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 is defined as a persistent/recurrent pattern of ejaculation occurring during partnered sexual activity within 1 minute following vaginal penetration and before the individual wishes it + present for 6 months + causing significant distress for individual.
  • Natural biologic response is to ejaculate within 2 to 5 minutes after vaginal penetration.
  • Ejaculatory control is an acquired behavior that increases with experience.
  • Comorbidities common (diabetes, hypertension, sexual desire disorder, erectile dysfunction [ED])
• DE: prolonged time to ejaculate (>30 minutes) despite desire, stimulation, and erection
• Aspermia (lack of sperm in the ejaculate):
  • AE: lack of emission or contractions of bulbospongiosus muscle
  • RE: partial or complete ejaculation of semen into the bladder
  • Obstruction: ejaculatory duct obstruction or urethral obstruction
• Also:
  • Painful ejaculation: genital or perineal pain during or after ejaculation
  • Ejaculatory anhedonia: normal ejaculation lacking orgasm or pleasure
  • Hematospermia: presence of blood in the ejaculate (often not a serious condition)

Epidemiology

Etiology and Pathophysiology

Male sexual response:

• Erection mediated by parasympathetic nervous system
• Normal ejaculation consists of three phases:
  • Emission phase: Semen is deposited into urethra by contraction of prostate, seminal vesicles, vas deferens; under autonomic sympathetic control
  • Ejaculation phase: semen forcibly propelled out of urethra by rhythmic contractions of the bulbospongiosus and ischiocavernosus muscles; this is mediated by the somatic nervous system on the motor branches of the pudendal nerve. Bladder neck contracture by α-adrenergic receptors ensures anterograde ejaculation.
  • Orgasm: the pleasurable sensation associated with ejaculation (cerebral cortex); smooth muscle contraction of accessory sexual organs; release of pressure in posterior urethra
• PE:
  • Hypersensitivity/hyperexcitability of glans penis
  • 5-hydroxytryptamine (5-HT) receptor sensitivity
  • Psychogenic (inexperience, anxiety/guilt, low frequency of sex, relationship problems)
  • Urologic (ED, prostatitis, urethritis)
  • Endocrine (hyperthyroid, obesity, diabetes)
  • Lack of physical or sexual activity
  • Withdrawal or detox from prescription or illicit drugs (e.g., opioids)
• DE:
  • Rarely due to underlying painful disorder (e.g., prostatitis, seminal vesiculitis)
  • Often has a psychogenic component
  • Sometimes associated with low testosterone levels
  • Sexual performance anxiety and other psychosocial factors
  • Drugs or medications may impair ejaculation (e.g., MAOIs, SSRIs, α-blockers and β-blockers, thiazides, antipsychotics, tricyclic antidepressants, NSAIDs, opiates, alcohol, cannabis).
• AE:
  • Never has ejaculate: congenital structural disorder (müllerian duct cyst, Wolffian abnormality)
  • Acquired causes: surgery (radical prostatectomy, retroperitoneal lymph node dissection), spinal cord injury or other sympathetic nerve injury (especially T10–T12 level), diabetes mellitus (DM) with neuropathy, and medications (α-blockers and β-blockers, benzodiazepines, SSRIs, MAOIs, TCAs, antipsychotics, aminocaproic acid)
• RE:
  • Transurethral resection of the prostate (25%) or other prostate resection procedures
  • Surgery on the neck of the bladder
  • Extensive pelvic surgery
  • Retroperitoneal LN dissection for testicular cancer (also may produce failure of emission)
  • Neurologic disorders (multiple sclerosis [MS], DM)
  • Medications (tamsulosin, other α-blockers, SSRIs, antipsychotics)
  • Urethral stricture (may be posttraumatic)
• Painful ejaculation:
  • Infection or inflammation (orchitis, epididymitis, prostatitis, urethritis)
  • Ejaculatory duct obstruction
  • Seminal vesicle calculi
  • Obstruction of the vas deferens
  • Psychological/functional
• Hematospermia (often unable to find cause):
  • Usually not a serious condition
  • Inflammation/infection
  • Calculi: bladder, seminal vesicle, prostate, urethra
  • Trauma to genital area (cycling, constipation, masturbation)
  • Obstruction
  • Cyst
  • Tumor (1–3% prostate cancers present with hematospermia)
  • Arteriovenous malformations
  • Iatrogenic
  • Hypertension

Risk Factors

ED: pudendal neuralgia, substance use, psychotropic medications, psychological distress, or relationship issue

General Prevention

Screen for sexually transmitted infections (STIs).

Commonly Associated Conditions

• Neurologic disorders (e.g., multiple sclerosis)
• Diabetes
• Prostatitis
• Ejaculatory duct obstruction
• Urethral stricture
• Psychological disorders
• Endocrinopathies
• Relationship/interpersonal difficulties