Update on medical treatment of ejaculatory disorders¹

Abstract

Among the treatment modalities for ejaculatory disorders pharmacological treatment is the least invasive option. In this review, medical treatments for retrograde ejaculation (RE) and anejaculation (AE) are discussed systematically. Thirty-six studies dealing with patients with RE and 40 with AE evaluated the use of medical treatment and were included in this review. In addition four articles dealing with prostatic massage in anejaculatory patients were considered. Sperm quality in patients with retrograde and AE is often impaired. In patients with RE no differences in response to medical treatment could be detected between the different underlying diagnoses. Compared with ephedrine, imipramine and chlorpheniramine + phenylpropanalamine showed significantly higher reversal rates, while differences between the other treatments were not significant. Regarding the reversal of AE, the alpha agonistic drugs were significantly inferior to treatment with parasympathetic drugs. Of the different alpha agonistic medical treatments for the reversal of AE, milodrin showed significantly better rates than imipramine (p = 0.008), pseudoephidrine (p = 0.02) and ephedrine (p = 0.044), while all other treatments were not significantly different (p = 0.4). In conclusion, medical treatment for reversal of RE offers a realistic chance of conceiving offspring naturally and should be the treatment modality of first choice. In contrast, in AE, medical treatment cannot be recommended generally as treatment of first choice as it shows low overall success rates compared with electrovibration stimulation and electroejaculation. Under consideration of the mostly uncontrolled design of the majority of studies published, controlled clinical trials comparing different treatment options appear urgently warranted.

Successful treatment of retrograde ejaculation with the α1-adrenergic agonist methoxamine: case study

“…These results confirm that medical treatment should the modality of first choice in male infertility due to RE; 3 we suggest that if oral medications, such as imipramine or ephedrine, are not effective, a trial with self-administered i.m. methoxamine may be warranted.…”

“…3 In our two patients, a previous therapeutic trial with imipramine (25 mg p.o. 2 h prior to masturbation) had not been effective, with a comparable (very low) ejaculated volume in the first, and persistence of complete RE in the second.…”

“…3 The second approach involves collecting the retrograde ejaculate and using it for assisted reproduction techniques. For example, prefilling of the bladder with a suitable medium (or alkalinization with bicarbonate), followed by masturbation and immediate recovery of the emptied bladder content, has been used for successful artificial insemination; 4 electroejaculation induced by a rectal probe 5 has had limited success.…”

Steps in the investigation and management of low semen volume in the infertile man

“…The two agents most commonly used are pseudoephedine and imipramine; they can be used individually or in combination. [34][35][36] These agents have sympathomimetic properties and increase the tone at the bladder neck, and can also stimulate seminal emission. Imipramine can be taken (25 mg orally daily, escalated to 50 mg orally daily if no response) for 7 days prior to attempted ejaculation, and pseudoephedrine (30 mg orally) may be taken daily or 30 to 60 minutes prior to ejaculation.…”

“…38 Anejaculation, as in retrograde ejaculation, may also respond to oral treatment, especially in patients with diabetes mellitus who have progressed from retrograde ejaculation to anejaculation. 36 Other alternatives in these patients are penile vibratory stimulation or electroejaculation, especially in patients with spinal cord injury. 39,40 Sperm retrieval with either percutaneous epididymal sperm aspiration (PESA) or testicular sperm extraction (TESE) and subsequent IVF is also possible.…”