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International Journal of Impotence Research (2004) 16, 456–458
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Case Report
Analysis of retrograde ejaculation using color Doppler
ultrasonography before and after transurethral collagen injection
A Nagai*1, Y Nasu, M Watanabe, M Tsugawa, H Iguchi and H Kumon
1
Department of Urology, Okayama University Graduate School of Medicine and Dentistry, Okayama, Japan
Transurethral bladder neck collagen injection therapy was performed in a patient with retrograde
ejaculation. The phenomenon of retrograde ejaculation and its correction after the therapy were
clearly demonstrated by color Doppler ultrasonography. To our knowledge this is the first report
showing successful observation of retrograde ejaculation using color Doppler ultrasonography.
International Journal of Impotence Research (2004) 16, 456–458. doi:10.1038/sj.ijir.3901202
Keywords: retrograde ejaculation; color Doppler ultrasound; collagen injection; spinal cord
injuries; sexual dysfunction
Introduction
Retrograde ejaculation accounts for not only male
infertility but also impaired sexual satisfaction. We
report a case of retrograde ejaculation treated by
transurethral collagen injection. The phenomenon
of retrograde ejaculation and its correction after
therapy were clearly demonstrated by color Doppler
ultrasonography.
Case report
A 40-y-old male presented with retrograde ejaculation caused by incomplete spinal cord injury at the
level of the thoracic vertebrae due to a traffic
accident. He had been suffering from a slight gait
disturbance and performed intermittent self-catheterization because of urinary retention for 6 y. He
complained of lack of sexual satisfaction at orgasm
due to the absence of antegrade ejaculation. No
improvement of retrograde ejaculation was made by
conventional oral medication including imipramine
hydrochloride and antihistamines. A real-time ima-
*Correspondence: A Nagai, MD, PhD. Department of
Urology, Okayama University Graduate School of Medicine and Dentistry, 2-5-1 Shikata, Okayama 700-8558,
Japan.
E-mail: [email protected]
Received 3 September 2003; revised 7 December 2003;
accepted 26 January 2003
ging of the ejaculation was conducted using an
ultrasonic image directed color Doppler system
(Aloka SSD-2000) with a 7.5 MHz. electro-probe
(UST-669). The probe was introduced into the
rectum in the left lateral decubitus position. Ejaculation was induced by manual stimulation combined with audiovisual-sexual stimulation. These
ejaculatory processes were observed before and after
transurethral collagen injection. Before treatment,
the prostatic urethra became distended immediately
after seminal expulsion began. The inframontanal
and distal prostatic urethra was distended into a
globular-shaped sac filled with semen during expulsion. No relaxation of the external sphincter
was observed during expulsion. There was no flow
towards the bulbous urethra. At 2 s after the end of
expulsion, the fluid in the prostatic urethra flowed
slowly into the bladder (Figure 1).
Transurethral collagen injection was performed
under lumbar anesthesia. A total of 6.0 ml collagen
was injected submucosally at 4-, 6- and 8-h
positions at the bladder neck (Figure 2). At 14 days
after surgery, the examination was repeated. The
injected collagen was clearly detected at the neck of
the bladder. The inframontanal and distal prostatic
urethra was filled with semen during expulsion,
followed by antegrade ejaculation (Figure 3). After
surgery, the patient attained sexual satisfaction due
to the commencement of normal antegrade ejaculation, but he complained of a gradual decrease of
seminal volume 6 months postop. And retrograde
ejaculation, the procedure same as before, reappeared 1 y after surgery. Therefore, collagen injection therapy was repeated and there were no
complications.
Analysis of retrograde ejaculation
A Nagai et al
457
Figure 1 Color Doppler images of retrograde ejaculation: (a) bladder (b) and prostate (p) were normal before stimulation; (b) prostatic
urethra (pu) opened at the beginning of expulsion from the seminal vesicle (sv); (c) inframontanal urethra dilated widely and was filled
with semen during expulsion. Seminal flow through the ejaculatory duct was observed (black arrow); (d) At 2 s after the end of expulsion,
semen in the inframontanal urethra slowly flowed into bladder (white arrow); (e) retrograde ejaculation lasted about 60 s; (f) posterior
urethra and the bladder neck returned to normal 117 s after the end of expulsion.
Figure 2 Transurethral collagen injection therapy: (a) The bladder neck before surgery; (b) collagen is injected submucosally using
a 22-gauge needle (white arrow); (c) the bladder neck is narrowed after collagen injection.
Figure 3 Color Doppler images of ejaculation after collagen injection therapy: (a) accumulation of collagen was observed in the prostate
at the bladder neck; (b) pu opened at the beginning of expulsion from the sv; (c) inframontanal urethra dilated widely and seminal flow
through the ejaculatory duct was observed (black arrow) during expulsion; (d, e) the bladder neck did not open and there was no seminal
flow into the bladder; (f) flow of semen to the bulbous urethra was observed after the end of expulsion.
International Journal of Impotence Research
Analysis of retrograde ejaculation
A Nagai et al
458
Comments
To our knowledge, this is the first report of
successful observation of retrograde ejaculation
using color Doppler ultrasonography. Only one
previous study of transrectal ultrasonographic imaging during ejaculation in a healthy male has been
reported, demonstrating antegrade ejaculation.1 In
the present patient, neither relaxation of the external
sphincter nor contraction of the bladder neck was
observed after the prostatic urethra was filled with
semen. This suggested that detrusor sphincter
dysynergia (DSD) might be responsible for retrograde ejaculation. Although DSD persisted after
surgery, a sufficient pressure chamber can be created
by collagen injection for a reasonable period of
time.
International Journal of Impotence Research
Collagen injection for retrograde ejaculation resulting in pregnancy has been reported.2 The
purpose of collagen injection in our patient was
to achieve an antegrade ejaculation resulting in a
satisfactory sexual relationship with the partner.
Noninvasive dynamic observation of human ejaculation using Doppler ultrasound is feasible, providing a new method of diagnosing ejaculatory
disorders.
References
1 Gil-Vernet Jr JM et al. Ejaculation in men: a dynamic
endorectal ultrasonographical study. Br J Urol 1994; 73:
442–448.
2 Reynolds JC et al. Bladder neck collagen injection restores
antegrade ejaculation after bladder neck surgery. J Urol 1998;
159: 1303.