Page 81 - Remedial Andrology

Endocrine Hypothyroidism
Hypogonadism
Hyperprolactinaemia
Bladder neck incompetence Congenital defects/dysfunction of hemitrigone
Bladder neck resection (transurethral resection of the prostate)
Prostatectomy

6.6.3 Disease management
Medical and surgical strategies exist for the treatment of retrograde ejaculation. In recent years the reliance on
medical treatment as first-line management has become common practice.

6.6.3.1 Pharmacological
Sympathomimetics stimulate the release of noradrenaline as well as activating α- and β-adrenergic receptors,
resulting in closure of the internal urethral sphincter, restoring the antegrade flow of semen. The most common
sympathomimetics are synephrine, pseudoephedrine hydrochloride, ephedrine, phenylpropanolamine and
midodrine [888]. Unfortunately, as time progresses their effect diminishes [889]. Many of the studies published
about the efficacy of sympathomimetics in the treatment of retrograde ejaculation suffer from small sample
size, with some represented by case reports.

A double-blind controlled study randomised patients to one of four α-adrenergic agents (dextroamphetamine,
ephedrine, phenylpropanolamine and pseudoephedrine) with or without histamine. The patients suffered from
failure of ejaculation following retroperitoneal lymphadenectomy. They found that 4 days of treatment prior to
ejaculation was most effective and that all the adrenergic agonists restored antegrade ejaculation [888]. In a
systematic review, the efficacy of this group of medications was found to be 28% [204]. The adverse effects of
sympathomimetics include dryness of mucous membranes and hypertension.

The use of antimuscarinics has been described, including brompheniramine maleate and imipramine, as well
as in combination with sympathomimetics. The calculated efficacy of antimuscarinics alone or in combination
with sympathomimetics is 22% and 39%, respectively [204]. Combination therapy appears to be more effective
although statistical analysis is not yet possible due to the small sample sizes.

6.6.3.2 Management of infertility
Infertility has been the major concern of patients with retrograde ejaculation. Beyond the use of standard
sperm-retrieval techniques, such as testicular sperm extraction (TESE), three different methods of sperm
acquisition have been identified for the management of infertility in patients with retrograde ejaculation. These
include; i) centrifugation and resuspension of post-ejaculatory urine specimens; ii) the Hotchkiss (or modified
Hotchkiss) technique; and, iii) ejaculation on a full bladder.

1. Centrifugation and resuspension. In order to improve the ambient conditions for the sperm, the patient is
asked to increase their fluid intake or take sodium bicarbonate to dilute or alkalise the urine, respectively.
Afterwards, a post-orgasmic urine sample is collected by introducing a catheter or spontaneous voiding. This
sample is then centrifuged and suspended in a medium. The types of suspension fluids are heterogeneous
and can include bovine serum albumin, human serum albumin, Earle’s/Hank’s balanced salt solution and the
patient’s urine. The resultant modified sperm mixture can then be used in assisted reproductive techniques.
A systematic review of studies in couples in which male partner had retrograde ejaculation found a 15%
pregnancy rate per cycle (0-100%) [204].

2. Hotchkiss method. The Hotchkiss method involves emptying the bladder prior to ejaculation, using a
catheter, and then washing out and instilling a small quantity of Lactated Ringers to improve the ambient
condition of the bladder. The patient then ejaculates, and semen is retrieved by catheterisation or voiding [890].
Modified Hotchkiss methods involve variance in the instillation medium. Pregnancy rates were 24% per cycle
(0-100%) [204].

3. Ejaculation on a full bladder. Few papers have described results using this technique [891, 892]. The patient
is encouraged to ejaculate on a full bladder and semen is suspended in Baker’s Buffer. The pregnancy rate in
the two studies, which included only five patients in total, was 60% [204].

6.7 Anorgasmia
6.7.1 Definition and classification
Anorgasmia is the perceived absence of orgasm and can give rise to anejaculation. Regardless of the presence
of ejaculation, anorgasmia can be a lifelong (primary) or acquired (secondary) disorder [201].

80 SEXUAL AND REPRODUCTIVE HEALTH - MARCH 2021