Pravin K. Rao, MD
BASICS
DESCRIPTION
• Anorgasmia or delayed orgasm/ejaculation
– Difficulty/inability to reach orgasm
• Low volume ejaculate
– Suspect if <1.5 cc ejaculate volume
• Aspermia
– Orgasm with zero ejaculate volume
• Retrograde ejaculation
– Sperm seen in post-ejaculatory urine
• Ejaculatory duct obstruction (EDO)
– Congenital, acquired, iatrogenic
• Failure of emissions
– Can also cause low/zero volume
EPIDEMIOLOGY
Incidence
• Increased in aging (age 50–80 yr) men with BPH/LUTS (1)[B]
– 46% decreased ejaculation
– 5% anejaculation
• Men on tamsulosin 0.8 mg
– ∼90% report decreased ejaculatory volume (2)[B]
• Selective serotonin reuptake inhibitors (SSRIs)
– 16–37% delayed or difficult orgasm
• Anorgasmia is rare:
– 0.14–0.4% in general population
Prevalence
N/A
RISK FACTORS
• Age
• Benign prostatic hyperplasia
• Lower urinary tract symptoms
• Prostatitis/Ejaculatory duct stones
• Depression and related medications
• Hypogonadism
• Hypertension medications
• Prostate/Urethral /Bladder neck surgery
• Retroperitoneal lymph node dissection (RPLND)
• Cystic fibrosis
• Neurologic conditions/Diabetes
– Multiple sclerosis, spinal cord injury (SCI), spina bifida, diabetes
• Rectal surgery
• Radiation therapy
Genetics
N/A
PATHOPHYSIOLOGY
• Normal ejaculation:
– Central control in multiple brain regions
Can promote or inhibit ejaculation
– Sympathetic (T12–L3):
Hypogastric nerve (thoracolumbar)
Seminal emission by contraction of epididymis, vas deferens/ampulla, seminal vesicle (SV), and prostate smooth muscle
Bladder neck closure preventing retrograde ejaculation
– Parasympathetic (S2–S4):
Pelvic nerve
Gland secretions of prostate SV
– Somatic (S2–S4):
Pudendal nerve
Efferents from sacral cord
Contraction of bulbocavernosal and ischiocavernosal muscles
Relaxation of external urethral sphincter
Projectile expulsion of ejaculate
– Sensory
Pudendal nerve
Tactile stimulation of penis can activate ejaculatory reflex
• Anorgasmia/Delayed orgasm
– Hypogonadism
– Medication side effect
– Psychological/Psychiatric (depression)
• Retrograde ejaculation
– Damage to ejaculatory nerves/reflexes
– Bladder neck surgery or dysfunction
– Medications affecting bladder neck
• Low volume ejaculate
– Poor development/absence of accessory sex organs
– Retrograde ejaculation or functional problem
– Medications affecting accessory glands
– Decreased prostate and SV secretions seen in hypogonadism
• Ejaculation requires intact, properly developed, and coordinated accessory sex organs, nerves, and muscles
– Congenital, acquired, iatrogenic, infectious, inflammatory causes can all prevent normal ejaculation
– Functional causes may lead to the complaint of decreased force of ejaculate
– Ejaculate volume commonly decreases by ∼0.03 mL each year with advanced age
ASSOCIATED CONDITIONS
• Psychological/Psychiatric conditions
• See Risk Factors
GENERAL PREVENTION
• Avoidance of bladder neck procedures
– Transurethral prostate, bladder neck surgery
• Avoidance/decreased use of medications
– SSRI, α−blockers, 5α-reductase inhibitors
• Nerve sparing at time of RPLND
• Strict diabetic control
DIAGNOSIS
HISTORY
• Duration of symptoms
• No defined criteria for diagnosis of delayed ejaculation
– Mostly normal men ejaculate after 4–10 min of penetration
– Presence of significant distress to patient or partner important to diagnosis
• Presence or absence of orgasm
• Perceived ejaculate volume
• Sources of stress/psychological disturbance
• Past medical history
• Retroperitoneal and genitourinary operations
• Family history of cystic fibrosis
– See vas deferens, congenital absence
• Medications:
– Antidepressants/antipsychotics
– Bladder outlet medications
– Antihypertensives (clonidine)
– Methyldopa
PHYSICAL EXAM
• Absence or diminished development of epididymides and vasa deferentia
– Congenital bilateral or unilateral absence of the vas deferens (CBAVD/CUAVD)
• Enlarged SV
– EDO
• Hypospadias or epispadias
– Hypogonadism
DIAGNOSTIC TESTS & INTERPRETATION
Lab
• Semen analysis
– Volume: Suspect if ejaculate volume <1.5 cc
– Concentration: Low volume azoospermia suspicious for EDO
– Absence of seminal fructose suggests EDO
• Post-ejaculatory urinalysis (PEU): >10–15 sperm/HPF demonstrates retrograde ejaculation
Imaging
• Transrectal ultrasound (TRUS)
– Usually done for low volume azoospermia
For patients with negative PEU
– Normal SV A-P diameter <1.5 cm
• MRI
– Can help identify structural abnormalities
Diagnostic Procedures/Surgery
• TRUS with SV aspiration: Presence of numerous sperm suggests obstruction
– Rare: Seminal vesiculography
Pathologic Findings
Scar tissue at ejaculatory duct
DIFFERENTIAL DIAGNOSIS
• Anorgasmia
• Retarded/Delayed orgasm
• Erectile dysfunction
– May present as inability to reach orgasm, or with weak force of ejaculate
• Retrograde ejaculation
• Aspermia
• EDO (ejaculatory duct obstruction)
TREATMENT
GENERAL MEASURES
• Remove/modify correctible causes
– Medications
Alfuzosin 21% vs. tamsulosin 90% of patients reported reduced ejaculatory volume (2)[B]
– Psychological/Stress factors
• Psychological assessment/counseling
• Treat erectile dysfunction
• Sexual counseling on techniques for optimal arousal
MEDICATION
First Line
• Anorgasmia/Delayed ejaculation
– No drug treatments FDA approved
– Medications that can be tried include:
Pseudoephedrine
Yohimbine
• See “Retrograde Ejaculation”
Second Line
N/A
SURGERY/OTHER PROCEDURES
• Most procedures reserved for infertility treatment
• Transurethral resection of ejaculatory ducts (TUREDs) for EDO
• Penile vibratory stimulation (PVS)
– For anorgasmic/anejaculatory men
– Integration with cognitive-behavioral therapy
– High success (>75%) in SCI, though usually for fertility purposes
– Procedure: Apply to ventral/frenular region for 1–3 min at a time, with 1 min rest periods, for up to 15–20 min
– See images of PVS devices:
Ferticare
Viberect (dorsal and ventral stimulation)
• Electroejaculation (EEJ) via rectal probe
• Autonomic dysreflexia
– Risk for SCI lesions above T6
– Can occur with PVS or EEJ
– Consider nifedipine 10–20 mg PO 10–15 min before treatment initiated
– Monitor at-risk patients for hypertension, tachycardia, sweats
• Retrieval of sperm from bladder
– See “Retrograde Ejaculation”
• Testicular or epididymal sperm retrieval
– Requires IVF/ICSI
– Donor sperm or adoption may circumvent the need for IVF/ICSI
ALERT
Men with spinca cord injury (SCI) above the T6 level are at risk of autonomic dysreflexia (3).
ADDITIONAL TREATMENT
Radiation Therapy
N/A
Additional Therapies
• Pelvic floor physical therapy for associated symptoms of pain or voiding symptoms
• Cognitive-behavioral sex therapy
• Changing idiosyncratic masturbation style if present
Complementary & Alternative Therapies
N/A
ONGOING CARE
PROGNOSIS
• Depends on the etiology, duration, and severity
• >40% SCI men doing PVS with home insemina-tion can achieve pregnancy (3)[B]
COMPLICATIONS
• Infertility implications
• Relationship stress and difficulty
FOLLOW-UP
Patient Monitoring
Based on response to therapy and needs of specific patient
Patient Resources
N/A
REFERENCES
1. Rosen R, Altwein J, Boyle P, et al. Lower urinary tract symptoms and male sexual dysfunction: The multinational survey of the aging male (MSAM-7). Eur Urol. 2003;44(6):637–649.
2. Hellstrom WJ, Sikka SC. Effects of acute treatment with tamsulosin versus alfuzosin on ejaculatory function in normal volunteers. J Urol. 2006;176(4 Pt 1):1529–1533.
3. Sønksen J, Fode M, Löchner-Ernst D, et al. Vibratory ejaculation in 140 spinal cord injured men and home insemination of their partners. Spinal Cord. 2012;50(1):63–66.
ADDITIONAL READING
• Fode M, Krogh-Jespersen S, Brackett NL, et al. Male sexual dysfunction and infertility associated with neurological disorders. Asian J Androl. 2012;14(1):61–68.
• Nelson CJ, Mulhall JP. Male orgasmic disorders: What do we know? Comtemp Urol. 2007; February
See Also (Topic, Algorithm, Media)
• Anorgasmia/Dysorgasmia
• Ejaculation, Painful
• Ejaculation, Premature
• Ejaculatory Disturbances (Delayed, Decreased, or Absent) Images 
• Ejaculatory Duct Obstruction
• Retrograde Ejaculation
• Vas Deferens, Congenital Absence
CODES
ICD9
• 302.79 Psychosexual dysfunction with other specified psychosexual dysfunctions
• 608.87 Retrograde ejaculation
• 608.89 Other specified disorders of male genital organs
ICD10
• F52.32 Male orgasmic disorder
• N53.14 Retrograde ejaculation
• N53.19 Other ejaculatory dysfunction
CLINICAL/SURGICAL PEARLS
Inclusion of partner in treatment important if recommending change in sexual practice.