Skip to content
Home » Andrology » Ejaculatory disorders

Ejaculatory disorders

Premature ejaculation

There have been many variable definitions over decades. ISSM 2014:

Male sexual dysfunction characterised by:

  1. Ejaculation always or nearly always occurring before or within 1 minute of penetration (life-long PE)
  2. Clinically significant or bothersome reduction in intravaginal ejaculatory latency time, often to approximately 3 minutes or less (acquired PE)

The inability to delay ejaculation on all or nearly all penetrations

Negative personal consequences such as distress, bother, frustration of avoidance

 

Large variation in prevalence depending on studies and definition – 4 – 39 %

Median IELT 5.4 minutes, range 0.5 – 44 minutes

 

Lifelong PE may be due to variation in sensitivity of two classes of serotonin receptors.

Acquired PE may be due to:

  • Performance anxiety
  • Psychological or relationship concerns
  • ED
  • Prostatitis
  • Hyperthyroidism
  • Withdrawal or detoxification from prescribed or recreational drugs
  • Metabolic syndrome

 

Assessment:

  • Lifelong or acquired (different partners or just now)
  • Estimation of time from penetration to ejaculation – every time or variable
  • Level of bother and effect on relationship
  • Erectile function (is orgasm being rushed before losing erection)
  • Previous trials of treatment
  • Evaluation of medical and medication causes
  • Consider partner involvement
  • Routine examination

 

 

Treatment options for premature ejaculation:

  • Increasing physical fitness and exercise, and treating medical co-morbidities
    • Important for men with metabolic syndrome
  • Psychosexual counselling
    • Education on normality and correction of myths and misunderstanding
    • Encourage open conversation with partner
    • Performance anxiety counselling if needed
    • Can be combined with medical treatments
  • Topical agents and local anaesthetics
    • Lignocaine jels/sprays/wipes, condoms
  • SSRIs
    • Daily or on-demand
    • Serotonin suppresses ejaculatory response
    • Dapoxetine 30 mg (Priligy) best studied as on demand, incr IELT 3 x in RCT
    • Any of paroxetine, sertraline, fluoxetine, citalopram – can increase IELT 2 – 11 x
    • Side effects – sleepiness, nausea, diarrhea, sweating, ED, dry mouth
    • Beware of serotonin syndrome with recreational drugs, avoid other SSRIs etc
  • Tramadol
    • Opioid with serotonergic effects – can be used on-demand
    • Side effects – dependence, constipation, nausea, headaches, ED
  • PDE5-inhibitors
    • Especially in men with concomitant ED – treating ED alone may be useful
  • ?Acupuncture

 

Delayed orgasm / anejaculation

Delayed ejaculation:

  • 2 std dev above mean = 22 – 25 minutes
  • Any subjective delay in ejaculatory time plus seeking help is probably enough for a formal diagnosis
  • May be lifelong or acquired, and situational or global

 

  • Multitude of causes for delayed ejaculation or anejaculation
    • Psychological (performance anxiety, relationship conflict, fear of fatherhood, religious shame)
    • Ageing related neural degeneration
    • Diabetic (autonomic neuropathy, ductal calcification)
    • Neural damage – multiple sclerosis
    • Spinal cord injury
    • Hypogonadism
    • Hypothyroidism
    • SSRIs or other serotonergic medications
    • Other drugs and alcohol (anything affecting neurotransmitters can interfere with ejaculatory response)
    • Ejaculatory duct obstruction (congenital or acquired)
    • Radical prostatectomy or pelvic surgery
    • Radiation therapy
    • Should be differentiated from retrograde ejaculation

 

Management of delayed ejaculation or anejaculation:

  • Identify underlying cause
  • Stop offending medications
  • Psychosexual counselling
  • Address infertility related
  • Neuropathic ejaculatory dysfunction is often irreversible
  • Medical therapy has limited success
    • Targeting dopaminergic stimulation or anti-serotonergic, or pro oxytoxin
    • Cabergoline (D2 agonist)
    • Pseudoephredine (alpha agonist)
    • Intranasal oxytocin
    • All relatively poor results

 

Retrograde ejaculation:

Failure of the bladder neck to close during ejaculation, resulting in retrograde passage of ejaculate into the bladder.

Causes include:

  • TURP or bladder neck surgery
  • Selective alpha blockers
  • Diabetic autonomic neuropathy
  • Sympathetic nerve injury during RPLND or other surgery
  • Stricture
  • Trauma
  • Some anti-psychotics
  • Neurologic conditions – MS, stroke

Sympathetic agonists have mixed success, occasionally up to 50 % when taken the day prior and day of sex.

  • Pseudoephedrine – 120 mg QID
  • Imipramine – blocks reuptake of noradrenaline in synaptic cleft – 25 mg BD – occasionally useful

 

Retrograde ejaculation can be distinguished from failure of emission by a post-ejaculatory urinalysis for spermatozoa or fructose.

 

What urological surgeries can cause ejaculatory dysfunction?

TURP/BNI – retrograde ejaculation.

RPLND – failure of emission and retrograde ejaculation

Radical prostatectomy – anejaculation – no seminal fluid and vasectomy

Prostate biopsy – haematospermia

Ejaculatory pain can be described after vasectomy or inguinoscrotal surgery.

 

Semen retrieval for ejaculatory failure

Alpha agonists – pseudoephedrine or imipramine as above.

Penile vibratory stimulation – aims to trigger ejaculation via spinal reflex despite absent connection between spinal cord and higher cortex

  • Applicable for SCI above T10-L2 with preserved cord function below. Most successful in those with intact bulbocavernosus reflex. Be wary of autonomic dysreflexia.

Rectal probe electroejaculation – direct electrical stimulus to vasal ampullae and SVs – causing contraction and emission of their substances.

  • Does not induce reflex ejaculation so can be used in men without intact spinal reflexes. Be wary of autonomic dysreflexia. Only induces emission – semen then passive flows antegrade or may go retrograde and need to be retrieved.

 

Surgical sperm extraction methods

 

Retrieval of retrograde ejaculation

Trial of alpha agonists to promote antegrade ejaculation.

Retrieval of sperm from alkalinised post ejaculatory urine sample:

  • Normally acidic urine is thought to be spermicidal
  • 1 g sodibic night before and morning of
  • Void prior to masturbation
  • Void ASAP after ejaculation and deliver sample to lab immediately

Alternate is catheterisation to obtain post ejaculatory sample (should still be alkalinised).

 

Diabetic ejaculatory dysfunction  – sympathetic autonomic neuropathy can cause failure of bladder neck closure (retrograde ejaculation) and failure of emission due to absent smooth muscle contraction of vasa and ejaculatory ducts, or fibrosis and calcification of the vasa and ducts.