What Is Retrograde Ejaculation (Dry Orgasm)? How Does It Affect Fertility?

Some men notice that although they reach orgasm during intercourse, no semen comes out, or the amount that does is markedly reduced. Known colloquially as dry orgasm or backward ejaculation, the medical name for this condition is retrograde ejaculation. Although it often causes concern, it is not harmful to general health; in couples who wish to have a child, however, it can become an important male factor.

This article explains how it occurs, its causes, how it is diagnosed and the treatment options from a fertility perspective.

What is retrograde ejaculation and how does it occur?

Normal ejaculation takes place in two stages. In the first stage, sperm and the secretions that make up seminal fluid are carried into the initial part of the urethra, which passes through the prostate. In the second stage, semen is expelled by rhythmic contractions of the pelvic floor muscles. During this time the bladder neck, the outlet of the bladder, closes tightly. This closure ensures that semen travels in one direction only, outwards.

In retrograde ejaculation the bladder neck does not close sufficiently at the moment of ejaculation. Semen escapes backwards into the bladder, where resistance is lower. The result is that orgasm occurs but no semen, or only a very small amount, comes out. This semen is later passed with urine. The condition may be complete or partial; in partial cases some of the semen comes out while some is directed into the bladder.

Which conditions lead to retrograde ejaculation?

Closure of the bladder neck is a muscular action regulated by the nervous system. Any condition that affects the structure of the bladder neck or the nerves supplying this area can therefore cause retrograde ejaculation:

• Prostate surgery: In endoscopic operations for prostate enlargement and in laser removal of prostate tissue, the bladder neck region is also affected, so dry orgasm is a common finding after surgery.
• Certain prostate medicines: The group of medicines used for urinary symptoms due to prostate enlargement, which relax the muscles of the bladder neck and prostate, can reduce ejaculate volume or cause dry orgasm. This effect usually reverses when the medicine is stopped.
• Diabetes: Nerve damage (autonomic neuropathy) that develops with long-standing, poorly controlled blood sugar can weaken the nerve signals that close the bladder neck.
• Spinal cord injury and neurological disease: Spinal cord damage and conditions such as multiple sclerosis can affect the ejaculatory reflex.
• Retroperitoneal and pelvic surgery: Lymph node surgery for testicular tumours, major vascular operations and colorectal surgery can affect the nerves that govern ejaculation.

Symptoms: why is orgasm preserved and why does urine turn cloudy?

The most distinctive feature of retrograde ejaculation is that the sensation of orgasm is usually preserved. Orgasm and the expulsion of semen accompany each other but are separate processes. Because the ejaculatory reflex still takes place even though the bladder neck does not close, most patients experience orgasm in the usual way; some may say the sensation feels slightly different.

The second important clue is that the first urine passed after ejaculation is cloudy or milky white. This cloudiness comes from semen that has entered the bladder mixing with urine.

It should also be noted that a dry orgasm does not always mean backward ejaculation. Situations in which no semen is produced at all (anejaculation), blockage of the seminal ducts and hormone deficiency can cause a similar complaint.

How is it diagnosed?

Diagnosis begins with a detailed history, covering previous operations, medicines in use and any history of diabetes, and a physical examination.

The key test in diagnosis is the post-ejaculatory urine analysis. The patient is asked first to give a semen sample and then, immediately afterwards, a urine sample. Finding a significant number of sperm in the post-ejaculatory urine supports retrograde ejaculation.

If no sperm are found in the urine, causes such as absent semen production or duct blockage are investigated with hormone tests and, where needed, ultrasound.

Is it harmful to health, and how does it affect fertility?

Semen that passes into the bladder is expelled from the body with urine. This does not harm the bladder, the kidneys or general health; it does not increase the risk of infection and does not physically restrict sexual life.

From a fertility perspective, however, the picture is different. Although sperm production in the testicles continues normally, the sperm cannot reach the female reproductive tract, so natural conception becomes difficult. In couples wishing to have a child, retrograde ejaculation is therefore a male factor that deserves attention. Encouragingly, in most cases sperm are still produced and can be obtained.

What are the treatment options?

Treatment is determined by the underlying cause and the couple's plans for children. The general approach proceeds in steps:

• Adjusting medication: Where the cause is a prostate medicine that relaxes the bladder neck, stopping it or switching to a different option under medical supervision often allows ejaculation to return. The medicine should not be stopped without consulting a doctor.
• Medicines that help close the bladder neck: Particularly in cases related to diabetes or nerve damage, certain medicines that support contraction of the bladder neck muscles may be tried. Because these medicines can affect blood pressure and heart rhythm, they are used according to the individual's general health and under medical follow-up. The response is usually limited where there are structural changes after surgery.
• Assisted reproduction techniques: In cases that do not respond to medication or that develop after surgery, treatment is planned by obtaining sperm from the urine.

For men planning prostate treatment who wish to have children in future, discussing sperm freezing beforehand is useful.

Retrieving sperm from urine and assisted reproduction

In retrograde ejaculation, sperm pass into the bladder and can therefore be retrieved from the urine. However, the acidity and concentration of urine can damage sperm, so the procedure is carried out with specific preparation:

• Before the procedure, preparation that reduces the acidity of the urine is carried out as advised by the doctor, and fluid intake is adjusted.
• The bladder is emptied just before ejaculation; in some centres a special fluid that protects sperm is placed in the bladder.
• Immediately after ejaculation a urine sample is collected and washed in the laboratory to separate the sperm.

Depending on their number and motility, the sperm obtained can be used for insemination (intrauterine insemination) or IVF (microinjection, ICSI); in suitable cases they can be frozen and stored. Where sufficient sperm cannot be obtained from urine, testicular sperm retrieval may be considered. Which route is chosen is planned at the level of the couple, together with the female partner's age and assessment.

When should a doctor be consulted?

A urology and andrology assessment is advised in the following situations:

• No semen coming out despite orgasm, or a marked reduction in its volume
• The first urine after ejaculation regularly appearing cloudy or white
• A change in ejaculation after starting a prostate medicine or after prostate surgery
• An ejaculation problem together with a history of diabetes, spinal cord injury or retroperitoneal surgery
• No conception within a year of regular, unprotected intercourse
• A wish to have children in future when prostate treatment is being planned

Retrograde ejaculation is the backward flow of semen into the bladder because the bladder neck does not close sufficiently. It is harmless to general health and the sensation of orgasm is mostly preserved; in couples wishing to have a child, however, it is an important male factor. It can be diagnosed with a simple post-ejaculatory urine analysis, and options range from adjusting medication to assisted reproduction techniques using sperm retrieved from urine. Assoc. Prof. Zülfü Sertkaya practises in urology and andrology in Istanbul; assessment and treatment planning in ejaculatory disorders and male infertility are carried out with individual assessment and confidentiality.

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