Ejaculatory Disorders
Disordered ejaculation in which there is no semen from the penile at the time of climax is called aspermia. This is different from azoospermia in which semen is present but contains no sperm.
In the absence of any ejaculate, it is important to figure out whether there is a failure of ejaculation (anejaculation) or whether there is ejaculation into the bladder (retrograde ejaculation). Failure of ejaculation can be a lifelong, primary event (congenital anorgasmia) or an acquired problem (secondary anorgasmia).
With board certified Dr. Paul Turek, who has been designated as one of the "Best Doctors in America" for the past 5 years, there are two different treatments for these two conditions, which are important to distinguish.
To learn more about ejaculatory disorders, please select one of the following topics. If you are ready to schedule a consultation for treatment, please request a consultation here.
The Normal Ejaculation Process
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Although commonly viewed as a single event, ejaculation is actually two separate processes, termed emission and ejaculation. Emission is the process in which semen is "loaded" into the chamber of the penis near the prostate within the body. After this, ejaculation is the forcible expulsion of semen from the penis. During climax, the ejaculate is expelled from the penis in a series of spurts caused by rhythmic contractions, about 1 second apart, of the pelvic muscles. Ejaculation is different from orgasm, an event that is centered in the brain and is closely associated with ejaculation.
Similar to a sneeze, ejaculation is a reflex. Also similar to a sneeze, it has a "point of no return" which occurs after the spinal reflex is stimulated. Ejaculation is under control of two kinds of nervous system input. The sympathetic (autonomic) nervous system governs emission and the somatic nervous system controls ejaculation. The sympathetic nerves come from thoraco-lumbar spine at levels T10-L2. They form the superior hypogastric plexus and run in front of the aorta in the back and pelvis. Expulsion of the ejaculate is governed by the somatic nervous system through the pudendal nerve (S2-S4). Interruption of either of these 2 nervous system components can result in ejaculatory disorders.
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Inside the Ejaculate
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The normal ejaculate has a volume of at least 1.5-2 mL. It includes fluid from the prostate (10% of volume), the vas deferens (sperm, 10%), the seminal vesicles (80%) and a small amount from Cowper's glands. The first part of the ejaculate contains the most sperm and the highest amounts of prostatic enzymes, zinc and citrate, suggesting that is it compose of mainly fluid from the vas deferens and prostate. Fructose levels are highest in the latter half of the ejaculate, which is largely from the seminal vesicles. The normal pH of the ejaculate is 7.2-8.0. A low pH on a semen analysis suggests that there might be an obstruction in the system. Similarly, a lack of fructose in the semen implies seminal vesicle blockage. So, a semen analysis can be very valuable aid to use to evaluate ejaculatory disorders.
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Ejaculatory Disorder Evaluation
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The most informative part of the evaluation of ejaculatory disorders is a detailed patient history. It is important to understand whether normal ejaculation was ever present, which can suggest whether the problem is congenital or acquired. The physical examination includes an assessment of the testicles and genitalia to make sure all necessary components are present, including the vas deferens. As part of the evaluation, the patient should try to produce a semen sample for analysis. If there is no ejaculate, a post-ejaculate urine sample should be obtained and examined for the presence of sperm. If sperm are present in the bladder urine after ejaculation, this indicates retrograde ejaculation. Blood tests including FSH and testosterone are also assessed, as a low testosterone level may cause low semen volume. Other tests may include imaging with transrectal ultrasound (TRUS) to define structural abnormalities in the prostate or seminal vesicles.
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Ejaculatory Disorders and Treatment
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Premature Ejaculation
The average time from vaginal penetration to ejaculation in the average US man is 9 minutes. The definition of premature ejaculation is reaching orgasm within 1 minute or less after vaginal penetration (intercourse), or ejaculation that occurs too early for female partner satisfaction. This problem is common, occurring in 30% of adult men, and it is the most common form of male sexual dysfunction. It can be caused by erectile dysfunction, anxiety and nerve hypersensitivity and is, in general, quite treatable. Treatments for premature ejaculation include oral medical therapy, local therapy and psychotherapy. The goal of therapy is to increase patient control over the ejaculation process by decreasing penile sensitivity and adjusting the behavioral response. A list of treatments currently used for premature ejaculation can be found in Table 1.
Importantly, while medications can "control" the problem and delay ejaculation in most men, truly "curing" the problem usually requires sex education involving the patient and his partner. Dr. Turek specializes in "curing" this problem and not simply treating it. He collaborates with Melody Lowman, a noted sex educator and counselor, and has excellent treatment success in motivated patients. Sex education seeks to provide more patient control and satisfaction from sexual stimulation. During this "education" process, the sensation of ejaculatory inevitability is explained so that patients can understand and observe what sensations are actually experienced in the body, to enhance both sexual control and pleasure. Education often involves learning relaxation techniques and using new skills to perform prolonged self- or partner-performed sexual stimulation without demand for erection or ejaculation. Subsequently, patients learn methods of passive coitus without thrusting and, eventually, coitus with pelvic thrusting. Partner participation and cooperation with such therapy is important for long-term success. With this approach, medications can eventually be discontinued and the problem cured. See also our video "Not so Fast: Early Ejaculation Cure".
TABLE 1. MEDICATIONS THAT TREAT PREMATURE EJACULATION. 
Generic Name Trade name Dose Frequency Side Effects Dapoxitene 20mg daily Not FDA approved in US Paroxetine Paxil 10-20mg daily or as needed Constipation;drowsiness Fluoxetine Prozac 10-20mg daily or as needed Diarrhea, anxiety Sertaline Zoloft 25-50mg daily or as needed Appetite loss, anxiety, drowsiness Clomipraimine Anafranil 25-50mg daily or as needed Dry skin and mouth, drowsiness, insomnia Tramadol Ultram 25-50mg daily or as needed Seizures, rash, dizziness
PRIMARY PREMATURE EJACULATION-LOCAL THERAPY Generic Name Trade Name Dose Frequency Side Effects Lidocaine/Prilocaine EMLA 2.5% as needed Penile and vaginal numbness, redness Herbal extract SS cream packets as needed Minimal
PRIMARY PREMATURE EJACULATION-BEHAVIORAL THERAPY Technique Description "Start-stop" Approach climax and stop to reduce stimulation "Pull-out" Approach climax, vaginal withdrawl to reduce stimulation "Pull-out and squeeze" Approach climax, vaginal withdrawl and squeeze penis tip to reduce stimulation "Mind distraction" Couple or individual thinks about unrelated subjects to reduce stimulation Sex education Couple learns ways to reduce stimulation and delay climax
SECONDARY PREMATURE EJACULATION-ORAL THERAPY Generic Name Trade name Dose Frequency Side Effects Sildenafil Viagra 25-100mg as needed Blue or blurry vision, flushing, nasal stuffiness, upset stomach, (rare) vision and hearing loss, dizziness. Vardenafil Levitra 5-20mg as needed Nasal stuffiness, headache, upset stomach, dizziness, (rare) visionand hearing loss. Tadalafil Cilias 5-20mg as needed Nasal stuffiness, headache, dizziness, stomach upset, back or muscle pain (5%) Retrograde Ejaculation
Among infertile men, a little less than 1% will have retrograde ejaculation as the underlying cause of infertility. However, about 15% of men with aspermia will have retrograde ejaculation. Retrograde ejaculation is a relatively straightforward diagnosis that requires a history of aspermia with a post-ejaculate urine sample showing sperm. There are many reasons for retrograde ejaculation including medical conditions such as diabetes mellitus (32% of diabetics have this), nerve problems, drug related reasons and as a side effect of surgery. A list of the causes of retrograde ejaculation is outlined in Table 2.
The treatment of retrograde ejaculation is related to its cause. If drug-induced, then the offending medication should be discontinued, if possible. When caused by other medical conditions, oral therapy can be tried as these treatments have a low side effect profile. Listed in Table 3, this therapy generally helps to close the bladder neck and avoid entry of the semen into the bladder during ejaculation. Approximately one-third of men will respond to this treatment if the problem is not related to a prior surgical procedure. Generally, oral therapy is limited by side effects, especially in young men who may be sensitive to taking medications. It is also true that one drug may work where another has failed, so it might make good sense to try a second medication if the first one fails.
TABLE 3. MEDICATIONS THAT TREAT RETROGRADE EJACULATION. Generic Name Trade name Dose Frequency Pseudoephedrine Sudafed Plus 120mg 90 min prior to ejaculation Pseudoephedrine Sudafed Plus 60mg 4x daily x 2 days prior to ejaculation Imipramine Tofranil Plus 25-50mg Daily for 1 month Phenylephrine Neo-Synephrine Nasal 1-2 hours prior to ejaculation Ephedrine Ventolin 30-60mg 1-2 hours prior to ejaculation (inhalers) Apulent 1-2 hours prior to ejaculation ProVentil 1-2 hours prior to ejaculation Chlorpheniramine Atarax Twice daily x 1 month Bromopheniramine Vistaril Twice daily x 1 month When fertility is desired and oral therapy fails to correct retrograde ejaculation, sperm can be harvested from the bladder or bladder urine and be used with assisted reproduction. In the simplest case, the patient can take medications to raise the urine pH and then ejaculate and urinate. The post-ejaculate urine can be processed and the sperm removed and concentrated. The sperm can then be inseminated into the partner's uterus in a procedure called intrauterine insemination (IUI) with good success. If sperm numbers and motility are too low for IUI, then in vitro fertilization (IVF) can also be used. Sometimes, exposure to the bladder urine causes all of the sperm to die despite regulating the urine pH. In this situation, a "bladder sperm harvest" can be performed. With this technique, a small, lubricated catheter is placed in the patient's bladder through the penis and the urine removed. After carefully washing the bladder, it is partially filled with culture medium, a fluid that supports sperm motility. After the catheter is removed, the patient then ejaculates and voids. The voided “urine” is now enriched with culture medium and the sperm within it is more likely to be motile and therefore usable for assisted reproduction. Dr. Turek likes encourages patients to do a “trial run” of such therapy in advance of assisted reproductive procedures to: (1) understand the quality of the semen sample and the degree of retrograde ejaculation and (2) work out the details of what is necessary to do to get motile sperm for IUI or IVF.
Anejaculation
Anejaculation can be congenital or acquired in nature. Congenital anorgasmia, also termed primary anejaculation, is a well-described cause of anejaculation. This occurs in about 1/1000 men in the general population, and in 4/100 male infertility patients. Despite the lack of orgasm, nocturnal emissions, or semen discharge during sleep, may occur. The cause is thought to be overly strict childhood upbringing: a classic setting includes parenting with intense performance demands and minimal physical affection. Treatment of primary anejaculation is difficult. Often affected individuals lack sensual awareness of their bodies. In addition, they may often seek a partner from a similar background who may accommodate to an asexual or minimally sexual lifestyle. Because of this, treatment is generally sought when the couple desires a pregnancy, as erections and sexual performance are otherwise unaffected. Again, sex education has the highest chance of curing this problem. It begins with instruction in sex education, followed by cognitive behavioral treatment that includes systematic relaxation and sensate focus exercises. At first, partners are taught to tolerate and become comfortable with touch. Later in therapy, after touch induces pleasure, sexual stimulation is encouraged as the shaping of the sexual response and orgasm occurs. Fertility issues can be easily bypassed with one or more of the following techniques: prostatic massage for sperm, collection and insemination of nocturnal semen emissions, penile vibratory stimulation or rectal probe electroejaculation, and sperm retrieval.
Secondary or acquired anejaculation can have several identifiable causes. The same medications that cause retrograde ejaculation (Table 2) can also cause anejaculation in some men. In this case, discontinuing the offending medication should reverse the problem. Acquired anejaculation can also be due to medical conditions such as diabetes, multiple sclerosis and spinal cord injury. In these cases penile vibratory stimulation, rectal probe ejaculation or surgical sperm retrieval techniques may be used to achieve fertility. Finally, anejaculation can occur as a result of surgical procedures that affect the nerves that control ejaculation including retroperitoneal lymph node dissection and radical prostatectomy. Again, depending on the kind of surgery, rectal probe ejaculation or surgical sperm retrieval techniques may be used for fertility. Pediatric congenital defects of the pelvis are also associated with anejaculation later in life. Anejaculation may also be due to both anatomical nature of the anomaly (cloacal exstrophy, imperforate anus) or associated surgical procedures (exstrophy/ epispadias repair, bladder neck reconstruction) to correct the birth defect.
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The Case of Spinal Cord Injury
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Anejaculatory spinal cord injured patients can be helped to ejaculate by two procedures, depending on the level of the spinal injury. Those with injuries above the T10 spinal level generally have an intact ejaculatory reflex arc, since the nerves from T10-L2 and S2-S4 are intact. An intact bulbocavernosus reflex and the ability to perform hip flexion, both of which predict for successful ejaculation with technological assistance, can confirm the integrity of this reflex arc. Penile vibratory stimuation is the simplest from of ejaculatory stimulation and involves placement of a high frequency, high amplitude vibrator on the bottom tip of the penis for several minutes to induce ejaculation. With this technique, ejaculation is achieved painlessly in the majority of patients with cord injuries above the T10 level. Importantly, patients with high spinal cord injuries (especially above T4) are also prone to autonomic dysreflexia from penile vibration, so they should be given a calcium channel blocker before the stimulation procedure to reduce symptoms.
Figure 1. THE SEAGER RECTAL PROBE ELECTROEJACULATOR, USED TO TREAT ANEJACULATION.
For men with lower spinal cord lesions (below T10) in whom penile vibratory therapy has failed, rectal probe eletro-ejaculation is an excellent alternative to achieve ejaculation (Figure 1). Dr Turek is one of only a few specialists in the world trained to perform this technique.
The retrieved sperm by this method is often of sufficient sperm to use low levels of assisted reproduction such as IUI to conceive.
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Blood in the Ejaculate
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Blood in the ejaculate is called hematospermia. When it occurs, it is very alarming, usually painless and the ejaculate is red or brown in color. Blood clots may or may not be present in the semen. It is common in young, sexually active males and it generally resolves over time without further therapy. If it occurs with pain, then it may indicate ejaculatory duct obstruction and this evaluation is recommended. Recurrent hematospermia, painful hematospermia or hematospermia in men > 50 years old deserves further evaluation for anatomical and infectious causes. The incidence of cancer, including sarcoma, bladder or prostate cancer and, rarely, seminal vesicle cancer, is more prevalent in men > 50 years old. After a prostate examination, further evaluation includes examination and culture of urine and expressed prostatic secretions, measurement of prostate specific antigen (PSA) and transrectal ultrasound.
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