra during ejaculation.

Retrograde ejaculation occurs due to dysfunction of the internal urethral sphincter at the bladder neck. Retrograde ejaculation is associated with dysfunction of the internal urethral sphincter mechanism which can be caused by autonomic neuropathy or iatrogenic damage to sympathetic nerves or the bladder neck ¹. Diabetes mellitus can cause the microvascular complication of neuropathy, including autonomic neuropathy, which can result in retrograde ejaculation ¹. Retrograde ejaculation is typically a late symptom of diabetes mellitus.

Men with retrograde ejaculation still experience the feeling of an orgasm and retrograde ejaculation doesn’t pose a danger to your health. However, retrograde ejaculation can affect your ability to father a child.

During a male orgasm, a tube called the vas deferens transports sperm to the prostate, where they mix with other fluids to produce liquid semen (ejaculate). During normal ejaculation, the opening of the bladder (bladder neck muscle or internal urethral sphincter) tightens under α1-adrenergic sympathetic control, causing the bladder neck to close with high pressure to prevent ejaculate from entering the bladder as it passes from the prostate into the tube inside the penis (urethra). This is the same muscle that holds urine in your bladder until you urinate. The ejaculate then follows the path of least resistance, thus passing antegrade. Interference with this ejaculatory reflex results in the bladder neck (internal urethral sphincte being unable to close with high pressure and thus resulting in a low pressure path for the ejaculate to pass into the bladder instead of being ejected out of your body through your penis ².

Retrograde ejaculation can either be partial (with a decreased ejaculate volume, as seen initially in our case) or complete (with absence of any ejaculate following orgasm).

Retrograde ejaculation isn’t harmful. However, potential complications include:

• Inability to get a woman pregnant (male infertility)
• Less pleasurable orgasm due to worries about absent ejaculate

The true prevalence of retrograde ejaculation in the general population is unknown, though complete absence of ejaculation has been reported in up to 5% of men aged 50-80 years ². Retrograde ejaculation has a strong association with diabetes, but retrograde ejaculation and autonomic neuropathy are rarely presenting symptoms of the diagnosis of diabetes ³. In a small case-control study, the prevalence of retrograde ejaculation was estimated to be approximately 34% in men with diabetes aged between 35 and 55 years, though other studies of young male diabetics have estimated retrograde ejaculation and anterograde ejaculation to be present in only 6% of patients ². There are no studies comparing the rates of retrograde ejaculation in Type 1 vs Type 2 diabetes mellitus. Men with retrograde ejaculation tend to have had a diagnosis of diabetes mellitus for longer than those without retrograde ejaculation (20 years vs 13 years) ⁴. This implies that the autonomic neuropathy of diabetes associated with retrograde ejaculation tends to be a late presenting feature. retrograde ejaculation and anejaculation are amongst the most common causes of infertility in diabetic men ⁵.

Figure 1. Male reproductive system

Figure 2. Male urinary bladder anatomy

Is retrograde ejaculation harmful?

No. Retrograde ejaculation isn’t harmful and requires treatment only if you’re attempting to father a child. However, if you have dry orgasms, see your doctor to be sure your condition isn’t caused by an underlying problem that needs attention.

If you and your female partner have had regular, unprotected intercourse for a year or longer and have been unable to conceive, see your doctor. Retrograde ejaculation might be the cause of your problem if you ejaculate very little or no semen. Retrograde ejaculation can cause male infertility.

See your doctor if you are worried about retrograde ejaculation or are having trouble conceiving a child. Semen can often be removed from the bladder and used during assistive reproductive techniques.

What causes retrograde ejaculation

Retrograde ejaculation is caused by damage to the nerves or muscles that surround the neck of the bladder (the point where the urethra connects to the bladder).

Usually when you ejaculate, semen is pushed out of your urethra. It is prevented from entering your bladder by the muscles around the neck of the bladder, which close tightly at the moment of orgasm.

However, damage to the surrounding muscles or nerves can stop the bladder neck closing, causing the semen to move into the bladder rather than up through the urethra.

Prostate gland surgery or bladder surgery is the most common cause of retrograde ejaculation. Other causes are diabetes, multiple sclerosis, and a class of medicines known as alpha blockers, which are often used to treat high blood pressure (hypertension).

Retrograde ejaculation may be caused by:

• Side effect of certain medications, including drugs used to treat high blood pressure (e.g., alpha blockers), prostate enlargement and depression or some mood-altering drugs
• Surgery, such as bladder neck surgery, retroperitoneal lymph node dissection surgery for testicular cancer or prostate surgery
• Nerve damage caused by a medical condition, such as diabetes, multiple sclerosis, Parkinson’s disease or a spinal cord injury

Diabetes can cause autonomic neuropathy which affects the sympathetic fibers arising from the superior hypogastric plexus which normally mediate contraction of the internal urethral sphincter during ejaculation ³. Damage to these sympathetic nerves during pelvic or spinal surgery can also cause retrograde ejaculation. Medications such as sympathetic antagonists (particularly α-antagonists) may also contribute to retrograde ejaculation.

Risk factors for retrograde ejaculation

You’re at increased risk of retrograde ejaculation if:

• You have diabetes or multiple sclerosis
• You’ve had prostate or bladder surgery
• You take certain drugs for high blood pressure or a mood disorder
• You had a spinal cord injury

Retrograde ejaculation prevention

To avoid retrograde ejaculation:

• If you have diabetes, maintain good control of your blood sugar.
• Avoid drugs that can cause retrograde ejaculation.

If you take medications or have health problems that put you at risk of retrograde ejaculation, ask your doctor what you can do to lower your risk.

If you need to have surgery that might affect the bladder neck muscle, such as prostate or bladder surgery, ask about the risk of retrograde ejaculation. If you plan to have children in the future, talk with your doctor about options for preserving semen before the surgery.

Retrograde ejaculation symptoms

There is usually a total absence of semen (ejaculate emission) or a progressive decline in ejaculate volume after orgasm. Patients may report cloudy urine following orgasm and diagnosis of retrograde ejaculation is confirmed by the presence of spermatozoa in a post-ejaculatory urine sample.

The main symptoms of retrograde ejaculation include:

• producing no semen, or only a small amount, during ejaculation
• producing cloudy urine after orgasm (because of the semen in it) when you first go to the toilet after having sex
• inability to get a woman pregnant (male infertility)

A dry orgasm is the primary sign of retrograde ejaculation. But dry orgasm — the ejaculation of little or no semen — can also be caused by other conditions, including:

• Surgical removal of the prostate (prostatectomy)
• Surgical removal of the bladder (cystectomy)
• Radiation therapy to treat cancer in the pelvic area

Retrograde ejaculation diagnosis

Your doctor will:

• Ask questions about your symptoms and how long you’ve had them. Your doctor might also ask about any health problems, surgeries or cancers you’ve had and what medications you take.
• Do a physical exam, which will likely include an exam of your penis, testicles and rectum.
• Examine your urine for the presence of semen after you have an orgasm. This procedure is usually done at the doctor’s office. Your doctor will ask you to empty your bladder, masturbate to climax and then provide a urine sample for laboratory analysis. If a high volume of sperm is found in your urine, you have retrograde ejaculation.

If you have dry orgasms, but your doctor doesn’t find semen in your bladder, you might have a problem with semen production. This can be caused by damage to the prostate or semen-producing glands as a result of surgery or radiation treatment for cancer in the pelvic area.

If your doctor suspects your dry orgasm is something other than retrograde ejaculation, you might need further tests or a referral to a specialist to find the cause.

Retrograde ejaculation treatment

Most men do not need treatment for retrograde ejaculation because they are still able to enjoy a healthy sex life and retrograde ejaculation does not have adverse effects on their health. But if treatment is required (usually because of wanting to father a child), there are options to try.

If your doctor thinks drugs you are taking might be affecting your ability to ejaculate normally, he or she might have you stop taking them for a period of time. Drugs that can cause retrograde ejaculation include any sympathetic blocking agents, certain medications for depression and alpha blockers — drugs used to treat high blood pressure and some prostate conditions. Speak to your doctor before stopping any prescribed medication.

However, if the retrograde ejaculation has been caused by significant muscle or nerve damage, treatment may not be possible.

For men who want to have children with retrograde ejaculation which are non-responsive to medical treatment, assisted reproductive techniques may be of benefit, with sperm being harvested directly from testis or retrieved from the bladder for use in artificial insemination or in-vitro fertilisation (IVF) ⁵.

Involve your partner

If you’re having problems with your sex life and are seeking treatment, it is usually recommended you involve your partner as much as possible.

Communicating your concerns can often go a long way to helping to resolve them. And, in some cases, your partner may also have their own problems that are contributing towards problems with your sex life.

Retrograde ejaculation medication

Medications might work for retrograde ejaculation caused by nerve damage. This type of damage can be caused by diabetes, multiple sclerosis, certain surgeries, and other conditions and treatments.

Medications generally won’t help if retrograde ejaculation is due to surgery that causes permanent physical changes of your anatomy. Examples include bladder neck surgery and transurethral resection of the prostate.

Medications to treat retrograde ejaculation are drugs primarily used to treat other conditions, including:

• Imipramine (Tofranil)
• Midodrine
• Chlorpheniramine (Chlor-Trimeton, others) and brompheniramine (Veltane, others)
• Ephedrine (Akovaz, others), pseudoephedrine (Sudafed, others) and phenylephrine (Vazculep, others)

These medications help keep the bladder neck muscle closed during ejaculation. While they’re often an effective treatment for retrograde ejaculation, medications can cause side effects or adverse reactions with other medications. Certain medications used to treat retrograde ejaculation can increase your blood pressure and heart rate, which can be dangerous if you have high blood pressure or heart disease.

Medical treatment with sympathomimetics with α-adrenergic action, such as imipramine and pseudoephedrine, have been shown to offer benefit for some patients with retrograde ejaculation in diabetes ⁵. Pseudoephedrine (commonly used as a decongestant) has proved effective in treating retrograde ejaculation caused by diabetes or surgery. These agents can be used individually or in combination ⁶. In a small non-controlled study of 33 men, imipramine or pseudoephedrine were able to produce antegrade ejaculation in approximately 40% of patients. This increased to 61% of patients when these agents were used in combination ⁶.

Infertility treatment

If you have retrograde ejaculation, you’ll likely need treatment to get your female partner pregnant. In order to achieve a pregnancy, you need to ejaculate enough semen to carry your sperm into your partner’s vagina and into her uterus.

If medication doesn’t allow you to ejaculate semen, you will likely need infertility procedures known as assisted reproductive technology to get your partner pregnant. In some cases, sperm can be recovered from the bladder, processed in the laboratory and used to inseminate your partner (intrauterine insemination).

Sometimes, more-advanced assisted reproductive techniques are needed. Many men with retrograde ejaculation are able to get their partners pregnant once they seek treatment.

Coping and support

Alterations in orgasm are linked with lower emotional and physical satisfaction, which might lead to stress for you and your partner. Retrograde ejaculation can be especially challenging if you and your partner want to conceive a child.

While most men can get their female partners pregnant with infertility treatment, it can be costly and require stressful medical procedures for both you and your partner. Talking with a counselor might help.

Understanding all of your options and communicating with your doctor and partner can help.

• Know what it will cost. Your insurance may or may not cover the costs necessary for sperm retrieval and artificial insemination of your partner.
• Talk to your doctor. Ask about all your options. You’ll need to meet with a urologist who specializes in male infertility.
• Communicate with your partner. Make sure you and your partner both understand your options and the potential risks of fertility procedures. You should both attend every consultation appointment.

Retrograde ejaculation prognosis

If retrograde ejaculation is caused by a medicine, normal ejaculation will often come back after the drug is stopped. Retrograde ejaculation caused by surgery or diabetes often can’t be corrected. This is most often not a problem unless you are trying to conceive. Some men do not like how it feels and seek treatment. Otherwise, there is no need for treatment.

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