“I am 48 years old. For the last two years I have noticed a low quantity of ejaculate and I also have to wait and exert some pressure before urine passes. I have no pain. I also have a history of recurrent stones in my urethra. Could this be related to my prostate?”
Quick Answer
Difficulty starting urination can occur with an enlarged prostate, but BPH is not the only possible explanation—especially because you have a history of urethral stones.
A urethral stone, previous stone-related injury or scar narrowing of the urethra can interfere with urine flow. Other possibilities include bladder-neck obstruction, prostatitis, pelvic-floor dysfunction and other urinary tract conditions.
The reduced amount of fluid during ejaculation also needs to be considered separately. Low ejaculate volume can occur with certain medicines, retrograde ejaculation, obstruction of the ejaculatory ducts, diabetes, previous surgery or other reproductive problems.
A urological assessment is appropriate rather than assuming that both symptoms are caused by BPH.
First, “Low Semen Volume” Is Not the Same as “Low Sperm Count”
Patients often say they are producing “fewer sperm” when what they can actually see is a smaller amount of semen.
These are different measurements.
Semen volume is the amount of fluid ejaculated.
Sperm count is the number of sperm cells within that semen and can only be assessed properly with a semen analysis.
If fertility is an issue, laboratory semen analysis is much more useful than judging the amount by appearance.
Could an Enlarged Prostate Cause Difficulty Starting Urine?
Yes.
As the prostate enlarges, it can compress the urethra and increase resistance at the bladder outlet.
Typical BPH symptoms can include:
- difficulty starting the urine stream
- weak urine flow
- stopping and starting during urination
- straining
- dribbling
- feeling that the bladder has not emptied completely
- urgency or frequent urination
- waking repeatedly at night to urinate
At age 48, BPH is certainly possible, but urinary hesitancy alone cannot establish the diagnosis.
Could the Previous Urethral Stones Be Important?
Yes. This part of your medical history changes the assessment significantly.
Stones can obstruct the urinary tract directly. Repeated stone passage, inflammation, instrumentation or injury can also sometimes contribute to scar formation and narrowing of the urethra.
This narrowing is called a urethral stricture.
A urethral stricture may cause:
- weak urine flow
- difficulty starting urination
- straining
- incomplete emptying
- spraying or abnormal urine stream
- recurrent urinary infection
- urinary retention in more severe cases
Your urologist should know about this history when deciding which tests are appropriate.
Can BPH Reduce the Amount of Ejaculate?
The relationship is not as simple as the old answer suggested.
Men with lower urinary tract symptoms can also experience sexual or ejaculatory problems, but low semen volume is not enough by itself to diagnose an enlarged prostate.
In fact, some of the treatments for BPH are more clearly associated with changes in ejaculation than BPH itself.
Could BPH Medicines Reduce Ejaculation?
Yes.
Certain alpha-blockers used for urinary symptoms can cause reduced or absent forward ejaculation in some men.
This can occur because ejaculation into the urethra or closure of the bladder neck is altered.
If you take medication for BPH, high blood pressure, depression or another condition, tell the urologist exactly which medicines and supplements you use.
See my BPH medication guide for more information.
What Is Retrograde Ejaculation?
Normally, the bladder neck closes during ejaculation so that semen travels forward through the urethra and exits through the penis.
With retrograde ejaculation, some or most of the semen instead passes backward into the bladder.
A man may therefore notice:
- very little semen during orgasm
- no visible semen during orgasm
- cloudy urine after ejaculation
- fertility problems
Retrograde ejaculation can occur after some prostate or bladder procedures and with certain medications. Diabetes and neurological conditions can also interfere with bladder-neck function.
How Is Retrograde Ejaculation Checked?
If it is suspected, the doctor may examine urine collected shortly after ejaculation.
If substantial sperm are present in that urine, this supports retrograde ejaculation.
This test is particularly useful when a man reaches orgasm normally but produces very little or no visible semen.
Could There Be a Blockage in the Ejaculatory Ducts?
Yes, although this is much less common than ordinary BPH.
The ejaculatory ducts carry seminal fluid into the urethra.
Obstruction can sometimes reduce semen volume and may contribute to fertility problems.
Depending on the clinical situation, a urologist or fertility specialist may consider semen analysis and imaging such as transrectal ultrasound.
Other Causes of Low Ejaculate Volume
| Possible cause | Clues that may be relevant |
|---|---|
| Medication effect | Symptoms began after starting an alpha-blocker, antidepressant or another medicine affecting ejaculation. |
| Retrograde ejaculation | Very little semen, dry orgasm or cloudy urine after ejaculation. |
| Ejaculatory duct obstruction | Persistently low semen volume, fertility difficulties or abnormal semen analysis. |
| Diabetes or neurological disease | May affect the nerves controlling ejaculation and bladder-neck closure. |
| Previous pelvic or prostate treatment | Prostate/bladder surgery or pelvic radiation can alter ejaculation. |
| Frequent ejaculation | Several ejaculations within a short period may temporarily reduce semen volume. |
| Other reproductive or hormonal causes | May require semen analysis, hormonal testing or specialist evaluation when clinically appropriate. |
Does No Pain Rule Out Urinary Disease?
No.
The old answer implied that a bladder or urinary problem would normally cause pain and was therefore unlikely because Manzoor had no pain.
That is not reliable.
Chronic urinary obstruction, BPH and urethral stricture can sometimes cause significant urinary difficulty without pain.
Even chronic urinary retention may develop gradually with relatively few symptoms.
Could This Be Prostate Cancer?
These symptoms do not specifically point to prostate cancer.
Difficulty urinating is much more commonly caused by benign urinary conditions such as BPH or obstruction.
However, the old statement that prostate cancer is essentially too rare below age 60 is too reassuring.
Prostate cancer can occur in men younger than 60, although risk rises considerably with age.
Whether prostate-cancer evaluation is appropriate should depend on the overall clinical picture, including age, family history, examination findings, previous PSA results and other risk factors—not simply the presence of low semen volume.
If PSA testing is appropriate, see my guide to understanding PSA.
Do You Automatically Need a PSA Test?
Not solely because you produce less semen.
PSA is not a test for low ejaculate volume.
However, a clinician evaluating persistent urinary symptoms in a 48-year-old man may discuss PSA testing depending on the circumstances and after explaining the benefits and limitations.
What Tests Might the Urologist Consider?
The exact evaluation should be individualized, but it may include:
- medical and medication history
- assessment of urinary symptoms
- physical examination
- urinalysis
- urine culture if infection is suspected
- urinary flow-rate testing
- measurement of urine remaining after urination
- ultrasound when indicated
- assessment for urethral narrowing or stones
- PSA after an appropriate discussion when clinically relevant
- semen analysis when fertility or semen production is a concern
- post-ejaculation urine testing when retrograde ejaculation is suspected
Additional investigation such as cystoscopy or specific urethral imaging may be considered if the history suggests urethral obstruction or stricture.
Why the Stone History Matters So Much
If you had not mentioned recurrent urethral stones, BPH would be one of several reasonable considerations.
Once that history is known, however, the possibility of a structural urinary problem becomes more important.
A urologist needs to determine whether there is:
- a current stone
- scar-related narrowing
- another urethral obstruction
- BPH as well
- or a combination of problems
It is entirely possible for more than one condition to exist at the same time.
Is BPH Easy to Cure With Herbs?
No.
The old answer said BPH could easily be treated with medicines and herbs and that normal urination and ejaculation would then return.
That promises too much.
BPH can often be managed effectively, but treatment depends on symptom severity, prostate size, degree of obstruction and complications.
Options may include lifestyle measures, BPH medications, minimally invasive procedures or surgery.
Herbal supplements have not been shown to reliably cure BPH or restore normal ejaculation.
When Should You Seek Urgent Medical Care?
- cannot urinate at all
- develop severe lower abdominal pain with inability to empty the bladder
- have fever or shaking chills with urinary symptoms
- have substantial blood in the urine
- become acutely unwell
Complete inability to urinate can represent acute urinary retention and requires prompt treatment.
What Should Manzoor Do Next?
Because these symptoms have persisted for approximately two years, I would arrange a urology assessment rather than simply trying BPH supplements.
Bring information about:
- your previous urethral stones
- any procedures used to remove them
- your current medications
- how long it takes to start urination
- whether the urinary stream is weak or interrupted
- whether you feel completely empty afterward
- whether urine looks cloudy after orgasm
- whether fertility is currently important to you
These details can help separate prostate enlargement from urethral obstruction and an ejaculation disorder.
Manzoor, I would not diagnose BPH from these symptoms alone. Your difficulty starting urination certainly could come from an enlarged prostate, but your history of recurrent urethral stones makes urethral obstruction or scar narrowing particularly important to exclude. The lower amount of ejaculate should also be assessed separately because it can have causes unrelated to prostate size. A urologist can evaluate both problems together and decide whether urine-flow testing, residual urine measurement, imaging, urethral evaluation or semen-related testing is appropriate.