A 34-year-old man presented with a four-year history of absent ejaculation and difficulty conceiving with his wife.
He initially noticed a gradual reduction in semen volume, which eventually led to a complete absence of ejaculation despite reaching orgasm. However, he had no issues with libido, erection, or sexual satisfaction.
One year after these symptoms began, he was diagnosed with Type 2 Diabetes Mellitus (T2DM) and started on oral medication. His brother also has diabetes. He has no history of pelvic surgery, cancer, radiation exposure, spinal injury, or mumps. He has not experienced symptoms of hormonal imbalance, such as headaches, thyroid issues, or breast enlargement. He does not smoke or use recreational drugs and drinks alcohol only occasionally.
The patient fathered a child in a previous relationship and now wishes to have children with his wife. After visiting multiple fertility clinics without receiving a clear diagnosis, he sought a second opinion at our facility.
On examination, he was 1.75 meters tall and weighed 65 kg (143.3 lbs). His genitalia appeared normal, with a circumcised penis and typical male hair distribution. There were no scars, masses, or abnormalities. His testes were normal in size and texture, and his urethra opened at the tip of the penis without additional openings.
Diagnostic assessment and Management
The patient underwent a series of diagnostic tests. At presentation, his random blood glucose was 391 mg/dL (21.72 mmol/L), which improved to 191 mg/dL (10.61 mmol/L) after dietary and medication adjustments. His HbA1c was 12%, indicating poor long-term glycemic control. Routine blood tests, including full blood count (FBC) which was within normal limits, however electrolyte, urea, and creatinine (EUCr) had a slight elevation in sodium and creatinine suspected to be from dehydration as patient was in a habit of not inadequate hydration. (Table 1.0)
Hormonal assay including Follicle stimulating hormone(FSH),Testosterone and Thyrotropin(TSH) were also within normal limits.(Table 1.0)
Imaging studies, including abdominopelvic and penoscrotal ultrasound, showed no abnormalities. Urinalysis revealed glucosuria (+++), but there were no ketones present. Urine culture and sensitivity yielded no bacterial growth.
A post-ejaculatory urine microscopy, performed after 72 hours of abstinence, showed a high concentration of sperm cells (+++) of about 32 X 106mls in the urine and fructose was also found in urine.
The World Health Organization(WHO) criteria for retrograde ejaculation were met (with retrograde ejaculation ratio(RER) of infinity) and the patient was clinically diagnosed as having retrograde ejaculation secondary to uncontrolled diabetes mellitus.
The Patient was counseled on the above findings, on the need for strict adherence to oral glycaemic control medications with advice on Kegel‘s exercises before the commencement of medication.
The patient was then placed on Tab Chlorpheniramine 4 mg 12 hourly and 4 days post drug initiation, he was able to achieve antegrade ejaculation (AE) with about 1 ml.
Tab Imipramine 50mg daily was added on day 5 and the ejaculate achieved was 2 mls on day 10, which was subjected to Semen Analysis and the results were unremarkable following WHO 2010 parameters for semen analysis.
The patient was subsequently tried on Tab Imipramine alone from day 12 - day 16 and in the end, was unable to achieve an adequate amount of ejaculate being only able to achieve 0.9mls of ejaculate.
Following the cessation of medications, the patient failed to achieve AE. However, when recommenced on medication (Tab Chlorpheniramine + Tab Imipramine), the patient was able to do so making about 2.5mls, however this was not analyzed. The patient was then counselled on the need to have his spouse examined for possible female factors that could also play a role in preventing pregnancy while being counselled on the need to look out for possible side effects associated with the combination of both drug regimens,however spouse could not be evaluated and she failed to report at the facility. He was also counseled on alternative to achieving pregnancy via Assisted Reproductive Technologies.
Table 1.0
|
Investigations
|
Result
|
Normal Range
|
|
Full blood count
|
|
|
|
Packed Cell Volume
|
35%
|
34 - 54%
|
|
White Blood Cell Count
|
7000cells/mm3
|
3,500 - 10,000mm3
|
|
Neutrophil
|
50%
|
40 - 60%
|
|
Lymphocyte
|
42%
|
20 - 40%
|
|
Eosinophil
|
03%
|
1 - 4%
|
|
Monocyte
|
05%
|
2 - 8%
|
|
Basophil
|
00%
|
0.5 - 1%
|
|
Electrolyte Urea and Creatinine
|
|
|
|
Urea
|
54
|
11 - 55mg/dl
|
|
Creatinine
|
1.2
|
0.3 - 1.5mg/dl
|
|
Sodium
|
155
|
135 - 150mmol/l
|
|
Potassium
|
5.3
|
3.4 - 5.3mmol/l
|
|
Chloride
|
109
|
96 - 106mmol/l
|
|
Hormonal Assay
|
|
|
|
Follicle stimulating Hormone
|
4.485
|
1 - 13mIU/ml
|
|
Testosterone
|
2.939
|
2.2 - 10.5nmol/l
|
|
Thyrotropin
|
1.475
|
0.3 - 4.5uIU/ml
|