From the Guidelines
For treating retrograde ejaculation in a patient with mild BPH, hyperlipidemia, hypertension, and diabetes when imipramine is not covered by insurance, pseudoephedrine (60-120 mg taken 120-150 minutes prior to sex) is a recommended alternative medication. According to the 2022 AUA/SMSNA guideline on disorders of ejaculation 1, pseudoephedrine has potential efficacy for the treatment of delayed ejaculation, which can be applied to retrograde ejaculation. This sympathomimetic medication works by increasing the tone of the bladder neck and internal sphincter, helping to prevent retrograde flow of semen into the bladder during ejaculation.
Other alternatives include ephedrine (15-60 mg taken 1 hour prior to sex) and midodrine (5-40 mg daily, taken 30-120 minutes prior to sex) 1. However, caution is needed when using these sympathomimetics due to potential blood pressure effects, especially in patients with hypertension.
Key considerations for this patient with multiple comorbidities:
- Pseudoephedrine would likely be the first choice due to its availability and established efficacy, but blood pressure should be monitored closely.
- The patient should be advised that these medications are typically taken on-demand before sexual activity rather than continuously.
- If medication therapy fails, the patient might consider sperm retrieval from urine for fertility purposes if that is a concern.
- Treatment of the underlying BPH with alpha-blockers should be approached cautiously as these can sometimes worsen retrograde ejaculation.
It is essential to weigh the benefits of enhanced orgasmic function against the potential risks and make an individualized decision, as there is insufficient evidence to assess the risk-benefit ratio of oral pharmacotherapy for the management of delayed ejaculation 1.
From the Research
Alternatives to Imipramine for Treating Retrograde Ejaculation
If imipramine is not covered by insurance, there are alternative treatments for retrograde ejaculation that can be considered. These alternatives are based on studies that have shown efficacy in treating retrograde ejaculation in patients with various underlying conditions, including diabetes and benign prostatic hyperplasia (BPH).
- Pseudoephedrine: This alpha-adrenergic agonist has been shown to be effective in treating retrograde ejaculation, particularly in patients with diabetes 2, 3. A study published in 2017 found that pseudoephedrine treatment resulted in improved seminal parameters in 70% of patients with retrograde ejaculation, with 38.5% achieving antegrade total sperm counts over 39 million 3.
- Methoxamine: This pure alpha1-adrenergic agonist has been used to treat retrograde ejaculation in patients who have not responded to oral imipramine 4. A case study published in 2005 found that methoxamine treatment resulted in substantial increases in sperm count and motility, with two clinical pregnancies achieved in the partner of one patient.
- Ephedrine sulfate: This medication has been used in combination with imipramine to treat retrograde ejaculation in patients with diabetes and retroperitoneal lymphadenectomy 5. A study published in 1994 found that ephedrine sulfate treatment resulted in positive outcomes in 29.3% of patients with retrograde ejaculation and diabetes.
Considerations for Treatment
When considering alternative treatments for retrograde ejaculation, it is essential to take into account the patient's underlying medical conditions, such as diabetes and BPH. The choice of treatment should be based on the patient's individual needs and medical history.
- Diabetes: Patients with diabetes may require closer monitoring and adjustment of their treatment regimen to ensure optimal outcomes 2, 5, 3.
- BPH: Patients with BPH may require additional treatments to manage their symptoms, such as alpha-blockers or 5-alpha-reductase inhibitors.
- Side effects: Patients should be informed of potential side effects associated with each treatment, such as dizziness, weakness, nausea, and sweating 6, 4.