Sexual dysfunction is a common issue in people assigned male at birth (AMAB) and can be due to various disorders that can affect the ability to orgasm, achieve or maintain an erection, ejaculate, and have a normal libido. An orgasm and ejaculation are two separate events for people AMAB. In the normal ejaculation process, sperm travels from the testicles to the urethra through the vas deferens. After an orgasm, ejaculation typically occurs due to nerve stimulation, making muscles in the reproductive system contract.1 During this journey, sperm passes through the prostate, where it mixes with the fluid produced by the prostate to create semen. These muscle contractions propel the semen down the urethra and out of the penis. Simultaneously, the bladder neck constricts to prevent backflow.
Retrograde ejaculation is a form of sexual dysfunction in which semen, instead of passing through the urethra during climax, goes backwards and enters the bladder. This occurs when normally closed muscles near the bladder opening accidentally remain open. Although this condition is not harmful, it can have an impact on fertility. During ejaculation, the bladder neck, also known as the internal urethral sphincter, must be closed.1
This article reviews the causes, symptoms, management, and treatment options for retrograde ejaculation.
Causes of retrograde ejaculation
Various conditions can cause retrograde ejaculation. Retrograde ejaculation can result from spinal injuries, bladder neck surgery, birth defects, and retroperitoneal lymph node dissection (where the lymph nodes at the back of the abdomen are removed).1 One of the reasons could be damaged or malfunctioning nerves of the bladder neck. Damage to the nervous system is a common cause of this condition.
Prostate surgery for non-cancerous prostate enlargement is a frequent cause of retrograde ejaculation. Procedures such as transurethral resection of the prostate (removal of part of the prostrate) or retroperitoneal lymph node dissection after testicular cancer can easily result in retrograde ejaculation. Additionally, radiation cancer treatment in the pelvic areas can be a contributing factor.
Certain medical conditions that affect muscles and the nervous system can increase the risk of developing retrograde ejaculation due to their ability to cause nerve damage. Examples of such conditions include Parkinson's disease, multiple sclerosis, diabetes, and diabetic neuropathy (nerve damage caused by diabetes).
Additionally, certain medications that impact the nervous system, like alpha-blockers and antidepressants, can have retrograde ejaculation as a side effect. Alpha-blockers used to treat blood pressure, such as doxazosin, and those used to treat benign prostatic hyperplasia (enlarged prostate), like tamsulosin, can affect bladder muscles and trigger retrograde ejaculation. Antidepressants such as duloxetine or selective serotonin reuptake inhibitors, as well as antipsychotics like thioridazine and risperidone, have also been associated with retrograde ejaculation.1
Signs and symptoms of retrograde ejaculation
Even if you experience retrograde ejaculation, you are still able to orgasm. However, the absence of semen or a reduced amount of semen production during orgasm is a key indicator of retrograde ejaculation. Another symptom that may indicate retrograde ejaculation is the presence of semen in the urine, which makes urine cloudy after an orgasm.1,3 Infertility is also a common symptom associated with this condition.1
Management and treatment for retrograde ejaculation
Medical and surgical options can be considered to treat retrograde ejaculation and the infertility it may cause. To improve fertility, sperm can be retrieved from the urine for use in in vitro fertilisation (IVF) or insemination. Surgical treatments aim to improve bladder neck integrity, while medications focus on making sure that the bladder neck can close fully. Acupuncture and traditional Chinese medicines have also been found to improve retrograde ejaculation.1
If retrograde ejaculation is caused by weakened nerves due to conditions like multiple sclerosis, medications that assist in muscle tightening may help keep the bladder and neck closed during ejaculation. These medications include midodrine, imipramine, brompheniramine, and pseudoephedrine and have shown improvement in roughly a third of men. However, these treatments can have side effects such as increased blood pressure and heart rate, and these drugs will not improve retrograde ejaculation caused by spinal cord injuries or surgeries.
A fertility specialist may be necessary for impregnation. In vitro fertilisation (IVF) and artificial insemination are two conception techniques used in conjunction with sperm retrieval methods.
Sperm retrieval techniques include:
- urinary sperm retrieval, where sperm is recovered from the urine
- testicular sperm aspiration, where a needle is inserted into the testicles to retrieve sperm
- Percutaneous epididymal sperm aspiration, which involves extracting sperm through a needle from the epididymis (a tube at the back of each testicle)
Surgical treatments such as these can be used as a last resort, but there is a risk of testicular damage associated with inserting needles into the testes. Another surgical option is the injection of collagen into the bladder neck, which may help to keep it closed.
Finally, electroejaculation has been used as a treatment for individuals with spinal injuries, retroperitoneal lymph node dissection, and diabetes.1
If infertility is not a concern, no treatment for retrograde ejaculation is necessary.
Management of retrograde ejaculation needs to be highly individualised, taking into consideration the partner's fertility and investigating the best procedure accordingly.1 Ejaculating with a full bladder could also be a technique to consider for natural conception at home.
Diagnosis of retrograde ejaculation
If you are concerned about experiencing retrograde ejaculation, it is recommended to consult a doctor for a physical examination. The doctor may analyse your urine to check for the presence of sperm. Fructose, a sugar found in semen but not normally present in urine, can also be assessed. Additionally, the doctor will request a detailed medical history. A urine analysis is necessary to determine if semen is present in the bladder, and a sperm analysis may be required to assess sperm quantity and quality. In some cases, imaging tests such as X-rays and ultrasounds of the bladder may be necessary to evaluate the urinary system.
Risk factors for retrograde ejaculation
Those with diabetes are at a higher risk of developing retrograde ejaculation, and prostate/pelvic surgery may further increase the odds of this condition if the procedure damages the nerves near the bladder. Spinal cord injuries are another cause of nerve damage that can lead to retrograde ejaculation. Additionally, medications used for various conditions, such as those for high blood pressure and antidepressants, can trigger retrograde ejaculation as a side effect. However, this side effect should resolve once the person stops taking the medication. Nervous system disorders, such as Parkinson's disease and multiple sclerosis, can also impact the functioning of the muscles and nerves involved in ejaculation. Congenital abnormalities present from birth can be a permanent cause of retrograde ejaculation, often requiring surgical intervention to rectify the issue.
A loss in sexual satisfaction and infertility are potential complications of the condition. Among these complications, infertility is the most significant, as it can significantly affect young couples who are trying to conceive naturally. In such cases, artificial insemination and sperm retrieval techniques may be required, adding emotional, physical, and financial strain to the couple. The absence of normal ejaculation can also impact the couple's relationship and sexual satisfaction. As a result, people AMAB with retrograde ejaculation may experience psychological effects, including disappointment and anxiety. Although retrograde ejaculation itself may not have any harmful side effects, the complications associated with it can have a detrimental impact on an individual's confidence and relationships.
How can I prevent retrograde ejaculation?
Since retrograde ejaculation can be caused by various medical conditions, it may not be possible to completely prevent the condition. However, there are ways to mitigate the risk. Maintaining a healthy lifestyle is always recommended, along with effectively managing any underlying conditions such as diabetes. If you are scheduled for pelvic or prostate surgeries, it is important to be aware of the associated risks and discuss them with your healthcare provider. If you are taking medication that carries the potential risk of retrograde ejaculation, it may be worth discussing alternative medications and treatment options with your doctor.
How common is retrograde ejaculation?
Retrograde ejaculation is a relatively rare sexual dysfunction condition, and its prevalence varies based on the risk factors and underlying causes associated with it. In fertility clinics, retrograde ejaculation is estimated to contribute to less than 2% of infertility cases.1
When should I see a doctor?
If you recognize any of the symptoms and are concerned about having the condition, it is advisable to consult with a doctor. Symptoms such as experiencing a dry orgasm (ejaculating little or no semen) and noticing cloudy urine after sex can be clear indicators of retrograde ejaculation. Additionally, if you and your partner are facing difficulties in conceiving, it may be worth considering retrograde ejaculation as a potential cause. Seeking medical advice can help confirm the diagnosis and explore appropriate treatment options.
Retrograde ejaculation occurs when sperm enters the bladder instead of being expelled from the penis during ejaculation. Although it does not pose a health risk, it can significantly affect fertility. Common symptoms of the condition include the absence of ejaculate and cloudy urine after sex. Fortunately, there are several medical and surgical treatments available to manage retrograde ejaculation. Additionally, sperm retrieval techniques can be utilised for procedures such as in vitro fertilisation (IVF) and artificial insemination. It is recommended to explore the available fertility options and discuss them with your partner to determine the best course of action for your specific situation.
- Jefferys A, Siassakos D, Wardle P. The management of retrograde ejaculation: a systematic review and update. Fertility and Sterility [Internet]. 2012 Feb [cited 2023 Oct 29];97(2):306-312.e6. Available from: https://linkinghub.elsevier.com/retrieve/pii/S0015028211027956