Robert L. Segal, MD, FRCS(C)
Arthur L. Burnett, II, MD, MBA, FACS
BASICS
DESCRIPTION
• Anorgasmia is defined as the complete inability to achieve an orgasm (the physical and emotional sensation experienced at the peak of sexual excitation) (1)
– In males, orgasm is typically associated with ejaculation (antegrade semen passage through the urethra)
– There is more robust literature in the female population with anorgasmia
– Also described in some references as orgasmic disorder, orgasmic dysfunction, or orgasmic inhibition
• Anorgasmia is often associated with delayed/inhibited ejaculation or anejaculation, although orgasm and ejaculation are separate phenomena
– Orgasm is a cerebrally mediated event, whereas ejaculation is localized to the genitourinary tract
• Must result in personal distress or interpersonal difficulty according to definitions by the DSM-IV-TR and the World Health Organization Second Consultation on Sexual Dysfunction (2)
• May be lifelong or acquired; may be global (every sexual encounter), intermittent or situational (in a certain environment, with a particular partner)
EPIDEMIOLOGY
Incidence
N/A
Prevalence
• Difficult to clearly report, as there is no clear definition of normal ejaculatory latency time
• In general, DE is reported at low rates in the literature, rarely exceeding 3% (3,4), but has been reported in up to 25% of clinical cohorts (2)
RISK FACTORS
• Advancing age
• Endocrinopathies (hypothyroidism, hypogonadism)
• Pelvic trauma/surgery (radical prostatectomy, proctocolectomy, bilateral sympathectomy)
• Pelvic radiation therapy
• Neuropathy (multiple sclerosis, diabetes mellitus, spinal cord injury)
• Secondary to medication (thiazide diuretics, tricyclic and selective serotonin reuptake inhibitor [SSRI] antidepressants, alcohol, gabapentin)
Genetics
N/A
PATHOPHYSIOLOGY
• Unless a specific organic cause is noted (see Risk Factors), anorgasmia is associated with underlying psychological factors
– Fear, anxiety, hostility, and relationship difficulties
– It has been suggested to relate to orthodoxy of religious belief (ie, it is sinful to experience orgasm/sexual pleasure)
– “Performance anxiety” may be a common cause
• May relate to men deriving greater arousal/enjoyment from masturbation than intercourse (2)
– Masturbatory frequency/style may be predisposing factors, as men with coital anorgasmia may report high levels of masturbation (2)
• Alcohol may transiently cause anorgasmia
ASSOCIATED CONDITIONS
• Anejaculation
• Delayed/inhibited ejaculation
• Depression
• Infertility
GENERAL PREVENTION
N/A
DIAGNOSIS
HISTORY
• Is the problem lifelong or acquired?
• Sexual history
– Establish the conditions (if any) where the patient is able to experience orgasm
• Assess the presence of life stressors or other psychological factors, the quality of the patient’s nonsexual relationship with the partner
• Medication use
– SSRIs and gabapentin have been implicated
PHYSICAL EXAM
• Genital exam to verify the presence and normalcy of testicles and epididymides bilaterally
• Secondary sexual characteristics and hair distribution
• Neurologic exam to assess genital sensation
• May not be contributory
DIAGNOSTIC TESTS & INTERPRETATION
Lab
• Serum morning testosterone level
• As indicated
– Semen analysis
– Semen culture
– Urine culture
– Urine cytology
– Thyroid screen
Imaging
Scrotal/transrectal ultrasound if indicated
Diagnostic Procedures/Surgery
None
Pathologic Findings
N/A
DIFFERENTIAL DIAGNOSIS
• Psychiatric distress (anxiety, depression)
• Retrograde ejaculation
• Anejaculation
• Delayed ejaculation
• Reduced ejaculation
• Penile hypnoanesthesia
TREATMENT
GENERAL MEASURES
• Treatment should be etiology specific
• May include patient/couple psychoeducation and/or psychosexual therapy [C]
• Pharmacologic treatment has met limited success (2)
MEDICATION
First Line
None currently FDA approved
Second Line
• No drugs are specifically approved for treatment of anorgasmia, so any treatment is off-label (2)
– Cyproheptadine (increases cerebral serotonin levels)
– Amantadine (stimulant of dopaminergic nerves)
– Bupropion, buspirone, and yohimbine have been anecdotally employed to reverse SSRI-induced anorgasmia
SURGERY/OTHER PROCEDURES
None
ADDITIONAL TREATMENT
Radiation Therapy
N/A
Additional Therapies
• Psychotherapy
• Masturbation retraining
• Education on revised sexual techniques which maximize arousal
Complementary & Alternative Therapies
Yohimbine has utility in anecdotal reports
ONGOING CARE
PROGNOSIS
• Continued support/psychotherapy may be required
• Anorgasmia related to trauma/surgery, radiation therapy, and neuropathies may not be reversible
COMPLICATIONS
None
FOLLOW-UP
Patient Monitoring
N/A
Patient Resources
N/A
REFERENCES
1. Mulhall JP, Nelson CJ. Male orgasmic disorder: What do we know? Contemp Urol. 2007;Feb 1.
2. McMahon CG, Jannini E, Waldinger M, et al. Standard operating procedures in the disorders of orgasm and ejaculation. J Sex Med. 2013;10:204–229.
3. Rowland D, McMahon CG, Abdo C, et al. Disorders of orgasm and ejaculation in men. J Sex Med. 2010;7(4 Pt 2):1668–1686.
4. McMahon CG, Abdo C, Incrocci L, et al. Disorders of orgasm and ejaculation in men. J Sex Med. 2004;1:58–65.
ADDITIONAL READING
• Perloff MD, Thaler DE, Otis JA. Anorgasmia with gabapentinxs may be common in older patients. Am J Geriatr Pharmacother. 2011;9(3):199–203.
• Segraves RT. Considerations for a better definition of male orgasmic disorder in DSM V. J Sex Med. 2010;7(2 Pt 1):690–695.
See Also (Topic, Algorithm, Media)
• Ejaculatory Disturbances (Delayed, Decreased, or Absent)
• Erectile Dysfunction, Following Pelvic Surgery or Radiation
CODES
ICD9
• 302.74 Male orgasmic disorder
• 608.89 Other specified disorders of male genital organs
ICD10
• F52.32 Male orgasmic disorder
• N53.11 Retarded ejaculation
CLINICAL/SURGICAL PEARLS
• Anorgasmia is often associated with ejaculatory disorders.
• Unless a specific organic cause is noted, anorgasmia is associated with underlying psychological factors.
• Anorgasmia related to trauma/surgery, radiation therapy, and neuropathies may not be reversible.
• There are no approved pharmacologic treatments for anorgasmia.