Workup for Dry Ejaculation
A comprehensive workup is necessary for dry ejaculation, including a detailed sexual history, physical examination, laboratory testing, and potentially imaging studies to identify the underlying cause and guide appropriate treatment. 1, 2
Initial Evaluation
History Taking
- Duration and onset of symptoms (lifelong vs. acquired)
- Relationship to specific partners or situations
- Presence of ejaculatory sensation without fluid
- Medication history (particularly alpha-blockers, antidepressants)
- Surgical history (prostate, bladder neck, or retroperitoneal surgeries)
- Neurological conditions (diabetes, multiple sclerosis)
- Impact on quality of life and fertility goals
Physical Examination
- Genital examination: testicular size and consistency
- Digital rectal examination to assess prostate
- Neurological examination focusing on sacral reflexes
- Assessment for varicocele or other anatomical abnormalities
- Examination of vas deferens and epididymis 2
Laboratory Testing
Essential Tests
- Post-ejaculatory urinalysis to check for retrograde ejaculation (presence of sperm in urine) 2
- Semen analysis (if any ejaculate is produced)
- Morning testosterone level 1
- FSH, LH, and prolactin levels
Additional Testing Based on Initial Findings
- Glycosylated hemoglobin (HbA1c) if diabetes is suspected
- Basic serum studies including electrolytes and lipids 1
- Genetic testing if severe sperm abnormalities are present 2
Imaging Studies
- Transrectal ultrasonography (TRUS) if ejaculatory duct obstruction is suspected 2
- Scrotal ultrasound if testicular abnormality is suspected or physical examination is difficult 2
- Pelvic MRI if TRUS is negative or inconclusive 2
Differential Diagnosis
Retrograde Ejaculation
- Confirmed by finding sperm in post-ejaculatory urine
- Often associated with diabetes, alpha-blocker use, or prior bladder neck/prostate surgery 3, 4
Anejaculation
- Complete absence of ejaculation (no antegrade or retrograde ejaculation)
- May be due to neurological disorders, medications, or psychological factors 4
Ejaculatory Duct Obstruction
- May present with low-volume or absent ejaculate
- Often diagnosed with TRUS showing dilated ejaculatory ducts or seminal vesicles 2
Hypogonadism
- Low testosterone levels can affect ejaculatory function
- Requires hormonal evaluation 1
Common Pitfalls to Avoid
- Failing to distinguish between retrograde ejaculation and anejaculation
- Not checking post-ejaculatory urine when ejaculate volume is <1 mL 2
- Overlooking medication effects, particularly alpha-blockers which can cause dry ejaculation in up to 22% of men 5
- Premature treatment before establishing a clear diagnosis
- Delaying referral to a reproductive specialist when fertility is desired 2
Management Considerations
- Treatment should be tailored to the underlying cause and patient's fertility goals
- For retrograde ejaculation, options include medication adjustment, sympathomimetics, or sperm retrieval from urine for fertility purposes 3, 4
- For ejaculatory duct obstruction, transurethral resection of ejaculatory ducts (TURED) may be indicated 2
- For hormonal abnormalities, appropriate hormone replacement therapy may be beneficial 1
- Referral to a urologist with expertise in sexual medicine is recommended for specialized evaluation and treatment 2