Disorders of Orgasm and Ejaculation in Men: Diagnosis & Treatments

Definition, Epidemiology and Pathophysiology

Definitions of premature ejaculation (PE) is characterized by : an ejaculation that always or nearly always occurs prior to or within about 1 minute of vaginal penetration, an inability to delay ejaculation on all or nearly all vaginal penetrations, and with negative personal consequences, such as distress, bother, frustration, and/or the avoidance of sexual intimacy.

The population of men with PE is not homogenous and includes lifelong PE, acquired PE, natural variable.

Various epidemiological studies have shown that about 20–30% of men have complaints of premature ejaculation.

Ejaculatory latency time in life long PE is probably a biological variable, which is genetically determined and may differ between populations and cultures, ranging from extremely rapid through average to slow ejaculation.

Acquired PE can often be traced to either neurobiogenic (endocrine, urologic, neurobiologic) or psychogenic factors, or in some instances, both.

PE co-exists in about one-third of patients complaining of erectile dysfunction.

Hypoactive sexual desire may lead to PE, due to an unconscious desire to abbreviate unwanted penetration.

Female sexual dysfunctions (such as anorgasmia, hypoactive sexual desire, sexual aversion, sexual arousal disorders, and sexual pain disorders, as vaginismus) may also be related to acquired PE.

PE exerts a significant psychological burden on men, their partners, the male/partner relationship, and their overall relationship. Men with PE show other negative effects, including a general negative affect associated with sexual situations, and more intense feelings of embarrassment/guilt, worry/tension and fear of failure.

Psychotherapy and behavioral interventions improve ejaculatory control by helping men/ couples to: learn techniques to control and/or delay ejaculation; gain confidence in their sexual performance; lessen performance anxiety; modify rigid sexual repertoires; surmount barriers to intimacy; resolve interper-sonal issues that precipitate and maintain the dysfunction; increase communication and come to terms with feelings/thoughts that interfere with sexual function.
The use of anesthetics to diminish the sensitivity of the glans penis is probably the oldest known form of treating PE.

On-demand administration of Dapoxetine has received regulatory approval as an on-demand treatment for PE in several parts of the world.

Delayed Ejaculation (DE), Anejaculation, and Anorgasmia:

Delayed (DE), retarded ejaculation (RE), or inhibited ejaculation (IE) are probably the least common, least studied, and least understood of the male sexual dysfunctions.

Problems with “difficulty” in ejaculating may range from varying delays in the latency to ejaculation to complete inability to ejaculate (anejaculation). Reductions in the volume, force, and sensation of ejaculation may occur as well. At the extremes are anejaculation (time) and retrograde ejaculation (direction).

The prevalence of ejaculatory disorders is unclear.

A number of pathophysiologies have been associated with ejaculatory problems. These include congenital disorders, as well as ones caused by trauma, infection, disease, and treatment for other disorders.

Traumatic damage may result from prostate surgery.

Various cancers in the pelvic region, as well as their treatment (surgical or radiotherapy), may interfere with normal ejaculatory function. Finally, spinal injury and other neurological disorders are prime candidates for ejaculatory dysfunction.

In summary, delayed or absent ejaculation can be a lifelong or an acquired problem. Many psychodynamic explanations have been offered for DE, and these may account for the problem in specific individual cases.

Treatment should be etiology specific and address the issue of infertility in men of a reproductive age.

Before considering a psychological/behavioral approach toward the treatment of DE, clinicians first need to exclude probable iatrogenic and pathophysiological causes.

It is also important to establish whether ejaculation is retrograde or absent, with the presence of spermatozoa in urine indicating retrograde ejaculation.

Culture of expressed prostatic secretion and urine will define the nature of an infective process such as prostatitis and urine cytology, and serum prostate specific antigen should be assayed to exclude bladder or prostatic cancer. Ultrasound scan of the testicles and epididymes may define any local disease.

Patients with ejaculatory duct obstruction usually present with infertility. Seminal analysis may simply be reported as showing azoospermia or oligozoospermia.

The man who presents with DE for whom organic and pharmacologic causes have been eliminated requires thorough psychosexual assessment. His partner and the quality of the relationship also warrant exploration. Numerous psychotherapeutic processes are described for the management of delayed or inhibited ejaculation and some appear to be effective sex education reduction of goalfocused anxiety; increased, more genitally-focused stimulation; patient roleplaying an exaggerated ejaculatory response on his own and in front of his partner; masturbatory retraining; and realignment of sexual fantasies and arousal strategies.

Treatment of delayed or inhibited ejaculation with pharmaceuticals has met with limited success.