Shinshu Med J, 69⑴：53～56, 2021

A Rare Complication of Retrograde Ejaculation after Lumbar
Sympathetic Block and its Spontaneous Recovery : A Case ReportKenji Yamamoto1）, Keiko Mamiya2）＊ and Hiroyuki Furukawa1）3）
1） Department of Anesthesiology & Critical Care, Asahikawa Medical University
2） Division of Palliative Medicine, Shinshu Cancer Center, Shinshu University Hospital3） Division of Gastroenterologic and General Surgery, Department of Surgery, Asahikawa Medical University

Bilateral block of the lumbar sympathetic nerve may lead to ejaculation disorders, but few cases have beenreported. A 40-year-old man developed TAO (thromboangiitis obliterans) in his left lower extremity 18 years ago.
He underwent left lumbar sympathectomy (L2-L4) for the ulcer and pain in the left extremity 2 years later. He
then developed an ulcer in his right extremity and received a chemical right lumbar sympathetic block at theL3-L4 level. After the procedure, the ulcer healed and the pain disappeared, but the patient developed retrograde
ejaculation, which continued for 18 months. Seven months after recovery from the retrograde ejaculation, thepain in his right extremity recurred. We recognized that a patient with left lumbar sympathectomy (L2-L4) was
at risk for retrograde ejaculation when the right lumbar sympathetic nerve block was added. Thus, we blocked
the right lumbar sympathetic ganglia at the L3-L4 level to ameliorate the pain and ulcer in his toes while
preserving the ganglion at L2. In this case, the retrograde ejaculation lasted for 18 months. The patient’s pain in
the right extremity recurred 7 months after recovery from the retrograde ejaculation. We assume that regeneration of his right lumbar sympathetic nerve contributed to the spontaneous recovery from the retrograde ejaculation, and subsequently the recurrence of the pain in the right extremity. Shinshu Med J 69 : 53―56, 2021
(Received for publication June 1, 2020 ; accepted in revised form September 8, 2020)
Key words : chemical lumbar sympathetic block, lumbar sympathectomy, retrograde ejaculation

Ⅰ Introduction
The chemical lumbar sympathetic block is a technique that relieves limb pain caused by ischemic ulcers in patients with advanced peripheral arterial1）

tion caused by chemical lumbar sympathetic blockand recovered 18 months later.
Ⅱ Case report
A 40-year-old man who was a chain smoker with-disease . Bilateral block of the lumbar sympatheticout a previous medical history developed TAO in his

nerve has been known to cause ejaculation disorders2）

left lower extremity 18 years ago. Oral administra-

although few cases were reported previously. Also,tion of cilostazol and smoking cessation therapy were

there is little information about the prognosis of ejac-

given but the symptoms gradually worsened proba-ulation disorders caused by chemical lumbar sympa-

bly because of his smoking. He underwent leftthetic block. We report a case with thromboangiitis

lumbar surgical sympathectomy (L2-L4) for the ulcer

obliterans (TAO) who developed retrograde ejacula-and pain in the left extremity in the department ofvascular surgery of our hospital 2 years later. It has＊

Corresponding author : Keiko Mamiya
Division of Palliative Medicine, Shinshu Cancer Center,
Shinshu University Hospital
3-1-1 Asahi, Matsumoto, Nagano 390-8621, Japan
E-mail : keiko@shinshu-u.ac.jp

No. 1, 2021

not recurred in his left lower extremity to date. Sixyears after that, he developed an ulcer in the second
toe on the right foot and underwent poplitealplantar artery bypass surgery in the right extremity.
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Yamamoto・Mamiya・Furukawa

Six years after the bypass surgery, he developed anties in the anatomy of the ganglion structure. The

ulcer in the first and third toes on the right foot due

number of ganglia reported is generally 3, but may

to the graft occlusion but did not undergo bypass

be as many as 5, which are separated or fused in asurgery because of his nicotine dependency. Then hechain3）4）. The lumbar sympathetic ganglia are com-visited our outpatient clinic for nerve block treat-monly blocked at the L2-L4 levels for pain relief 2）.

ment in his right lower extremity. He had four chil-

Retrograde ejaculation is most commonly due todren and did not want future reproductive activities.

the use of medications or surgical procedures that

He understood the risk of sexual dysfunctions caused

relax the bladder neck, but can also result from ret-by the bilateral lumbar sympathetic blockade androperitoneal lymph node dissection, spinal cord inju-

written informed consent was obtained. The proce-ry, neurologic disorders, diabetes mellitus anddure of the right lumbar sympathetic block was per-bilateral lumbar sympathetic blockade2）5）.

formed as follows.

Ejaculation is a complex process controlled by theUnder fluoroscopic guidance, a 23-gauge 140-mm

interaction of peripheral, cerebral, and spinal sensory

spinal needle was advanced to the right anterolateraland motor neuron pathways. Normal ejaculationborder of the L3 and L4 vertebral bodies. The needle

comprises a sequential series of events : emission

position was confirmed by fluoroscopic imaging.

transport of seminal fluid and sperm into the prostatic

Injection of 3.0 mL iohexol with 3.0 mL of 2 ％ lido-

urethra, closure of the bladder neck, and ejaculation

caine was performed at each vertebral level (L3, L4),of seminal fluid in an antegrade direction. Sympa-and smooth spread of the contrast media along thethetic nerves arising from the Th10-L2 spinal levelpsoas fascia was confirmed. The skin temperature of

mediate contraction of the prostate and seminal vesi-

the right first toe increased by 0.7°
C (34.2°to 34.9°).

cles to deposit seminal fluid into the posterior ure-

We confirmed the absence of changes in the sensory

thra (emission), with simultaneous closure of theand motor functions of his left extremity 15 minbladder neck to prevent retrograde flow of the se-after the injection. Absolute ethanol (3 mL) was in-men. On the right, the postganglionic sympathetic

jected at each vertebral level, and no complications

fibers arise from the right sympathetic trunk, whichwere observed.

is located posterior to the vena cava. These fibers

After this procedure, the ulcer healed and the pain

travel anteriorly along the posterior surface of thedisappeared, but the patient developed retrograde

inferior vena cava to the interaortocaval space andejaculation just after the bilateral lumbar sympathetic

course over the anterior aorta. On the left, the sym-

blockade, which continued for 18 months. He has nopathetic fibers arise from the left sympathetic trunkother sexual dysfunctions such as erectile dysfunctionposterior to the aorta and travel anteriorly along theexcept for the retrograde ejaculation. The pain andsurface of the aorta. The left and right postganglion-

ulcer in his right great toe occurred seven months

ic fibers coalesce in the hypogastric plexus at theafter the recovery from retrograde ejaculation. He

level of the inferior mesenteric artery, where they

underwent smoking cessation therapy in hospitaliza-organize into the hypogastric nerves, which againtion and amputation of his right great toe in the de-coalesce in the pelvic plexus in the presacral region

partment of vascular surgery. It has not recurred inand travel by way of the pelvic nerves to their tar-

his right extremity to date.

get organs including the bladder neck6）. Closure ofⅢDiscussion

the bladder neck is bilaterally controlled by the lumbar sympathetic nerve through the hypogastric plex-

The lumbar sympathetic ganglia are anatomic

us and lumbosacral trunk which compensate eachstructures located anterolateral to the vertebral bod-other. A study showed that bilateral hypogastricies, where the psoas muscle attaches. Dissection ofnerve transection caused the disability of bladdercadaveric specimens demonstrates marked variabili-neck closure and retrograde ejaculation7）8）. From the54

Shinshu Med Jol. 69

Retrograde ejaculation

past study, it can be supposed that bilateral lumbar

generation of his right lumbar sympathetic nerve

sympathetic blockade induces retrograde ejaculation.

contributed to the spontaneous recovery from theSome studies reported that high sympathetic de-retrograde ejaculation and the recurrence of the pain

generation at the L2-L3, the presacral plexus, andthe hypogastric plexus resulted in retrograde ejacu9）10）in the right extremity subsequently.
Treatment for retrograde ejaculation is further. Thus, we recognized that the patient who

advanced by using assisted reproductive technolo-

had undergone left lumbar sympathectomy (L2-L4)

gies, but not for retrograde ejaculation resulting

was at risk for retrograde ejaculation following thefrom sympathetic neurolysis4）. There are few caseright lumbar sympathetic nerve block. We blockedreports regarding the prognosis of retrograde ejacu-

the right lumbar sympathetic ganglia at the L3-L4

lation caused by chemical lumbar sympathetic block.

level without compromising the ganglion at L2, after

This case report provides valuable information on

obtaining the patient’s informed consent regarding

retrograde ejaculation as a rare complication after

the risk. We now think that we should have firstchemical lumbar sympathetic block and possible

performed the contralateral blockade of the ganglion

spontaneous recovery from it.

lationonly at the L4, and added a block of the ganglion atⅣ

the L3 after confirming the absence of complications
such as retrograde ejaculation.

Conclusion

We experienced rare complication of retrograde

Chemical lumbar sympathetic block for chronic

ejaculation after lumbar sympathetic block and its

lower limb ischemia provides significant pain relief for

spontaneous recovery. We assume that regeneration11）

at least 6 months . In the present case, retrogradeof the patient’s right lumbar sympathetic nerve con-ejaculation lasted for 18 months, and the patient’s left

tributed to the spontaneous recovery from the retro-extremity pain recurred 7 months after recovery

grade ejaculation, and subsequently the recurrence

from the retrograde ejaculation. We assume that re-of the pain in the right extremity.

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