What is retrograde ejaculation and what causes it?

Retrograde ejaculation occurs when the ejaculate flows backward into the bladder instead of forward and out the tip of the penis. There are three potential causes of retrograde ejaculation:

1. Anatomic—that which occurs following surgery on the bladder neck or from a congenital process. Retrograde ejaculation is very common in men who have underdone a transurethral prostatectomy (TURP^[1]). A TURP is usually performed to treat benign enlargement of the prostate.

2. Neurologic—resulting from disorders that interfere with the ability of the bladder neck to close during emission such as diabetes mellitus or retroperitoneal surgery.

3. Pharmacologic—caused by paralysis of the bladder neck by certain medications. Such medications include the blood pressure medications phenoxy-benzamine (Dibenzyline), phentolamine, prazosin (Minipress), and the antipsychotic medications thioridazine (Mellaril), chlorpromazine (Thorazine), triflupromazine (Vespein), and mesoridazine (Serentil). Tamsulosin (Flomax) was thought to cause retrograde ejaculation but it appears to cause anejac-ulation.

Retrograde ejaculation does not cause any harm—one simply urinates out the ejaculate.

What is anejaculation and what causes it?

Anejaculation is the condition in which there is no flow of ejaculate in either direction. This condition occurs in some men with spinal cord injuries and in some men with cancer of the testis who have undergone surgery to remove affected lymph nodes, a procedure called retroperitoneal lymph node dissection. Anejaculation may also occur if the outflow of the ejaculate is blocked; this may be caused by a small stone in the ejaculatory duct (the structure through which the ejaculate passes into the urethra), or by prior infection and scarring of the male reproductive tract from sexually transmitted diseases, such as gonorrhea, and other diseases that affect the genitourinary tract, including tuberculosis. In such cases, the ejaculatory duct may be opened surgically. Anejaculation occurs after a radical prostatectomy because the seminal vesicles and prostate gland are removed and the vas deferens is tied off. Congenital disorders such as imperforate anus and their treatment may also cause anejaculation. Tamsulosin is thought to cause reversible anejaculation.

How are the different types of ejaculatory dysfunction treated?

There are two main types of treatment available for the management of premature ejaculation, behavioral therapy and medical therapy (see Table 17). Behavioral therapy starts with education regarding what premature ejaculation is and the possible causes as well as teaching the

Table 17. Pharmacologic Therapies Used to Treat Premature Ejaculation

male strategies to manage the premature ejaculation. The squeeze technique is the most common technique used to treat premature ejaculation. The male is instructed to interrupt sexual relations when he feels that he is about to experience premature orgasm and ejaculation. He or his partner then squeezes the shaft of the penis between a thumb and two fingers, applying light pressure for about 20 seconds, then letting go and resuming sexual relations. Behavioral therapy is successful in 60 to 90% of men with premature ejaculation, however, it requires the cooperation of both partners.

Although pharmacologic therapy is used in men with premature ejaculation, none of the medications currently used in the management of premature ejaculation have been approved by the FDA for this specific indication. Premature ejaculation can be treated effectively with serotonin reuptake inhibitors (SRIs) or topical anesthetics (Table 17). A variety of SRIs including fluoxetine, paroxetene, sertaline, and the tricyclic anti-depressant, clomipramine have been used. SRIs have provided significant benefit over placebo in clinical trials.

PSD502 is a topical spray comprised of lidocaine 7.5 mg and prilocaine 3.5 mg that is under investigation for the treatment of premature ejaculation. Preliminary studies have demonstrated that it is superior to placebo.

The treatment options for retrograde ejaculation vary with the cause.

The treatment options for retrograde ejaculation vary with the cause. If the retrograde ejaculation is related to an anatomic abnormality, it is rarely treatable. If the retrograde ejaculation is the result of medications, it may resolve with discontinuation of the medication. It is important to check with your medical doctor prior to discontinuing any of your medications to ensure that it is safe to do so. Lastly, if the retrograde ejaculation is related to a neurologic problem, it may respond to pharmacologic therapy. Medications that have been used in the treatment of retrograde ejaculation are alphasympathomimetics, medications that stimulate the bladder neck to close. These medications include pseudoephedrine, ephedrine, phenylephrine, chlorpheniramine, bromphenramine, or imipramine. These medications may increase your blood pressure and your heart rate. Thus if you have any history of hypertension or heart disease it is important to check with your medical doctor before trying any of these medications.

With anejaculation, treatment is focused only on those men who wish to father a child. Electroejaculation (EEJ), the low-current stimulation of the ejaculatory organs via a rectal probe, can lead to emission in men with anejaculation. This form of treatment requires anesthesia in nonspinal cord injury males. Penile vibratory stimulation (PVS) may also be effective in spinal cord injury males.

• [1] A surgical technique performed under anesthesia using a specialized instrument similar to the cystoscope that allows the surgeon to remove the prostatic tissue that is bulging into the urethra and blocking the flow of urine through the urethra. After a TURP, the outer rim of the prostate remains.