Differential Diagnosis for Ejaculatory Dysfunction

The patient's history of vasectomy and current symptoms of ejaculatory dysfunction can be approached by considering the following categories:

• Single most likely diagnosis
  • Ejaculatory duct obstruction: This is a possible complication of vasectomy, where the ejaculatory ducts become blocked, preventing semen from being ejaculated. The patient's history of vasectomy and symptoms of dry orgasm (achieving orgasm but with no ejaculation) support this diagnosis.
• Other Likely diagnoses
  • Retrograde ejaculation: This condition occurs when semen enters the bladder instead of being ejaculated out of the body. It can be caused by diabetes, surgery, or certain medications. The patient's age and potential for underlying medical conditions make this a plausible diagnosis.
  • Bladder neck contracture or stricture: This condition can cause obstructive symptoms, including ejaculatory dysfunction. The patient's history of vasectomy and potential for scarring or fibrosis make this a possible diagnosis.
• Do Not Miss (ddxs that may not be likely, but would be deadly if missed.)
  • Neurological disorders (e.g., multiple sclerosis, spinal cord injury): These conditions can affect the nerves responsible for ejaculation, leading to ejaculatory dysfunction. Although less likely, it is essential to consider these diagnoses due to their potential impact on the patient's quality of life and overall health.
  • Testicular or prostate cancer: Although rare, testicular or prostate cancer can cause ejaculatory dysfunction. It is crucial to rule out these diagnoses due to their potential severity and impact on the patient's health.
• Rare diagnoses
  • Congenital or acquired cysts or tumors of the seminal vesicles or ejaculatory ducts: These conditions can cause obstructive symptoms, including ejaculatory dysfunction. However, they are relatively rare and would require further imaging and diagnostic testing to confirm.
  • Hormonal imbalances (e.g., low testosterone): Hormonal imbalances can affect libido, erectile function, and ejaculation. Although less common, it is essential to consider these diagnoses, especially in older adults.

Further workup with testing, such as:

• Urinalysis to rule out infection or retrograde ejaculation
• Post-ejaculatory urinalysis (if possible) to check for sperm in the urine
• Transrectal ultrasound (TRUS) to evaluate the prostate, seminal vesicles, and ejaculatory ducts
• Hormone level testing (e.g., testosterone, follicle-stimulating hormone) to assess for hormonal imbalances
• Imaging studies (e.g., MRI) to rule out neurological disorders or other rare conditions

may be necessary to determine the underlying cause of the patient's symptoms and guide appropriate treatment.