Cornell University

Cornell University
Weill Medical College

Cornell Institute for Reproductive Medicine

Center for Male Reproductive Medicine and Microsurgery

"State-of-the-Art Compassionate Care for the Infertile Couple"



Ejaculation involves coordinated muscular and neurological events that involve deposition of semen in the urine channel (emission) and ejection of the fluid from the urethral meatus (ejaculation proper). Emission is accomplished by contraction of the the vas deferens, seminal vesicles and ejaculatory ducts. This process is under adrenaline control. Ejaculation proper results from the rhythmic contractions of the muscles around the urethra, which causes the forcible ejection of the ejaculate. Within the spinal cord lies the “ejaculation center” which is the area involved in the coordination of signals from the brain and penis that eventually lead to ejaculation

There are 4 main ejaculatory disorders that are seen in clinical practice:
  1. Retrograde ejaculation
  2. Premature ejaculation
  3. Retarded ejaculation (orgasm)
  4. Failure of ejaculation (anejaculation).
Retrograde ejaculation

Retrograde ejaculation is the process whereby the semen is passed in a retrograde fashion into the bladder as opposed to out the urethra. There are 3 potential causes to this problem; anatomic (following bladder neck surgery or from a congenital process), neurologic (due to disorders that interfere with the ability of the bladder neck to close during emission, such as diabetes mellitus, retroperitoneal surgery) and pharmacologic (due to paralysis of the bladder neck certain medications). This process is diagnosed by the finding of seminal fluid and/or sperm within a urine specimen obtained immediately after orgasm.

The treatment of retrograde ejaculation depends to some extent on the cause. Anatomic causes are rarely curable and sperm harvesting from the bladder is required for those patients wishing to initiate a pregnancy. Pharmacologic causes are generally reversible by withdrawal of the offending medication. Neurologic causes are difficult to treat if there is complete nerve damage such as may occur in spinal cord injured patients. In those patients with a partial neural injury, (diabetes) the use of certain medications (pseudoepohedrine for example) may convert the patient to an antegrade ejaculator.

Premature ejaculation

Premature ejaculation also known as rapid ejaculation lacks a definition that is agreed upon by all practitioners but essentially is the condition whereby a patient ejaculates with minimal sexual stimulation and before he wishes it to occur. It can be life-long (primary) or secondary. There are numerous theories as to the cause but most cases are probably multi-factorial with a contribution from both psychological and physical factors. This is believed to be the most common sexual dysfunction in males with almost 30% of men of all ages suffering from this condition. Interestingly however, the quality of life of these patients is not negatively affected by their condition. The management of this problem is best handled in a combined psycho-pharmacologic fashion. The use of medications to increase ejaculation time is useful in permitting the patients to practice senate focus exercises to recondition the ejaculatory reflex. The latter technique is essential to the long-term cure of premature ejaculation.

To date, there is minimal evidence-based data assessing the outcome of this therapeutic approach. At the Sexual Medicine Program at New York Presbyterian Hospital Dr. Mulhall works very closely with Dr. Michael Perelman, Co-Director of the Human Sexuality Program in the Department Of Psychiatry in the management patients with this problem.

Retarded orgasm

Retarded orgasm is a very difficult sexual dysfunction to treat. This condition involves the inability of the patient to achieve orgasm (ejaculation) in a timely manner and in severe cases men fail to achieve orgasm on any occasion. As men age, there is an increase in the time it takes to achieve ejaculation, however, in some men this increase may lead to the inability of men to ejaculate within a 30 minute time period from the initiation of sexual stimulation. The causes of this condition include the use of certain anti-depressant medciations (Prozac, Zoloft, Paxil, Luvox, Celexa) medications, sensory neurologic disorders affecting penile sensation (as may occur with diabetic nerve damage), psychological disorders (this is frequently seen in older men in their early experiences following divorce or being widowed). Finally there are men in whom there is no clear etiology for this problem and these are believed to have either a physiological or idiopathic form of this condition. There does not exist any pharmacologic strategy for these patients although there are anecdotal reports of the use of the anti-depressant buproprion. If patients are significantly bothered by this problem, as many of the sufferers are, the use of penile vibratory therapy has the ability to permit patients to avhieve orgasm. The results are better in patients in whom there is a delay in orgasm as opposed to those who have a consistent complete failure to achieve orgasm.

Suggested Reading

1. Althof S et al. Clomipramine for the treatment of rapid ejaculation. Journal of Clinical Psychiatry, 56:402-407, 1995
2. Kaplan P. The use of SSRI medications in the treatment of premature ejaculation. Journal Of Sex And Marital Therapy, 20:321-324, 1995.
3. Seftel AD et al. Premature ejaculation. In Mulcahy J (ed) Diagnosis And Management Of Male Sexual Dysfunction. Igaku-Shoin, New York, 196-204, 1996.
4. Xin ZC et al. Penile sensitivity in patients with primary premature ejaculation. Journal of Urology, 156:979-981, 1996.
5. Benson GS. Erection, emission and ejaculation: physiologic mechanisms. In Lipshultz, LI (ed) Infertility in the male. Mosby, St. Louis, 155, 1997.
6. Mulhall JP et al. An Analysis Of Then Utility Of Penile Vibratory Stimulation In Restoring Orgasmic Function In Men With Idiopathic Retarded Orgasm. Journal of Urology 165(5):930A, 2001.
7. Mulhall JP et al. Resolution Of Secondary Premature Ejaculation In Impotent Men By Successful Treatment Of Their Erectile Dysfunction. International Journal of Impotence Research, 11:S70.

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