Ejaculatory disorders

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.

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)

Psychogenic

Congenital

Anatomic

Neurogenic

Infectious

Endocrine

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

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.

Patient has never had control of ejaculation,

Probable causes are neural, endocrine or genetic

Unlikely to diagnose an underlying disease.

Patient was previously able to control ejaculation,

Probable causes are psychological and/or comorbidity.

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.

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)

Ejaculation latency

Sexual stimuli

Impact on sexual activity

Impact on quality of life

Distinguish between early ejaculation and erectile dysfunction

General medical history

General medical history

Trauma (urogenital, neurological, surgical)

Prostatitis or hyperthyroidism (uncommonly associated)

Depression

Anxiety

Stressors

Taboos or beliefs about sex (religious, cultural)

Relationship issues

General examination

Genito-urinary: penile and testicular

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

Neurological assessment of genital area and lower limb

Aetiology

Patient needs and preferences

The impact of the disorder on the patient and his partner

Whether fertility is an issue

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.

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

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).

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

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

Can diminish sensitivity and delay ejaculation, especially condoms containing anaesthetic

Can be used in combination with other treatments

‘Stop-start’ technique

‘Squeeze’ techniques

Extended foreplay

Pre-intercourse masturbation

Cognitive distractions

Alternate sexual positions

Interval sex

Increased frequency of sex

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

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

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

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

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).

Establish if early ejaculation is lifelong or acquired

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

Sexual and ejaculatory responses

Sexual sensation

Sexual frequency

Sexual activity, techniques

Cultural context

Partner’s assessment

Partner’s sexual function

Relationship issues

General medical history

Medications (prescription and non-prescription)

Hormonal milieu

Medications (prescription and non-prescription)

Trauma (urogenital, neurological, surgical)

No specific associated findings but may provide reassurance of patient

May provide clues about comorbidities or cause(s)

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

Effective in combination with pharmacotherapy for treatment of delayed ejaculation.

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

Some men with anorgasmia experience nocturnal or spontaneous ejaculation.

Aetiology is usually psychological.

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)

Changing masturbation style

Increasing intimacy

Reduce alcohol consumption

Altered arousal methods

Sexual anxiety reduction

Role-playing

Increased genital stimulation

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

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

Calculi in seminal vesicles

Sexual neurasthenia

Sexually transmitted infection

Prostatitis

Prostate cancer

Benign prostatic hyperplasia

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

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

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

Withdrawal of suspected agents

Psychotherapy or relationship counselling

Behavioural therapy

Pelvic floor exercises

Muscle relaxants, antidepressants, anticonvulsants, opioids

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

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

Patients experience normal or decreased orgasmic sensation

Retrograde ejaculation is benign, but it may impair fertility

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)

The presence of sperm in postejaculatory urine indicates retrograde ejaculation.

Provide reassurance

Normalise the condition

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

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

Anejaculation is the complete absence of anterograde or retrograde ejaculation

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

The absence of sperm in postejaculatory urine indicates anejaculation

Provide reassurance

Normalise the condition

Psychotherapy is ineffective

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

Ineffective for anejaculation caused by neuropathy or lymphadenectomy

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

Refer to fertility specialist if fertility is an issue

Haemospermia is the appearance of blood in the ejaculate

Haemospermia causes anxiety in many men

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

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

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

Conservative treatment

Watchful waiting

Reassurance

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

Prostate cancer screening

Imaging

Rule out testicular cancer in men <40 years

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