Ejaculatory Disorders

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Basics

Description

  • Group of dysfunctions involving altered time and control (premature ejaculation [PE], delayed ejaculation [DE]), presence (anejaculation [AE]), direction (retrograde ejaculation [RE]), volume (perceived ejaculate volume reduction [PEVR]), or force (decreased force of ejaculation [DFE]) of ejaculation
  • PE is defined (DSM-V, 2013) as a persistent/recurrent pattern of ejaculation occurring during partnered sexual activity within 1 minute following vaginal penetration and before the individual wishes it + present for 6 months + causing significant distress for individual.
    • Natural biologic response is to ejaculate within 2 to 5 minutes after vaginal penetration.
    • Ejaculatory control is an acquired behavior that increases with experience.
    • Comorbidities common (diabetes, hypertension, sexual desire disorder, ED)
  • DE: prolonged time to ejaculate (>30 minutes) despite desire, stimulation, and erection; problematic for couples trying to conceive
  • Aspermia (lack of sperm in the ejaculate):
    • AE: lack of emission or contractions of bulbospongiosus muscle
    • RE: partial or complete ejaculation of semen into the bladder
    • Obstruction: ejaculatory duct obstruction or urethral obstruction
  • Also:
    • Painful ejaculation: genital or perineal pain during or after ejaculation
    • Ejaculatory anhedonia: normal ejaculation lacking orgasm or pleasure
    • Hematospermia: presence of blood in the ejaculate (often not a serious condition)

Epidemiology

Prevalence
  • PE is common; reported prevalence in U.S. males in up to 20–30%
  • DE is reported in 5–8% of men age 18 to 59 years, but <3% have the problem for >6 months.
  • Predominant age: all sexually mature age groups
  • Predominant sex: male only

Etiology and Pathophysiology

Male sexual response:

  • Erection mediated by parasympathetic nervous system
  • Normal ejaculation consists of three phases:
    • Emission phase: Semen is deposited into urethra by contraction of prostate, seminal vesicles, vas deferens; under autonomic sympathetic control
    • Ejaculation phase: semen forcibly propelled out of urethra by rhythmic contractions of the bulbospongiosus and ischiocavernosus muscles. This is mediated by the somatic nervous system on the motor branches of the pudendal nerve. Bladder neck contracture by α-adrenergic receptors ensures anterograde ejaculation.
    • Orgasm: the pleasurable sensation associated with ejaculation (cerebral cortex); smooth muscle contraction of accessory sexual organs; release of pressure in posterior urethra
  • PE:
    • Hypersensitivity/hyperexcitability of glans penis
    • 5-hydroxytryptamine (5-HT) receptor sensitivity
    • Psychogenic (inexperience, anxiety/guilt, low frequency of sex, relationship problems)
    • Urologic (ED, prostatitis, urethritis)
    • Endocrine (hyperthyroid)
    • Lack of physical activity
    • Withdrawal/detox of prescription or illicit drugs
  • DE:
    • Rarely due to underlying painful disorder (e.g., prostatitis, seminal vesiculitis)
    • Often has psychogenic component
    • No relation to testosterone levels
    • Sexual performance anxiety and other psychosocial factors
    • Medications may impair ejaculation (e.g., MAOIs, SSRIs, α- and β-blockers, thiazides, antipsychotics, tricyclic and quadricyclic antidepressants, NSAIDs, opiates, alcohol).
  • Never any ejaculate:
    • Congenital structural disorder (müllerian duct cyst, Wolffian abnormality)
    • Acquired (radical prostatectomy, postinfectious, posttraumatic, T10–T12 neuropathy)
  • AE:
    • Retroperitoneal lymph node (LN) dissection
    • Spinal cord injury or other (traumatic) sympathetic nerve injury
    • Medications (α- and β-blockers, benzodiazepines, SSRIs, MAOIs, TCAs, antipsychotics, aminocaproic acid)
    • Diabetes mellitus (DM) (neuropathy)
    • Radical prostatectomy
  • RE:
    • Transurethral resection of the prostate (25%) or other prostate resection procedures
    • Surgery on the neck of the bladder
    • Extensive pelvic surgery
    • Retroperitoneal LN dissection for testicular cancer (also may produce failure of emission)
    • Neurologic disorders (MS, DM)
    • Medications (tamsulosin, other α-blockers, SSRIs, antipsychotics)
    • Urethral stricture (may be posttraumatic)
  • Painful ejaculation:
    • Infection or inflammation (orchitis, epididymitis, prostatitis, urethritis)
    • Ejaculatory duct obstruction
    • Seminal vesicle calculi
    • Obstruction of the vas deferens
    • Psychological/functional
  • Hematospermia (often unable to find cause):
    • Usually not a serious condition
    • Inflammation/infection
    • Calculi: bladder, seminal vesicle, prostate, urethra
    • Trauma to genital area (cycling, constipation)
    • Obstruction
    • Cyst
    • Tumor (1–3% prostate cancers present with hematospermia)
    • Arteriovenous malformations
    • Iatrogenic
    • Hypertension

Commonly Associated Conditions

  • Neurologic disorders (e.g., multiple sclerosis)
  • DM
  • Prostatitis
  • Ejaculatory duct obstruction
  • Urethral stricture
  • Psychological disorders
  • Endocrinopathies
  • Relationship/interpersonal difficulties

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