What are the causes of absent ejaculate (azoospermia) in an 83‑year‑old man?

Causes of Absent Ejaculate in an 83-Year-Old Man

In an 83-year-old man, absent semen production is most commonly due to age-related testicular atrophy with non-obstructive azoospermia, retrograde ejaculation, or medication-induced ejaculatory dysfunction—not true azoospermia in the reproductive sense, as fertility is not a concern at this age. 1, 2

Primary Age-Related Causes

Testicular Atrophy and Spermatogenic Failure

• Age is one of the most significant factors in delayed or absent ejaculation, combining psychological and physiological processes that may result in complete absence of ejaculate 1
• Non-obstructive azoospermia in elderly men is characterized by testicular atrophy, elevated FSH levels (typically >7.6 IU/L), and reduced testicular blood flow on Doppler ultrasonography 2, 3
• Atrophied testes demonstrate decreased arterial velocity, increased resistive index, and reduced or absent diastolic flow on color Doppler examination 2

Retrograde Ejaculation

• Post-ejaculatory urinalysis is mandatory when ejaculate volume is <1 mL to diagnose retrograde ejaculation, which is common in elderly men with diabetes, neurologic conditions, or after prostate surgery 2
• Low ejaculate volume (<1.5 mL) may suggest ejaculatory duct obstruction or retrograde ejaculation 2

Medication-Induced Causes

Common Culprits in Elderly Men

• Alpha-blockers (tamsulosin, alfuzosin) used for benign prostatic hyperplasia commonly cause retrograde ejaculation or absent ejaculate 1
• Antidepressants (SSRIs, SNRIs) are well-established causes of delayed or absent ejaculation 1
• Antipsychotics and medications affecting the autonomic nervous system can impair ejaculatory function 1
• Clinicians should suggest replacement, dose adjustment, or staged cessation of medications that may contribute to delayed or absent ejaculation 1

Neurologic and Vascular Causes

Age-Related Dysfunction

• Diabetes mellitus with associated neuropathy impairs ejaculatory function through autonomic nerve damage 1
• Vascular disease affecting pelvic blood flow can contribute to ejaculatory dysfunction 1
• Prior pelvic surgery (prostatectomy, colorectal surgery) may damage sympathetic nerves controlling ejaculation 1

Diagnostic Approach

Essential Initial Steps

• Obtain detailed medication history, focusing on alpha-blockers, antidepressants, and antipsychotics 1
• Perform post-ejaculatory urinalysis if any ejaculate is produced to check for sperm in urine (retrograde ejaculation) 2
• Assess for diabetes, neurologic conditions, and history of pelvic surgery 1

Physical Examination Findings

• Assess for presence of vasa deferentia, as congenital bilateral absence can be diagnosed by physical examination 2
• Digital rectal examination to assess prostate size and consistency 2
• Evaluate for varicocele, hydrocele, or other scrotal abnormalities 2

Hormonal Evaluation (If Indicated)

• Measure serum testosterone and FSH levels, as FSH levels are negatively correlated with spermatogonia number 2
• Morning testosterone testing is recommended if hypogonadism is suspected 1
• Basic serum studies including electrolytes, lipids, and glycosylated hemoglobin may identify conditions predisposing to neuropathy 1

Management Strategies

Behavioral and Positional Modifications

• Modifying sexual positions or practices to increase arousal may be of benefit for men with delayed or absent ejaculation 1
• Behavioral interventions including incorporation of alternative sexual practices or sexual enhancement devices are low-risk options 1

Pharmacologic Options (If Ejaculation Desired)

• Pseudoephedrine 60-120 mg taken 120-150 minutes prior to sexual activity may facilitate ejaculation 1
• Ephedrine 15-60 mg taken 1 hour prior to sexual activity is an alternative 1
• Midodrine 5-40 mg daily may improve ejaculatory function 1

Addressing Reversible Causes

• Discontinue or switch alpha-blockers if medically feasible 1
• Optimize diabetes control to prevent further neuropathic progression 1
• Consider referral to mental health professional with expertise in sexual health for psychological contributors 1

Important Clinical Caveats

• At age 83, absent ejaculate is rarely investigated for fertility purposes—the focus should be on quality of life, sexual satisfaction, and ruling out serious underlying conditions 1
• Retrograde ejaculation is benign and requires no treatment unless the patient desires intervention for sexual satisfaction 2
• Complete absence of orgasm with absent ejaculate warrants neurologic evaluation for autonomic dysfunction 1
• If testicular masses are suspected on examination, scrotal ultrasonography is indicated 2