Facts about Ejaculation and Orgasm Disorders

Clinically significant disorders of ejaculation include failure of emission, retrograde ejaculation, premature ejaculation, delayed ejaculation, painful ejaculation, hematospermia, and anorgasmia.

Failure of emission occurs when semen is not propulsed into the urethra during orgasm, resulting in a dry ejaculate. Retrograde ejaculation is a backward flow of semen into the bladder.

Premature ejaculation exists when there is an inability to delay ejaculation such that ejaculation occurs sooner than desired, either before or shortly after penetration, causing distress to either one or both partners.

Hematospermia is the appearance of blood in the ejaculate. Anorgasmia is the inability to achieve orgasm in a timely manner.

CLINICAL PRESENTATION

  • Failure of emission: no ejaculate is produced during orgasm. Physical findings may reveal nervous system dysfunction (e.g., spinal cord injury); may present with infertility (e.g., ejaculatory duct obstruction).
  • Retrograde ejaculation: little or no ejaculate is expelled out of the urethra at orgasm. Patients may report cloudy postcoital urine. Physical examination is usually normal; may present with infertility.
  • Premature ejaculation: ejaculation occurs sooner than desired, either before or shortly after penetration. Physical examination is normal. Sexual and psychological history may be revealing. Up to 30% of patients may report concomitant erectile dysfunction.
  • Painful ejaculation: perineal, scrotal, or testicular pain during or shortly after ejaculation. Physical examination may demonstrate pain on examination of external genitalia, or with digital rectal examination; may present with infertility.
  • Hematospermia: reddish-brown ejaculate, usually painless. Physical findings usually unremarkable; not associated with malignancy.
  • Anorgasmia: patient is not able to achieve orgasm despite appropriate stimulation.

ETIOLOGY

  • Retrograde ejaculation may be caused by anatomic abnormalities of the bladder neck, or nerve injury affecting the bladder neck sphincter.
  • Either retrograde ejaculation or failure of emission may result from functional abnormalities, such as spinal cord injury, diabetes mellitus, retroperitoneal surgery, transurethral prostate surgery, urethral strictures, alpha-blocker therapy, antipsychotics, multiple sclerosis, and peripheral neuropathy.
  • The etiology of premature ejaculation is complex and multifactorial, and includes genetic, behavioral, and psychologic contributions.
  • Causes of painful ejaculation may be infectious (e.g., epididymo-orchitis, urethritis, prostatitis), obstructive (e.g., vasectomy, prostatectomy, hernia repair), or psychologic.
  • Hematospermia may be idiopathic, secondary to prolonged abstinence, or due to infection or inflammation of the genitourinary tract.
  • Anorgasmia may be caused by spinal cord injury, psychologic factors, dysfunctional sexual techniques, or medications, particularly serotonin re-uptake inhibitors.

DIAGNOSIS

DIFFERENTIAL DIAGNOSIS

  • Erectile dysfunction
  • Low seminal fluid volume attributable to hypogonadism or ejaculatory duct obstruction

C. Inflammatory disorders of the genitourinary tract

C. Hypoactive sexual desire

LABORATORY TESTS

  • In the setting of a dry or low-volume ejaculate, post-ejaculate urine should be evaluated for the presence of spermatozoa, in order to differentiate failure of emission from retrograde ejaculation.
  • Hematuria, in the setting of hematospermia or painful ejaculation, may signal an underlying inflammatory disorder or a malignancy and should prompt a complete evaluation.
  • A fasting blood glucose may be considered if diabetes is suspected as a cause of lack of emission or retrograde ejaculation.
  • Urinalysis, urine culture, and screening for sexually transmitted diseases, when indicated, can rule out an infectious etiology of painful ejaculation.

IMAGING STUDIES

Transrectal ultrasonography can rule out ejaculatory duct obstruction or absence of the seminal vesicles.

TREATMENT

NON-PHARMACOLOGIC THERAPY

  • Retrograde ejaculation and failure of emission do not require treatment unless fertility is desired.
  • In the setting of retrograde ejaculation, viable sperm can be recovered from the postejaculate urine and used for intrauterine insemination or in vitro fertilization.
  • Premature ejaculation can improve with psychotherapy and behavioral interventions (e.g., “coronal squeeze” or “start-and-stop” technique) and effective partner communication. These approaches may be more effective when combined with pharmacologic therapy.
  • Idiopathic hematospermia may be followed expectantly and is usually self-limited to 10 to 15 ejaculations.
  • Anorgasmia caused by serotonin reuptake inhibitors usually improves with withdrawal of the medication. Sexual therapy and counseling can improve anorgasmia caused by dysfunctional sexual techniques or psychologic issues. Vibratory or electrical stimulation of emission is helpful in selected cases.

ACUTE GENERAL Rx

  • Retrograde ejaculation: pharmacologic therapy is only effective in patients without an anatomic disturbance of the bladder neck. Sympathomimetic medications (phenylpropanolamine, ephedrine, pseudoephedrine) and imipramine may be useful in converting retrograde ejaculation to antegrade ejaculation.
  • Failure of emission: may be converted to retrograde ejaculation by oral sympathomimetic therapy, as listed above.
  • Premature ejaculation: selective serotonin reuptake inhibitors (SSRI) (sertraline, fluoxetine) and the tricyclic antidepressant clomipramine can successfully delay ejaculation when taken daily. Recent research has focused on dapoxetine, a short-acting SSRI, which has shown promise as an “on-demand” treatment for premature ejaculation. Topical anesthetics such as lidocaine cream and topical sprays have also been used, with variable success. The use of phosphodiesterase inhibitors (PDE5i) (sildenafil, vardenafil, tadalafil) with SSRIs may be beneficial in men with concomitant erectile dysfunction and premature ejaculation.
  • Antimicrobial treatment (if indicated), NSAIDs, and muscle relaxants may help decrease discomfort associated with painful ejaculation.
  • The use of the pharmacologic therapies listed above for the treatment of various disorders of ejaculation is strictly off label and does not carry FDA approval.

SURGICAL THERAPY

There is no role for surgery for the majority of ejaculatory disorders. Rarely, painful ejaculation due to obstructive causes may show improvement with surgical intervention (e.g., vasectomy reversal).

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