Retrograde ejaculation

Specialty: Nephrology and urology.

• dry orgasm
• semen in the bladder
• semen reflux

Why it occurs

• Previous prostate surgery (such as transurethral resection of the prostate - TURP, laser enucleation or open adenomectomy, where the bladder neck is resected, mechanically preventing its sphincter closure during ejaculation)
• Use of alpha-1 adrenergic receptor blockers (drugs such as Tamsulosin or Silodosin that relax the smooth muscles of the neck of the urinary bladder so that semen takes the path of least resistance to the bladder)
• Advanced diabetic neuropathy (damage to the sympathetic nerve fibers that innervate the smooth internal bladder sphincter prevents its contraction during seminal emission)
• Spinal cord injury or bilateral lumbar sympathectomy (disruption of the spinal sympathetic reflexes that control the bladder neck)
• Gynecological or oncological retroperitoneal or major pelvic surgery (due to direct injury to the hypogastric sympathetic nerves)

Initial workup

Microbiological and histological analysis of the first urine emitted immediately after orgasm (the microscopic finding of a massive concentration of sperm and fructose in the post-orgasm urinary sediment is pathognomonic and confirms the diagnosis of retrograde ejaculation); complete evaluation of pelvic pharmacological and surgical history.

Standard management

• Imipramine — 10-25 mg every 12-24 hours orally; tricyclic antidepressant with a powerful indirect sympathomimetic effect that increases the tone of the smooth sphincter of the bladder neck, helping to redirect semen toward the anterior urethra; monitor QT interval on electrocardiogram and monitor anticholinergic side effects
• Pseudoephedrine — 60 mg every 12 hours orally, as a direct alpha-adrenergic sympathomimetic alternative to close the bladder neck, closely monitoring blood pressure levels in hypertensive patients
• Suspension of the alpha-blocker involved (for example, suspend Tamsulosin or Silodosin if clinically viable and urinary emptying is not compromised).