J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.44.1.9 on 1 January 1981. Downloaded from http://jnnp.bmj.com/ on September 30, 2020 by guest.

Journal of Neurology, Neurosurgery, and Psychiatry, 1981, 44, 9-18

Electroejaculation: its technique, neurological

implications and uses
G S BRINDLEY
From the Department of Physiology, Institute of Psychiatry, London

SUMMARY An improved technique for electroejaculation is described, with the results of

applying it to 84 men with spinal injuries and five men with ejaculatory failure from other
causes. Semen was obtained from most patients, but good semen from very few. Only one
pregnancy has yet been achieved. The technique has diagnostic applications.

"Electroejaculation" is the word generally used the least possible risk of thermal and electrolytic
to denote the obtaining of semen by electrical damage to the rectal mucosa. To select a particular
stimulation with electrodes in the rectum. The nerve or compact plexus it is advantageous to have
name is a little misleading, because the semen is a single circular cathode and a larger anode or group
rarely or never ejaculated in the strict sense; it of anodes. The diameter of the cathode should be

Protected by copyright.
roughly equal to its least distance from the nerve or
trickles from the external urinary meatus without plexus; a greater diameter worsens the discrimination,
the help of contractions of striated muscles. The and a smaller diameter causes the current density
technique has been used in domestic animals since close to the electrode to be unnecessarily and perhaps
1936. Most veterinary users have employed sinu- harmfully high. These desiderata are roughly obvious
soidal alternating current of frequencies from 15 from theory, and can be confirmed from experience
to 100 Hz, delivered through rigid rectal probes, in stimulating motor points and cutaneous nerves
a substantial fraction of whose surface was covered through the skin.
with electrodes.' In attempting to stimulate from the rectum ana-
Published accounts of its application to man2-7 tomically defined structures in the pelvis one would
consider only its use for rendering paraplegic men expect discrimination to be better with an electrode
mounted on a glove-finger than with one mounted on
fertile. Two pregnancies thus achieved have been a rigid probe, and probably the risk of doing mech-
reported,4 7 one of them7 yielding a live baby. anical damage is less with a glove-finger. To minimise
Stimuli have been sinusoidal at frequencies from electrolytic damage, one should ensure that no net
two3 to 906 Hz or have consisted of trains of uni- direct current is passed (which some earlier workers
directional pulses of duration one" to 156 ms and have done), and also minimise the electrical charge
frequency five6 to 1405 Hz, and they have been transferred per cycle (which none of them have done).
applied through probes similar to those used in To minimise thermal damage, one should, amongst
veterinary practice. No writer, I believe, has dis- other things, minimise the electrical power consumed,
cussed the rational choice of stimulus parameters and this has never before been attempted. For both
these purposes, if the fibres that one is intending to
or electrode sizes or positions, and I can find stimulate are myelinated (and it will be argued below
no substantial body of empirical observation on that they are), the stimulating pulses should be short.
these matters in either the abundant veterinary Charge per pulse at the threshold for a myelinated
literature or the scanty medical literature. fibre falls with duration down to roughly 80 /is and
remains nearly constant below this. Energy per pulse
Preliminary investigations at such a threshold falls with duration down to
roughly 150 ,us and rises below this. Thus pulses of
Theory What is needed is to stimulate the right nerve 100 pis duration will be not very far from minimising
fibres, and as few as possible of the wrong ones, with both charge and energy; at least they will be much
better in both respects than the sinusoidal currents or
1 to 15 ms pulses used in previous published work.
Address for reprint requests: Professor GS Brindley, Institute of A nimal Experiments All experiments and surgical
Psychiatry, De Crespigny Park, Denmark Hill London SE8 8AF. procedures on animals were done under deep pento-
Accepted 18 September 1980 barbitone anaesthesia. In ten male baboons and four
9
 J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.44.1.9 on 1 January 1981. Downloaded from http://jnnp.bmj.com/ on September 30, 2020 by guest.
10 G S Brindley
male rhesus monkeys, I explored what happened when duration relation for producing such contraction was
sites accessible to a cathode of 4 mm diameter measured. The chronaxie was 0 4 ms.
mounted on a glove-finger were stimulated electrically Experiments on myself In me, trains of 100 lAs pulses
through the rectum. I was able to produce separately, passed through a 6 mm circular cathode mounted
on either side, the movements appropriate to the either on a glove-finger or on a rigid probe will stimu-
pudendal, sciatic, inferior gluteal, superior gluteal, late both motor and sensory fibres of the pudendal
obturator, or genitofemoral nerve. The femoral nerve nerves from the upper part of the anal canal without
could be stimulated, but usually not without also causing severe pain, though always with some pain.
stimulating the genito-femoral. In all 14 animals, It is even possible to produce a maximal contraction
stimulation at sites giving obturator or genitofemoral of the muscles innervated by the pudendal nerve.8
effects gave full or nearly full erection, with threshold From the posterolateral rectal wall, pressing back-
roughly two or three times that for somatic effects. wards towards the sacral plexus of one side, I can
In two baboons a urethral catheter was passed and produce ipsilateral toe flexion or plantarfiexion of
the bladder pressure measured. The region from which the foot, and tingling in various parts of the ipsilateral
a rise in bladder pressure was obtained with lowest S2 and S3 dermatomes. These are always accompanied
threshold was centred on the best site for stimulating by diffuse deep pelvic pain, but the pain is not pro-
the obturator nerve. All stimulation which increased hibitively unpleasant at threshold for the muscular
the bladder pressure also caused some erection, but in and "cutaneous" effects. I cannot produce contraction
the more caudal part of the effective region the erec- of the gluteal or adductor muscles, or erection, ejacu-
tion was slight though the rise in bladder pressure was lation, micturition or the sensation of impending mic-
large (40 mmHg or more). Just rostral to the effective turition. The strongest stimuli that pain allows me to
region was one from which erection could be pro- tolerate are roughly 1/4 (in voltage or current) of
voked without any rise in bladder pressure. those needed for electroejaculation in patients.
In seven of the 10 baboons and three of the four
rhesus monkeys semen was obtained as a result of Methods

Protected by copyright.
the procedure, but it was often not clear which of
several sites of stimulation had caused the emission. I EQUIPMENT FOR ELECTROEJACULATION IN MAN
therefore repeated the procedure in one of the Electrode mounts My first glove-finger electrode
baboons and one of the rhesus monkeys with the mounts were made from dental acrylic. The rigidity
abdomen opened and the vas deferens of both sides sur- of this material hindered accurate palpation, but not
gically exposed in the spermatic cord and upper scro- as severely as one might expect. After about a year
tum. In both animals, the site that gave contraction of using acrylic electrode mounts I changed to silicone
of the seminal vesicle and vas deferens with lowest rubber. Whatever the material of the electrode
threshold was just rostral to the ipsilateral obturator mount, it is made to extend beyond the tip of the
nerve point. The response fatigued if stimulation was finger by about 20 mm, and the cathode, whose di-
repeated at 15 second intervals, but two minutes' rest ameter is about 8 mm, lies on the palmar surface of
sufficed for its recovery. The contraction produced this extension. There are two anodes in parallel, each
from either obturator point was restricted to the ipsi- of area equal to that of the cathode or a little greater,
lateral seminal vesicle and vas deferens. Stimulation on the dorsal surface centred 18 and 50 mm proximal
in the midline just rostral to the prostate caused con- to the cathode. Such electrode mounts are made by
traction on both sides, but with threshold higher by a Mr C M Andrew of 43 Landcroft Road, London
factor of 1-6 to 1-8. The contractions involved all the SE22, and can be bought from him.
visible part of the vas deferens, that is from the upper Stimulator I assume that in man, as in the baboon
border of the testis to about 2 cm below the pubic and rhesus monkey, electroejaculation depends on the
crest and from the lateral inguinal fossa to the stimulation of myelinated fibres. I therefore adhere
bladder. The most easily visible manifestation of them rigidly to 100 /As as the duration of the stimulating
was a shortening, so that undulations of the vas dis- pulses. Until May 1980 I always used 30 pulses per
appeared and it took as straight a course as possible second, because I had found in 1977 that this was
between its points of attachment. No peristaltic waves effective, and there seemed to be no reason to change
were seen. The strength-duration relation for produc- it. Since May 1980 I have had reason to use lower
ing contraction of the left vas deferens by stimulating frequencies, and have often done so. At first I used
the left obturator point was measured in the baboon. a general purpose electrophysiological stimulator, put-
The chronaxie was 0-6 ms. ting a capacitor in series with the output to prevent
In four male baboons and three male rhesus mon- the passage of direct current. Now I use a compact
keys I implanted electrodes on the hypogastric plexus (19X 11 X8 cm) battery-driven stimulator designed by
immediately in front of the bifurcation of the aorta. (and purchasable from) Mr C M Andrew, giving the
In all animals, stimulation through the implanted following stimulus parameters: pulse duration 100 its;
electrodes caused shrinkage of the penis together with peak voltage of pulse up to 108 V (9 equally-spaced
a contraction of the seminal vesicles and vasa defer- steps) into 1 MQ2 load, up to 80 V into the usual load
entia very similar to that seen during electroejacula- of 250Q2; time-constant of sag of pulse 800 us; peak
tion. In one of the rhesus monkeys the strength- current into 250Q up to 316 mA; nett current less
 J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.44.1.9 on 1 January 1981. Downloaded from http://jnnp.bmj.com/ on September 30, 2020 by guest.
Electroejaculation: its technique, neurological implications and uses I1I
than 0-1 AsA; output impedance 60-902 (highest at (84 with spinal injuries and five others), I have
highest voltage setting); time-constant of decay of obtained semen externally in 163 (64'1%), retro-
return current between pulses 10 ms; frequency of gradely in 44 (17'2%) and not at all in 49 (19'1%).
pulses 30, 15 or 10 per second (switchable). But these figures are overweighted with men on
PROCEDURE
whom I have had many (in one case 31) successes.
My usual practice is to have the patient supine with Table 1 classifies the results on men with spinal
knees bent (though it is possible to use the left lateral, injuries by patients rather than by attempts. "Ex-
or even the prone position). It is useful to have a ternal success" means that on at least one occasion
helper standing on the patient's left to hold the left liquid containing spermatozoa (not necessarily
leg. I stand on the right and put the electrode mount motile) trickled from the meatus. On 11 of these
on the right index finger over a plastic or rubber 36 men only one attempt was made. On four of
glove. I put some aqueous jelly (KY jelly is suitable) them two attempts were made, and both were
on the tip of the electrode mount and over the elect-
rodes, and insert the electrode mount into the anal externally successful. On 21 of them from three
canal until the cathode and distal anode and half of to thirty-three attempts were made, of which some
the proximal anode are within the canal. Then stimu- (usually most) were externally successful, the re-
lation at 9 volts should cause contraction of the anal mainder being either retrograde or unsuccessful.
sphincter, and, with a little adjustment of the rotation "Retrograde success" means a patient from
and depth of the electrode mount, the left or right whom I have never obtained semen externally, but
ischiocavernosus muscle. I next turn my hand so that whose next urine passed after an attempt at
its palm faces down and, pressing gently downward electroejaculation has contained at least 5 X 106
with the finger-tip, advance the electrode mount as spermatozoa. On six of these 14 men only one
far in as it goes easily with very gentle pressure. The attempt was made. On five men two or more
cathode is now near the best places for stimulating the

Protected by copyright.
sacral plexus and its somatic branches. Using 36 to attempts were made, all retrogradely successful.
54 volt pulses, I explore the posterior wall of the On three men two attempts were made, one
pelvis for sites giving flexion of the toes, plantar- retrogradely successful and the other unsuccessful.
flexion at the ankles, visible contraction of the ham- "Definite failure" means a patient in whom on
strings, abduction of the thighs, visible contraction of one occasion (17 cases) or on three occasions
the buttocks, external rotation at the hips, or palpable (three cases), attempted electroejaculation has
contraction of the obturator internus muscles. It is yielded no liquid at the meatus (15 cases) or
usually possible to obtain all of these, separately or liquid containing no spermatozoa (five cases), and
in various combinations, on either side, and this may the next urine passed has contained no sperma-
provide useful diagnostic information. But when the
procedure is being used solely to obtain semen, it tozoa (13 cases) or fewer than 5 X 106 spermatozoa
suffices to obtain any one of the somatic motor effects. (seven cases).
If I get none at 54 V I try at 80 V. If still none can "External failure" means a patient from whom
be obtained, then either no anterior horn cells sur- no semen was obtained externally, and who failed
vive from the 5th lumbar to the 2nd sacral segment, to provide a specimen of urine. All such patients
or the stimulator is not working, or there is much were seen once only.
gas in the rectum, preventing the anodes from making "Pain prevented" means a patient in whom, at
good contact. In the last case the gas can be expelled
by pressing on the abdomen, pulling laterally with the the only attempt at electroejaculation, stimulation
finger to assist its release. at less than the strength needed for success in
I next turn the palmar surface of the finger so that other patients was intolerably painful.
it faces directly to the patient's right, and advance the Partly retrograde ejaculation Ten of the 36 men
finger as far as possible, pushing hard. I then explore listed in table 1 as external successes also on
the right lateral wall of the pelvis for the obturator occasion gave purely retrograde ejaculation. It
point, that is the site where 80-volt stimulation causes would thus not be surprising if ejaculation was
powerful adduction of the right thigh. Stimulation here sometimes partly external but partly retrograde.
usually yields semen (if semen can be obtained at all) Merely finding spermatozoa in the next urine
after from 5 to 20 seconds. If there is none in 40 sec-
onds I try the left obturator point. To reach the left passed after an externally successful electroejacu-
obturator point it is sometimes necessary to transfer lation is insufficient to prove such an occurrence;
the electrode mount to the left hand and stand on the it is necessary to collect the urine in two lots, the
patient's left. first (of at least 20 ml) to wash out the urethra,
and the second as a sample of real bladder con-
Results tents. I have done this on three occasions (differ-
ent patients) when I already suspected that ejacu-
In 256 attempts at electroejaculation on 89 men lation was partly retrograde, and on all three
B
 J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.44.1.9 on 1 January 1981. Downloaded from http://jnnp.bmj.com/ on September 30, 2020 by guest.
12 G S Brindley
occasions found more spermatozoa in the bladder done under general anaesthesia without muscle
urine than in the external ejaculate. relaxant, was retrogradely successful. Five sub-
Prevention by pain Every patient who could sequent electroejaculations, all done with neuro-
recognise pinprick in no lumbar or sacral derma- muscular block, have yielded semen externally.
tome could tolerate electroejaculation without
anaesthesia. Every patient who could recognise pin- SIDE-EFECTS OF ELECTROEJACULATION
prick in a sacral or L5 or L4 dermatome was un- Contractions of striated muscles These are a valu-
able to tolerate it. Patients who could recognise able guide to the position of the stimulating
pinprick in an LI to L3 dermatome but not below cathode. Under general anaesthesia they agree
were unpredictable. with what would be expected from the stimulation
General anaesthesia and neuromuscular block of nearby a motor fibres. In unanaesthetised
Table 2 summarises the ten patients on whom I patients these direct motor effects are accom-
have attempted electroejaculation under general panied by reflex effects. Often the reflex effects are
anaesthesia, usually with neuromuscular block variable from time to time in the same patient,
(succinylcholine). Six had spinal injuries or spina and they may occur after rather than during
bifida, and in four of these the reason for using stimulation; but sometimes they are so repeatable
general anaesthesia was that an attempt at electro- and so immediately related to the stimulus that
ejaculation without anaesthesia had been prevented only their anatomical inappropriateness shows that
by pain. In the other two, the reason was that they are not direct motor effects. The commonest
attempts without anaesthesia had been retro- such pseudo-direct response of striated muscle is
gradely successful. I then tried under general contraction of the abdominal muscles on stimu-
anaesthesia with neuromuscular block, and from lation of branches of the sacral plexus; I have
one of the two patients obtained semen externally. notes of its occurring in seven patients and think

Protected by copyright.
A similar conversion from retrograde to external it occurred in a few others. Almost simultaneous
ejaculation was achieved in one of the two other- contraction of the adductors of both sides in re-
wise healthy men who had never ejaculated in the sponse to stimulation of the obturator nerve on
waking state. My first electroejaculation of him, one side has occurred in at least four patients. I

Table 1 Success and failure of electroejaculation in patients with spinal injuries

Highest clinically External success Retrograde success Definite failure Externalfailure Pain prevented Total
damaged cord
segment
C6 to Tl 13 1 5 3 0 22
(4 incomplete) (incomplete) (2 incomplete)
T2 to T12 21 11 13 3 2 50
(3 incomplete) (1 incomplete) (6 flaccid) (2 flaccid) (both incomplete)
(1 flaccid) (1 incomplete)
Ll orbelow 2 2 2 1 5 12
(1 incomplete) (flaccid) (1 flaccid) (flaccid) (2 incomplete)
(1 flaccid)
Total 36 14 20 7 7 84

Table 2 Electroejaculation under general anaesthesia

External success Retrograde success Definite failure
1 complete L2 lesion I complete T5 lesion (patient with 1 T12/L2 lesion (flaccid patient)
transurethral resection of bladder neck)
1 incomplete T12 lesion 1 abdomino-perineal excision of rectum for
carcinoma (electrodes inserted through
colostomy)
I complete T4 lesion I diabetic non-ejaculator without other
evidence of neuropathy
I lumbar spina bifida
2 otherwise healthy lifelong non-ejaculators
(5 and 6 external successes respectively)
The fi e patients in table 2 who had spinal injuries are listed also in table 1.
 J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.44.1.9 on 1 January 1981. Downloaded from http://jnnp.bmj.com/ on September 30, 2020 by guest.
Electroejaculation: its technique, neurological implications and uses 13
have never seen pseudo-direct contraction of the baboon. In man they are at least sometimes ade-
quadriceps, adductors or ilio-psoas in response to quate, and yield pure semen where 30/s had
stimulation of the sacral plexus, or pseudo-direct yielded mixed semen and urine from the same
contraction of the gluteal muscles, or of any patient.
muscle below the knee, to stimulation on the oppo- Erection I have done some externally successful
site side. electroejaculations without causing any penile
In six of the 146 externally successful electro- erection, and very many with only a slight erec-
ejaculations without general anaesthesia, emission tion. But there are men in whom seminal emission
of semen has been accompanied by rhythmic con- cannot, with my technique, be achieved without
tractions of the abdominal muscles. The temporal an accompanying full erection, and others in
pattern of these contractions roughly resembled whom erection sometimes but not always occurs.
that of orgasmic pelvic floor contractions,9 but Contraction of the dartos muscle A train of large
they lacked the progressive increase in interval pulses delivered to almost any site in the pelvis
that occurs at orgasm. On two of these six oc- causes in nearly all patients a conspicuous con-
casions the rhythmic contractions included the traction of the dartos after a delay of 3-5 seconds.
anal sphincter. This response is absent or very feeble under gen-
Rhythmic abdominal contractions (not including eral anaesthesia, but I have seen it clearly and
the anal sphincter) were seen in one of 47 unsuc- reproducibly present in a patient with a T8 lesion
cessful and in one of 44 retrogradely successful in whom there was no evidence (unless this dartos
electroejaculations. response be such) of any functioning cord or
After-effects on spasm Several patients have surviving anterior horn cells below the level of the
mentioned that for a few hours after electroejacu- lesion. In two otherwise similar patients with T6
lation their legs are less spastic than usual. Others, and T7 lesions the dartos response was absent.

Protected by copyright.
when directly questioned, have denied any such Rise in blood pressure In patients with lesions
effect. No patient has reported increase in spasm. at T5 or below I do not usually record the blood
Micturition Stimulation that is intended to yield pressure. No such patient has reported headache
semen sometimes yields urine instead, or a mixture during the procedure. In patients with lesions
of urine and semen. Of the 15 men whom I have above T5, electroejaculation nearly always raises
electroejaculated three or more times with exter- the blood pressure. I formerly used an automatic
nal success (most of them six or more times), eight sphygmomanometer (Dynamap 845). Now I use
have never given semen mixed with urine, three an ordinary sphygmomanometer repeatedly, or feel
have done so on a minority of occasions, and four the pulse, inflate a sphygmomanometer cuff to
on the majority of occasions. Of the 22 men whom 200 mmHg, and not whether the pulse reappears.
I have electroejaculated once or twice with ex- If the systolic pressure reaches 200 mmHg or if
ternal success, three have given semen mixed with the patient reports headache I stop stimulating.
urine. The blood pressure then always falls within a
There are two means by which the release of few tens of seconds, and I often resume stimula-
urine with semen can sometimes be prevented. The tion (if semen has not yet been obtained) within a
first uses the anatomical separation of sympathetic minute.
and parasympathetic fibres that might be expected
from anatomical textbooks, and was seen in the CORRELATES OF FAILURE
baboon experiments. Stimulation near the best In five of the 20 patients classified as definite
site for stimulating the superior gluteal nerve failures, electroejaculation yielded liquid at the
often gives urine without semen. When the bladder external urinary meatus that looked like semen
has by this means been made emptier than the but contained no spermatozoa. The volumes were
patient can get it by his own efforts, stimulation at 3.5, 2-0, 0 3, 0-2 and 0 1 ml. In another three
or a little cranial to the best site for the obturator patients, no liquid appeared at the meatus, but
nerve may give pure semen. The second method acid phosphatase and fructose were substantially
uses the effect of pulse frequency. In the baboon'0 more abundant in the next urine passed after
and in human patients (Brindley, Polkey & Rush- electroejaculation than in urine passed before it.
ton, unpublished), stimulation of preganglionic Another patient was of eunuchoid appearance
sacral parasympathetic fibres at 30 pulses/s gives and had very small testes. It seems likely that in
very much stronger detrusor contractions than at all or most of these nine patients the electrical
15 or fewer pulses/s. For electroejaculation, how- stimulation had its proper effect on the prostate,
ever, 15 pulses/s are almost as good as 30/s in the seminal vesicles, and vasa deferentia, but the
 J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.44.1.9 on 1 January 1981. Downloaded from http://jnnp.bmj.com/ on September 30, 2020 by guest.
14 G S Brindley
patients were azoospermic from disease or injury The volume can be from 0-2 ml to 10-5 ml
of the upper genital tract. (the latter without evident contamination by
Six patients with whom I definitely failed had no urine). The average is about 2 ml. The number of
evidence of any surviving anterior horn cells spermatozoa per unit volume can be normal, but
below T6, T7, T8, T9, LI and L2. In the last two is more often low (less than 40 million/ml). Two
of these, damage extended on one side up to T12. patients have repeatedly given specimens with
Two patients, both with complete Tl 1 lesions, counts exceeding 500 million/ml, and six other
had intact muscles of the L5 and sacral myotomes, patients have at least once had counts exceeding
but severe wasting of the quadriceps, adductors, 200 million/ml. The fraction of spermatozoa that
and iliopsoas. It seems likely that in all or most swim is almost always low. Among 166 external
of these patients the sympathetic fibres that the ejaculates examined, the highest motilities were
procedure should stimulate were lost. 78% (T10 complete lesion of one year's duration),
There remain two patients where definite failure 48% and 33% (T5 complete lesion of 17 years'
is entirely unexplained. Both had cervical lesions, duration, injured at age 19 and first electroejacu-
and only one attempt at electroejaculation was lated at age 36), 41% (T5 complete lesion of 1I
made. Their urines were not examined for fruc- years' duration), 34% (T7 complete lesion of
tose, acid phosphatase or other genital-tract seven years' duration), and 26% (C7 complete
markers (eg arginine or y-glutamyl transferase). lesion of two years' duration). All the other 161
specimens had motilities under 26%. In the 44
THE INFLUENCE OF SURGICAL OPERATIONS ON THE retrograde ejaculates (which by definition con-
BLADDER NECK AND URETHRA tained at least five million spermatozoa), motilities
Twelve patients have had transurethral resection were zero in 32, and between 1% and 20% in 12.
of the bladder neck; of these, three have also had Fourteen wives of men with spinal injuries have

Protected by copyright.
transurethral external sphincterotomy. Five of been inseminated with the husband's semen, all of
these patients were external successes, and five them more than once. Only one pregnancy has
retrograde successes. Two were "definite failures", been achieved. Paternity was verified by exam-
in both cases with evidence that retrograde ination (by Prof B E Dodd of the London
emission of azoospermic semen had occurred. 1Hospital) of 17 blood antigens, not including
Thus transurethral resection of the bladder neck HLA. The child is healthy, walked at 11 months,
certainly does not make external emission imposs- and could say six distinguishable words at 14
ible, though it probably increases the proportion months.
of retrograde to external emissions. Only one
patient has had external sphincterotomy and no DOMESTIC ELECTROEJACULATION
resection of the bladder neck. He is the one patient The wives of 12 paraplegic men were asked
who has become a father. Of 33 attempts at whether they wished to learn to electroejaculate
electroejaculation on him, 31 have been externally their husbands. Ten wished to and two did not.
successful. The other two (both early in the series) All the 10 who wished to learn have now learned,
were definite failures. and are using the technique successfully at home.
One of these wives is a physician, one a nurse, and
one a physiotherapist. The other seven had no
ELECTROEJACULATION IMMEDIATELY AFTER relevant previous knowledge or experience.
REMOVING A FOLEY CATHETER
This lhas been done 34 times on 13 patients. Discussion
Twenty-one attempts (seven different patients)
were externally successful, seven attempts (on four SAFETY
of the preceding patients) were retrogradely suc- Local heating The calculated power dissipation
cessful, and six attempts (six different patients) at the cathode during stimulation at 30/s at the
were definite failures. highest voltage setting is at most 0- 11 watt cm2.
In two recent electroejaculations done at these
QUALITY OF SEMEN IN MEN WITH SPINAL INJURIES settings the temperature rise was monitored by a
I nearly always measure the specimen, and do bead thermistor mounted on the centre of the
counts of motile spermatozoa and all spermatozoa, cathode. The temperature rises in 30 seconds of
within 40 minutes. Paraplegic semen is usually stimulation were 0 25 and 0 300C. There is no
liquid; only for about one specimen in 10 is there kind of single or double failure in the stimulator
need to wait for liquefaction. that could increase the power dissipation by more
 J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.44.1.9 on 1 January 1981. Downloaded from http://jnnp.bmj.com/ on September 30, 2020 by guest.
Electroejaculation: its technique, neurological implications and uses 15
than a factor of five; such an increase could occur electrodes of area 5 cm-2 in the mouth and in the
only if there were three simultaneous faults, one rectum and switched on for a minute at maxi-
of them being the insertion of the wrong kind of mum amplitude (EMF 108 V) and 30 pulses per
fuse in the fuse-holder. second. This caused very powerful tonic contrac-
Electrolysis The net direct current passed by the tion of the trunk muscles which probably involved
blocking capacitors during stimulation at 30/s at every motor unit in the whole trunk. Breathing
the highest voltage-setting is less than 10-7A, that ceased, but the heart continued to beat in regular
is at least 100 times too low to cause electro- sinus rhythm throughout the minute of stimula-
lytic damage. In five patients I examined the tion. Breathing returned within a few seconds of
rectal mucosa with a sigmoidoscope a few minutes the end of stimulation. This baboon weighed 12 Kg
after electroejaculation. The sites of stimulation and the non-lung cross-sectional area of its chest
were indistinguishable from the surrounding was about 350 cm2. The peak current in each
mucosa. Blood-staining of the next faeces passed pulse was 520 mA, so the peak current density
has been reported to me after only two of 256 through the heart was about 1'5 mA cm-.
electroejaculations on 89 patients. There are two Elevation of blood pressure When electroejacu-
blocking capacitors in series, each rated at 160 V, lation is being done on patients with high lesions
and the potential across them cannnot exceed 96 V. the blood pressure must be measured, and stimu-
It is thus very unlikely that either will fail, and lation stopped if it rises too high or if the patient
much more unlikely that both will. reports severe headache. What pressure should be
Ventricular fibrillation The current density at regarded as too high, and whether mild headache
the heart produced by the pelvic stimulation used should be taken as a ground for stopping, are
for electroejaculation can be calculated if we matters on which I can give no authoritative
assume the human body to be a uniform con- opinion. But it seems reasonable to suggest that

Protected by copyright.
ductor. Though this assumption is inaccurate, it if the systolic pressure does not rise above 200
is unlikely to overestimate or underestimate the mmHg and the headache is neither distressing to
current density by more than a factor of 2 or the patient nor more severe than he has already
3. The current density in a uniform conductor at experienced in previous episodes of autonomic
distance D from a dipole of length d carrying dysreflexia, no excessive risk has been taken.
current I, where D is substantially greater than d,
is dI/2srD3 along the axis of the dipole and less WHAT IS BEING STIMULATED TO CAUSE EMISSION
at any other orientation. In the present case the OF SEMEN
length of the dipole is at most 3 cm, the distance Electroejaculation works well under general
from the dipole to the heart at least 20 cm, and anaesthesia, and is then very unlikely to depend
the current during a pulse at most 316 mA, giving bon a reflex. In unanaesthetised patients, the
a peak current density at the nearest part of the emission of semen was in all but 2 of 146 exter-
heart of 19 MtAcm-2, and an rms current density nally successful trials unaccompained by rhythmic
of 1[0 MAcm-2 at 30 pulses per second and 05 pelvic floor contractions such as occur in normal
[Acm'2 at 15 pulses per second. The official safe orgasm. It is thus unlikely that success in the un-
limit for 50 Hz alternating current is 50 uAcm-2 anaesthetised ordinarily depends on triggering a
rms. In pigs of weight 15-25 Kg, 300 mA peak reflex response of the cord; if it did, this reflex
current from head to knee in trains of 3-7 ms would have to be very different from the orgasmic
pulses was required to produce ventricular fibrilla- reflex of the intact cord. What of the two oc-
tion." Assuming 600 cm2 (probably a substantial casions when rhythmic pelvic floor contractions
overestimate) for the non-lung non-fat cross- did accompany seminal emission? One of these
sectional area of the chests of such pigs, the peak was the only electroejaculation of a patient, but
current density at the heart would be 500 ltAcm . the other was one of five electroejaculations of a
Even on these criteria the currents used for patient who emitted semen externally on all five
electroejaculation should be safe by a factor of at occasions, with rhythmic abdominal contractions
least 25, and the 100 ,us pulses used should be less including the anal sphincter once, rhythmic ab-
(and perhaps very much less) effective in causing dominal contractions without anal sphincter con-
ventricular fibrillation than 3-7 ms pulses of the tractions twice, irregular abdominal contractions
same peak amplitude. To further confirm that the once, and no obvious skeletal muscular activity
stimulus parameters used have a large margin of once. It seems likely that even here the seminal
safety for the heart, in one anaesthetised baboon emission depends on ele_trical stimulation of
the 100 us pulse stimulator was connected between efferent fibres; rhythmic reflex activity can occur
 J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.44.1.9 on 1 January 1981. Downloaded from http://jnnp.bmj.com/ on September 30, 2020 by guest.
16 G S Brindley
simultaneously with it, but is probably a separate stimuli can have excited more than a very few
and independent phenomenon. favourably placed unmyelinated fibres.
The sites that are best for causing seminal
emission agree fairly well with those that one THE SEGMENTAL ORIGIN OF THE NERVE FIBRES
would expect, from known anatomy, to contain INVOLVED IN SEMINAL EMISSION
substantial numbers of sympathetic fibres to the Table 3 shows all patients with complete traumatic
genital tract, and they are remote from the sensory lesions at T6 or below who gave external success,
fibres that serve the known receptive field for re- good retrograde success (>20X 106 spermatozoa)
flex ejaculation. In me, and in the patients with or definite failure without evidence for azoosper-
incomplete or low lesions, the sensations produced mic emission. The more stringent criterion of
by stimulating at these sites are nongenital, wholly retrograde success is to reduce the risk of includ-
unpleasant, and not conducive to sexual arousal. ing cases where spermatozoa were released spon-
These facts provide further reasons for doubting taneously into the urine of expressed mechanically
whether the seminal emission produced by my by the electroejaculation procedure. Two patients
technique is ever reflex. are thus excluded; they have Tl and T12 lesions.
The chronaxies found for contraction of the vas Four "definite failures" in the sense of table 1 are
deferens in the rhesus monkey and baboon are excluded, two (both T6 lesions) because they gave
very much lower than those found for unmyelin- azoospermic external ejaculates and two (T 11 and
ated fibres,12 and are typical of myelinated fibres. T12) because of high fructose and acid phospha-
This leads immediately to the conclusion that the tase in the urine collected after electroejaculation.
relevant sympathetic fibres are myelinated (and From cases 1-18 it seems that no single seg-
hence presumably preganglionic) at the sites stimu- ment (unless just possibly T8 or Tl 1) is the source
lated, that is in front of the bifurcation of the of all the fibres involved in seminal emission. Since
aorta and between the rectum and the obturator cord lesions are rarely if ever as short as one

Protected by copyright.
nerve. segment, we may even tentatively infer that no
It would be very difficult to measure the chro- pair of consecutive segments is the source of all
naxie for electroejaculation in men, and I have the fibres. Case 17 is very informative. He twice
not attempted it. But the relatively low thresholds gave good retrograde emission, despite complete
found for 100 ,us pulses make it probable that absence of responses to electrical stimulation of
myelinated fibres are being stimulated. The largest motor nerves in all segments from T12 downward
unmyelinated fibres have electrical thresholds on the left and from LI downward on the right.
only twice those of small myelinated fibres for He had no trace of erection, reflexly or in the
long pulses, but at least 20 times for short pulses,12 electroejaculation procedure or (he says) psychic-
so that it is difficult to believe that the present ally. For him we can say almost certainly that the

Table 3 Patients with complete lesions at T6 or below who gave external success, good retrograde success,
or definite failure not attributable to azoospermia
External success Good retrograde success Definitefailure
I T6 14 T7 (resection of bladder neck) 19
T6, flaccid
2 T6 15 T12 20T7, flaccid
3 T6 16 T12 21T8, flaccid
4 T6 left, T7 right 17 T12 left, Li right, flaccid 22T9, incomplete, flaccid
5 T7 18 T12 left, L2 right 23T1 1, partly wasted muscles down to L4
6 T7 right, T8 left 24Ti 1, completely wasted muscles down to
L4
7 T9 25 T12 right, Li left, flaccid
8 T9 26 T12 right, L2 left, flaccid (general
anaesthetic)
9 T9, partly wasted muscles down to L3
10 T9
11 TIO
12 T12
13 L2 (general anaesthetic)
 J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.44.1.9 on 1 January 1981. Downloaded from http://jnnp.bmj.com/ on September 30, 2020 by guest.
Electroejaculation: its technique, neurological implications and uses 17
lumbar and sacral segments of the cord are un- carbonate 5 g, given by mouth one or two hours
necessary for seminal emission. The only slight before, ensures appropriate pH and concentration.
reservation is that loss of all a anterior horn cells However, centrifugation may not be harmless,
does not absolutely prove loss of all intermediate and even the best urine is unlikely to be a good
horn cells in the same segment. environment for spermatozoa.
Cases 25 and 26 seem to conflict with case 17, In two men who previously ejaculated retro-
but both were failures on a single occasion without gradely I have obtained semen externally by
chemical analysis of the urine for genital-tract electroejaculating under general anaesthesia with
markers. neuromuscular block. It seems likely that this
Cases 23 and 24 suggest that loss of all the technique will be widely applicable. The same end,
sympathetic outflow from Tll downwards prob- that is relaxation of the striated muscles that close
ably prevents success in electroejaculation. Case 9 the urethra, could doubtless be achieved by
(in whom I have had many external successes) is pudendal block or sacral epidural block.
not in sharp conflict, because of the incomplete-
ness of his wasting. RANGE OF APPLICATION
Cases 19-22 all showed no trace of somatic Diagnostic use The electroejaculation procedure
motor responses in the electroejaculation pro- provides a quick and simple means of examining,
cedure. Even the dartos response was absent in in a patient of either sex with a complete transec-
cases 19, 20 and 22, though it was present (to my tion of the spinal cord, which muscles of the lower
surprise) in case 21. Case 22 was incomplete only limbs retain a motor innervation. It is applicable
in having slightly preserved tactile sensation. during the period of spinal shock, provided that
The predominance of low lesions among the three or four days have elapsed since injury, so
retrograde successes suggests that a low lesion may that motor fibres whose perikarya have been
interrupt the sympathetic fibres to the bladder destroyed have lost their excitability. The same

Protected by copyright.
neck without destroying all those to the vasa de- end can be achieved by stimulation of motor points
ferentia and seminal vesicles. through the skin, but the electroejaculation pro-
cedure is much quicker.
IMPROVING THE QUALITY OF SEMEN In theory, the electroejaculation procedure
The figure of merit that I use is the estimated should distinguish between a deafferented and a
number of motile spermatozoa in the whole totally denervated bladder. These behave alike
ejaculate, that is the product of volume, count per in ordinary cystometry. At present the distinction
ml, and fraction motile. On this index the best makes little or no difference to treatment, but this
paraplegic ejaculate that I have seen does not may not remain true in the future.
match average normal semen, and most paraplegic Fertility of men with injury or disease affecting
ejaculates are very bad. They are also usually ab- the spinal cord or cauda equina This is the
normal in being liquid when emitted. "established" (though as yet only slightly success-
Possible reasons for the poor quality include ful) field of application. It will probably be the
non-drainage, chronic infection, and raised scrotal most important, if means can be found for improv-
temperature. I have some evidence that all these ing the quality of the semen.
three are contributory, and that remedying them Fertility of otherwise healthy men with ejaculatory
is practicable and beneficial; but this work has a failure Only two such patients have been re-
long way to go before it will be fit to publish, ferred to me. With both I have been regularly
except for the firm finding that deep scrotal tem- successful, and the counts and motilities are within
peratures are on the average higher in paraplegics normal limits. Though no pregnancy has yet been
in wheelchairs than in age-matched and similarly achieved, there is ground for optimism.
clothed seated normal men.13 Injuries and disease affecting peripheral nerve
fibres in the pelvis It seems likely that when these
THE TREATMENT OF MEN WHO EJACULATE conditions cause ejaculatory failure they usually
RETROGRADELY do so by destroying the efferent pathway, so
Spermatozoa may remain motile for three hours electroejaculation will fail. However, there may
or more in urine provided that it is not too acid be few cases where it will succeed.
a
(pH less than about 6-2) or too dilute (total solutes
less than about 150 mosm/Kg). It thus seems References
possible that retrograde ejaculates might be used. 1 Ball L. Electroejaculation. In: Klemm WR, ed.
after centrifugation, for inseminating. Sodium bi- Applied Electronics for Veterinary Medicine and
 J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.44.1.9 on 1 January 1981. Downloaded from http://jnnp.bmj.com/ on September 30, 2020 by guest.
18 G S Brindley
Animal Physiology. Springfield, CC Thomas, 1976; plegic followed by pregnancy. Paraplegia 1978;
394-441. 16:248-51.
2 Horne HW, Paull DP, Munro D. Fertility studies 8 Brindley GS, Rushton DN, Craggs MD. The
in human male with traumatic injuries of the pressure exerted by the external sphincter of the
spinal cord and cauda equina. New Engl J Med urethra when its motor nerve fibres are stimulated
1948; 239:959-61. electrically. Br J Urol 1974; 46:453-62.
3 Bensman A, Kottke FJ. Induced emission of 9 Masters WH, Johnson, VE. Human sexual re-
sperm utilizing electrical stimulation of the sponse. Boston: Little, Brown & Co., 1966:185.
seminal vesicles and vas deferens. Arch Phys Med 10 Brindley GS. An implant to empty the bladder
Rehab 1966; 47:436-43. or close the urethra. J Neurol, Neurosurg Psy-
4 Thomas RJS, McLeish G, McDonald IA. Eectro- chiatry 1977; 40:358-69.
ejaculation of the paraplegic male followed by 11 Jacobsen J. Die Gefahrdung durch phasenange-
pregnancy. M J Aust 1975; 2:798-9.
schnittene und gleichgerichtete elektrische Strome.
Hannover: Technische Universitat (Dr. Ing.
5 David A, Ohry A, Rozin R. Spinal cord injuries: thesis) 1973.
male infertility aspects. Paraplegia 1977; 15:11-14. 12 Blair EA, Erlanger, J. A comparison of the
6 Res P, Plevnik S, Suhel P. Electroejaculation in characteristics of axons through their individual
spinal cord injured patients. International Con- electrical responses. Am J Physiol 1933; 106:
tinence Society, 7th Annual Meeting 1977; Paper 524-64.
6:21-22. 13 Brindley GS. Deep scrotal temperature and the
7 Francois N, Maury M, Jouannet D, David G, effect on it of clothing, air temperature, activity,
Vacant J. Electroejaculation of a complete para- posture, and paraplegia. Br J Urol (in Press).

Protected by copyright.