Ejaculatory Disorders

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: persistent/recurrent ejaculation within 1 minute of vaginal penetration, present >6 months, causing significant distress. Normal ejaculation time is 2-5 minutes.
Ejaculatory control is an acquired behavior improving with experience.
Common comorbidities: diabetes, hypertension, sexual desire disorder, erectile dysfunction (ED).
DE: prolonged ejaculation time >30 minutes despite desire, stimulation, erection.
Aspermia (no sperm in ejaculate):
AE: lack of emission or bulbospongiosus muscle contractions.
RE: semen ejaculated into bladder (partial or complete).
Obstruction: ejaculatory duct or urethral obstruction.
Others: painful ejaculation, ejaculatory anhedonia (ejaculation without pleasure), hematospermia (blood in ejaculate).

EPIDEMIOLOGY

PE prevalence: 5-20% in US males.
DE prevalence: 5-8% men 18-59 years; <3% chronic >6 months.
Affects all sexually mature age groups.

ETIOLOGY AND PATHOPHYSIOLOGY

Male sexual response:
Erection: parasympathetic nervous system mediated.
Ejaculation phases:
- Emission phase: semen deposited in urethra by prostate, seminal vesicles, vas deferens (sympathetic control).
- Ejaculation phase: semen expelled by bulbospongiosus and ischiocavernosus muscles (somatic via pudendal nerve); bladder neck closure prevents retrograde flow.
- Orgasm: pleasurable sensation from cerebral cortex, smooth muscle contraction, pressure release.
PE causes:
Hypersensitivity/hyperexcitability of glans penis.
5-HT (serotonin) receptor sensitivity.
Psychogenic factors: inexperience, anxiety, guilt, low sex frequency, relationship problems.
Urologic: ED, prostatitis, urethritis.
Endocrine: hyperthyroidism, obesity, diabetes.
Drug withdrawal (opioids).
DE causes:
Rare painful disorders (prostatitis).
Psychogenic factors, low testosterone, sexual anxiety.
Medications: MAOIs, SSRIs, α-/β-blockers, thiazides, antipsychotics, TCAs, NSAIDs, opiates, alcohol, cannabis.
AE causes:
Congenital: Müllerian duct cyst, Wolffian anomalies.
Acquired: prostate surgery, retroperitoneal LN dissection, spinal injury (T10-T12), diabetes neuropathy, medications (α-/β-blockers, benzodiazepines, SSRIs, MAOIs, TCAs).
RE causes:
Prostate surgery (TURP 25%).
Bladder neck surgery, pelvic surgery.
Neurologic: MS, diabetes.
Medications: tamsulosin, α-blockers, SSRIs, antipsychotics.
Urethral stricture.
Painful ejaculation causes:
Infection/inflammation: orchitis, epididymitis, prostatitis, urethritis.
Ejaculatory duct obstruction, seminal vesicle stones, vas deferens obstruction.
Psychological factors.
Hematospermia causes:
Usually benign.
Infection, calculi, trauma, obstruction, cyst, tumor (1-3% prostate cancer cases), arteriovenous malformations, hypertension, iatrogenic.

RISK FACTORS

ED, pudendal neuralgia, substance use, psychological or relationship issues.

GENERAL PREVENTION

Screen for sexually transmitted infections (STIs).

COMMONLY ASSOCIATED CONDITIONS

Neurologic disorders (MS), diabetes, prostatitis, ejaculatory duct obstruction, urethral stricture, psychological and endocrine disorders, relationship difficulties.

DIAGNOSIS

HISTORY

Detailed sexual history: timing, control, distress, relationship assessment.
Medications, trauma, infections, surgeries, supplements.
Include partner when possible.
Review systems for testosterone deficiency or prolactin excess.

PHYSICAL EXAM

Vitals, neurologic exam for focal signs.
GU exam: testes size/texture, vas deferens presence, urethral meatus patency, digital rectal exam for prostate.

DIAGNOSTIC TESTS & INTERPRETATION

Fasting glucose/HbA1c for diabetes.
Postorgasmic urinalysis: confirms RE (fructose, sperm).
Infection workup in painful ejaculation: urinalysis, culture.
PSA for prostate cancer suspicion.
Hormones: testosterone, prolactin, TSH in anhedonia.
TRUS and TRUS-guided aspiration for ejaculatory duct obstruction.
Scrotal US/MRI for anatomic abnormalities.
Labs: CBC, coagulation, chem panel, STI screening, semen analysis as indicated.

TREATMENT

GENERAL MEASURES

Identify medical causes, improve partner communication, psychological counseling, reduce performance pressure.

PE TREATMENT

Behavioral: sensate focus, quiet vagina technique, squeeze or start-stop methods.
Medication:
First-line: antidepressants (clomipramine, sertraline, paroxetine) on demand or daily dosing; PDE5 inhibitors for ED.
Second-line: topical anesthetics (2.5% prilocaine ± lidocaine), tramadol on demand, modafinil, pelvic floor therapy.

DE TREATMENT

No FDA-approved drugs.
Switch antidepressants if possible.
Sex therapy, self-stimulation, oxytocin, pseudoephedrine, midodrine considered.

AE & RE TREATMENT

Discontinue offending meds, control diabetes, treat obstruction.
RE: intercourse with full bladder, α-agonists (pseudoephedrine), anticholinergics (imipramine).
AE: penile vibratory stimulation, electroejaculation, midodrine.
Postejaculation bladder sperm harvest for fertility.

PAINFUL EJACULATION

Treat infections/inflammation, counseling.
Refer urology if seminal vesicle stones suspected.

HEMATOSPERMIA

Usually self-limited; reassurance.
Empiric antibiotics if needed.
Refer if persistent or suspicious.

MEDICATION SUMMARY

Disorder	Medication/Intervention	Level of Evidence
Premature Ejaculation (PE)	Clomipramine, sertraline, paroxetine (on demand or daily); PDE5 inhibitors	[A]
	Topical anesthetic gel (EMLA), tramadol (on demand), modafinil, pelvic floor therapy	[B], [C]
Delayed Ejaculation (DE)	Switch antidepressants; sex therapy; oxytocin, pseudoephedrine, midodrine	[C]
Anejaculation (AE) & Retrograde Ejaculation (RE)	Sympathomimetics (pseudoephedrine), anticholinergics (imipramine); penile vibratory stimulation; electroejaculation	[B]
Painful Ejaculation	Treat infection/inflammation; no specific drugs	[C]

ISSUES FOR REFERRAL

Urologist referral for ejaculatory duct obstruction, seminal vesicle/prostate stones, urethral obstruction, vas deferens obstruction, calculi, or persistent/severe hematospermia.

SURGERY/OTHER PROCEDURES

Transurethral resection of ejaculatory ducts if obstruction present.

COMPLEMENTARY & ALTERNATIVE MEDICINE

Possible benefits from daily caffeine and folic acid supplementation.

ONGOING CARE & PATIENT EDUCATION

Emphasize general measures, counseling, and partner involvement.

PROGNOSIS

PE often improves with therapy and counseling.

COMPLICATIONS

Psychological distress: inadequacy, anxiety, guilt.

CLINICAL PEARLS

Manage ED before treating ejaculatory disorders.
Medications are common causes of ejaculatory problems.
PE and DE have both psychogenic and physical causes; AE and RE usually due to organic neurogenic/autonomic dysfunction.
Multidisciplinary care involving primary care, urologists, psychologists essential.

REFERENCES

Shindel AW, Althof SE, Carrier S, et al. Disorders of ejaculation: an AUA/SMSNA guideline. J Urol. 2022;207(3):504-512.
Chen T, Mulloy EA, Eisenberg ML. Medical treatment of disorders of ejaculation. Urol Clin North Am. 2022;49(2):219-230.
Haghighi M, Jahangard L, Meybodi AM, et al. Influence of modafinil on early ejaculation—Results from a double-blind randomized clinical trial. J Psychiatr Res. 2022;146:264-271.

Codes

ICD10: F52.4 Premature ejaculation
ICD10: N53.11 Retarded ejaculation
ICD10: N53.14 Retrograde ejaculation