Sexual dysfunction, anejaculation
Ejaculatory disorders include a class of sexual disorders, which leads to impaired ejaculation. Male sexual function depends on the complex interaction of multiple dimensions of human sexuality: arousal, sexual desire, orgasm, erectile function, and ejaculation. Sexual dysfunction is often multi- dimensional that occurs as a spectrum of disorders involving any or a combination of these factors. Sexual dysfunction is a common problem in males with 35% of men aged 40 to 70 years experiencing moderate to complete erectile dysfunction, and in an analysis of more than 3000 individuals, 31% of men reported some sexual dysfunction.
Major advances have been made in understanding the neurovascular mechanisms of sexual response and function in men, with the development of several drugs for the treatment of erectile dysfunction. Ejaculatory dysfunction, which includes a spectrum of disorders such as premature ejaculation, delayed ejaculation, anejaculation, painful ejaculation, retrograde ejaculation, and diminished volume or force of ejaculation, is an important public health problem that is often comorbid with erectile dysfunction and orgasmic dysfunction. Premature ejaculation can be a frequent source of distress and sexual dissatisfaction. It is estimated that 10-20% of men will have delayed ejaculation or an ejaculation, with 20-40% of men experiencing ejaculatory dysfunction at some point in their lives.
Although ejaculatory dysfunction is prevalent, it has not been well characterized or evaluated. There are currently no standardized assessments of ejaculatory function, and little is known about the relationship between ejaculatory force and orgasm satisfaction. More detailed description of the most prevalent ejaculatory dysfunctions can be found below.
Premature (early) ejaculation
Premature ejaculation (PE) occurs when a man experiences orgasm and expels semen soon after sexual activity and with minimal penile stimulation. It has also been called early ejaculation, rapid ejaculation, rapid climax, premature climax, and (historically) ejaculatio praecox.
The causes of premature ejaculation are unclear. Many theories have been suggested, including that PE was the result of masturbating quickly during adolescence to avoid being caught by an adult, of performance anxiety, of an unresolved Oedipal conflict, of passive-aggressiveness, and having too little sex; but there is little evidence to support any of these theories.
Several physiological mechanisms have been hypothesized to contribute to causing premature ejaculation including serotonin receptors, a genetic predisposition, elevated penile sensitivity, and nerve conduction atypicalities.
Delayed ejaculation
Delayed ejaculation, also called retarded ejaculation or inhibited ejaculation, is a man's inability for or persistent difficulty in achieving orgasm, despite typical sexual desire and sexual stimulation. Generally, a man can reach orgasm within a few minutes of active thrusting during sexual intercourse, whereas a man with delayed ejaculation either does not have orgasms at all or cannot have an orgasm until after prolonged intercourse which might last for 30–45 minutes or more. In most cases delayed ejaculation presents the condition in which the man can climax and ejaculate only during masturbation, but not during sexual intercourse. It is the least common of the male sexual dysfunctions, and can result as a side effect of some medications. Medical conditions that can cause delayed ejaculation include hypogonadism, thyroid disorders, pituitary disorders such as Cushing's disease, prostate surgery outcome, and drug and alcohol use. Difficulty in achieving orgasm can also result from pelvic surgery that involved trauma to pelvic nerves responsible for orgasm. Some men report a lack of sensation in the nerves of the glans penis, which may or may not be related to external factors, including a history of circumcision.
Delayed ejaculation is a possible side effect of certain medications, including selective serotonin reuptake inhibitors (SSRIs), opiates such as morphine or oxycodone, many benzodiazepines such as Valium, certain antipsychotics, and antihypertensives.
Psychological and lifestyle factors have been discussed as potential contributors, including insufficient sleep, distraction due to worry, distraction from the environment, anxiety about pleasing their partner and anxiety about relationship problems.
Odynorgasmia
Odynorgasmia, or painful ejaculation, is a physical syndrome described by pain or burning sensation of the urethra or perineum during or following ejaculation. Causes include infections associated with urethritis, prostatitis, epididymitis, as well as use of anti-depressants.
Anejaculation
Anejaculation is defined as the complete absence of antegrade or retrograde ejaculation. It is caused by failure of emission of semen from the prostate and seminal ducts into the urethra. Causes of anejaculation include spinal cord injury, cauda equina lesions, multiple sclerosis, Parkinson's disease, diabetes mellitus, medication (antihypertensive, antipsychotic, antidepressants, alcohol) and surgery (aortoiliac surgery, retro peritoneal lymph node dissection, colorectal resection). The thoracolumbar sympathetic nerves cause contraction of the smooth muscles of the prostate, seminal vesicles and vas deferens leading to emission of seminal fluid into the urethra. These nerves are prone to injury during abdominal aortic aneurysm repair, especially when undertaken as an emergency. Aortoiliac surgery can also lead to damage of the superior hypogastric plexus and result in erectile dysfunction.
Retrograde ejaculation
Retrograde ejaculation occurs when semen, which would normally be ejaculated via the urethra, is redirected to the urinary bladder. Normally, the sphincter of the bladder contracts before ejaculation forcing the semen to exit via the urethra, the path of least resistance. When the bladder sphincter does not function properly, retrograde ejaculation may occur. Conditions which can caused retrograde ejaculation are bladder neck surgery, prostate surgery, diabetes mellitus, multiple sclerosis, and spinal cord injury. Also medications such as antihypertensive drugs or treatment of prostate enlargement and mood disorders can causesphincter insuficiency because of their side effects.
Diminished volume or force of ejaculation
Hypospermia is the medical term when a man has an unusually low ejaculate (or semen) volume, less than 1.5 ml. Normal ejaculate when a man is not drained from prior sex and is suitably aroused, is around 1.5-6 ml, although this varies greatly with mood, physical condition and sexual activity. Of this, around 1% by volume is sperm cells. Hypospermia would only usually be a factor in infertility if the two conditions - hypospermia and oligospermia - are combined. The U.S. based National Institutes of Health defines hypospermia as a semen volume lower than 2 ml on at least two semen analyses.
Associated disease
Complications
Risk factors
Ejaculatory dysfunction is very common and stressful thing for men. It is a significant cause of male subfertility, posing distinct reproductive challenges for couples attempting to conceive. While delayed ejaculation and premature ejaculation are sources of sexual dissatisfaction for men and their partners, patients with these disorders could retain fertile in most cases.
Men with anejaculation or retrograde ejaculation are unable to deliver sperm into the female genital tract and are therefore rendered subfertile. For them, there are techniques of assisted reproduction.
To prevent some of ejaculatory disorders you should limit your alcohol intake, quit smoking, do some sport which could also reduce stress in your life and communicate with your partner.
Premature ejaculation:
Many men attempt to treat themselves for premature ejaculation by trying to distract themselves, such as by trying to focus their attention away from the sexual stimulation. There is little evidence to indicate that it is effective, however and tends to detract from the sexual fulfilment of both partners. Other self-treatments include during the act thrusting more slowly, withdrawing the penis altogether, purposefully ejaculating before sexual intercourse, and using more than one condom. To treat premature ejaculation, Masters and Johnson developed the "squeeze technique". Men were instructed to pay close attention to their arousal pattern and learn to recognize how they felt shortly before their "point of no return", the moment ejaculation felt imminent and inevitable. Sensing it, they were to signal their partner, who squeezed the head of the penis between thumb and index finger, suppressing the ejaculatory reflex and allowing the man to last longer.
Delayed ejaculation:
Therapy usually involves homework assignments and exercises intended to help a man get used to having orgasms through insertional intercourse, vaginal, anal, or oral, that is through the way to which he is not accustomed. Commonly, the couple is advised to go through three stages. At the first stage, a man masturbates in the presence of his partner. Sometimes, this is not an easy matter as a man may be used to having orgasms alone. After a man learns to ejaculate in the presence of his partner, the man's hand is replaced with the hand of his partner. In the final stage, the receptive partner inserts the insertive partner's penis into the partner's vagina, anus, or mouth as soon as the ejaculation is felt to be imminent. Thus, a man gradually learns to ejaculate inside the desired orifice by an incremental process.
For odynorgasmia, anejaculation and retrograde ejaculation there is no alternative or self-therapy.
Pharmacotherapy
Premature ejaculation:
Drugs that increase serotonin signalling in the brain slow ejaculation and have been used successfully to treat PE. These include selective serotonin reuptake inhibitors (SSRIs), such as paroxetine or dapoxetine, as well as clomipramine. Ejaculatory delay typically begins within a week of beginning medication. The treatments increase the ejaculatory delay to 6–20 times greater than before medication. Men often report satisfaction with treatment by medication, many discontinue it within a year. SSRIs can cause various types of sexual dysfunction such as anorgasmia, erectile dysfunction, and diminished libido.
Desensitizing topical medications that are applied to the tip and shaft of the penis can also be used. These are applied "as needed", 10–15 minutes before sexual activity and have fewer potential systemic side effects as compared to pills. Use of topicals is sometimes disliked due to the reduction of sensation in the penis as well as for the partner (due to the medication rubbing onto the partner). Penis insensitivity and transference to the partner are practically eliminated when
using topical anesthetic sprays based on absorption technologywhich enable the active ingredient to penetrate through the surface skin of the penis (stratum corneum) to the sensory nerves which reside in the dermis.
Retrograde ejaculation:
Substances which help the bladder neck muscle close during ejaculation are used:
Delayed ejaculation:
The most important is to eliminate iatrogenic causes, including medications such as alpha-adrenergic blockers, other antihypertensives, antidepressants, and antipsychotics. But fot the conditon itself, there is no exact pharmacotherapy.
Odynorgasmia, anejaculation and diminished volume of ejaculate can not be treated pharmacologically.
Surgical therapy
Retrograde ejaculation:
In surgical intervention goal is restoration of bladder neck integrity. It is possible to injected collagen into the bladder neck of a male to achieve antegrade ejaculation. For men with spinal cord injury, electroejaculation is primarily used to achieve ejaculation.
Premature ejaculation:
One possible surgical treatment of premature ejaculation is circumcision. Because the prepuce contains rich and complex network of nerves, it is a specific erogenous zone. The penis is radically desensitized after the circumcision, but if it is done incompletely, man could suffer from premature ejaculation. What surgery significantly do is decrease of penile sensitivity.
Other ejaculatory disorders cannot be treated surgically.
For those who unsuccessfully tried conventional medicine, there is surgical sperm retrieval which uses microsurgical epididymal sperm aspiration, percutaneous epididymal sperm aspiration, testicular sperm aspiration, or testicular sperm extraction, following by intracytoplasmic sperm injection to achieve pregnancy.
Complete absence of sperm in the ejaculate of a man.
The inability (that lasts more than 6 months) to develop or maintain an erection of the penis during sexual activity.
A disease of excess body fat that can have a negative effect on health, leading to reduced life expectancy and other health problems.
The pathological inability to ejaculate in males, with (orgasmic) or without (anorgasmic) orgasm.
The semen, which would normally be ejaculated via the urethra, is redirected to the urinary bladder.
A medical condition impairing the function of the thyroid.
Complete absence of sperm in the ejaculate due to testicular failure.
Semen with a low concentration of sperm and is a common finding in male infertility.
A medical term which describes a diminished functional activity of the gonads – the testes and ovaries.
An inflammation of the prostate gland.
Male diagnosis connected with male infertility characterised by the complete absence of semen.
A condition in which a man has an unusually low ejaculate (or semen) volume.
A man experiences orgasm and expels semen soon after sexual activity and with minimal penile stimulation.
A man's inability for or persistent difficulty in achieving orgasm, despite typical sexual desire and sexual stimulation.
A physical syndrome described by pain or burning sensation of the urethra or perineum during or following ejaculation.
Absence of sperm in the ejaculate despite normal spermatogenesis, caused by an obstruction of the genital tract.
An inflammation of epididymis.
External male sex organ that additionally serves as the urinal duct.
A walnut-sized structure that is located below the urinary bladder in front of the rectum.
Male gonads which produce both sperm and androgens, such as testosterone, and are active throughout the reproductive lifespan of the male.
The duct in the testicle that carries semen from the epididymis to the ejaculatory duct.
The cell in seminiferous epithelium responsible for nutrition and development of germ (sperm) cells.
An undifferentiated male germ cell with self-renewing capacity representing the first stage of spermatogenesis.
FSH is a hormone secreted by the anterior pituitary gland. It regulates the development, growth, pubertal matur and reproductive functions of the body
A releasing hormone responsible for the release of follicle-stimulating hormone (FSH) and luteinizing hormone (LH) from the anterior pituitary.
A hormone, that stimulates ovulation and the development of the corpus luteum in females, and the production of androgens in males.
Steroid hormone produced primarily in the testes of the male; responsible for the development of secondary sex characteristics in the male.
The physiological process by which a penis becomes erect by being engorged with blood.
The fusion of an ovum with a sperm to initiate the development of a new individual organism.
Process in which spermatozoa are produced from male primordial germ cells in testicles by way of mitosis and meiosis.
Surgical procedures that involve opening the abdomen.
A pattern of drinking that results in harm to one’s health, interpersonal relationships, or ability to work.
A broad group of drugs that are used in the treatment of depression and could negatively affect sexual function.
A class of drugs that are used to treat high blood pressure.
A class of medications prescribed to treat mental health issues involving psychosis or delusions and leading to hormonal imbalances.
Disorder characterized by symptoms of both anxiety and depression that may cause sexual disorders and anovulation.
A condition in which the body either does not produce enough, or does not properly respond to insulin, a hormone produced in the pancreas.
A patterned use of a drug in which the user consumes the substance in amounts or with methods which are harmful to themselves or others.
A medical condition of excess body fat that can have a negative effect on health, leading to reduced life expectancy and other health problems.
A medical term for the surgical removal of all or part of the prostate gland.
Surgical removal of all or part of the prostate gland.
The inflammation (swelling) of the prostate gland.
A damage of the spinal cord that causes changes in its function, either temporary or permanent.
Damage of the testicles or scrotum which may be temporary or permanent.
A surgical procedure for male sterilization or permanent contraception.
The pathological inability to ejaculate in males, with (orgasmic) or without (anorgasmic) orgasm.
A type of sexual dysfunction in which a person cannot achieve orgasm despite adequate stimulation.
The emotional state characterized by unpleasant feelings such as uneasiness, worry, apprehension and dread.
A man's inability for or persistent difficulty in achieving orgasm, despite typical sexual desire and sexual stimulation.
The inability to develop or maintain an erection of the penis during sexual activity in humans.
The failure to achieve a clinical pregnancy after 12 months or more of regular unprotected sexual intercourse.
Aspermia is the complete lack of semen with ejaculation.
The absence of sexual appetite.
Body weight that's greater than what is considered healthy for a certain height.
The painful feelings during sexual intercourse.
An uncontrolled ejaculation either before or shortly after sexual penetration.
A frustration caused by a discrepancy between a person's desired and achieved sexual activity.
Abnormally small testicular volume.
A term describing a person whose body weight is considered too low to be healthy.
Process by which a woman donates eggs for purposes of assisted reproduction or biomedical research.
A micromanipulative fertilization technique in which a single sperm is injected directly into an egg.
The way a person lives.
It is a therapeutic approach to treating medical conditions and their associated symptoms via the use of a specifically tailored diet.
Medications used to treat retrograde ejaculation.
Physical exercise is any bodily activity that enhances or maintains physical fitness and overall health and wellness.
A non-invasive method of the sperm isolation in the case of retrograde ejaculation.
The procedure in which a man (sperm donor) provides his sperm for fertility treatment.
A process in which an egg is fertilised by sperm outside the body: in vitro. Own or donated gametes may be used.
Surgery used to treat retrograde ejaculation.
