Ejaculation Disorders

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 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.  

In normal men there exists a linear sexual response cycle;

desire, arousal, plateau, orgasm, and resolution. 

Orgasm can be subdivided into climax and ejaculation.  During the resolution phase it is normal for men to experience a refractory period; during the refractory period it is not possible to stimulate the penis back into the erect state. The refractory period is typically very brief in young men but becomes progressively longer with age.

There are 4 main ejaculatory disorders that are seen in clinical practice (i) retrograde ejaculation (ii) premature ejaculation (iii) retarded ejaculation (orgasm) and, (iv) 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 by 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 (pseudoephedrine 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 The New York Presbyterian Hospital, the physicians work very closely with Dr. Michael Perelman, Co-Director of the Human Sexuality Program in the Department of Psychiatry in the management of 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 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 medications (Prozac, Zoloft, Paxil, Luvox, Celexa), sensory neurologic disorders affecting penile sensation (as may occur with diabetic nerve damage), and 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 bupropion. 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 achieve 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.

Symptoms and Evaluation 

A comprehensive medical and sexual history is the most important aspect in the diagnosis of men with ejaculatory dysfunction.  A focused genital exam is also indicated in most circumstances.  Testosterone is often the most commonly performed blood test in the evaluation of ejaculatory dysfunction.  

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.

PE is currently defined by the International Society of Sexual Medicine as a lifelong history of ejaculation occurring within less than 1 minute of penetration (lifelong PE) or a clinically significant and bothersome reduction in latency time, often to about 3 minutes or less (acquired PE).  Patients will also have reduced or absent ejaculatory control.  Premature ejaculation often causes negative personal consequences, such as distress, bother, frustration and/or the avoidance of sexual intimacy.

Patients with retrograde ejaculation will have a normal sensation of orgasm and climax but will have little to no anterograde (forward) propulsion of semen.  This is often referred to as a dry orgasm.  This process is diagnosed by the finding of seminal fluid and/or sperm within a urine specimen obtained immediately after orgasm.

Delayed ejaculation or anorgasmia 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 to ejaculate within a 30 minute time period from the initiation of sexual stimulation.

Treatment Options

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 (pseudoephedrine for example) may convert the patient to an antegrade ejaculator.

The management of Premature Ejaculation is best handled in a combined psychotherapy and pharmacologic fashion. Mean ejaculation latency time in healthy men is between 5-6 minutes.  Men who have ejaculation latencies within this time period should be reassured.  In men with lifelong and acquired premature ejaculation there are several treatment options.  First line therapy generally involves behavioral techniques in combination with psychotherapy.   The most commonly used behavioral techniques are the squeeze or stop-start techniques.  Topical local anesthetics are often used in combination with behavioral modifications.  Topical anesthetics are usually applied to the head of the penis (glans) 5-10 minutes prior to planned sexual activity.

Off-label use of selective serotonin reuptake inhibitors (SSRI) and tri-cyclic antidepressant (TCA) such as paroxetine, sertraline and fluoxetine or clomipramine are used in order to take advantage of their side effect profile of delaying ejaculation.  Dapoxetine, a short acting SSRI, is the only medication that has been approved in some countries for the sole purpose of treating premature ejaculation.

Treatment of PE with phosphodiesterase type 5 inhibitors (PDE5-I) has been reported but is best reserved for men with co-morbid erectile dysfunction (ED) and PE.

Delayed ejaculation and anorgasmia are very difficult sexual dysfunctions to treat.  There does not exist any FDA approved pharmacologic strategy for these patients.  The use of penile vibratory therapy is used as a first line therapy in order to increase penile stimulation and has the ability to help patients achieve 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.  Cabergoline, a dopamine receptor agonist used in patients with hyperprolactinemia and Parkinson's disease, has been shown in preliminary studies to decrease ejaculatory latency time and may be useful in the treatment of delayed ejaculation or anorgasmia.  Buproprion is another drug that has had some anecdotal success in these patients.