Dear Dr. G,

I understand you are focusing on the issues of ejaculatory dysfunction for the month of February.

I have a curious and frustrating climatic problem that I hope you can resolve.

I am a 46-year-old man who is reasonably fit and healthy.

I wake up with an erection and could have normal sexual intercourse until six months ago, when the amount of ejaculate I produce started becoming less. It got to a point where I

The strange thing is that my erection and degree of climax remains unchanged.

Although I am not currently thinking about childbearing, I am somewhat worried that something is going wrong with my sexual abilities.

I am also worried as so many serious medical problems are associated with the inability to ejaculate and I am eager to put Dr. G on the spot for some clarification.

Although I have some idea the physiology of ejaculation, can you please outline it for me in

layman’s terms?

How much semen is considered normal and is there a possibility of blockage resulting in no ejaculation?

Apart from blockages, what else can render a man unable to produce semen and if I can’t ejaculate does that mean I am infertile for the rest of my life?

Lastly, I understand from many articles on the Internet that an inability to ejaculate is not life- threatening, however this is incredibly frustrating. Can you offer any treatment?

Yours truly,

Frustrated Fruitless Frederick

The World Health Organization (WHO) outlines the average volume of ejaculate for men as 3.7ml, roughly equivalent to three-quarters of a teaspoon and the normal ejaculation volume in a man with after a few days of abstinence actually ranges from 2-6 ml.

However, this varies greatly with mood, state of arousal, physical health and the interval of prior ejaculation.

Generally, a case of a low volume of ejaculation in a man is called hypospermia. This is generally defined as total ejaculation volume of less than 1.5ml and the pathological inability of a man to ejaculate despite arousal is anejaculation and such a complete absence of ejaculation in men happens either with or without an orgasm.

Normal reproductive physiology requires the bladder sphincter to close prior to ejaculation, prohibiting the mixture of urine and semen. The semen is then forced to exit the urethra through the penile opening, without going backwards.

The complete absence of the emission of semen can be caused by the occlusion of ejaculatory ducts or the backwards flow of semen, known as retrograde ejaculation. The occlusion of the ejaculatory ducts can be congenital or acquired. Prostatic cysts are a common inborn error resulting in obstruction, while sexually transmitted infections such as chlamydia and gonorrhoea are also common acquired causes of occlusions.

Retrograde ejaculation occurs when the semen that is supposed to be propelled forward can also be directed backwards to the urinary bladder due to neurological dysfunctions. The commonest cause of pelvic neuropathy is diabetes. 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 causing the derangement of the sphincter including prostate operations such as TURP, which destroys 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 a dry orgasm, and the incidence of drug induced retrograde ejaculation is a common cause of low semen volume, which is completely reversible.

The differentiation of retrograde ejaculation and anejaculation requires a simple urinalysis obtained shortly after sexual climax.

In the cases of retrograde ejaculation, the urine will contain copious amount of sperm, which can be identified by microscopic examinations.

In fact, for men facing the challenge of male-factor infertility related to ejaculatory dysfunction, the retrieval of the live sperm from the urine can often be used for IVF fertilization. Otherwise, no sperm will be detected in men with occluded sperm ducts following sexual climax.

The treatment of retrograde ejaculation usually depends on the cause. The reversal of spermatic occlusion such as aspiration of the prostatic cyst can often restore normal ejaculation. On the other hand, the cessation of medication such as antidepressants and alpha-blockers are usually effective in reversing the 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 absent 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 destruction that interferes with the intricate control of the forward propulsion of semen. Apart from disease awareness, open communication with a partner is also important to avoid the misunderstanding of “faking an orgasm”.

When frustrated men trying to move forward with the challenges of backward fruitless climaxes put Dr. G on the spot for a solution, his view is simply that there is no point looking backwards or forwards, as keeping it upwards is already a blessing!

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