Andrology

Ejaculatory Disorders

Male ejaculation is a complex process that requires central and peripheral nervous system integration and coordination. During ejaculation, the bladder neck must close, and sperm must be forced from the vas deferens into the ejaculatory ducts along with fluid from the seminal vesicles. Rhythmic contractions of the muscles around the urethra in the penis help to move the ejaculate from the ejaculatory ducts through the urethra and out of the body. Men can have ejaculatory dysfunction from radical pelvic surgery, spinal cord injury, spina bifida, psychological difficulty with the timing of ejaculation (premature ejaculation), or prior prostate surgery.

For patients who have bladder neck dysfunction where the sperm is propelled adequately into the urethra but travels retrograde (back into the bladder), a simple test called a post-ejaculatory urinalysis, retrograde semen analysis, can often diagnose this condition. This test involves providing a semen sample and then a urinalysis after the semen sample. The presence of sperm in the urinalysis is diagnostic of retrograde ejaculation. This condition can often be treated with oral medication.

Spinal Cord Injury Patients

For patients with a spinal cord injury, there are three treatment options. Prior to undergoing any of these, patients should have a male endocrine hormone evaluation to ensure that they have adequate bioavailable testosterone. The first is vibratory stimulation. This is a procedure where a vibratory device is applied to the base of the penis to induce ejaculation. This is typically performed in clinic with blood pressure monitoring in case the patient develops autonomic dysreflexia (a condition with a dangerous elevation of the blood pressure from the stimulation).

If vibratory stimulation does not work, the second line of treatment is electro ejaculation. This is where the patient is put to sleep with general anesthesia and then a trans-rectal probe is used to stimulate the nerves to induce ejaculation. Both this technique and the vibratory stimulation technique involve multiple ejaculations to obtain high quality sperm. A third alternative is more invasive but can be completed with one trip to the operating room. Here, the surgeon performs either testicular sperm extraction (TESE) or microsurgical testicular sperm extraction (microTESE) to obtain sperm.

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