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Saturday, August 23, 2025

Ejaculation problems


Introduction

Ejaculation is a complex reflex involving coordination between the central nervous system, peripheral nerves, seminal vesicles, prostate, and urethra. Any disruption in this pathway can lead to ejaculatory dysfunction.

Ejaculation problems can significantly affect sexual satisfaction, fertility, psychological well-being, and relationships. Although often underreported due to embarrassment, these disorders are common and have effective treatment options.

Types of Ejaculation Problems

  1. Premature Ejaculation (PE): Ejaculation occurs sooner than desired, often within 1–2 minutes of penetration.

  2. Delayed Ejaculation (DE): Difficulty or inability to ejaculate despite adequate stimulation.

  3. Retrograde Ejaculation (RE): Semen flows backward into the bladder instead of exiting via urethra.

  4. Painful Ejaculation: Ejaculation associated with discomfort or burning sensation.

  5. Anejaculation: Complete absence of ejaculation (often neurological).

Physiology of Ejaculation

  • Emission phase: Contraction of vas deferens, seminal vesicles, and prostate → semen enters posterior urethra. Controlled by sympathetic nervous system (T10–L2).

  • Expulsion phase: Contraction of bulbospongiosus and pelvic floor muscles expels semen. Controlled by somatic and parasympathetic nerves (S2–S4).

Causes of Ejaculation Problems

1. Premature Ejaculation (PE)

  • Primary (lifelong): Often neurobiological hypersensitivity (e.g., serotonin receptor dysfunction).

  • Secondary (acquired): Associated with erectile dysfunction, prostatitis, hyperthyroidism, performance anxiety.

2. Delayed Ejaculation (DE)

  • Psychological: anxiety, depression, relationship issues.

  • Neurological: spinal cord injury, multiple sclerosis, peripheral neuropathy.

  • Medications: SSRIs, antipsychotics, opioids.

  • Endocrine: low testosterone, hypothyroidism.

3. Retrograde Ejaculation (RE)

  • Post-prostate surgery, bladder neck surgery.

  • Diabetic autonomic neuropathy.

  • Drugs: alpha-blockers (tamsulosin), antidepressants.

4. Painful Ejaculation

  • Prostatitis, seminal vesiculitis.

  • Urethritis (often STI-related).

  • Ejaculatory duct obstruction.

  • Post-surgical scarring.

5. Anejaculation

  • Spinal cord injuries.

  • Pelvic surgery nerve damage.

  • Severe diabetes neuropathy.

  • Psychological inhibition.

Clinical Features

  • PE: Ejaculation with minimal stimulation, distress, lack of control.

  • DE: Long latency, inability to climax.

  • RE: “Dry orgasm,” cloudy urine post-orgasm.

  • Painful ejaculation: Dysuria, perineal pain, hematuria.

  • Anejaculation: Absence of ejaculation despite orgasm.

Diagnostic Approach

1. History

  • Onset (lifelong vs. acquired).

  • Duration, severity, situational factors.

  • Associated erectile dysfunction or libido changes.

  • Medical history (diabetes, surgeries, neurological disease).

  • Drug history (SSRIs, antihypertensives, opioids).

2. Physical Examination

  • Genital exam (testes, prostate, penile abnormalities).

  • Neurological exam.

  • Digital rectal exam (prostate tenderness or enlargement).

3. Laboratory Investigations

  • Blood glucose, HbA1c (diabetes).

  • Hormonal profile: total testosterone, prolactin, TSH.

  • Urinalysis (retrograde ejaculation, infections).

  • STI screening if urethritis suspected.

4. Specialized Tests

  • Semen analysis (infertility cases).

  • Post-ejaculatory urine analysis (retrograde ejaculation).

  • Ultrasound (ejaculatory duct obstruction, prostate pathology).

Management and Treatment

Treatment depends on type and underlying cause.

A. Premature Ejaculation (PE)

Behavioral Therapy:

  • Stop–start technique, squeeze technique.

  • Use of condoms to reduce sensitivity.

  • Psychological counseling if anxiety-related.

Pharmacological Options:

  • SSRIs (off-label, daily use):

    • Paroxetine: 10–40 mg orally daily.

    • Sertraline: 50–100 mg orally daily.

    • Fluoxetine: 20–40 mg orally daily.

  • Dapoxetine (short-acting SSRI):

    • 30–60 mg orally, 1–3 hours before intercourse (on-demand use).

  • Topical anesthetics (lidocaine/prilocaine creams or sprays):

    • Apply to glans 15–30 minutes before intercourse, remove before penetration.

  • Tramadol (off-label, last resort):

    • 25–50 mg orally 2–3 hours before intercourse.

B. Delayed Ejaculation (DE)

Address underlying causes:

  • Reduce/adjust medications (SSRIs, antipsychotics, opioids).

  • Treat endocrine disorders (testosterone deficiency, hypothyroidism).

  • Psychotherapy for anxiety/depression.

Pharmacological Options (limited evidence):

  • Bupropion: 150–300 mg orally daily.

  • Amantadine: 100 mg orally twice daily.

  • Cabergoline: 0.25–0.5 mg orally twice weekly.

C. Retrograde Ejaculation (RE)

Management:

  • Treat underlying diabetes or surgical complications.

  • Adjust/stop causative drugs (e.g., alpha-blockers).

  • Sympathomimetic agents (enhance bladder neck closure):

    • Pseudoephedrine: 60 mg orally 3 times daily.

    • Imipramine: 25–75 mg orally at bedtime.

  • Assisted reproductive techniques if fertility is affected.

D. Painful Ejaculation

  • Antibiotics for prostatitis/urethritis:

    • Ciprofloxacin: 500 mg orally twice daily for 4–6 weeks.

    • Doxycycline: 100 mg orally twice daily for 7–14 days (if chlamydia suspected).

  • Alpha-blockers (tamsulosin 0.4 mg daily): May relieve post-prostate surgery pain.

  • NSAIDs for symptomatic relief (ibuprofen 400 mg every 6–8 hours).

E. Anejaculation

  • Neurological rehabilitation (if spinal cord injury).

  • Penile vibratory stimulation or electroejaculation (assisted ejaculation for fertility).

  • Medications:

    • Amantadine: 100 mg orally twice daily.

    • Yohimbine: 5.4–10.8 mg orally three times daily (limited efficacy).

Complications

  • Infertility (retrograde ejaculation, anejaculation).

  • Psychological distress, depression, relationship strain.

  • Reduced sexual satisfaction and quality of life.

Prognosis

  • Premature ejaculation: Excellent prognosis with behavioral + pharmacological therapy.

  • Delayed ejaculation: Often chronic, but manageable with medication adjustment and psychotherapy.

  • Retrograde ejaculation: Benign but problematic for fertility; treatable with sympathomimetics.

  • Painful ejaculation: Usually resolves with treatment of underlying infection/inflammation.

  • Anejaculation: Often permanent if neurological, but assisted reproduction possible.

Patient Education

  • Ejaculation problems are common and treatable.

  • Open communication with healthcare providers and partners is crucial.

  • Avoid self-medication with unapproved “sexual enhancers.”

  • Treat underlying systemic illnesses (diabetes, hypertension, thyroid disease).

  • Combination of behavioral, psychological, and medical therapy often yields best outcomes.



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