Ejaculatory Dysfunction

Ejaculation involves coordinated muscular and neurological events that involve deposition of semen in the urethral (emission) and propulsion of the fluid from the urethral meatus (ejection). 

Emission is accomplished by contraction of the vas deferens, seminal vesicles, and ejaculatory ducts. This process is under adrenaline control. Ejection results from the rhythmic contractions of the muscles around the urethra, which causes the forcible ejection of the ejaculate. Within the spinal cord lies the ejaculation center which is the area involved in the coordination of signals from the brain and penis that eventually lead to ejaculation. 

In normal men there exists a linear sexual response cycle: desire, arousal, plateau, orgasm, and resolution. 

Orgasm can be subdivided into climax and ejaculation. During the resolution phase it is normal for men to experience a refractory period; during the refractory period it is not possible to stimulate the penis back into the erect state. The refractory period is typically very brief in young men but becomes progressively longer with age. 

There are four main ejaculatory disorders that are seen in clinical practice: (i) premature ejaculation, (ii) retrograde ejaculation, (iii) delayed ejaculation (orgasm), and (iv) anorgasmia. 

Risks & Causes 

Premature ejaculation can be life-long (primary) or aquired. There are numerous theories as to the cause, but most cases are probably multi-factorial with a contribution from both psychological and physical factors. This is believed to be the most common sexual dysfunction in males. The lifelong prevalence of premature ejaculation is roughly 4% but as many as 30% of men of all ages will self-report it. 

Retrograde ejaculation is the process whereby the semen is passed in a retrograde fashion into the bladder as opposed to anterograde out the urethra. There are three potential causes to this problem; anatomic, neurologic, and pharmacologic. Anatomic causes can result from prior prostate surgery (i.e., transurethral resection of the prostate) or from congenital disorders. Neurologic disorders can interfere with the ability of the bladder neck to close during emission and ejection. This can be a result of diabetes mellitus or retroperitoneal or pelvic surgery. Finally, certain medications result in a paralysis of the bladder neck which often results in retrograde ejaculation. 

Delayed ejaculation and anorgasmia involve the inability of the patient to achieve orgasm (ejaculation) in a timely manner, and in severe cases men fail to achieve orgasm on any occasion. Failure to achieve orgasm may be due to inadequate sexual stimulation, psychological disorders or medical conditions. Psychological disorders and/or psychosocial variables may include relationship stressors, partner conflict and personal distress regarding sexuality. Other causes of this condition include the use of certain anti-depressant medications (fluoxetine, sertraline, paroxitine, fluvoxamine, citalopram) and sensory neurologic disorders affecting penile sensation (as may occur with diabetic nerve damage). Finally, there are men for whom there is no clear etiology for this problem who are believed to have either a physiological or idiopathic form of this condition. 

Symptoms & Evalution 

A comprehensive medical and sexual history is the most important aspect in the diagnosis of men with ejaculatory dysfunction. A focused genital exam is also indicated in most circumstances. Testosterone is often the most commonly performed blood test in the evaluation of ejaculatory dysfunction. 

Premature ejaculation (PE), also known as rapid ejaculation, lacks a definition that is agreed upon by all practitioners, but essentially is the condition whereby a patient ejaculates with minimal sexual stimulation and before he wishes it to occur. 

Premature ejaculation is currently defined by the International Society of Sexual Medicine as a lifelong history of ejaculation occurring within less than one minute of penetration (lifelong PE), or a clinically significant and bothersome reduction in latency time, often to about three minutes or less (acquired PE). Patients will also have reduced or absent ejaculatory control. Premature ejaculation often causes negative personal consequences, such as distress, bother, frustration, and/or the avoidance of sexual intimacy. 

Patients with retrograde ejaculation will have a normal sensation of orgasm and climax but will have little to no anterograde (forward) propulsion of semen. This is often referred to as a dry orgasm. This process is diagnosed by the finding of seminal fluid and/or sperm within a urine specimen obtained immediately after orgasm. 

Delayed ejaculation or anorgasmia involves the inability of the patient to achieve orgasm (ejaculation) in a timely manner, and in severe cases, involves failure to achieve orgasm on any occasion. As men age, there is an increase in the time it takes to achieve ejaculation. However, in some men, this increase may lead to the inability to ejaculate within a 30-minute time period from the initiation of sexual stimulation. 

Treatment Options 

The treatment of retrograde ejaculation depends to some extent on the cause. Anatomic causes are rarely curable, which results in the need for sperm harvesting from the bladder for patients wishing to initiate a pregnancy. Pharmacologic causes are generally reversible by withdrawal of the offending medication. Neurologic causes are difficult to treat if there is complete nerve damage, such as may occur in spinal cord injured patients. In patients with a partial neural injury (diabetes), the use of certain medications (pseudoepohedrine, for example) may convert the patient to an antegrade ejaculator. 

The management of premature ejaculation (PE) is best handled in a combined psychotherapy and pharmacologic fashion. Mean ejaculation latency time in healthy men is between 5-6 minutes. Men who have ejaculation latencies within this time period should be reassured. For men with lifelong and acquired premature ejaculation, there are several treatment options. First line therapy generally involves behavioral techniques in combination with psychotherapy. The most commonly used behavioral techniques are the squeeze or stop-start techniques. Topical local anesthetics are often used in combination with behavioral modification. Topical anesthetics are usually applied to the head of the penis (glans) 5-10 minutes prior to planned sexual activity. 

Off-label use of selective serotonin reuptake inhibitors (SSRI) and tri-cyclic antidepressant (TCA) such as paroxetine, sertraline and fluoxetine or clomipramine are used in order to take advantage of their side effect profile of delaying ejaculation. Dapoxetine, a short acting SSRI, is the only medication that has been approved in some countries for the sole purpose of treating premature ejaculation. 

Treatment of PE with phosphodiesterase type 5 inhibitors (PDE5-I) has been reported, but is best reserved for men with co-morbid erectile dysfunction (ED) and PE. 

Delayed ejaculation and anorgasmia are very difficult sexual dysfunctions to treat. There does not exist any FDA approved pharmacologic strategy for these patients. The use of penile vibratory therapy is used as a first line therapy in order to increase penile stimulation and has the ability to help patients achieve orgasm. The results are better in patients in whom there is a delay in orgasm, as opposed to those who have a consistent complete failure to achieve orgasm. Cabergoline, a dopamine receptor agonist used in patients with hyperprolactinemia and Parkinsons disease, has been shown in preliminary studies to decrease ejaculatory latency time and may be useful in the treatment of delayed ejaculation or anorgasmia. Buproprion is another drug that has had some anectdotal success in these patients.