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Urology/ED and no ejaculation

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Hello Doctor Goldstein, I'm a 29 yo male

From mid 2006 I started to notice a decrease on the ejaculation, sometimes i didnt ejaculate at all, which i found strange, and consulted a urologist.The urologist made me a prostate transrectal utrasound and found a cyst that was compressing the ejaculatory duct and was causing the obstruction of the ejaculation. He said that I could be like this and do not have any more problems or I could perform a surgery to drain the cyst and hopefully improve the ejaculation again.

On june 2007 I decided to improve the situation and the urologist performed the surgery, the cyst was drainned. For the next weeks I ejaculated a few times in small quatities, and then I stopped ejaculate for good. No more sperm was coming out. But when I urinated I see the sperm come out with the urine. My urologist said the sperm was moving into the bladder when the orgasm oucours but I would not have any other problem... I was heartbroken about this situation but i got over it, because my sex life was not that affected.

Over the next years I did another prostate transrectal utrasound to see if everything was ok, and the cyst was gone.
Also I stopped seeing the sperm coming out with the urine, just some quantitie group of small boubles. Where is the sperm going?

5 years have passed...

I have never had erections problems before, I was always very sexualy active, specially on masturbation, I normaly used to masturbate at least 2times p/ day

Until the Main problem:

Since June 2012 I started to notice that my erections were going away quickly (erectile dysfunction). To keep the erection I had to constantly stimulate / masturbate my penis, so i can get a strong erection, when I stopped stimulating the penis, i rapidly loose the erection. It is a bit easier to keep the erections sitting on a chair or laying on the bed. If stand still on foot I rapidly loose erection, but in the firsts I need to stimulate the penis with my hand.

Also I started to experience pain in the perineum, pelvic congestion, lower back pain too.

I went to my 1st urologist he said it was all psycological and not related with the previous event, he prescribed me daily cialis 5mg.
Cialis help me in the first times and there were weeks i was ok, but then i started to get worse again with pelvic pain too on the perineum and anus.
During this year I masturbate daily and orgams to keep my penis active.
I went to other urologists I did a bunch of exams, they all say it is psycological but I am not convienced of that. I think they dont know what else to say...
Exams i did:prostate transrectal utrasound, scrotal ultrasound, penile color doppler ultrasound (i could not get erection with carveject 5mg), hormones testosterone estradiol psa levels, pelvic MRI

All exams were considered normal by the urologists, expect for the prostate that it is a bit enlarged for my age group, slight varicose on the peri-prostatic venous plex, one urologist suggest some sort of prostatitis. There is NO trauma on the perineum or pelvic area.
The urologists told me to use daily Cialis 5mg and that was all psycological again.

Since the ED problem started two veins on the left and right started to be more proeminent and darker blue, almost looking like varicose veins. Urologist didnt worried on that..

On May 2013 I decided to have another approach I started to do exercise every day (running mostly) to improve the blood flow. Do a rigurous diet. Also I stopped struggling with masturbation i decided not to masturbate the next 2 weeks.
Results: My Erections started to come back normally and expontaniously on the waking up and sometimes during the day all this without Cialis. But still i decided not to orgasm. I dont have perineum/pelvic/lowerback pain anymore.

Then I dediced to Masturbate and to orgasm, i orgams 4 times after the pause period, the 1st time i ejaculated a bit of prostate seminal liquid and a bit of white sperm that was not diluded like normally should be. the next times i didnt ejaculate anything.

When I orgasmed I felt the sperm being trapped inside and I felt a disconfourt on the perineum and anus, that continued the next day.

My erections got worse again after the orgasm. I quitted masturbation for the next days, and then the erections got better again and stronger always if i avoid the orgasm.

I've been repeating this same process for a while now, and having good erections after not orgasming for a while and weak erections after orgasm!

In my opinion i strongly belive that the seminal fluids are being trapped inside some sort of blood blockage? or leaking somewhere they shouldnt...

Where is the sperm going?  is the sperm going into my blood flow or nerves?

Please doctor what should I do?

Thanks and regards

Answer
Antonio, as you might imagine, for this type of problem it is not possible for me to make an exact diagnosis or give specific recommendations over the internet because of the inability to take a more complete history and do a physical examination.  In addition, your case is much longer and more complicated than usual for this type of forum.  However, I shall try to help you.

I suspect that you have retrograde ejaculation accounting for the limited amount of semen noted on ejaculation.  
First, let me give you some background information on retrograde ejaculation to be sure that you understand the condition and the available treatments for same.    During sexual arousal the prostate gland & seminal vesicles manufactures fluid that account for the majority of the semen. The seminal vesicles are paired structures located behind the prostate gland that are also sensitive to sexual excitement.  Sperm from the testicles (which account for only 1-2 % of the semen) travel up a series of tubes (epididymis and vas deferens) on each side to join the seminal vesicles forming the paired ejaculatory ducts.  These structures empty into the prostatic portion of the urethra.  At the time of ejaculation, fluid is discharged from the prostate gland and ejaculatory ducts into the urethra (urinary canal) forming the semen.  The average semen volume is 2-6 cc.  With the inception of ejaculation, the bladder neck closes and the semen is forced forward out the urethra by contraction of the pelvic muscles.

Since there are several organs that make the various components of the semen, it is unlikely that all of them are malfunctioning.  Therefore, the most common causes of minimal or absent semen at the time of ejaculation are either a blockage of the ejaculatory ducts or retrograde ejaculation.

Blockage of the ejaculatory ducts may be congenital or acquired usually due to scarring from infection or trauma.  It is best diagnosed by ultrasound of the prostate and seminal vesicles where markedly swollen seminal vesicles are seen.  Sometimes these may be palpable on digital rectal examination.  They can generally be cured by simple transurethral resection of the scarred duct openings through an endoscope.  The small cyst you had causing blockage has apparently been cured so I suspect you have th next disorder.

Retrograde ejaculation occurs when the bladder neck does not close  at the initiation of ejaculation.  This results in semen taking the path of least resistance which is backward into the bladder rather than forward out the urethra. The diagnosis is made by a typical history and the finding of sperm in the first voided urine specimen after orgasm & ejaculation.  This can be congenital or acquired.  Most often is due to malfunction of the pelvic nerves that stimulate closure of the bladder neck.  Common causes of this are pelvic surgical damage and certain diseases of the nervous system such as diabetes, multiple sclerosis & spinal injuries.  Certain medications (such as those used for high blood pressure and emotional problems) may also produce this side effect.  The diagnosis is made by examination of the first voided urine specimen obtained after ejaculation.  The presence of semen elements, namely sperm, on examination of the urine clinches the diagnosis.  The treatment depends on the cause but sometimes drugs containing pseudoephedrine may help to stimulate bladder neck closure with ejaculation.  This medication is taken 30-60 minutes prior to sexual intercourse.  Another option is to take the first voided urine after ejaculation and use this for artificial insemination.  The latter options, of course, would only be indicated if you wanted to get your wife (or girlfriend) pregnant.

I suggest that your see a urologist who specializes in male infertility problems.  Help is available.  

I am sure the perineal pressure and discomfort is due to prostatitis, most likely from too frequent ejaculation which can inflame the prostate.    To follow is a "macro" I have written on this condition which should tell you all you need to know.  The beginning is a bit redundant as it goes over the act of normal  ejaculation that I have already mentioned in my information regarding retrograde ejaculation.  

Symptoms that might occur with prostatitis include frequency of urination, slowing of the urinary stream, burning with voiding or ejaculation, burning in the penile tip unrelated to voiding, urethral discharge, sexual dysfunction (such as difficulty with erection), aching in the penis, testicles, and discomfort in the lower abdomen, low back, groin, rectum or perineum (the area between the scrotum and rectum – between the “wind and the rain”) and constipation. The passage of blood at the initiation or termination of urination or in the semen can also be noted. During sexual arousal the prostate gland & seminal vesicles manufacture fluid that account for the majority of the semen. The seminal vesicles are paired structures located behind the prostate gland that are also sensitive to sexual excitement.  Sperm from the testicles (which account for only 1-2 % of the semen) travel up a series of tubes (epididymis and vas deferens) on each side to join the seminal vesicles forming the paired ejaculatory ducts.  These structures empty into the prostatic portion of the urethra.  At the time of ejaculation, fluid is discharged from the prostate gland and ejaculatory ducts into the urethra (urinary canal) forming the semen.  The average semen volume is 2-6 cc.  With the inception of ejaculation, the bladder neck closes and the semen is forced forward out the urethra by contraction of the pelvic muscles.  

It is not uncommon for inflammation and/or infection to spread in a retrograde manner into the vas and epididymis.  Even without such spread, prostatic discomfort is often referred into the testicle.  Too frequent or too infrequent ejaculation, sexual arousal without ejaculation, withdraw at the time of ejaculation, aggressive bike or horse back riding, and excessive spicy foods, alcohol, and caffeine in the diet can predispose you to this.  Sitting for long periods of time, especially in an automotive vehicle, can put undo pressure on the prostate and aggravate the condition.  For the latter, it is best not to sit more than 2-3 hours at a time.  Stop the vehicle periodically, take a short walk and go to the bathroom to urinate.  A thick pad or piece of sponge rubber on your seat will also help to cushion the prostate.  One should avoid any of the above that apply.  Eliminating all of these factors that apply to you are just as important, if not more so, than taking medication!  Ejaculation beyond the tolerance of the prostate to fill and empty may also cause discomfort.  Likewise if one does so infrequently, fluid still builds up from thoughts, dreams, fantasies, etc. and has to be released periodically to decompress the gland and relieve the symptoms.  For most men, ejaculation in moderation, perhaps 1-2 times a week, is reasonable.  A daily warm bath for 10-15 minutes 1-2 times daily also lessens the discomfort.  Attention to sexual activity and warm bathes should be utilized regardless of the type of prostatitis and whether or not medications are prescribed.

There are several types of prostatitis.  Sometimes prostatitis can be due to an infection of the gland with bacteria.  Typically, pus cells and bacteria are found in the prostatic fluid. The infection usually requires an initial 4 week course of an appropriate antibiotic (the commonest prescribed are the fluoroquinolones, but tetracyclines, sulfas and other agents can also work).  

Abacterial prostatitis has several varieties. In one, the prostatic fluid demonstrates pus cells but no bacteria.  In the other, there are neither pus cells nor bacteria in the fluid, just the symptoms.  In all types of prostatitis, the urinalysis generally is normal unless the infection spreads into the bladder.  Abacterial prostatitis is an elusive entity that has been called by a variety of names including nonbacterial prostatitis, prostadynia, pelvic congestion syndrome and most recently pelvic myoneuropathy.  The latter name was coined by Dr. David Wise of Stanford.  He believes that this may represent up to 95% of all cases of prostatitis.  This variant may be an expression of interstitial cystitis and possibly is due to autoimmune or neurogenic factors. Dr. Wise suggests that  the primary cause of the symptoms involves pelvic muscle spasm, nerve trigger points and some degree of anxiety (either the cause or result of the symptoms).  His therapy involves the use of anti-depressents (we have used Elavil for years in refractory patients), relaxation techniques, trigger point physiotherapy, and biofeedback.  Some others recommend Yoga & meditation as being useful.  Although he may well prove to be correct,  I generally recommend an initial course of antibacterial therapy for patients who clinically have symptomatic prostatitis of any variety.  The majority of patients (even those with nonbacterial prostatitis) seem to respond favorably.  It has been know for decades that many patients with the abacterial variety of prostatitis do well with antibiotics but the reason has been vague.  Some theorized that they may harbor bacteria in the tissues of the prostate that are not being picked up in cultures (possibly walled off loci of infection).  For more information on Dr. Wise's studies check out:
http://www.pelvicpainhelp.com  /

In my experience, symptoms usually responds to the general measures mentioned in the initial paragraph.  Medications that sometimes help include the over-the-counter natural supplement saw palmetto 320 mgm daily and alpha-blockers (such as Flomax, Hytrin, Cardura & Uroxatral).  The latter require a prescription from you physician if he thinks it is indicated.  More recently, a naturally occurring flavinoid with anti-oxidant and anti-inflammatory properties (such as quercetin) has been used in prostatitis.  It's success is yet to be confirmed.  

Prostatitis may also be classified as acute (severe), subacute (mild), or asymptomatic.  It may also occur as a single episode, be recurrent or chronic.  In chronic bacterial prostatitis, long term low dose antibacterial therapy often works well in suppressing symptoms.  In refractory cases, culture of the prostatic fluid or semen often will disclose the offending bacteria.  If found, sensitivity studies can identify which antibiotics are most likely to eliminate that particular germ.  One should be off of all antibiotics for 7-10 days before the culture is taken.  Otherwise, if there is residual antibiotics in your system, this may prevent bacteria from growing in culture.  

In other cases refractory to treatment, there is another condition that can produce similar symptoms. This disorder is ejaculatory duct obstruction. Usually the doctor will find the seminal vesicles to be very swollen on rectal examination. The patient will notice either absence or a markedly diminished semen volume. The diagnosis is made by doing a transrectal ultrasound of the prostate and seminal vesicles.

Therefore, if symptoms persist, consultation with a urologist should be scheduled.  In cases with recurrent prostatitis or hematuria, it often is necessary to study the urinary tract more completely.  Predisposing factors to prostatitis such as a urethral stricture (narrowing) and other disorders can then be evaluated.  A man should learn to listen to his body.  Good luck.  

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Arthur Goldstein, M.D.

Expertise

Problems or questions related to the field of urology; ie urinary stone disease, urinary cancers (kidney, bladder, prostate, testis, etc.), urinary infections, etc. I no longer answer questions related to erection problems or male sexual dysfunction.

Experience

I am retired from the active practice of urology. My 34 years was totally in the clinical field and involved the entire gamut of genitourinary problems, with special interest in endourology.

Organizations
American Medical Association, American Urological Association, American College of Surgeons

Education/Credentials
College degree - BS Medical degree - MD Master of Science - MS

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