Sexual medicine consultant Professor Kevan Wylie describes the diagnosis and treatment options of five common orgasm disorders
Ejaculatory/orgasmic disorders are common male sexual dysfunctions, and include premature ejaculation (PE), failure to ejaculate, retrograde ejaculation, painful orgasm and orgasmic headache.
These disorders are sometimes associated with specific conditions and medication and psychological factors may be contributory. Some will require thorough investigation.
Four PE syndromes have been proposed:
• Lifelong PE is likely to be consistent, have a genetic and neurobiological contribution and require medication as primary treatment. It is defined as ejaculation that always or nearly always occurs prior to or within about one minute of vaginal penetration.1
• Acquired PE is more likely to be variable in nature and onset may be either sudden or gradual. It may be the result of urological dysfunctions, thyroid dysfunction, or psychological or relationship problems. Treatment often involves medication and counselling or therapy.
• In naturally variable PE, ejaculation occurs between three and eight minutes after penetration. This is far more common than the first two types. Education and reassurance – that this is part of the normal variation of ejaculatory performance – is likely to be the most beneficial approach.
• Inconsistent PE – with the individual varying anywhere between three and 30 minutes – is again seen relatively frequently. The aetiology is almost certainly psychological and treatment should therefore be with sex therapy or psychotherapy.
For all patients presenting with PE symptoms, take a detailed sexual history and ask about any associated urinary symptoms.
A physical examination can exclude localised pathology such as prostatitis. Developmental and cultural factors in the history may be important.
An account from the partner is often helpful in differentiating between the four types.
The only currently available medical treatments are the off-label use of SSRIs and the tricyclic antidepressant clomipramine.
Clomipramine can be used on both a daily and on-demand basis, but on-demand use of SSRIs is less satisfactory as it may take up to four hours to establish effective serum levels.
A recent meta-analysis suggested paroxetine exerted the strongest ejaculatory delay, but bear in mind all SSRIs are associated with other sexual side effects – including reduced libido, anorgasmia and erectile dysfunction.2
Dapoxetine is a short-acting SSRI licensed in some countries as a PE treatment.3 It is well suited as an on-demand treatment, although restricted to private prescription through import in the UK.
Other treatments include use of topical desensitising agents, including lignocaine spray and lidocaine and prilocaine creams.
If there is an indication for the use of a PDE5 inhibitor, this may improve overall patient satisfaction with both erectile function and ejaculatory control.
There have been reports that tramadol can be useful, although naturally there are concerns about potential dependence.
These include both cognitive and behavioural approaches using the classic techniques of ‘stop start' and ‘squeeze'.
Detailed information on both these methods is available through a patient information leaflet, available at www.pulsetoday.co.uk/downloads.
Psychosexual therapy can also help.
Painful ejaculation is relatively uncommon and may be associated with acute or chronic prostatitis and – less rarely – ejaculatory duct obstruction or with calculi.
Conditions such as polyps in the ejaculatory ducts and seminal vesicles or prostatic carcinoma are even rarer. An STI should be excluded if suspected.
Haemospermia may be associated with these conditions and urological investigation is advised.
The role of anti-inflammatories, a-blockers and antimicrobials has been described with varying benefit, with poorer efficacy in the more chronic cases.
Other ejaculation problems
A failure of ejaculation – often presenting as inhibited ejaculation or retarded ejaculation – can have a significant impact, particularly when a couple starts trying for a family.
Men may complain of reduction in the volume, force or sensation of ejaculation, or may only be able to ejaculate while masturbating or outside penetrative intercourse.
In some men, successive attempts to control ejaculation have affected the normal ejaculatory reflex.
Anorgasmia is ejaculation without the sensation of orgasm and it is important to establish this from a detailed history. This involves asking detailed questions, so should be approached sensitively.
It is important to exclude organic factors in men who describe a lifelong history of absent – or a small volume of – ejaculate.
Some men may have nocturnal emissions, suggesting the ejaculatory ducts and pathway are intact.
Similarly, if a man can masturbate and ejaculate or ejaculate with oral stimulation from a partner or in specific positions, it would suggest the problem is more psychological.
Refer men with no ejaculation for urological assessment. Problems can include:
• an absence of vas deferens – commonly seen in cystic fibrosis
• ejaculatory duct atresia – possibly a blockage of the ejaculatory pathway identified using transrectal ultrasound or secondary to some inflammatory conditions, including prostatitis or an STI.
For those men with no sensation of orgasm the following should be excluded:
• neurogenic conditions
• metabolic conditions including diabetes
• side-effects of medication, particularly SSRIs
• other causes of neuropathy including vitamin deficiencies and alcohol neuropathy.
Testosterone deficiency should be considered. For those men where orgasm occurs occasionally, the problem may be age-related impairment of the normal ejaculatory process or specific psychological or relationship factors which need further consideration.
For men who reach orgasm with no sign of ejaculation, arrange for the first urine sample after sex to be analysed.
If there are sperm present, then retrograde ejaculation should be considered. This may occur after bladder-neck surgery or as a side-effect of some drugs, including a-blockers.
If sperm are not present in the urine, there may be aspermia due to ejaculatory duct obstruction, in which case referral to a andrologist may be necessary.
Practical advice may improve the chances of successful ejaculatory and orgasmic control – including sexual intercourse when both partners are awake and alert, reducing alcohol consumption and using techniques to maximise penile stimulation, including pelvic floor training.
Applying high-speed vibration to the ventral surface of the penis may also bring about ejaculation.
Other techniques include the bridging manoeuvre, partner stimulation of the perineal region or even digital prostatic stimulation where acceptable to both partners.
Off-label use of sympathomimetic agents such as pseudoephedrine and ephedrine has been reported as beneficial for both delayed ejaculation and retrograde ejaculation. Imipramine may also be useful for retrograde ejaculation.
A number of headache syndromes can occur during sexual activity.
• Early coital headache is associated with increased muscular tension and is described as a tight dull headache which tends to be bilateral and in the occipital/cervical region.
• Coital cephalgia occurs more suddenly at the point of orgasm, is more severe and generalised, lasting around 20 minutes. It is more common in men with a history of migraine and is thought to be associated with a temporary rise in blood pressure and may be due to vasoconstriction.
• Late coital cephalgia occurs after sexual activity and tends to last for hours, often develops after standing up and may be secondary to a dural tear. Risk factors include obesity and having sex in the kneeling position. A history of migraine and medications such as nitrates and sildenafil have been implicated – as well as recreational use of amyl nitrite and marijuana.
Management of all three includes exclusion of any significant pathology including arteriovenous malformations, subarachnoid bleeds and basilar artery dissection by CT scan.
Relaxation techniques, delaying orgasm and biofeedback mechanisms can be helpful. Indomethacin and diltiazem may also be worth trying.
Professor Kevan Wylie is a consultant in sexual medicine at the Royal Hallamshire Hospital and the BMI Thornbury Hospital, Sheffield
Competing interests: Within the last three years, Professor Wylie has received honoraria, research grants and support to attend medical conferences and meetings from AstraZeneca, Bayer Schering Pharma, Boehringer Ingelheim, imedicare, Ipsen, Janssen-Cilag, J&J, Meda Pharmaceuticals, Pfizer, Procter and Gamble, Prostrakan and Durex/SSLPainful ejaculation can be caused by an ejaculation duct obstruction (normal duct, centre) Male urethra