Overview of Ejaculation

Ejaculation is a relatively complex phenomenon that involves coordinated muscular and neurological events to allow deposition of semen in the urine channel (emission) and ejection of the fluid from the urethral meatus (ejaculation). Emission is accomplished by contraction of several organs of the male reproductive tract, including the vas deferens, seminal vesicles, and ejaculatory ducts. This process is under the control of adrenaline. Ejaculation itself results from the rhythmic contractions of the muscles around the urethra, which causes the forcible ejection of the ejaculate from the tip of the penis. 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 seen in clinical practice:

• Premature Ejaculation
• Delayed (retarded) Ejaculation
• Retrograde Ejaculation
• Failure of Ejaculation (Anejaculation)

Premature Ejaculation

Premature ejaculation (PE) is defined by the American Urological Association as "ejaculation that occurs sooner than desired, either before or shortly after penetration, causing distress to either one or both partners." It is the most common type of sexual dysfunction in males, with an incidence of approximately 30% of men. This can be a lifelong issue (primary), or a new diagnosis (secondary). Diagnosis is made based on patient report. Causes vary and are often multifactorial, but include congenital abnormalities, psychological factors such as anxiety, opioid withdrawal, hyperthyroidism, and neurologic diseases such as Parkinson's.

Treatment typically involves a combination of psychological, physical, and pharmacological approaches. Several behavioral techniques can be employed to try to maximize the period of time before ejaculation. These include the "pause-squeeze" technique, whereby the patient stops sexual activity as the sensation of ejaculation approaches, and squeezes the glans penis until the urge to ejaculate ceases, and then resumes sexual activity. A similar technique is the "start-stop" technique. Finally techniques can be discussed with the female partner to decrease pelvic movement as her male partner is nearing ejaculation in order to temporarily decrease stimulation and delay ejaculation. If a psychological issue is suspected, a referral can be made to a therapist adept at treating these specific sexual complaints.

From the pharmacologic approach, several topical therapies, and oral therapy with antidepressants have been shown to help with treatment of PE in certain patients. Topical agents such as lidocaine/prilocaine (EMLA) cream can be placed on the shaft of the penis prior to intercourse to decrease sexual stimulation. Other topical agents such as Promescent spray have been utilized for this purpose as well. The use of condoms can decrease sexual stimulation as well, and be helpful in prolonging orgasm in some men. Clomipramine and selective serotonin reuptake inhibitors (SSRIs) are antidepressant medications that have a known side effect of delayed orgasm and ejaculate. They are not FDA approved for the treatment of premature ejaculation, but have been reported to help in this patient population. These therapies should only be initiated with the supervision of a trained physician.

Delayed (Retarded) Ejaculation

Delayed ejaculation is defined as prolonged time to ejaculation despite desire, stimulation, and erection. This sexual dysfunction is fairly challenging to treat.
Causes of this condition include:

• {C}
• Medications:
  • Antidepressants including selective serotonin reuptake inhibitors (SSRIs) and clomipramine
• Neurologic Disorders:
  • Diabetes with resultant neuropathy
  • Spinal cord injury or traumatic brain injury
  • Parkinson's Disease
• Psychological Disorders:
  • Anxiety
  • Depression
  • Grieving
• Idiopathic (no identifiable cause)

Treatments are fairly limited for this issue. If psychological causes are believed to be a component of the cause, referral to an appropriate therapist with specific experience with sexual dysfunction has been helpful. Use of penile vibratory therapy has been helpful has been useful in helping some men achieve orgasm and ejaculation, particularly those with neurological causes for this condition. There have been reports of the use of the antidepressant bupropion for treatment of delayed ejaculation, but these studies are anecdotal at this point, and no goo pharmacological therapy has been demonstrated in the literature at this time.

Retrograde Ejaculation

Retrograde Ejaculation is defined as partial or complete ejaculation of the semen into the bladder. Typically during ejaculation, the bladder neck muscles tighten to assist with movement of sperm in the antegrade direction out of the tip of the penis. In retrograde ejaculation, this bladder neck contraction fails to occur, causing semen to move backwards into the bladder. This can result in low volume ejaculate, or absent ejaculate.

Diagnosis is typically made by collecting a urine specimen immediately after ejaculation and examining this sample microscopically to determine if sperm is present in the urine. This is called a post-ejaculatory urinalysis.

Causes of this condition include:

• Medications:
  • a-blockers (tamsulosin, terazosin, doxazosin, alfuzosin)
  • Ganglion blockers (methyldopa, guanethidine, reserpine)
  • Antipsychotics (chlorpromazine, haloperidol)
• Sympathetic nerve injury:
  • Surgical procedures (retroperitoneal lymph node dissection, colorectal surgery, abdominal vascular surgery)
  • Spinal cord injury
• Neurologic Disorders:
  • Diabetes mellitus with resultant sensory neuropathy
• Urethral Stricture:
  • Scarring and prior urethral surgery may impede forward progression of ejaculate.
• Partial prostate resection/ablation or bladder neck surgery
  • Procedures such as TUNA, TURP, TUIP, etc.

Treatment options for retrograde ejaculation are dependent upon the cause for this issue. Pharmacologic causes are often reversible with discontinuation of offending medication. However neurologic causes from spinal cord injury or anatomic causes are rarely curable and often require sperm harvesting from the bladder with use of this sperm with assisted reproductive techniques such as intrauterine insemination and in vitro fertilization.

• Discontinue offending medication if medically safe
• Maintain excellent control of diabetes mellitus
• If cause is urethral obstruction, surgery can potentially be performed to relief this issue
• a-agonists (pseudoephedrine, imipramine, ephedrine sulfate) can be utilized with some success in certain patients to convert them to antegrade ejaculators with subsequent harvest of sperm from the bladder.
  • Contraindicated in narrow angle glaucoma, severe or uncontrolled hypertension, congestive heart failure, arrhythmia, urinary retention, patients on MAO-I medications, cardiac arrhythmias, hyperthyroidism, or cardiovascular disease.
  • Not FDA approved for treatment of ejaculatory disorders

Failure of Ejaculation (Anejaculation)

Anejaculation is failure of emission, or failure of the rhythmic contractions of muscles responsible for delivery of sperm and seminal fluid into the urethra. Often patients have normal sperm production within their testicles, but are unable to deliver that sperm into the reproductive tract further downstream. Patients with this issue produce no ejaculate, even though they may be capable of experiencing the sensation of orgasm.

Failure of ejaculation can be caused by:

• Medications:
  • a-blockers (tamsulosin, terazosin, doxazosin, alfuzosin)
  • Beta blockers
  • Antipsychotics (chlorpromazine, haloperidol)
  • Antidepressants (SSRIs, MAOIs, tricyclics such as clomipramine)
  • Benzodiazepines
• Sympathetic nerve injury:
  • Surgical procedures (retroperitoneal lymph node dissection, colorectal surgery, abdominal vascular surgery)
  • Spinal cord injury
• Neurologic Disorders:
  • Diabetes mellitus with resultant sensory neuropathy impairing pathways responsible for erection, emission, and ejaculation
  • Surgical disruption of ejaculatory organs:
• Radical prostatectomy, epididymectomy

Treatment of anejaculation is similar to that of retrograde ejaculation.

• Discontinue offending medication if medically safe
• Maintain excellent control of diabetes mellitus
• If cause is urethral obstruction, surgery can potentially be performed to relief this issue
• a-agonists (pseudoephedrine, imipramine, ephedrine sulfate) can be utilized with some success in certain patients to convert them to antegrade ejaculators with subsequent harvest of sperm from the bladder.
• Penile vibratory stimulation (PVS)
  • Can allow sperm retrieval from men who are anejaculatory.
  • A vibrator applied to the penis can be utilized in order to stimulate the ejaculation in men with spinal cord injury or processes impacting the triggering of the neurological ejaculation reflex pathway.
  • This is usually only successful in spinal cord injuries above the T10 level, or flaccid paralysis
• Electroejaculation (EEJ)
  • Can allow sperm retrieval from men who are anejaculatory.
  • A probe is placed in the rectum, and an electrical current is delivered to the pelvis in order to stimulate ejaculation. This may stimulate antegrade or retrograde ejaculation with subsequent collection of sperm from the bladder.
  • EEJ is not dependent on the ejaculatory reflex being intact; therefore it can be helpful in patients with spinal cord injury below T10, diabetes mellitus, or history of surgical sympathetic nerve injury.
  • In patients with intact pelvic sensation, general anesthetic is required, while those without sensation to the pelvis can undergo this procedure in the office.

Please consult your doctor with any questions or concerns you have regarding your condition.