The physiological and psychological disorders of sexual desire, arousal and orgasm are summarized in Table 8.1 and illustrated in Figures 8.1 and 8.2. Sexual dysfunction may be due to drug administration and/or medical-neural-psychogenic interaction (Table 8.2).
There are two main ejaculatory abnormalities: retrograde flow of semen is the complete or incomplete flow of semen into the bladder; and anejacula- tion is the complete absence of ejaculate due to total failure of seminal emission into the posterior urethra. Anejaculation is differentiated from retrograde flow by conducting a postorgasmic urinalysis test, which in anejaculation reveals a non-viscous, fructosenegative and sperm-negative result.
RETROGRADE FLOW OF SEMEN
‘Retrograde flow of semen’ erroneously referred to as ‘retrograde ejaculation’ involves the flow of semen into the urinary bladder during orgasm. In normal men the urinary sphincter remains closed during ejaculation to prevent retrograde semen flow into the bladder. However, if the sphincter is not contracted for any reason, the ejaculate may flow backwards into the bladder rather than flow normally through the urethra. Thus, retrograde flow of semen is caused by several physiological anomalies which interfere with sympathetic innervation and anatomical defects of the smooth musculature of the bladder neck. Retrograde flow of semen may be associated with various conditions:
(1) Men with multiple sclerosis, spinal cord injury or extensive pelvic surgery, e.g. prostatectomy;
(2) Retroperitoneal lymph node dissection to treat testicular cancer, probably due to the removal of
or damage to sympathetic ganglia/hypogastric plexus;
(3) Transurethral resection of prostate or bladder neck, resulting in interruption in sympathetic innervation to bladder neck;
(4) Diabetic visceral neuropathy, causing erectile dysfunction or retrograde flow of semen;
(5) Pharmacological agents causing psychogenic or idiopathic erectile or ejaculatory dysfunction, including antipsychotic drugs, chlorpromazine, antihypertensive drugs, a-adrenergic blockers, bethanidine, prazosin hydrochloride, phenoxy- benzamine hydrochloride (Jeyendran, 2003).
Symptoms and diagnosis
Symptoms of retrograde flow of semen include:
(1) Aspermia (total lack of an ejaculate after orgasm) caused by ‘complete’ retrograde flow of semen into the bladder;
(2) Absent or intermittent emission of ejaculate;
(3) Presence of sperm within voided urine after orgasm;
(4) Hypospermia (tiny semen volume (< 0.5 ml)) caused by ‘incomplete’ retrograde flow of semen.
Medical treatment for the correction of retrograde ejaculation is based on either increasing sympathetic tone at the bladder neck or decreasing parasympathetic activity, when alpha-agonistic or anticholinergic and antihistaminic drugs are used, respectively. At the administered doses, the side-effects of drugs given for the reversal of retrograde ejaculation include various degrees of dizziness, sleep disturbances, weakness, restlessness, dry mouth, nausea or sweating during the medical treatment.
The effect of amezinium, a new type of antihypotensive agent, on retrograde ejaculation has been studied. The patients received 10 mg amezinium orally once a day. All patients achieved antegrade ejaculation. Semen analyses revealed 650 x 106/ml (mean 28.7 x 106/ml) sperm with a motility of 20-50% (mean 36.7%). The wives of two of the patients became pregnant within 6 months of the initial treatment. None of the patients had any side-effects.
Sperm retrieval from urine
Urine, due to its acidity and other factors, is naturally detrimental to sperm quality. In order to obtain viable sperm from urine, the osmolality and acidity of bladder urine are adjusted using chemicals which minimize the detrimental qualities of urine towards semen. Two main methods are used to equalize osmolality and to neutralize the pH effects of urine.
Figure 8.1 (a) Areas of the brain that are important for normal sexual desire and responsiveness. (b) Types of hormones linked to desire and arousal. From Morrell and Flynn (2003), with permission
Figure 8.2 Physiological sexual response in men and women (upper panel). Blood flow measurements in male and female genitalia in response to erotic film (lower panel). From Morrell and Flynn (2003), with permission
Figure 8.3 Retrograde sperm collection device. Urine collection container (a), housing the semen collection device. Reusable semen collection device (b), designed to separate initial voided urine flow aliquot. Urine overflow ducts (c), facilitating separation of initial voided urine from remaining flow. Initial voided urine flow (high relative semen concentration) aliquot retention receptacle (d) and excess voided urine (e) (low semen concentration). Jeyendran, 2003
Aliquots of 5 ml of voided urine are collected, after masturbation, in buffered physiological solution or media.
A reusable device allows for easy and efficient collection of urine containing retrograde semen flow (Figures 8.3 and 8.4). Since such retrograde semen flow typically saturates the urine, the retrograde sperm collection device mechanically isolates only the initial portion of voided urine to facilitate optimal sperm separation.
The patient drinks large volumes of water to dilute the urine, starting 48h before and continuing on the morning of urine collection. Urine pH is raised above 7.5 by ingestion of 650mg sodium bicarbonate tablets 48h before and on the morning of collection or ingestion of Alka-Seltzer® (two tablets) on the night before and morning of collection. In patients who are unable to void urine, their bladder can be catheterized (30-60 ml media should be instilled into the bladder and sperm should be retrieved rapidly after orgasm to minimize any deleterious effects of urine on sperm quality).
A dose of 10-60 mg nifedipine given orally, singly or in combination with nitroglycerin tablets should be given sublingually 10 min before initiation of the procedure, when blood pressure is normal/ stabilized.
Three professionals are needed in the out-patient setting: a nurse to monitor the patient; a clinician to operate the electrostimulator; and an assistant to collect the ejaculate. The patient should be sedated with diazepam, hesperidins or midazolam. Blood pressure should be recorded when the patient is in a wheelchair, then when lying on a table.
The bladder should be emptied, flushed with 10 ml of media and infused with 10 ml media, the catheter then being withdrawn leaving media in situ.
If one finger can slip easily into the rectum a 2.5cm probe should be used; a 3-cm probe should be used if two fingers can slip in easily. The probe should be connected to a stimulator and inserted 10-11 cm inside the anal ring. Ejaculation occurs upon application of 4-10 V with higher cord lesions (T10 and above. The probe should be withdrawn immediately upon ejaculation, the rectum examined and the bladder catheterized and flushed to obtain any retrograde ejaculate (oral antibiotics may be required for 34 days after the procedure).
Figure 8.4 Sperm before (a) and after centrifugation (b)
Anejaculation, the physical inability to ejaculate, may result from diabetes, spinal cord injury, neurological disorders and idiopathic or psychogenic factors. In such cases, clinical semen collection can be achieved using mechanical, electrical or pharmacological procedures.
Several instruments have been used for vibratory stimulation of the penis to induce a reflex ejaculation, including ‘Swedish massager’ and Ling 201 vibrator (Ling Dynamics, Royston, UK).
Unfortunately, these techniques are not effective during the first 6 months after spinal injuries, and patients lose their capacity for reflex hip flexion. The success of such procedures depends on the location of the injury. Central nervous system lesions on T8 and above may tolerate artificially induced ejaculation; however, the procedure is ineffective with injuries to lower vertebrae.
This type of infertility refers to patients who cannot produce a semen specimen for analysis or for use in intrauterine insemination (IUI) and, in some cases, are also unable to ejaculate during intercourse. The patient is unable to ejaculate around the time of his wife’s ovulation, although sperm are present in the postcoital test. Vibratory stimulation is recommended because it is simpler and less invasive, and can be performed in the office or at home. Since electroejaculation (EEJ) requires general anesthesia, EEJ can be used in neurologically intact men. In men with a neurological problem, it is more cost-effective to perform in vitro fertilization (IVF) rather than IUI. Testicular sperm extraction and IVF/intracytoplasmic sperm injection (ICSI) can be performed for such patients, thus avoiding general anesthesia and EEJ altogether. IUI combined with EEJ or penile vibratory stimulation is cost-effective in patients with spinal cord injury who do not require anesthesia. If the patient cannot ejaculate at ovulation by vibratory stimulation, a semen sample can be cryopreserved. Sex therapy may also help the patient ejaculate intravaginally by gradual desensitization. Open micro- surgical vasal aspiration is another option. Sex therapy is considered for patients with initial complaints of erectile dysfunction and retarded ejaculation.
Pharmacology of anejaculation
Pharmacological drugs are not recommended for anejaculation, because of the inherent unpredictability of ejaculatory response, coupled with potentially deleterious side-effects. Tricyclic antidepressant drugs such as imipramine induce episodes of spontaneous ejaculation and orgasm in a dose-dependent manner during yawning and defecation. Such compounds and their metabolites inhibit norepinephrine reuptake by promoting a-adrenergic activity. Intrathecal neostigmine methylsulfate has been applied to obtain semen from physically disabled men.
The patient is placed in the supine position, the vibrator is turned on and adjusted to 100 Hz frequency.
Figure 8.5 Vibratory stimulation for ejaculation in an anejaculatory man. (a) Hand-held Multicept A/S Ferti Care® personal vibrator. (b) Standard Multicept A/S Ferti Care® clinic vibrator. (c) NeuroControlTM Life STM system (NeuroControl Corporation, Valley View, OH). Courtesy of Professor R. S.Jeyendran
Either a large clinic vibrator (Multicept A/S Ferti Care® Clinic Vibrator) (Multicept A/S, Rungsted, Denmark) or a hand-held personal vibrator can be used (Figure 8.5).
Flat applicators of vibrator are used for spinal cord-injury patients, while curved applicators are used for healthy men in a seated position; during the procedure the amplitude is adjusted for a peak- to-peak distance of 4 mm.
The prepuce is retracted and the vibrator is applied to the frenulum of the penis, with the tip of the penis in a sterile cup. The vibrator is applied to the penis and adjusted to a peak-to-peak distance of 2.5 mm. The procedure is repeated for up to 3.5 min if ejaculation does not occur; with an interval of 1.5 min the procedure can be repeated four times. The prepuce is then replaced to normal and the patient observed to ensure no episodes of ‘autonomic dysreflexia’ or skin discoloration occur. Ejaculation is usually accompanied by a rhythmic reflex contraction of genital/anal abdominal muscles.
This procedure is used within 6 months after spinal injury; it requires viability of at least T10-L2 segments (reflex function in the lumbar cord is not necessary). The procedure is used when vibratory stimulation is not effective or if autonomic dysreflexia occurs. A rectal probe is used to affect only the nerve fibers vital to accomplish the procedure; stimulation is limited to the myelinated sympathetic efferent fibers of hypogastric plexus, to avoid any possible thermal or electrolytic damage of rectal mucosa.