Ejaculatory dysfunction at a glance
- Ejaculatory dysfunction is the inability of a man to efficiently ejaculate semen from the penis at the moment of sexual climax.
- Ejaculatory dysfunction is the most prevalent form of male sexual dysfunction and is a common cause of male infertility.
- Ejaculatory dysfunction is classified into four types: premature ejaculation, delayed ejaculation, retrograde ejaculation and anejaculation (no ejaculation).
- Treatments for ejaculatory dysfunction include medications, behavioral therapy (for premature ejaculation) and sometimes surgery.
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What is ejaculatory dysfunction?
Ejaculatory dysfunction occurs when a man has a problem properly ejaculating his semen, either ejaculating too soon, too late, back into his own bladder or not at all. These situations can result in poor sexual satisfaction by the man and his partner, ineffective reproduction and emotional trauma.
Ejaculation disorders, also called aspermia, can be caused by a problem at birth (primary) or by acquired dysfunctions (secondary) after birth (often much later in life), such as disease, injury and adverse drug reactions. The four types of ejaculation dysfunction are premature ejaculation, delayed ejaculation, retrograde ejaculation and anejaculation.
Normal ejaculation involves an emission step, when semen is positioned in the penis near the prostate, and an ejaculation step, when the semen is forcefully expulsed from the penis.
Ejaculation occurs at sexual climax, or the expulsion of the sperm. Climax is different from an orgasm, which is centered in the brain and associated with ejaculation.
The mechanics of ejaculation are similar to a sneeze: both are reflexes with a point of no return. The average time from sexual penetration by the male to ejaculation is nine minutes.
Evaluation of ejaculatory dysfunction
Asking a patient about his personal history is generally the first step a physician takes in diagnosing and evaluating ejaculatory dysfunctions. This can reveal if the problem has always been present, which may indicate if it is due to a birth defect or to an acquired condition.
Elements of evaluation include:
- Physical exam of the genitalia and testicles for structural problems
- Semen sample for evaluation of sperm presence and health
- Post-ejaculate urine sample if no ejaculate was produced
- Hormonal testing
- Transrectal ultrasound (TRUS) to look for structural problems.
Following are the four different types of ejaculation disorders, along with their causes, symptoms and treatments.
Premature ejaculation: causes and treatments
Premature ejaculation (PE) is when the man ejaculates within a minute of vaginal penetration or, more generally, when he ejaculates sooner than he or his partner would like. PE occurs in about 30 percent of men and is the most common type of ejaculatory dysfunction. Most cases of PE are treatable.
Causes of premature ejaculation are erectile dysfunction, anxiety, heightened sensitivity and neurological problems.
Treatment of premature ejaculation
Medications, physical therapy and psychotherapy are tools for treating PE. The goal of treatment is to decrease penile sensitivity and increase the patient’s control over his behavioral responses.
Oral medications can delay ejaculation for many men. Urologists may prescribe one of several medications for men with PE. The choice depends on whether the PE is primary or secondary.
Another medication is a topical lidocaine-prilocaine cream applied to the penis before intercourse to reduce sensitivity and delay ejaculation.
While medications may provide temporary relief, behavioral therapy is the only way to cure premature ejaculation. This can involve sex education to modify behavior and psychological counseling to address such issues as anxiety that may be causing PE. Education can involve relaxation techniques and methods of prolonging excitement without erection or ejaculation.
Behavioral modification involves such methods as:
- Ceasing stimulation when the climax approaches
- Altering stimulation before climax
- Mental distraction from the stimulation
- Other ways to reduce stimulation and delay climax.
Delayed ejaculation: causes and treatments
Delayed ejaculation is when ejaculation is retarded beyond a reasonable period after sexual stimulation. This happens from time to time with many men as a normal occurence but can be problematic if it occurs over a long period or frustrates either sex partner.
Delayed ejaculation can be a permanent problem present from the beginning of sexual activity. Or it can be an acquired problem occuring after a history of normal ejaculation. It may be general or situational, in which it may occur only with certain partners or situations.
Causes of delayed ejaculation can be physical, psychological or the side effects of certain medications. Causes also include alcohol abuse, diuretics (drugs or food and beverage ingredients that accelerate the body’s loss of water), high blood pressure, or the use of antidepressant, anti-seizure or antipsychotic medications.
- Birth defects
- Injury to pelvic nerves
- Hormone issues
- Neurological disorders
- Prostate surgery.
- Sexual performance anxiety
- Sexual fantasy issues
- Low self esteem about body image
- Personal problems in the sexual relationship.
Treatment for delayed ejaculation
Psychotherapy can deal with underlying mental health and psychological issues. Some mental health counselors are specially trained to deal with sexual issues. Counseling can involve just the male or he and his partner.
A few medications are also used to treat delayed ejaculation. These are not specifically approved for treatment of delayed ejaculation but are approved for treatment of other conditions. This is referred to as “off-label” use.
Retrograde ejaculation: causes and treatments
Retrograde ejaculation, also called dry ejaculation, is when some or all of the ejaculate is discharged back up into the bladder at sexual climax rather than out of the body through the penis.
Retrograde ejaculation can cause infertility but not any other problems. Doctors most often diagnose it through physical exams and ordering tests of a post-ejaculation urine sample that may show semen in the urine.
The cause of retrograde ejaculation is a fault in the muscle at the neck of the bladder that usually prevents ejaculate from flowing back into the bladder through the tube carrying ejaculate from the prostate to the urethra. The fault may be due to nerve damage from a medical condition (diabetes, spinal cord injury), reaction to certain medications or surgery (bladder, prostate).
It’s usually not necessary to treat retrograde ejaculation unless it is causing infertility that the male wishes to reverse. Stopping medications that can cause retrograde ejaculation is one form of treatment.
Off-label drugs can help the bladder neck muscle remain closed during ejaculation, preventing ejaculate from going into the bladder.
Assisted reproductive technologies, such as intrauterine insemination (one form of artificial insemination), may be used to work around retrograde ejaculation. This can involve procedures to retrieve the sperm from the male’s body and place it in the female’s uterus or inject it directly into an egg in her ovary (intracytoplasmic sperm injection).
Anejaculation: causes and treatments
Anejaculation is when no ejaculation occurs at sexual climax. This can be total anejaculation, occuring always during sexual stimulation, or situational anejaculation, occuring only under certain conditions.
Anejaculation can be primary — present from the start of sexual response — or secondary, brought about by some acquired condition, such as diabetes or multiple sclerosis.
Situational anejaculation is usually caused by stress and/or psychological issues associated with a particular partner or situation. This may mean the male can ejaculate with one partner but not another, or in one setting but not another, such as in a doctor’s office to supply a sample.
Total anejaculation may be anorgasmic, meaning the man can never reach an orgasm and ejaculate. Total anejaculation can also be orgasmic, meaning the man has an orgasm but does not ejaculate. Despite the lack of orgasm in anejaculation, the male may still produce semen discharge during sleep.
Reactions to certain medications can cause anejaculation, as can surgical procedures that affect the nerves involved in ejaculation. Most likely, the cause is a psychological issue that may involve upbringing and lack of affection.
The most common treatment for anejaculation is psychological counseling to address underlying causes and sexual therapy. Sexual therapy can involve sex education for a clearer understanding of the arousal process by the affected person. It can also involve therapy to encourage pleasurable reaction to touching and progression toward orgasm and ejaculation.
Treatment of anejaculation to overcome infertility includes sperm retrieval and placement options through what’s known among doctors as assisted reproductive technologies.
For men experiencing anejaculation as a result of spinal cord injury, a therapy known as penile vibratory stimulation can result in ejaculation. This treatment utilizes a vibrating device designed to make the penis erect and help achieve ejaculation.