Archives of Andrology, 51:431–436, 2005
Copyright # Taylor & Francis Inc.
ISSN: 0148-5016 print/1521-0375 online
DOI: 10.1080/014850190953294
THE ONLY PRESENCE OF SPERM IN URINE DOES NOT IMPLY
RETROGRADE EJACULATION
J. I. Ariagno, G. R. Mendeluk, M. N. Pugliese, S. L. M. Sardi, C. Acuña,
H. E. H. Repetto, and S. M. Curi & Departamento de Bioquı´mica Clı´nica,
Facultad de Farmacia, Bioquı´mica, U.B.A. Proyecto UBACYT, Hospital de Clı´nicas
‘‘Jose´ de San Martı´n,’’ Buenos Aires, Argentina
& This is a retrospective study of clinical experience collected at the University Clinical Hospital
over a 19-year period. Semen samples were analyzed according to WHO criteria. In the postmasturbatory urine, sperm count was performed. Data were expressed as total sperm number in urine
(TSNU) and using a retroejaculation index. Patients were categorized into four groups according
to the presence of sperm in the studied samples: a) in semen and urine; b) only in urine; c) only in
semen; d) neither in semen nor in urine. A control group included nonretroejaculator patients.
Retroejaculator patients are those whose TSNU is superior to 3.8 106 and the RI superior to
2.16%. While diagnosing retroejaculation, the only presence of sperm in the postmasturbatory
urine is not adequate. The proposed index added to total sperm number in urine and semen volume
may identify true retroejaculator patients.
Keywords sperm in urine, retrograde ejaculation, diagnosis, prostatic surgery, diabetic
neuropathy
INTRODUCTION
The most widely accepted theory to explain ejaculation consists of two
phases: a) phase of accumulation of the various constituents of semen inside
the prostatic urethra and b) phase of expulsion with opening of the striated
sphincter, while the smooth sphincter of the bladder neck remains closed.
Antegrade ejaculation requires intact anatomy and innervation of the
bladder neck. Failure of the normal ejaculatory mechanism may lead to
retrograde ejaculation. Retrograde ejaculation is an uncommon cause of
infertility and can be defined as the escape of seminal fluid from the
Supported by a grant from the University of Buenos Aires, UBACYT (B=037).
Address correspondence to Julia Irene Ariagno, Departamento de Bioquı́mica Clı́nica, Facultad de
Farmacia, Bioquı́mica, U.B.A. Proyecto UBACYT, Hospital de Clı́nicas ‘‘José de San Martı́n,’’ Melian 3862
1430, Buenos Aires, Argentina. E-mail: [email protected] or [email protected]
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posterior urethra into the bladder [1]. This occurs most commonly as
a result of transurethral prostatectomy, retroperitoneal lymph-node
dissection [2] and diabetic neuropathy.
Surgical therapy of benign prostatic hyperplasia (open surgery or transurethral prostatic resection) is associated with retrograde ejaculation in
nearly 100% of cases [3]. Retrograde ejaculation also can be related to a
traumatic injury of the posterior urethra due to the trauma itself or the
therapy. Finally, the ejaculation disorder can be produced by several drugs
that block, as a main or secondary effect, the alpha-adrenoreceptors or act
at the central level.
Retroejaculation may be suspected on clinical grounds referred to previously and data from the seminal analysis, the finding of either aspermia or
a small volume of semen, which does not contain a normal number of
sperm. The diagnosis of the retrograde ejaculation in the infrequent complete form is established through its major sign: the aspermia. Hershlag
et al. [4] bases the diagnosis on the absence of sperm in the antegrade
ejaculate and the presence of sperm in the postmasturbatory urine. The
problem is to diagnose the minor forms where only part of the ejaculate
is driven into the bladder resulting in a diminution of sperm volume and
in some cases also sperm count. Male infertility due to retroejaculatory
problems can be effectively treated and accurate diagnosis is required.
This is a retrospective study of clinical experience collected at the
University Clinical Hospital ‘‘José de San Martin’’ over a 19-year period
(1983–2002). The aim of this work is to determine if the only identification
of spermatozoa in the postmasturbatory urine confirms the diagnosis or if a
cut-off value should be established.
MATERIALS AND METHODS
Patients
Following Institutional Review Board approval specimens in this study
were obtained from 87 men attending the Andrological Laboratory at
the University Clinical Hospital of Buenos Aires ‘‘José de San Martı́n.’’
The patients were referred to our clinic for infertility problems associated
with retrograde ejaculation on clinical or biochemical grounds. The control group included patients referred to our clinic for infertility problems
not associated with retrograde ejaculation, based on clinical grounds and
data from the seminal analysis (n ¼ 27).
Sample Collection and Analysis
Voided urine specimens were collected from the patients following
production of the semen specimen (masturbation). Semen analysis was
Retrograde Ejaculation Diagnosis
433
performed according to WHO regulations [5]. The post masturbatory
urine was observed in the microscope (400). If sperm were found, the
count was assessed using an improved Neubauer Chamber, if not it was centrifuged and the sediment observed; in case of finding sperm in the sediment its concentration was referred to the total urine volume.
Data Expression
The total sperm number was assessed when sperm were found either in
semen or in urine. Data were expressed as: total sperm number in urine
(TSNU) and retroejaculation index (RI)
RI ¼
total sperm number in urine 100
total sperm number in urine + total sperm number in semen
Statistical Analysis
Due to the skewed variables assessed, nonparametric methods were
used. Results are expressed as median; 25th percentile; 75th percentile.
Wilcoxon test was used to compare differences among groups while the
Kruskal-Wallis test was employed on comparing two particular groups;
p < 0.05 was accepted as statistically significant. The Spearman correlation
was applied between the studied parameters.
RESULTS
Men were categorized into four groups as follows. Group A had sperm
in semen and urine (n ¼ 47); Group B only in urine (n ¼ 7); Group C only
in semen (n ¼ 7); Group D neither in semen nor in urine (n ¼ 26).
(Figure 1). The high number of patients in Group A with sperm in semen
and urine probably includes the minor form of retroejaculation. The presence of sperm in urine in the control group was 1,118 sperm in total urine
(median). The sperm number in urine or the retroejaculation index
showed significant difference between Groups A and control (p < 0.0001;
Table 1); a good correlation was found between TSNU and RI (r ¼ 0.86,
p ¼ 0.00001). The TSNU did not correlate with the sperm number in
semen in Group A or in the control group.
On comparing semen volume in all the groups, a high statistical difference was found (p < 0.00001). The same difference was found on comparing
Group A and the control, while no difference was obtained between Group C
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FIGURE 1 Sperm distribution in groups.
and the control. All patients included in Group B were either aspermic
or severely hypospermic (median ¼ 0.00001 ml; 25th percentile ¼ 0; 75th
percentile ¼ 0.1).
Semen volume did not correlate with TSNU, suggesting that although
hypospermia may guide to suspect retroejaculation is not a sufficient tool
to arrive to the accurate diagnosis. Group A was divided according to semen
volume in hypospermic (< 2.0 mL) and normospermic; the median RI was
17.89% in the former and 0.004% in the latter.
According to NCCLS guidelines [6], the 2.5th and the 97.5th percentiles from the control group define the reference limits. Considering the
97.5th percentile, retroejaculators are those patients where the TSNU is
superior to 3.8 106 and the IR superior to 2.16%.
TABLE 1 Comparison between Groups
Total sperm
number in semen
GROUP B
38.4 106; 6.0 106;
155 106
0
GROUP C
GROUP D
CONTROL
GROUP
156000; 45100; 595000
0
92.4 106; 16.49 106;
357.05 106
GROUP A
Semen
volume (ml)
Total sperm
number in urine (TSNU)
RI
(%)
1.20; 0.60; 1.90
5.6 106; 7400; 39 106
10.64; 0.09; 48.87
0.00001; 0; 0.1
26 106; 8.7 106;
29.8 106
0
0
1118; 133; 7912
100
4.3; 3.5; 5.0
1.35; 0.8; 3.0
2.85; 2.02; 3.80
Data are expressed as: median; 25th percentile; 75th percentile.
—
—
0.0021; 0.0003;
0.0307
Retrograde Ejaculation Diagnosis
435
DISCUSSION
Strategy for male infertility is a compromise between diagnosis methods
with their efficacy and complexity and treatment with their own risk, cost,
and efficacy. Some situations may benefit from specific therapy such as
hypogonadotrophic hypogonadism, anejaculations, or retrograde ejaculation. Retrograde ejaculation causes less than 2% of male infertility but
is the leading cause of aspermia. The incidence of retrograde ejaculation
is increasing due to aggressiveness of modern urologic cancer surgery
and an increase in diabetes mellitus. Generally, the only adverse effect is
on fertility.
If pharmacological attempts to restore antegrade ejaculation fail, sperm
recovery from the urine is indicated. Modern assisted reproduction technology is a powerful treatment option for retrograde ejaculation when combined with a technique to retrieve spermatozoa of good quality from the
bladder [7]. The benefit of ICSI in cases of anejaculatory infertility due
to retrograde ejaculation who are resistant to medical treatment and whose
sperm quality is so low or unpredictable that intrauterine insemination or
conventional methods of in vitro fertilization are not possible were
reported by Okada et al. [8].
Thus, work is needed to achieve objectivity and standardization of the
laboratory diagnosis of retroejaculation that should finally be included in
the guidelines of the World Health Organization [5] to select an appropriate clinical management for patients looking for fertility.
The main purpose of the evaluation of retroejaculation should be established. It provides basic knowledge on the status of a given patient. The
information obtained may help to decide where to retrieve sperm in cases
of patients looking for fertility. On the other hand data obtained could
have a prognostic value, particularly in cases of Type I diabetes [9]. Further
studies should be conducted to evaluate the relation of RI and other
biochemical and biophysical markers like glycosilated hemoglobin or blood
rheology as well as with clinical data like retinopathy to interpret the
evolution of disease.
Low volume or absent ejaculate was a characteristic of Groups A and B,
with a few exceptions, data that could lead to investigate retroejaculation.
We tried to clarify the diagnosis and to establish rules that could help to
obtain a better diagnosis of the pathology under study. In a pragmatic
way patients were selected according to the presence of sperm either in
semen or in urine. Thus Group A is composed of true and nonretroejaculators as well as Group D. All the subjects classified into Group B are true
retroejaculators while those classified into Group C are nonretroejaculators
belonging to severe oligozoospermic patients. It is important to arrive to
an accurate diagnosis in Groups A and D. Focusing in this purpose we
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established a retroejaculation index, a biochemical analysis should be performed in Group D.
It is concluded that while diagnosing retroejaculation, the only presence of sperm in the postmasturbatory urine is not enough, the proposed
index added to total sperm number in urine and semen volume may lead
to identify true retroejaculator patients.
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