Clinical summary guide

Ejaculatory disorders

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The GP’s role

  • GPs are typically the first point of contact for men with a disorder of ejaculation.

  • The GP’s role in management of ejaculation disorders includes diagnosis, treatment and referral.

  • Offer brief counselling and education as part of routine management.

How to approach the topic with patients

“Many men experience sexual difficulties. If you have any difficulties, I am happy to discuss them.”

Overview

  • Ejaculatory disorders include:

    Early (premature) ejaculation

    Delayed ejaculation

    Anorgasmia

    Painful ejaculation

    Retrograde ejaculation

    Anejaculation

    Haemospermia

  • Ejaculatory disorders result from a disrupted mechanism of ejaculation (emission, ejaculation and orgasm)

Disorders of ejaculation are uncommon but are important to manage when fertility is an issue.

Etiologies of ejaculatory dysfunction are numerous and multifactorial, and include:

  • Psychogenic

  • Congenital

  • Anatomic

  • Neurogenic

  • Infectious

  • Endocrine

  • Pharmacological (antihypertensive, psychiatric (SSRIs), α-blocker).

Early (premature) ejaculation

Definition (ICD-11) and classification:

  • Ejaculation that occurs before or very soon after penetration or other sexual stimulation, with little or no perceived control,

  • Occurs episodically or persistently over several months,

  • Associated with clinically significant distress.

Primary (lifelong) early ejaculation

  • Patient has never had control of ejaculation,

  • Probable causes are neural, endocrine or genetic

  • Unlikely to diagnose an underlying disease.

Secondary (acquired) early ejaculation

  • Patient was previously able to control ejaculation,

  • Probable causes are psychological and/or comorbidity.

Clinical notes:

  • Early ejaculation is the most common ejaculatory disorder,

  • Early ejaculation is commonly associated with erectile dysfunction

  • Early ejaculation is a self-reported diagnosis and can be based on sexual history alone.

Diagnosis

Sexual history:

  • Establish if early ejaculation is lifelong or acquired

  • Establish if early ejaculation is consistent (i.e. all or most sexual encounters) or situational (i.e., under specific circumstances or with a specific partner)

  • Attention should be given to:

    Ejaculation latency

    Sexual stimuli

    Impact on sexual activity

    Impact on quality of life

  • Distinguish between early ejaculation and erectile dysfunction

The Premature Ejaculation Diagnostic Tool (PEDT) can help identify men who have early ejaculation.

Medical history:

  • General medical history

  • General medical history

  • Trauma (urogenital, neurological, surgical)

  • Prostatitis or hyperthyroidism (uncommonly associated)

Psychological:

  • Depression

  • Anxiety

  • Stressors

  • Taboos or beliefs about sex (religious, cultural)

  • Relationship issues

Physical examination:

  • General examination

  • Genito-urinary: penile and testicular

  • Rectal (prostate) examination (if PE occurs with painful ejaculation)

  • Neurological assessment of genital area and lower limb

Laboratory testing is not routinely necessary for primary early ejaculation but may be useful for identifying comorbid contributors to secondary early ejaculation.

Management

Treatment decision-making should consider:

  • Aetiology

  • Patient needs and preferences

  • The impact of the disorder on the patient and his partner

  • Whether fertility is an issue

Management should be guided by the underlying cause.

Primary (lifelong) early ejaculation

  • Primary early ejaculation

  • Behavioural interventions alone are unlikely to be effective but they may be beneficial in combination with pharmacological treatment.

  • Discontinuation of pharmacotherapy will likely result in return of early ejaculation.

Secondary (acquired) early ejaculation

  • Treatment of the underlying cause should be the focus of treatment

  • If early ejaculation is secondary to erectile dysfunction, treat erectile dysfunction first

  • Behavioural interventions and/or psychotherapy should be considered first-line treatment

  • Pharmacotherapy should be considered as second-line treatment

Many men recover longer ejaculation latency following treatment.

Oral pharmacotherapy

Dapoxetine hydrochloride is short-acting on-demand SSRI, and is the only SSRI approved in Australia for treatment of early ejaculation.

Dose: 30 mg taken 1-3 hours before intercourse

Off-label use of antidepressants (SSRIs and tricyclic):

  • Fluoxetine hydrochloride: 20 mg/day

  • Paroxetine hydrochloride: 20 mg/day. Some patients find 10 mg effective; 40 mg is rarely required. Pre-intercourse dosing regime is generally not effective

  • Sertraline hydrochloride: 50 mg/day or 100 mg/day is usually effective. 200 mg/day is rarely required. Pre-intercourse dosing regime is generally not effective

  • Clomipramine hydrochloride: 25-50 mg/day or 25 mg 4-24 hrs pre-intercourse (suggest 25 mg on a Friday night for a weekend of benefit).

PDE-5 inhibitors (e.g. Sildenafil, 50-100 mg, 30-60 minutes before intercourse):

  • May be used if early ejaculation is related to erectile dysfunction

  • ‘Start low and titrate slow’. Trial for 3-6 months and then slowly titrate down to cessation. If early ejaculation reoccurs, trial drug again

  • If one drug is not effective, trial another

Topical pharmacotherapy

Local anaesthetic gels/creams can diminish sensitivity and delay ejaculation. Excess use can be associated with a loss of pleasure, orgasm and erection. Apply 30 minutes prior to intercourse to prevent trans-vaginal absorption. Use a condom if intercourse occurs sooner.

Lignocaine spray:

  • Should be used with a condom to prevent numbing of partner’s genitalia

Condoms:

  • Can diminish sensitivity and delay ejaculation, especially condoms containing anaesthetic

  • Can be used in combination with other treatments

Behavioural techniques

  • ‘Stop-start’ technique

  • ‘Squeeze’ techniques

  • Extended foreplay

  • Pre-intercourse masturbation

  • Cognitive distractions

  • Alternate sexual positions

  • Interval sex

  • Increased frequency of sex

Techniques may be difficult to maintain long-term.

Psychosexual counselling

  • Address the issue that creates the comorbid anxiety, depression or other psychogenic cause

  • Therapy options include meditation, relaxation, hypnotherapy and neuro-biofeedback

Referral

For general assessment refer to a specialist (GP, endocrinologist or urologist) who has expertise in sexual medicine.

  • Refer to a urologist if there is suspicion of lower urinary tract disease

  • Refer to an endocrinologist if a hormonal problem is diagnosed

  • Refer to counsellor, psychologist, psychiatrist or sexual therapist if there are issues of a psychosexual nature

  • Refer to fertility specialist if fertility is an issue

Delayed ejaculation

Definition (ICD-11) and classification: 

  • Prolonged ejaculatory latency that causes distress and/or cessation of activity due to fatigue or sense of futility

Clinical notes:

  • Delayed ejaculation may be lifelong or acquired, generalised or situational.

  • Cause may be psychological, organic (e.g., nerve damage) or pharmacological (e.g., SSRI, alcohol).

Diagnosis

Sexual history:

  • Establish if early ejaculation is lifelong or acquired

  • Establish if early ejaculation is consistent (i.e. all or most sexual encounters) or situational

  • Attention should be given to:

    Sexual and ejaculatory responses

    Sexual sensation

    Sexual frequency

    Sexual activity, techniques

    Cultural context

    Partner’s assessment

    Partner’s sexual function

    Relationship issues

Idiosyncratic masturbation, fantasy or pornography use may contribute to delayed ejaculation.

Medical history:

  • General medical history

  • Medications (prescription and non-prescription)

  • Hormonal milieu

  • Medications (prescription and non-prescription)

  • Trauma (urogenital, neurological, surgical)

Physical examination:

  • No specific associated findings but may provide reassurance of patient

  • May provide clues about comorbidities or cause(s)

Investigation by a sex therapist may be required to obtain a complete psychological evaluation.

Management

Psychological treatment

  • Increased genital-specific stimulation

  • Sexual education

  • Role-playing

  • Retraining masturbatory practices

  • Anxiety reduction in relation to sexual performance and ejaculation

  • Recalibration of mismatch between fantasy and reality

Pharmacotherapy

Cessation of medications, dose adjustment or substitution should be considered for drugs that disrupt orgasm and ejaculation (e.g., SSRIs, SNRIs, tricyclic antidepressants, opioids).

There is limited evidence for any pharmacological agent in treating delayed ejaculation. Drugs used include α-1-adrenergic agents (e.g., pseudoephedrine, imipramine), dopamine agonists (e.g., apomorphine, cabergoline), and hormones (oxytocin, testosterone).

Penile vibratory stimulation

  • Effective in combination with pharmacotherapy for treatment of delayed ejaculation.

Anorgasmia (no orgasm) 

Definition and classification:

  • Anorgasmia is the perceived absence of orgasm, and can be lifelong (primary) or acquired (secondary)

Clinical notes:

  • Some men with anorgasmia experience nocturnal or spontaneous ejaculation.

  • Aetiology is usually psychological.

Diagnosis

  • Determine if anorgasmia is lifelong or acquired

  • Attention should be given to:
    Medication
    Disease history
    Penile sensitivity
    Psychological issues

  • Laboratory tests may be needed to rule out organic causes (e.g., testosterone, thyroid function)

Management

Behavioural changes:

  • Changing masturbation style

  • Increasing intimacy

  • Reduce alcohol consumption

Psychosexual therapy:

  • Altered arousal methods

  • Sexual anxiety reduction

  • Role-playing

  • Increased genital stimulation

Pharmacotherapy:

  • Cessation of medications, dose adjustment or substitution should be considered for drugs that disrupt orgasm and ejaculation

  • Current evidence does not support drug treatment of anorgasmia

Referral 

  • Loss of penile sensation requires further investigation

  • Refer to fertility specialist if fertility is an issue

  • Penile vibratory stimulation, electro-ejaculation or testicular sperm extraction are options for sperm retrieval

Painful ejaculation

Definition and classification:

  • Painful ejaculation ranges from mild discomfort to severe pain during or after ejaculation, in the penis, scrotum and/or perineum

Clinical notes:

  • Painful ejaculation may be idiopathic or arise from:

    Calculi in seminal vesicles

    Sexual neurasthenia

    Sexually transmitted infection

    Prostatitis

    Prostate cancer

    Benign prostatic hyperplasia

    Iatrogenic (prostate surgery, pelvic radiation therapy, herniorrhaphy, medication)

Diagnosis

  • Detection of the underlying cause is necessary to guide effective treatment.

Management

  • Appropriate medical treatment (e.g. antibiotics, anti-inflammatories, α-blockers)

  • Withdrawal of suspected agents

  • Psychotherapy or relationship counselling

  • For idiopathic painful ejaculation:

    Behavioural therapy

    Pelvic floor exercises

    Muscle relaxants, antidepressants, anticonvulsants, opioids

  • There is no strong evidence to support surgical interventions for painful ejaculation

Retrograde ejaculation (orgasm with no ejaculation)

Definition and classification:

  • Retrograde ejaculation is the total or partial absence of anterograde ejaculation, due to semen entering the urinary bladder via the bladder neck

Clinical notes:

  • Patients experience normal or decreased orgasmic sensation

  • Retrograde ejaculation is benign, but it may impair fertility

  • The cause of retrograde ejaculation may be:

    Neurogenic (e.g. spinal cord lesion, multiple sclerosis, diabetes, postoperative iatrogenesis)

    Urethral (e.g. stricture)

    Pharmacological (e.g. α-1-adrenoceptor antagonists, antidepressants)

    Endocrine (e.g. hypothyroidism, hypogonadism)

    Bladder neck incompetence (e.g. congenital, post-prostatectomy)

Diagnosis

  • The presence of sperm in postejaculatory urine indicates retrograde ejaculation.

Management

Counselling:

  • Provide reassurance

  • Normalise the condition

Pharmacotherapy:

  • Restoration of antegrade ejaculation may be possible, to facilitate natural conception. Agents include:

    Imipramine hydrochloride (10 mg, 25 mg tablets) 25-75 mg three times daily

    Pheniramine maleate (50 mg tablet) 50 mg every second day

    Decongestant medication such as pseudoephedrine

    Antihistamines, such as cyproheptadine

  • Consider medication modification, alternative agent or ‘drug holiday’ from causal agent

Behavioural techniques:

  • Ejaculation with a full bladder, to increase bladder neck closure, may achieve anterograde ejaculation.

Referral 

Refer to fertility specialist if fertility is an issue.

Anejaculation

Definition and classification:

  • Anejaculation is the complete absence of anterograde or retrograde ejaculation

Clinical notes:

  • Caused by failure of semen emission into the urethra from seminal vesicles, prostate and ejaculatory dusts

  • Usually associated with normal orgasmic sensation

  • Always associated with nervous system dysfunction or drugs

  • Aetiology is similar to delayed or retrograde ejaculation

  • Anejaculation is benign, but it may impair fertility

Diagnosis

  • The absence of sperm in postejaculatory urine indicates anejaculation

Management

Counselling:

  • Provide reassurance

  • Normalise the condition

  • Psychotherapy is ineffective

Pharmacotherapy:

  • Consider medication modification, alternative agent or ‘drug holiday’ from causal agent.

  • Ineffective for anejaculation caused by neuropathy or lymphadenectomy

Referral

  • Penile vibratory stimulation, electro-ejaculation or testicular sperm extraction are options for sperm retrieval

  • Refer to fertility specialist if fertility is an issue

Haemospermia

Definition and classification:

  • Haemospermia is the appearance of blood in the ejaculate

Clinical notes:

  • Haemospermia causes anxiety in many men

  • Causes include:

    Congenital (e.g. seminal vesicle or ejaculatory duct cysts)

    Inflammatory (e.g. prostatitis, urethritis, epididymitis, urinary tract infection, HIV)

    Obstruction (e.g. calculi, urethral stricture, benign prostatic hyperplasia)

    Tumours (e.g. prostate, bladder, urethra, epididymis, testis, melanoma).

    Vascular (e.g. prostatic varices, haemangioma, excessive sexual activity)

    Trauma or iatrogenic (e.g. perineum, testis, prostate biopsy)

    Systemic (e.g. hypertension, haemophilia, purpura, renovascular disease, cirrhosis)

    Idiopathic

  • Most cases have no identified cause

  • Urinary tract infection is a more common cause in males <40 years than older men

  • Calculi and malignancy are more common causes in males >40 years than younger men

Diagnosis

  • Aim to rule out serious (although infrequent) underlying cause. The risk of malignancy in any patient with haemospermia is approximately 3.5%

  • Prevent over-investigation

Medical history and examinations:

  • Systemic and symptom-specific history

  • Sexual history – STIs?

  • Rule our pseudo-haemospermia

  • Recent travel history – schistosomiasis, tuberculosis?

  • Comorbidity (e.g. hypertension, coagulopathy, liver disease, malignancy)

  • Blood pressure

  • Detailed physical examinination: penis, testes, DRE if risk factors for prostate CA

  • Urinalysis

  • Screen for sexually transmitted infections

  • Blood tests to identify systemic disease

Management

For men with isolated haemospermia and low risk of serious cause (e.g. aged <40 years, no other symptoms or sign of disease):

  • Conservative treatment

  • Watchful waiting

  • Reassurance

For men with recurrent haemospermia and high risk of serious cause (e.g. age >40 years, symptoms or signs of comorbidity):

  • Cure underlying aetiology (e.g. antibiotics, anti-inflammatories)

  • Prostate cancer screening

  • Imaging

  • Rule out testicular cancer in men <40 years

Consider medication modification, alternative agent or ‘drug holiday’ from causal agent.

Referral

Refer to a urologist any high risk patient or any with recurrent haemospermia. Specialist investigations may include TRUS, MRI, and cystoscourethroscopy. 

  • Refer to a urologist any high risk patient or any with recurrent haemospermia. Specialist investigations may include TRUS, MRI, and cystoscourethroscopy

Information sourced from

European Association of Urology. Sexual and Reproductive Health Guidelines

Disorders of Ejaculation: An UAA/SMSNA Guideline

Clinical review

Dr Vincent Chan, Men’s Health Melbourne and Western Health, Victoria; July 2023

Ejaculatory disorders

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