Dear Dr. G,

My wife and I have a very healthy sex life and engage in sexual activities about once or twice a week. Sadly, our sex lives have taken a curious turn lately.

I was recently diagnosed with hypertension and diabetes, and was started on blood pressure and diabetic medications.

Since the diagnosis of my condition, I have noticed the amount I ejaculate is diminishing significantly over the last few months.

Sometimes, even the amount of semen is hardly noticeable.

My wife made a comment on the reduction in semen and thought I don’t get so aroused anymore during intimacy. In fact I was accused of faking my orgasm.

Don’t get me wrong. I have no intention of sex for procreation, as I already have two wonderful children. However, I am just curious about my diminishing sperms.

I read somewhere this is due to a condition called retrograde or dry ejaculation.

Therefore, I would like to put Dr. G on the spot for the mystery of my missing sperms.

First of all, can you tell me how much does an average man ejaculate?

Is it normal to have less sperms as men age? Does it correlate to an aging male or sickness?

How common is retrograde ejaculation and how is the diagnosis made?

Once diagnosed, what treatment is available for my condition.

I really hate to be accused of “faking orgasm” and hope you can help me to move forward with my backwards climaxes!

Backward Benjamin

The World Health Organization (WHO) outlines the average volume of ejaculation for men is 3.7ml, roughly equivalent to three-quarter of a teaspoon. The normal ejaculation volume in a man after a few days of abstinence actually ranges between 2ml and 6 ml. However, this varies greatly with mood, state of arousal, physical health and the interval of prior ejaculation. The low volume of ejaculation in a man is called hypospermia. This is generally defined as total ejaculation volume of less than 1.5ml.

It is common sense to assume the ejaculation volume declines with age as the rest of the sexual parameters, including libido and erectile rigidity. The age-related decline starts in any decade of the men’s life and generally over five to 10 years’ interval. On the other hand, the sudden decline in the emission semen volume is more likely to be associated with certain medical conditions.

The complete absence of the emission of semen can be caused by retrograde ejaculation or “dry orgasm”. This occurs when the semen that is supposed to be propelled forward is directed backwards to the urinary bladder. The normal reproductive physiology requires the bladder sphincter to contract prior to ejaculation, prohibiting the mixture of urine and semen. The semen is then forced to exit the urethra through the penile opening. When the bladder sphincter does not function properly, retrograde ejaculation can occur.

The malfunction of the bladder sphincter is generally caused by the derangement of the nerve supply to the bladder neck. The most common cause of pelvic nerve destruction is diabetes, causing retrograde ejaculation. Other neurological causes of retrograde ejaculation can be multiple sclerosis and spinal cord injuries, resulting in the backflow of semen in addition to erectile dysfunction. Other non-neurological causes that can cause the derangement of the sphincter include prostate operations such as TURP (transurethral resection of the prostate), which destroy the bladder neck to overcome obstructions.

The other common aetiology of low ejaculate are the side effects of certain medications. The use of prostate and blood pressure medications, such as alpha-blockers are well recognised to relax the bladder neck resulting in retrograde ejaculation. Other groups of medications such as antidepressants and antipsychotics are also known to cause dry orgasm. The incidence of drug-induced retrograde ejaculation is a common manifestation of men with low semen volume, which is completely reversible.

The diagnosis of retrograde ejaculation requires a simple urinalysis obtained shortly after sexual climax. In the case of retrograde ejaculation, the urine will contain a copious amount of sperms, which can be identified by microscopic examinations. In fact, for men facing the challenges of male-factor infertility related to ejaculatory dysfunction, the retrieval of the live sperms from the urine can often be used for IVF fertilisation.

The treatment of retrograde ejaculation usually depends on the cause. The cessation of medications such as antidepressants and alpha-blockers are usually effective in reversing bladder neck dysfunctions. Other neurological and surgical causes of retrograde ejaculation may also be treated with medications such as tricyclic antidepressants and antihistamines like chlorphenamine. However, the success rates of such intervention are not so favourable.

Apart from the issues of infertility, the diminished or absence of ejaculation in men imposes no threat to health whatsoever. Although retrograde ejaculation may be just a bit of a nuisance for some men, others may have significant frustration when facing such sexual dysfunction. Understanding the pathophysiology of retrograde ejaculation is crucial to avoid certain medications and nerve destructions that interfere with the intricate control of the forward propulsion of semen. Apart from disease awareness, open communication with one’s partner is also important to avoid misunderstanding of “faking an orgasm”.

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