Editing Disorders of Ejaculation and Orgasm (section)

== Delayed Ejaculation (DE), Anejaculation, and Anorgasmia ==

* '''Definitions'''
**'''Delayed ejaculation: Ejaculation is considered delayed in men with latency times >25-30 minutes who report distress or simply cease sexual activity because exhaustion or irritation'''
* '''Failure of ejaculation'''
** '''Can be a lifelong problem (25%) or an acquired problem (75%)'''
** '''Can be global and happen in every sexual encounter or be intermittent or situational'''

=== Causes of retrograde ejaculation, delayed ejaculation, anejaculation, and anorgasmia ===
* '''Any psychological or medical disease or surgical procedure that interferes with either central control of ejaculation or the peripheral sympathetic nerve supply to the vas and bladder neck, the somatic efferent nerve supply to the pelvic floor, or the somatic afferent nerve supply to the penis can result in delayed ejaculation, anejaculation, retrograde ejaculation, and/or anorgasmia.'''
*'''Psychogenic'''
** '''Often described as inhibited ejaculation'''
** Usually related to sexual performance anxiety; in some men, may be associated with orthodoxy of religious belief; guilt and anxiety about “spilling seed”
** Disparity between the reality of sex with the partner and the sexual fantasy used during masturbation may inhibit sexual arousal and thus represent another contributor to DE
* '''Aging male'''
** '''Degeneration of penile afferent nerves and Pacinian corpuscles'''
* '''Endocrine'''
** '''Diabetes'''
** '''Hypogonadism and low testosterone are associated with DE or anejaculation'''
** '''Hypothyroidism is strongly associated with delayed ejaculation, hyperthyroidism is rarely associated with premature ejaculation'''
** '''Hyperprolactinemia''', via inhibition of hypothalamic GnRH is associated with low testosterone, reduced sexual desire, ED, and DE. The effect of prolactin on ejaculation is possibly mediated via its action on the serotinergic system
* '''Neurogenic'''
** '''Causes'''
***'''Surgical'''
****'''Radical prostatectomy'''
*****After RP/RALP, men no longer ejaculate, but maintain a sense of orgasm
****'''Retroperitoneal lymph node dissection'''
*****'''Anejaculation occurs in the majority of the patients in non–nerve-sparing techniques. With nerve sparing techniques, antegrade ejaculation is maintained in 80-100% of patients'''
****** The superior hypogastric plexus, a fenestrated network of fibers anterior of the lower abdominal aorta, is responsible for ejaculation and is mediated by the sympathetic system. The hypogastric nerves exit bilaterally at the inferior pole of the superior hypogastric plexus and have connections with the S1 to S2 roots. Normal emission requires integrity of this system. During RPLND, these nerves are difficult to recognize and might be damaged, resulting in decreased semen volume or dry ejaculation.
****Proctocolectomy
****Bilateral sympathectomy
****Abdominal aortic aneurysmectomy
****Para-aortic lymphadenectomy
***'''Radiotherapy'''
****Pathways for ejaculation are included in the RT fields for rectal and prostate carcinomas
***'''Diabetes (autonomic neurpathy)'''
***'''Multiple sclerosis'''
***'''Stroke'''
***'''Spinal cord injury'''
****'''Unlike erectile capacity, the ability to ejaculate increases with descending levels of spinal injury'''
*****< 5% of patients with complete upper motor neuron lesions retain the ability to ejaculate
* '''Medication:'''
** '''SSRIs''', '''antipsychotics, tricyclic antidepressants, thiazide diuretics,''' α-Methyldopa, phenothiazine, alcohol abuse
*** '''60% of patients on SSRIs report some form of treatment-related sexual dysfunction, most commonly ejaculatory dysfunction'''
*** '''Antipsychotics can cause either a direct and/or indirect dopamine antagonism or increased prolactin levels and are commonly associated with DE and retrograde ejaculation.'''
*** Retrograde ejaculation associated with antipsychotics is thought to be due to antagonistic effects on the α-adrenergic system at the level of the bladder neck
* '''Anatomic'''
** '''Transurethral resection of prostate''', bladder neck incision
*** TURP carries a high incidence of retrograde ejaculation
* '''Congenital'''
** Müllerian duct cyst, Wolffian duct abnormality, Prune belly syndrome
* '''Infection (causing obstruction)'''
** Urethritis, genitourinary tuberculosis, schistosomiasis
** Sexually transmissible infections such as gonorrhea or nonspecific urethritis can produce cicatrization and obstruction anywhere in the male reproductive tract, especially if treatment is delayed.
** Urinary infection, especially if complicated by epididymitis, also can produce obstruction that may be situated at the ejaculatory duct level.

=== Diagnosis and Evaluation ===
* '''History and Physical Exam'''
** Assessment begins by determining whether DE is lifelong or acquired, global or situational
* '''Labs'''
**'''Serum testosterone'''
* Any additional investigations suggested by the above findings.

=== Management ===
* DE is associated with high levels of relationship distress, sexual dissatisfaction, anxiety about their sexual performance, and general health issues
*'''Treatment may include patient/couple psychoeducation and/or psychosexual therapy, lifestyle changes, pharmacotherapy, or integrated treatment'''

==== Options (4): ====

# '''Psychological strategies'''
# '''Lifestyle changes'''
# '''Pharmacotherapy'''
# '''Vibratory stimulation and electroejaculation'''

===== Psychological strategies =====
* If organic and pharmacologic causes have been eliminated, referral to an expert psychosexual therapist is usually indicated to evaluate the causative psychological and behavioral issues.

===== Lifestyle changes =====
* Changes include enjoying more time together to achieve greater intimacy, minimizing alcohol consumption, having sex when not tired, and practicing techniques that maximize penile stimulation such as pelvic floor training

===== Pharmacotherapy =====
* '''Options include pseudophedrine (alpha-agnonist), reboxetine (SNRI), carbegoline, amantadine, oxytocin, burpropion, buspirone, and cyrohetadine.'''
** '''These drugs facilitate ejaculation''' by either a central dopaminergic, antiserotonergic, or oxytocinergic mechanism of action or a peripheral adrenergic mechanism of action. However, no drugs have been approved by regulatory agencies for this purpose and most drugs that have been identified for potential use have '''limited efficacy''', impart significant side effects, or are as yet considered experimental in nature.
* Results are relatively poor in men with psychogenic DE and neuropathic DE.

===== Vibratory stimulation and electroejaculation =====

*Several techniques for obtaining semen in men with SCI with ejaculatory dysfunction have been reported including vibratory stimulation and electroejaculation, both of which are associated with a significantly high risk of autonomic dysreflexia (see Surgery for Infertility Chapter Notes).