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BioMed Central
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Cases Journal
Open Access
Case Report
Anejaculation as an atypical presentation of prostate cancer: a case
report
Uwais Mufti, Khurshid R Ghani*, Rateb Samman, Jaspal Virdi and
Bernard Potluri
Address: Department of Urology, Princess Alexandra Hospital, Hamstel Road, Harlow, Essex, CM20 1QX, UK
Email: Uwais Mufti - umufti@googlemail.com; Khurshid R Ghani* - krghani@gmail.com; Rateb Samman - Rateb.Samman@pah.nhs.uk;
Jaspal Virdi - j.virdi@ntlworld.com; Bernard Potluri - potluri@doctors.org.uk
* Corresponding author
Abstract
Anejaculation may occur as a result of neurological disease, iatrogenic injury or be drug induced.
We report a case of a 66 year old man who presented with anejaculation following an emergency
abdominal aortic aneurysm repair. Due to an elevated prostate specific antigen (PSA) level, the
patient underwent a prostate biopsy and was diagnosed with a prostate adenocarcinoma. This was
effectively managed using active surveillance, a treatment modality that aims to select only those
patients with significant cancer for radical treatment. Despite the possible cause of anejaculation to
be iatrogenic, the reader should be aware that prostate cancer may co-exist in, or cause any
disorder of the lower urinary tract.
Background
Anejaculation is defined as the complete absence of ante-
grade or retrograde ejaculation [1]. It is caused by failure
of emission of semen from the prostate and seminal ducts
into the urethra. In the older man, prostate cancer is the
diagnosis of exclusion.
Case presentation
A 66 year old man with a history of hypertension and
ischaemic heart disease was referred by his general practi-
tioner complaining of anejaculation. He had no difficulty
in obtaining erections or orgasm and no history of lower
urinary tract symptoms. Anejaculation coincided with
recent emergency abdominal aortic aneurysm (AAA)
repair. Digital rectal examination (DRE) revealed a mod-
erately enlarged smooth prostate. The prostate specific
antigen (PSA) level was 4.5 ng/l (age related normal range
0–4). The likely cause for anejaculation in this patient was
injury to the sympathetic trunk during AAA repair. The
differential diagnosis was retrograde ejaculation and pros-
tate cancer. Semen analysis of the first voided urine fol-
lowing intercourse excluded retrograde ejaculation. After
informed consent the patient underwent a 14-core tran-
srectal ultrasound (TRUS) guided prostate biopsy. This
revealed a moderately differentiated prostate adenocarci-
noma (Gleason score 6) in only 2 cores (largest focus of
cancer = 2 mm). Following case discussion at a specialist
multi-disciplinary team meeting, the patient was offered
three prostate cancer management options: radical radio-
therapy, brachytherapy or active surveillance. Radical
prostatectomy was not a suitable option due to cardiac
risk factors. The patient opted for active surveillance and
was referred to the Medical Research Council active sur-
veillance study at the Royal Marsden Hospital, London.
Published: 11 August 2008
Cases Journal 2008, 1:81 doi:10.1186/1757-1626-1-81
Received: 22 June 2008
Accepted: 11 August 2008
This article is available from: http://www.casesjournal.com/content/1/1/81
© 2008 Mufti et al; licensee BioMed Central Ltd.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0),
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Cases Journal 2008, 1:81 http://www.casesjournal.com/content/1/1/81
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Discussion
Ejaculation is mediated by the sympathetic nervous sys-
tem. Causes of anejaculation include spinal cord injury,
cauda equina lesions, multiple sclerosis, Parkinson's dis-
ease, diabetes mellitus, medication (antihypertensive,
antipsychotic, antidepressants, alcohol) and surgery (aor-
toiliac surgery, retro peritoneal lymph node dissection,
colorectal resection) [1]. The thoracolumbar sympathetic
nerves cause contraction of the smooth muscles of the
prostate, seminal vesicles and vas deferens leading to
emission of seminal fluid into the urethra. These nerves
are prone to injury during AAA repair, especially when
undertaken as an emergency [2]. Aortoiliac surgery can
also lead to damage of the superior hypogastric plexus
and result in erectile dysfunction. In one study, up to 80%
of patients had some form of sexual dysfunction after AAA
surgery [3]. There are no published figures on the rate of
anejaculation only.
Even though a diagnosis of post-AAA repair anejaculation
may have been evident in this case, sexual dysfunction is
also a recognised presentation of prostate cancer. The case
we have presented is the first reported case of prostate can-
cer detected in a patient complaining of anejaculation.
When DRE finding or PSA level is unable to confidently
exclude prostate cancer, patients should be advised of the
risk of prostate cancer. Systematic TRUS guided prostate
biopsy is the gold standard method for diagnosing pros-
tate cancer. As a result of the PSA test, the majority of
modern day prostate cancers are PSA detected cancers.
These patients often have early localised asymptomatic
cancers.
Active surveillance is the most recent management option
in the treatment of localised prostate cancer. It aims to
individualise the management of early low grade
(Gleason score <= 7) prostate cancer by selecting only
those men with significant cancers for curative treatment.
It involves strict monitoring of the PSA level, DRE finding
and histological status by repeat prostate biopsy. Early,
radical treatment is offered to those with evidence of sig-
nificant biochemical or histological progression [4]. This
is in contrast to watchful waiting which for decades has
been associated with less stringent observation criteria
with late, palliative treatment offered to those who
develop symptoms of cancer progression. Early results of
active surveillance have been encouraging. A Royal
Marsden Hospital study found that 80% of 80 patients
recruited to active surveillance continued to be under sur-
veillance after a median of 42 months follow up. 14% of
patients received radical treatment of which all remained
biochemically controlled with no evidence of recurrent
disease. None of the patients in the study developed met-
astatic prostate cancer and there were no deaths from
prostate cancer [5]. A more recent study has examined the
effect of delaying radical treatment in active surveillance
[6]. 38 active surveillance patients were compared to 150
similar patients who underwent immediate surgical inter-
vention. The median interval for delayed surgical inter-
vention was 26.5 months (range 12–73 months). The
investigators found that delaying radical surgery did not
compromise curability.
Active surveillance aims to avoid the morbidity associated
with radical treatment and identify those men with clini-
cally insignificant prostate cancer. Although mature data
from studies on active surveillance is currently limited, it
seems to be an important management option to consider
in men with early low grade prostate cancer.
Competing interests
The authors declare that they have no competing interests.
Authors' contributions
UM and KRG were involved in collection of data and
material used during preparation of the paper. UM drafted
an initial version of the paper. KRG was involved in the
inception, drafting and editing of the paper. RS, JSV and
BSP contributed to the initial draft. BSP is the lead clini-
cian involved in the care of the patient and the prime
supervisor of the work. All authors read and approved the
final manuscript.
Consent
Written informed consent was obtained from the patient
for publication of this case report. A copy of the written
consent is available for review by the Editor-in-Chief of
this journal.
References
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2. Jimenez JC, Smith MM, Wilson SE: Sexual dysfunction in men
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