Dear Dr G,

I am a 50-year-old chap with a healthy sex life. My wife and I engage in sexual activities once or twice a week.

Sadly, our sex life has taken a curious turn lately.

It all started when I started waking up at night to urinate.

Apart from the night-time urination which awakens my wife too, I also started having difficulties aiming straight, and stain the toilet seat with urine.

My wife convinced me see a urologist, and I was diagnosed with benign prostatic hyperplasia (BPH).

The doctor started me on a medication called doxazosin, which helps with the flow.

Since I started taking the tablet, I have noticed the amount I ejaculate has diminished significantly. Sometimes, the semen is hardly noticeable.

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

I am really curious about my diminishing sperm.

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

I would like to put Dr G on the spot over the mystery of my missing sperm.

First of all, can you tell me how much average men ejaculate?

Is it normal to have less sperm as we age?

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

Is my lack of ejaculation related to the medicine for BPH?

Lastly, do I have to put up with retrograde ejaculation if I need to continue taking the medicine?

I really hate to be accused of faking it and hope you can me to move forward with my backwards climax!


Faking Freddy

It is common sense to assume the ejaculation volume declines with age as do other sexual parameters, including libido and erectile rigidity. The World Health Organization (WHO) outlines the average volume of ejaculate for men is 3.7ml, roughly equivalent to three-quarters of a teaspoon.

The normal volume after a few days of abstinence actually ranges from 2ml-6ml. However, this varies greatly with mood, state of arousal, physical health and the interval since prior ejaculation. Low ejaculation volume in a man is called hypospermia. This is generally defined as total ejaculation volume of less than 1.5ml.

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 through the urethra through the penile opening. Bladder sphincter malfunction can lead to a medical condition known as retrograde ejaculation.

The reduction or complete absence of emission occurs when the semen that is supposed to be propelled forward is directed backwards to the urinary bladder. 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 backflow of semen in addition to erectile dysfunction. Other non-neurological causes causing derangement of the sphincter including prostate operations such as transurethral resection of the prostate (TURP), which destroy the bladder neck to overcome obstructions. These causes of retrograde ejaculation are generally non-reversible.

The most 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 known to relax the bladder neck, resulting in retrograde ejaculation.

Medications such as alfuzosin, doxazosin, terazosin and tamsulosin are all effective in enhancing urinary flow, but the side effect of retrograde ejaculation is unavoidable. 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 cases of retrograde ejaculation, the urine will contain a copious amount of sperm, which can be identified by microscopic examination. In fact, for men facing the challenge of male-factor infertility related to ejaculatory dysfunction, the retrieval of live sperm from the urine can often be used for in vitro fertilisation. The treatment of retrograde ejaculation usually depends on the cause.

Stopping medications such as antidepressants and alpha blockers is usually effective in reversing bladder neck dysfunction. 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 rate of such intervention is not so favourable. Apart from issues of infertility, diminished or absent ejaculation in men poses 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 interfere with the intricate control of the forward propulsion of semen.

The famous actress Sharon Stone once said: “Women can fake an orgasm, but men can fake an entire relationship.”

When Dr G is put on the spot by men on alpha blockers being accused of faking an orgasm, his solution is to stop the medicine prior to the moment of intimacy to avoid being accused of faking both the orgasm and the relationship.

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