Retrograde ejaculation: when semen flows back to the bladder

Retrograde ejaculation (more rarely called dry ejaculation) occurs qwhen the semen, instead of being projected outside, flows back towards the bladder. In other words, the ejaculate is not expelled out of the penis. It is often the consequence of the treatment ofprostate adenoma orprostate cancer. What cause? Is that bad ? For fertility? What solutions and treatments to regain normal ejaculation?

Definition: what is retrograde ejaculation?

Usually, during a classic ejaculation, the contraction of the muscles of the perineum and the urethra allows the expulsion of sperm from the penis. “retrograde ejaculation, it is an orgasm that occurs without emission of sperm. Semen is returned back to the bladder“, defines Pr Aurel Messas, surgeon-urologist at the American Hospital of Paris. Retrograde ejaculation can be partial or total:

► For partial retrograde ejaculation: only part of the semen can go up into the bladder while the other follows the normal path of ejaculation.

► For total retrograde ejaculation: all the sperm goes back into the bladder

“During normal ejaculation, the neck of the bladder (vesical neck) closes and allows ejaculate to be expelled from the prostate, located below the bladder, to the lower located urethra and then outwards”, explains Dr. Ludovic Ferretti, urological surgeon, member of the Committee of Andrology and Sexual Medicine of the French Association of Urology (AFU). But during retrograde ejaculationthe neck of the bladder remains open (see causes below), the ejaculate bifurcates and goes towards the bladder.

What are the causes of retrograde ejaculation?

► The most common cause is prostate surgeryprecisely prostate adenoma surgery. “At the time, retrograde ejaculation was an almost obligatory consequence of surgical treatments, even minimally invasive, for prostate adenoma (or benign prostatic hyperplasia): the treatment commonly called scratchingwhich is an endoscopic resection – which consists of unblocking the urinary channel under the bladder, leading to an opening of the neck of the bladder – or Greenlight® laser treatment and the HoLEP-laser which are treatments that have arrived in the last ten years that also cause retrograde ejaculation. Until now, when a patient required surgical treatment, we looked him straight in the eye and told him that he was going to have to undergo retrograde ejaculation. Today this is no longer the case because we have new treatments that allow you to keep sexuality, erection and ejaculation intact.“, explains Professor Messas.

► prostate cancer surgery can “result in permanent ejaculation due to the removal of the sperm-producing glands and the ligation of the vas deferens”, continues Dr. Ludovic Ferretti.

► The spinal cord injury

► Taking certain medications in particular in psychiatry, certain treatments for hypertension (such as guanethidine) or certain drugs indicated in the event of prostate adenoma (alpha-1-blockers)

► Certain surgical procedures can damage the nerves connected to the bladder sphincter: endoscopy of the bladder neck, pelvic surgeries (such as the removal of lymph nodes for the treatment of testicular cancers)

► “Diabetes may be the cause of a peripheral neuropathy (complication of diabetes), i.e. impaired function of certain nerves. When the nerves that coordinate ejaculation are affected, the simultaneous contraction of the perineal muscles, allowing expulsion, and of the seminal vesicles and the prostate, which allow secretion and emission, cannot be done effectively and the ‘ejaculate disappears’, details Dr. Ferretti.

Is retrograde ejaculation serious?

“Semen that goes into the bladder, even if mixed with urine does not pose a problem for patients who have fulfilled their desire for a child, reassures Professor Messas. On the other hand, it can be problematic in men who want children because it renders sterile. In any case, it can be very bad for other patients, even if they no longer have the desire to fertilize.“.

When to consult a doctor ?

“Retrograde ejaculation is something that is perceived in very different ways depending on the individual and their age.“, specifies Professor Messas. It is therefore not necessarily necessary to consult in the event of retrograde ejaculation. But, it is advisable to consult a doctor in certain cases:

• If you want a child
• In case of difficulty urinating or pressing urges
• In case of other signs evoking a chronic disease such as diabetes or neuropathies such as multiple sclerosis.

Which men are more at risk of having retrograde ejaculation?

Men who have undergone prostate surgery are most at risk. Overall, men over the age of 60 are more at risk.

Retrograde ejaculation can pose a problem when the couple wishes to have a child, because, as said before, this non-expulsion of spermatozoa can lead to male sterility. In this case, the doctor can propose a treatment to his patient, which consists of to take pills which have the effect of closing the bladder neck to force the ejaculate to take the right path. “Most often it is milodrine, ephedrine or pseudoephedrine, drugs said alpha-stimulants that are to be handled with care, as they can cause significant side effects, such as high blood pressure and rapid pulsehowever, wishes to clarify Dr. Ludovic Ferretti. Blood pressure should be checked very regularly.

What treatments to preserve ejaculation during prostate surgery?

► In case of prostate adenoma:

→ For prostates that go up to 100 grams: “THE Rezum is a treatment that allows, through the urinary route, to inject water vapor into the prostate adenoma, under fairly light sedation. Due to the increase in temperature, the cells will be destroyed. The prostate adenoma, which encloses the urethral canal, will eventually reduce in volume and therefore leave more room for the urinary tract. This treatment is carried out in outpatient surgery, causes very few side effects and complications, and makes it possible to maintain 95% of cases a normal ejaculation and which a priori does not cause any erectile dysfunction“, explains Professor Messas.

→ For larger prostates (more than 100-120 grams): “We have two techniques which make it possible to preserve the ejaculation. The first technique works with the interstitial laser, to differentiate from the HoLEP laser. It is a laser fiber that will be placed inside the prostate adenoma, passing through the perineum under ultrasound control and which will make it possible to reduce the volume of the prostate adenoma. It is an act that is done in outpatient surgery and can be done under very light sedation, so it can also be applied to elderly patients or who could not bear a heavy gesture. The second techniquethis time for very large prostates, with which we also have good results is prostatic embolization. It is an act that is also done on an outpatient basis and can be done under local anesthesia. It is a gesture that is made in interventional radiology, after the patient has met a urologist in consultation“, details Professor Messas.

► In case of prostate cancer: “Instead of removing the whole organ as we did before (in the breast, at first, we even removed the muscle that was behind the breast, so a very mutilating operation) now, it is possible to propose, in certain cases , focal treatment. This is a treatment where we will try to destroy only the part of the prostate that contains the tumor, and preserve the rest of the prostate and therefore much better preserve the urinary and sexual functions of the man“, concludes the specialist of the American Hospital.

Thanks to Professor Aurel Messas, surgeon-urologist at the American Hospital of Paris. Interview on February 10, 2023 by Anaïs Thiébaux and thanks to Dr. Ludovic Ferretti, urological surgeon, member of the Andrology and Sexual Medicine Committee of the French Association of Urology (AFU). Interview on June 25, 2019 by Océane Redon.