Rectal ejaculation is a rare and serious urological condition characterized by the expulsion of seminal fluid through the anus or rectum during orgasm, which should instead exit the body through the tip of the penis. This symptom is not a variation of sexual experience, but rather a clear sign of severe underlying anatomical damage. It signals a pathological communication between the reproductive tract and the gastrointestinal tract, demanding immediate medical investigation.
Defining the Condition
Rectal ejaculation is defined as the passage of semen from the rectum upon achieving sexual climax. This symptom often presents as a noticeable discharge of fluid from the anus following a dry or significantly reduced ejaculate from the urethra. It is classified as an ejaculatory disorder stemming from a physical structural defect, rather than a functional nerve or muscle impairment. It is important to differentiate this from retrograde ejaculation, which occurs when the bladder neck fails to close properly during orgasm, causing semen to travel backward into the urinary bladder. The semen is then passed later with urine. Rectal ejaculation involves semen bypassing the urethra entirely and entering the rectum before exiting the anus. This indicates a structural hole or connection where none should exist. The presence of seminal fluid in the rectum often leads to secondary symptoms, including local irritation or infection.
The Role of Fistulas in Semen Diversion
The anatomical mechanism responsible for semen diversion is almost always the presence of a fistula, which is an abnormal, hollow tract connecting two epithelial-lined organs. The defect is typically a rectourethral fistula (RUF), a pathological connection between the rectum and the urethra. Less commonly, a rectovesical fistula may occur, connecting the rectum to the bladder and involving the seminal pathway.
During ejaculation, semen travels from the seminal vesicles and prostate into the posterior urethra. If an RUF is present, the path of least resistance for the high-pressure ejaculate is diverted through this abnormal opening into the adjacent rectum, bypassing the normal exit route. A fistula involving the prostatic urethra or the ejaculatory ducts allows the full volume of seminal fluid to be diverted. This diversion causes semen to exit the anus, often accompanied by other signs such as pneumaturia (gas in the urine) or fecaluria (fecal matter in the urine).
Primary Causes of the Anatomical Defect
The formation of a rectourethral fistula is primarily an acquired defect, developing later in life due to trauma, medical procedures, or disease. The most common cause is iatrogenic, arising as a complication following pelvic surgery, particularly for prostate cancer. Procedures like radical prostatectomy carry a risk of fistula formation due to accidental injury to the rectal wall during the removal of the prostate gland.
Radiation therapy directed at the pelvis is another significant cause. High-dose radiation causes tissue damage and inflammation, leading to necrosis and a breakdown of the tissue wall months or years later. Fistulas resulting from radiation are often complex and difficult to repair due to compromised surrounding tissues.
Inflammatory conditions, such as severe Crohn’s disease, can also lead to fistula development as chronic inflammation erodes tissue layers. External trauma, including pelvic fractures or penetrating injuries, can directly create a pathway. In rare instances, an improperly inserted Foley catheter can cause a pressure injury leading to a fistula.
Congenital rectourethral fistulas are related to anorectal malformations present from birth, where the rectum and urethra fail to separate completely during fetal development. Acquired causes are overwhelmingly prevalent in adult patients.
Clinical Diagnosis and Treatment
Diagnosing the cause of rectal ejaculation requires locating and characterizing the fistula. The initial workup involves a physical examination, including a digital rectal exam, and a review of the patient’s surgical and medical history.
Imaging studies are essential to visualize the abnormal tract and surrounding anatomy. A voiding cystourethrogram (VCUG) or a fistulography, which involves injecting a contrast dye, can highlight the communication. Cross-sectional imaging, such as magnetic resonance imaging (MRI) or computed tomography (CT), provides detailed anatomical context, helping to assess tissue damage.
Direct visualization is achieved through cystoscopy and rectoscopy, where a flexible tube with a camera is inserted into the urethra and rectum to locate the internal opening.
The definitive treatment is surgical repair. Management often involves a staged approach, especially if significant inflammation or infection is present. Initial steps include temporary fecal diversion, such as a colostomy, to prevent contamination and allow tissues to heal.
Urinary diversion, often with a catheter, is also employed to keep urine away from the repair site. Definitive surgery is performed to close the opening and separate the two organs. This repair often involves interposition techniques, where a healthy tissue flap is placed between the repaired rectum and urethra to provide structural support. The goal is to eliminate the abnormal connection, restoring the normal pathway for semen exit.