Page 80 - Remedial Andrology

[876-878]. Further case reports have suggested that mercury toxicity or Ciguatera toxin fish poisoning may
also result in painful ejaculation [879, 880]. Psychological issues may also be the cause of painful ejaculation,
especially if the patient does not experience this problem during masturbation [881].

6.5.3 Investigation and treatment
Treatment of painful ejaculation must be tailored according to the underlying cause, if detected. Psychotherapy
or relationship counselling, withdrawal of suspected agents (drugs, toxins, or radiation) [876, 877, 882] or
the prescription of appropriate medical treatment (antibiotics, α-blockers or anti-inflammatory agents) may
ameliorate painful ejaculation. Behavioural therapy, muscle relaxants, antidepressant treatment, anticonvulsant
drugs and/or opioids, pelvic floor exercises, may be implemented if no underlying cause can be identified
[883, 884].

6.5.3.1 Surgical intervention
If medical treatments fail, surgical operations such as TURP, transurethral resection of the ejaculatory duct
and neurolysis of the pudendal nerve have been suggested [885, 886]. However, there is no strong evidence
supporting that surgical therapy improves painful ejaculation and therefore it must be used with caution.

6.6 Retrograde ejaculation
6.6.1 Definition and classification
Retrograde ejaculation is the total, or sometimes partial, absence of antegrade ejaculation, as a result of
semen passing backwards through the bladder neck into the bladder. Patients may experience a normal,
or decreased, orgasmic sensation. The causes of retrograde ejaculation can be divided into neurogenic,
pharmacological, urethral, or bladder neck incompetence [865].

6.6.2 Pathophysiology and risk factors
The process of ejaculation requires complex co-ordination and interplay between the epididymis, vas
deferens, prostate, seminal vesicles, bladder neck and bulbourethral glands [887]. Upon ejaculation, sperm
are rapidly conveyed along the vas deferens and into the urethra via the ejaculatory ducts. From there,
the semen progresses in an antegrade fashion, in part maintained by coaptation of the bladder neck and
rhythmic contractions of the periurethral muscles, co-ordinated by a centrally mediated reflex [887]. Closure
of the bladder neck and seminal emission are initiated via the sympathetic nervous system from the lumbar
sympathetic ganglia and subsequently hypogastric nerve. Prostatic and seminal vesicle secretion, as well
as contraction of the bulbo-cavernosal, ischio-cavernosal and pelvic floor muscles are initiated by the S 2-4
parasympathetic nervous system via the pelvic nerve [887].

Any factor, that disrupts this reflex and inhibits contraction of the bladder neck (internal vesical sphincter) may
lead to retrograde passage of semen into the bladder. These can be broadly categorised as pharmacological,
neurogenic, anatomic and endocrinal causes of retrograde ejaculation (Table 21).

Table 21: Aetiology of retrograde ejaculation [847]

Neurogenic Spinal cord injury
Cauda equina lesions
Multiple sclerosis
Autonomic neuropathy
Retroperitoneal lymphadenectomy
Sympathectomy or aortoiliac surgery
Prostate, colorectal and anal surgery
Parkinson´s disease
Diabetes mellitus
Psychological/behavioural
Urethral Ectopic ureterocele
Urethral stricture
Urethral valves or verumontaneum hyperplasia
Congenital dopamine β-hydroxylase deficiency
Pharmacological Antihypertensives, thiazide diuretics
α-1-Adrenoceptor antagonists
Antipsychotics and antidepressants

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