Is retrograde (backward flow of semen) ejaculation common?

Retrograde Ejaculation: Prevalence and Management

Retrograde ejaculation is not rare, affecting approximately one-third of men with diabetes mellitus and is a recognized side effect of certain medications, particularly alpha-1 blockers used for lower urinary tract symptoms. 1

Prevalence and Epidemiology

• Retrograde ejaculation (RE) occurs in approximately one-third of men with diabetes mellitus, with longer duration of diabetes being associated with higher risk 1
• RE is a common side effect of selective alpha-1 blockers such as tamsulosin and silodosin used for treating lower urinary tract symptoms 2
• Although clinical guidelines report that disorders of ejaculation have a prevalence of less than 5% in the general population, clinicians suggest these problems are not rare in practice 2
• RE may be partial (low seminal volume) or complete (dry ejaculate), both potentially resulting in male infertility 3

Etiology

• RE can result from multiple causes:
  • Neurological conditions, particularly diabetes mellitus (most common medical cause) 1
  • Pharmacological causes, especially alpha-1 blockers used for LUTS 2
  • Surgical procedures, particularly retroperitoneal lymphadenectomy 4
  • Anatomical abnormalities affecting the bladder neck 3
  • Idiopathic causes (particularly in cases of partial RE) 5

Diagnosis

• RE should be suspected in men with:
  • Low ejaculate volume (<1 mL) or absent ejaculate 2
  • Normal testicular size and palpable vasa deferentia 2
  • History of diabetes, retroperitoneal surgery, or use of alpha-blockers 1, 4, 2
• Diagnosis is confirmed by post-ejaculatory urinalysis showing presence of sperm 2, 1
• In men with aspermia (no ejaculate), post-ejaculatory urinalysis should be performed to differentiate RE from other conditions like ejaculatory duct obstruction or hypogonadism 2

Management Options

For Men with Fertility Concerns

• Sympathomimetic medications can be effective in converting retrograde to antegrade ejaculation:

  • Pseudoephedrine 60-120 mg every 6 hours before ejaculation (58-63% success rate) 5, 2
  • Ephedrine 15-60 mg one hour prior to sexual activity 2, 4
  • Imipramine 25-75 mg daily (effective in some cases where sympathomimetics fail) 2, 4

• For men with persistent RE despite medical therapy, sperm retrieval techniques include:

  • Alkalinization of urine with oral medications or adding sperm wash media into the bladder prior to ejaculation 3, 6
  • Collection of post-ejaculatory urine for sperm extraction followed by intrauterine insemination or IVF 6
  • Surgical sperm extraction if medical management fails 2

• The American Urological Association recommends: "Infertility associated with retrograde ejaculation may be treated with sympathomimetics and alkalinization of urine with or without urethral catheterization, induced ejaculation, or surgical sperm retrieval" 2

For Men with Medication-Induced RE

• Consider modification of medications that may contribute to RE:
  • Dose adjustment or staged cessation of alpha-blockers when possible 2
  • Consider switching from selective alpha-1 blockers (tamsulosin, silodosin) to less selective agents with lower rates of ejaculatory dysfunction 2

Clinical Considerations and Caveats

• RE is often underdiagnosed as patients may not report symptoms unless specifically asked 1
• Men with diabetes should be routinely screened for RE, especially those with long-standing disease 1
• RE is often associated with other sexual dysfunctions, particularly erectile dysfunction in diabetic men 1
• When treating with sympathomimetics, monitor for potential side effects including hypertension, anxiety, and insomnia 5
• Success rates of medical therapy are higher in idiopathic and medication-induced RE compared to neurological or post-surgical causes 4, 5

In summary, retrograde ejaculation is not uncommon, particularly in specific populations such as diabetic men and those taking certain medications. Appropriate diagnosis and management can significantly improve quality of life and fertility outcomes for affected individuals.