bubble_chart Overview

Sexual desire, erection, intercourse, orgasm, and ejaculation are a series of interconnected reactions in male sexual function, each with its unique mechanism and not necessarily linked. Common ejaculatory dysfunctions include premature ejaculation, no ejaculation, and retrograde ejaculation.

bubble_chart Etiology

Premature ejaculation: Past sexual experiences are often the psychological factors leading to premature ejaculation. Pre-marital intercourse or masturbation aimed at achieving sexual satisfaction as quickly as possible, disharmonious sexual life, or short duration of erection, forming a habit of rapid ejaculation before the erection subsides, can lead to conditioned reflex rapid ejaculation due to resulting anxiety. Whether prostatitis, seminal colliculitis, and urogenital inflammation can cause premature ejaculation remains inconclusive.

It is divided into functional and organic categories, with the former being more common.

1. Functional factors: Often due to lack of pre-marital sex education, insufficient knowledge about sex leading to viewing intercourse as obscene, nervousness during newlywed periods, a spouse's indifference, poor sexual environment, fear of pregnancy, work fatigue, psychological trauma, etc., all of which can lead to functional no ejaculation. Excessive foreskin or phimosis reducing the sensitivity of the glans to stimulation can also be a cause.

2. Organic factors: Neurological disorders preventing or insufficiently transmitting stimulation impulses from the central or peripheral nerves to the ejaculation center. Lesions or removal of the brain's lateral lobes, spinal cord injury, lumbar sympathetic nerve injury or removal, pelvic surgery, etc., can all reduce or interrupt nerve impulse transmission. Whitelaw reported that among 116 hypertensive patients who underwent bilateral sympathetic ganglionectomy at T₈

～L₁, 24 developed no ejaculation; whereas all 19 patients who underwent ganglionectomy at T₂～T₁₁ retained ejaculatory function. Rose reported that out of 30 patients who underwent L₁～L₃ ganglionectomy, 3 experienced no ejaculation, while among 8 patients who underwent T₉～T₁ ganglionectomy, 5 lost ejaculatory function. Among 52 patients who underwent retroperitoneal lymphadenectomy for testicular tumors, 49 (94.2%) lost ejaculatory function. Narayan and Lange limited lymph node dissection to the common iliac stirred pulse on the non-tumor side, reducing postoperative ejaculatory dysfunction to 54.5%. Some patients regained ejaculatory function 3–36 months (average 12 months) post-surgery, primarily due to the regeneration of myelinated preganglionic nerves. Main stirred pulse and iliac vascular surgeries can also frequently cause ejaculatory disorders. Pelvic surgeries, depending on the extent of dissection and pelvic nerve injury, can affect ejaculatory function to varying degrees, with rectal cancer surgeries significantly more likely to cause ejaculatory dysfunction than ulcerative colitis requiring rectal and colon resection.

Antihypertensive drugs like α-adrenergic blockers can affect seminal vesicle contraction and cause ejaculatory disorders, such as guanethidine and phenothiazines.

Endocrine dysfunction (pituitary, gonadal, thyroid disorders, etc.) and penile abnormalities (penile induration, severe hypospadias) may also impair ejaculatory function.

Ejaculatory duct obstruction is rare and can be congenital atresia or acquired due to pelvic fracture, surgical injury to the seminal colliculus or ejaculatory duct.

Retrograde ejaculation:

1. Dynamic factors: Congenital or acquired sexually transmitted diseases causing bladder neck dysfunction leading to semen reflux, such as congenital wide bladder neck or post-surgical endoscopic or open bladder neck incision or Y-V plasty. Reports indicate retrograde ejaculation occurs in approximately 64.5% of retropubic prostatectomies, 59.5% of transurethral procedures, and 71.8% of suprapubic trans-bladder surgeries.

Diabetes-induced autonomic neuropathy, sympathectomy, or low-dose sympathetic blockers (e.g., reserpine, guanethidine) can weaken smooth muscle contraction, causing semen reflux.

2. Obstructive factors: Urethral strictures from trauma or chronic inflammation, prolonged dysuria leading to proximal urethral dilation, reduced bladder neck tension, and increased distal resistance can result in retrograde ejaculation.

bubble_chart Diagnosis

Premature ejaculation: The criteria for premature ejaculation remain controversial. Previously, the standard was based on whether the female partner could achieve sexual satisfaction, which is clearly one-sided, as women may have their own issues. Using the duration of the penis remaining in the vagina (less than 1.5 minutes) or fewer than 15 thrusts as a standard also fails to account for individual differences in sexual needs. In 1980, the American Psychiatric Association proposed that premature ejaculation occurs when ejaculation and orgasm cannot be controlled during intercourse and happen before the individual's desired time. However, this standard has not been universally accepted. Currently, it is generally considered premature ejaculation if ejaculation occurs before the penis enters the vagina, during entry, or immediately after insertion. Reports indicate that healthy males typically ejaculate 2–6 minutes after vaginal insertion. A survey of 2,709 individuals by Zhejiang Medical University found that intercourse usually lasts 5–10 minutes, with shorter durations of 1–2 minutes and longer ones up to 50–60 minutes, highlighting significant individual variation. Therefore, regardless of the speed of ejaculation, it cannot be termed premature ejaculation as long as it does not affect the couple's experience of sexual pleasure.

No ejaculation disorder: The diagnosis of no ejaculation disorder is made when a man cannot achieve orgasm or ejaculation after inserting an erect penis into the vagina. It is important to differentiate this from retrograde ejaculation or impaired semen production. Key distinguishing factors include whether sexual pleasure or orgasm occurs during intercourse and the presence of aspermia or fructose in post-coital urine. Endocrine function should also be assessed, along with checking for congenital or acquired sexually transmitted diseases that may cause ejaculatory duct obstruction.

Functional and organic causes should be distinguished. Functional no ejaculation disorder often involves seminal emission and the ability to ejaculate through masturbation, with a history of psychological trauma or lack of sexual knowledge but no neurological diseases, diabetes, or history of trauma or surgery.

Retrograde ejaculation: After experiencing orgasm and the sensation of ejaculation during intercourse or masturbation, the presence of sperm and/or fructose in urine confirms retrograde flow of semen into the bladder. Medical history should include inquiries about neurological diseases, trauma, surgery, or medication use. Voiding cystourethrography can assess structural abnormalities in the bladder neck and urethra, and urodynamic studies may be necessary for disease cause diagnosis.

bubble_chart Treatment Measures

Premature ejaculation:

1. Psychological therapy: It requires the cooperation and understanding of both spouses, recognizing the possibility of rebuilding the ejaculation reflex, eliminating the patient's anxiety, and establishing confidence as prerequisites for treatment.

2. Behavioral guidance: Guide the patient to experience the sensations before orgasm. Reduce or stop penile thrusting before uncontrollable ejaculation occurs to lower sexual arousal. The Semans method involves the female partner stimulating the penis to erection, stopping stimulation near orgasm, and repeating the stimulation after the penis softens, thereby establishing a new conditioned reflex through repeated practice. Alternatively, gently pulling down the scrotum and testicles or squeezing the glans with the thumb and forefinger can reduce excitability. Changing to the female-on-top position during intercourse, using a thrust-stop-thrust pattern, can gradually increase the threshold for stimulation and prolong ejaculation time.

3. Drug therapy: Apply 1% dicaine or 2% lidocaine topical anesthetics to the glans 10 minutes before intercourse to reduce sensitivity. Sedatives like Luminal or Phenergan can raise the ejaculation center's threshold. Alpha-adrenergic blockers like phenoxybenzamine may help reduce sympathetic nerve excitability and prolong ejaculation time.

No ejaculation disorder:

1. Sexual education and psychological therapy: Most patients with functional no ejaculation can achieve immediate results through sexual education, eliminating negative psychological influences and misconceptions, supplemented with behavioral guidance.

2. Vibratory and electrical stimulation therapy: About 50% of functional cases are cured in one session. Most patients recover after repeated treatments. Francois and Brandley treated spinal cord injury patients with vibratory therapy: success rates were 90.9% for cervical injuries, 67.5% for thoracic injuries, and only 22.2% for thoracolumbar injuries. Rectal electrical stimulation for no ejaculation has a success rate of 60.9%.

3. Drug therapy: Taking ephedrine, which acts on alpha and beta receptors, one hour before intercourse can help restore ejaculatory function.

4. Other treatments: Ejaculatory disorders caused by endocrine imbalances or medications may require hormone supplementation or discontinuation of the offending drugs. Ejaculatory duct obstruction can be treated with endoscopic incision of the duct opening.

Retrograde ejaculation:

1. Drug therapy: Effective only when the bladder neck is structurally intact and functional, such as in diabetic or autonomic neuropathy patients, where drugs can enhance stimulation to promote bladder neck closure. It is less effective for congenital wide bladder neck or post-bladder neck surgery cases.

Drugs like antihistamines and anticholinergics (e.g., brompheniramine maleate), imipramine, desipramine, and ephedrine have shown some efficacy.

2. Surgical treatment: For cases of retrograde ejaculation due to an overly wide bladder neck, bladder neck reconstruction can increase resistance, allowing semen to be expelled normally through the urethra.

3. Palliative treatment: For patients focused on fertility, adding a buffer solution (Baker's solution) to the bladder can adjust urine pH to minimize sperm damage. Semen-containing urine samples can be collected, centrifuged, or used directly for artificial insemination.