Ejaculatory Dysfunction and Male Infertility
Normal Ejaculation
Normal male ejaculation consists of three distinct stages:
1) Pre-ejaculate. During erection, prior to reaching orgasm, the bladder neck closes, and the bulbourethral glands (which sit under the prostate gland and open into the urethra) emit a small amount of fluid called pre-ejaculate. This fluid serves to lubricate the urethra as well as to neutralize the acidity of any remaining urine within the urethra, since the acidity can be damaging to sperm.
2) Emission. During orgasm, the stimulation of the sympathetic nervous system causes muscular contractions of the vas deferens, thereby carrying the accumulated vasal sperm into the ejaculatory ducts. Contraction of the seminal vesicles causes the seminal vesicle fluid (along with the sperm) to flow through the ejaculatory ducts and into the urethra, where it mixes with the prostatic fluid.
3) Ejaculation. Ejaculation occurs following emission. The rhythmic contraction of the muscles around the base of the penis results in the forceful expulsion of the seminal fluid from the urethra out the tip of the penis. The fluid comes out in a standard order, with the prostatic fluid coming out first, followed by the vasal fluid, and finally the seminal vesicle contents. In young men, this results in a series of rhythmic spurts occurring about 0.8 second apart. As men age into their thirties and forties, they tend to lose this forceful pulsing release of semen, and the fluid come out more slowly (or sometimes just oozes out).
[Alwaal A. FertSteril 2015][Phillips E. UrolClNAm 2014]
Several types of problems may occur with ejaculation: ejaculatory duct obstruction, retrograde ejaculation, retarded ejaculation, anejaculation, congenital anorgasmia, and painful ejaculation. Each will be discussed below.
Ejaculatory Duct Obstruction
The ejaculatory ducts carry fluid from the seminal vesicles and vas deferens into the urethra. When the ejaculatory ducts are completely blocked, the ejaculate is made up of only the fluid from the prostate.
Men with complete ejaculatory duct obstruction (EDO) therefore have the following semen analysis characteristics:
1) Low ejaculate volume (less than 1.0 cc), as the fluid from the seminal vesicles and testicles is missing
2) A semen pH under 7.2, as prostatic fluid is acidic, and the alkaline seminal vesicle fluid is missing
3) No semen fructose, as fructose comes from the seminal vesicles
4) Lack of sperm (azoospermia)
EDO is usually completely asymptomatic in men. However, it can sometimes be associated with perineal and/or scrotal pain on ejaculation. It can also be associated with hematospermia (blood in the ejaculate) in some circumstances.
Causes of ejaculatory Duct obstruction
EDO can be caused by a number of different problems, including:
1) Blockage of the ejaculatory duct by a nearby structure or object, such as a prostatic stone or a cyst (either arising from within the prostate or a cyst left over as a remnant from embryonic development, such as a Mullerian duct cyst)
2) Blockage of the ejaculatory duct from scar tissue (such as following urethral surgery, cystoscopy, or insertion of a Foley catheter) or from previous urethral or genital duct infections (such as chlamydia, gonorrhea, or tuberculosis)
3) Congenital absence of the ejaculatory duct, such as congenital bilateral absence of the vas deferens (see "Genetics" section of this website for more information.
[Avellino GJ. FertSteril 2019]
Partial ejaculatory Duct obstruction
The ejaculatory duct can also be partially blocked. The diagnosis of partial EDO can be very tricky, as it can present in a variety of ways.
Generally speaking, semen parameters can show any combination of the following, depending on the severity of the blockage:
1) Borderline low ejaculatory volume
2) Borderline pH
3) Decreased motility (often very low)
4) Decreased sperm density
5) Elevated sperm DNA fragmentation
Possible partial EDO should be suspected in men with borderline ejaculate volumes and very low sperm motility.
Diagnosis of ejaculatory Duct obstruction
Men who have azoospermia, low volume, and acidic, fructose-negative ejaculate despite having a normal FSH and normal testicular volume (indicative of likely normal sperm production) are likely not passing any fluid from the seminal vesicles and vas deferens into the urethra. If there is not a palpable vas deferens on each side of the scrotum, then the diagnosis is likely CBAVD (see “Genetics" section as mentioned above for more information). However, if a normal vas deferens can be felt on each side, then there is likely one of two problems present: blockage of the ejaculatory duct (EDO) or acontractile seminal vesicles. With the latter condition, the seminal vesicles cannot contract, which means that fluid may not travel through the ejaculatory ducts into the urethra; the semen analysis is consistent with EDO. Acontractile seminal vesicles are rare, but the condition can result from such problems as advanced diabetes or neurologic abnormalities like a spinal cord injury. Polycystic kidney disease, with large cysts involving the seminal vesicles, can also result in acontractile seminal vesicles. Acontractile seminal vesicles are not generally very responsive to treatment, though the condition may improve if an underlying condition improves (such as neurologic disease). [Modgil V. NatRevUrol 2016]
Using Transrectal Ultrasound (TRUS) for Diagnosis
Transrectal ultrasound (TRUS) involves placing a small ultrasound probe into the rectum. In men with blockage, the ejaculatory ducts and seminal vesicles are often dilated due to a backup of fluid within them.
TRUS measures the following:
1) Seminal vesicle diameter (normal is 1.5 cm AP diameter or less)
2) Seminal vesicle length (normal is 3 cm or less)
3) Ejaculatory duct width (normal is 2 mm, abnormal is 2.3 mm or more)
TRUS can also sometimes show the presence of sources of obstruction, including cysts, calcifications, or masses in the prostate or seminal vesicle. Despite its usefulness, TRUS used by itself has two main drawbacks. One of these drawbacks is that not all EDO patients have dilated seminal vesicles and ejaculatory ducts, though many do. The other is that TRUS cannot differentiate EDO from acontractile seminal vesicles. [Meacham RB. AJR 1995]
Seminal Vesicle Aspiration
In normal circumstances, sperm are not present within the seminal vesicles. However, if fluid is not flowing through the ejaculatory duct normally, then it often backs up into the seminal vesicles, taking sperm with it. At the time of TRUS, a long, narrow needle can be placed under ultrasound guidance into the seminal vesicles and be used to aspirate fluid. The fluid can then be examined microscopically for the presence of sperm. If sperm are present at levels of more than 3 sperm per high power field (hpf) when evaluated with a tabletop microscope, then this suggests possible EDO.
Seminal vesicle aspiration has three limitations:
1) If sperm are present in the seminal vesicles, it still does not tell you whether EDO or acontractile seminal vesicles are the problem.
2) Some normal, fertile men can have sperm in their seminal vesicles after extended periods of sexual abstinence. A 1996 study found that one-third of normal men have sperm in their seminal vesicles after five days of abstinence (compared to 0 percent at zero days of abstinence).
3) Infection risk. When seminal vesicle aspirations are performed, the needle must travel through the rectal wall before entering into the seminal vesicles. Even with a pre-procedure bowel preparation and antibiotics, the rectum is still filled with bacteria, and if these bacteria travel with the needle into a seminal vesicle that is obstructed, then an infection can follow. Since the infection has nowhere to drain, it can potentially form an abscess that may require surgical drainage. However, if the discovered blockage is going to be treated at the same time as needle aspiration (see “TURED,” below), then the risk of serious infection is significantly lower, as a successful procedure will involve removing the obstruction and therefore will decrease the risk of an abscess. Studies have not shown this sort of infection to be a major problem; the risk may be more theoretical than actual. However, if a rectal abscess does occur, the consequences can be significant. It is therefore my opinion that if seminal vesicle aspiration is going to be performed, the surgeon should ideally be prepared to perform immediate therapy (for example, TURED) at the same time if the findings are consistent with EDO. This recommendation is controversial, however, with some fertility experts routinely performing diagnostic seminal vesicle aspirations without simultaneous immediate TURED if sperm are found.
Aspirated seminal vesicle sperm (from the blocked seminal vesicles) can potentially be used for IVF/ICSI, but often this does not work very well, since the fluid that is aspirated usually contains large number of old and dead sperm that have accumulated there over time in the obstructed system. [Purohit RS. JUrol 2004]
Seminal Vesiculography
At the time of TRUS, X-ray contrast media (a special fluid that shows up easily on X-rays) can be injected into the seminal vesicles. A series of X-rays can then be taken to see if this media flows into the urethra and bladder. If the media does make it into the urethra, then EDO is not present (but acontractile seminal vesicles may be present). Enough contrast media needs to be injected so that it is forced to flow through the ejaculatory ducts if no blockage is present. [Modgil V. NatRevUrol 2016]
Chromotubation
Instead of injecting contrast media into the seminal vesicles, chromotubation involves injecting a colored dye (methylene blue or indigo carmine) into the seminal vesicles at the time of TRUS. The patient then undergoes cystoscopy (placing a small scope through the penis) and the doctor looks for the colored dye to come through the ejaculatory ducts into the urethra. Like with seminal vesiculography, if no dye is seen to emerge, then EDO is likely.
A combination of the above procedures can be utilized, in which TRUS is performed and measurements are made of the seminal vesicles and ejaculatory ducts. Seminal vesicle aspiration is performed to check for the presence of sperm. If sperm are seen, then either seminal vesiculography or chromotubation is undertaken in order to differentiate EDO from acontractile seminal vesicles. The whole process takes place at the same time, so if findings consistent with EDO are discovered, TURED can be performed right away (see below). [Purohit RS. JUrol 2004]
Vasogram
Another option for diagnosing EDO is vasography. In this procedure, a small opening is made in the vas deferens in the scrotum. The vasal fluid is checked for sperm. If sperm are present, then X-ray contrast medium is injected into the vas deferens and X-rays are taken. Similar to seminal vesiculography, if contrast media is seen to flow into the seminal vesicle but not into the urethra or bladder, then EDO is likely present, and TURED can be performed at that time. The risk forming obstructing scar tissue in the vas deferens where the opening was made is a potential drawback to this approach.
Ejaculatory Duct Manometry
A newer form of testing has recently been developed in which the pressures inside the seminal vesicles are measured at the time of TRUS with small pressure-sensitive probes. If EDO is present, then the backup of fluid should increase the pressure within the seminal vesicles. However, if no obstruction is present, then the pressure within the seminal vesicles should be normal. Although promising, this procedure is not widely available clinically. [Eisenberg ML. JUrol 2008]
Treatment of ejaculatory Duct obstruction
Several different treatment options are available, including resection of the ejaculatory duct (TURED) and sperm extraction combined with IVF/ICSI.
Sperm Extraction and IVF
Men with EDO typically have normal sperm production (which can be assessed with FSH blood testing). One option is to bypass the obstruction and proceed with sperm extraction combined with IVF/ICSI. This approach avoids the need for TURED (see below) with its possible complications, but the extracted sperm does need to be used for IVF/ICSI. See "Female Fertility Treatments" section for more information on IVF/ICSI.
Ejaculatory Duct Dilation
Original treatments designed for EDO included passing long, thin probes into the ejaculatory ducts under the guidance of cystoscopy (a scope through the urethra). Progressively larger probes could be passed in an attempt to dilate any narrowing of the ejaculatory ducts. More recent modifications include a small inflatable balloon on a wire that can be used to attempt to open a blocked ejaculatory duct. These techniques are generally not felt to be as effective as the TURED procedure (see below).
Transurethral Resection of the Ejaculatory Ducts (TURED)
Success rates for TURED vary widely in different studies. There are many factors that affect whether a TURED procedure will be successful, including the reason for blockage, the location and size of prostatic cysts, the presence of suspected prostatic calcifications or stones, and so on. For example, a big centrally located cyst within the prostate is a sign that TURED may be quite successful for that patient.
In general, for complete EDO, the success rates in returning good numbers of sperm to the ejaculate range from 21 to 75 percent, with the average around 50–60 percent. The rate of natural pregnancy is from 7 to 25 percent.
For incomplete EDO, success rates at significantly improving semen parameters range from 38 to 94 percent, with the average around 70 percent. The rate of natural pregnancy is from 16 to 66 percent. However, 5–10 percent of men with partial EDO also have progressive scar tissue formation and progress to complete azoospermia (no sperm in the ejaculate) following TURED due to recurrent blockage.
A successful TURED can also be helpful in men with EDO-related symptoms such as peri-ejaculatory discomfort. [Mekhaimar A. TJUrol 2022]
Risks and Complications of TURED
EDO is a relatively uncommon problem, so unlike other male fertility procedures (such as varicocele repairs), TURED procedures are not performed very often. Many fellowship-trained infertility experts have performed this procedure only a handful of times during their careers. The TURED procedure also has a significant risk of potentially serious complications. One is watery ejaculate. The ejaculatory ducts usually function like one-way valves that do not allow urine to backflow into them. When portions of the ejaculatory ducts are resected, urine can flow into the ducts and then subsequently come out with the next ejaculation. This problem is generally not reversible. [Mekhaimar A. TJUrol 2022]
Another potential complication is recurrent prostatitis or epididymitis. The ejaculatory ducts also help to keep urethral bacteria from entering the genital ducts. After a resection procedure, bacteria can more easily enter, which can result in chronic infections of the prostate and epididymis.
Urinary complications may occur as well. Urine can collect in the resected ejaculatory duct area during urination, and then come out later when the patient is walking around resulting in post-void dribbling. Another potential consequence can occur because the verumontanum is located right behind the urinary sphincter. If the urinary sphincter is damaged, then this could result in urinary incontinence- fortunately this is a rare complication.
Rectal injury is another possible complication. The part of the urethra that passes through the prostate is located above the rectum. Theoretically, if the ejaculatory ducts are resected too deeply, this could result in damage to the rectum, which may need to be repaired surgically. This is also a rare complication.
Summary of TURED
Success rates can be maximized and complications minimized by having a TURED performed by a fertility expert who specializes in this procedure. If you may have EDO and are considering a TURED, I recommend asking any prospective surgeon how many of these procedures he or she has performed. If that surgeon does not perform at least a few of these procedures a year, I suggest you consider finding someone else to do it. Complication rates with the procedure have been shown to be as high as 33 percent in some studies, so you want a specialist who is going to minimize your chances of problems as much as possible.
Retrograde Ejaculation
During normal ejaculation, the bladder neck closes so that the ejaculate fluid is pushed forward and out the tip of the penis. However, sometimes the bladder neck does not close completely, thereby allowing semen to flow backward into the bladder during ejaculation. In mild cases, only part of the ejaculate flows backward into the bladder, but in more severe cases all of the semen may be lost into the bladder. Men with retrograde ejaculation may sometimes notice whitish semen in their urine when they urinate after sexual intercourse.[Yavetz H. HumReprod 1994]
Causes of Retrograde Ejaculation
Alpha-Blockers
Alpha-blockers are medications used for the treatment of benign enlargement of the prostate (benign prostatic hyperplasia, or BPH) as well as hypertension. Alpha-blockers treat BPH by relaxing the prostatic capsule and bladder neck, thereby enlarging the channel through which the urine flows. However, when the bladder neck is relaxed, retrograde ejaculation can result.
Alpha-blockers can also cause a decrease in emission of sperm (transport of sperm from the vas deferens into the ejaculatory ducts), which can result in complete azoospermia without retrograde ejaculation. In some circumstances, alpha-blockers may even cause complete anejaculation (no antegrade or retrograde flow of ejaculate with orgasm). If alpha-blockers are causing the ejaculatory dysfunction, typically it can be reversed by stopping the medication.
Commonly used alpha-blockers include prazosin (Minipress), doxazosin (Cardura), terazosin (Hytrin), alfuzosin (Uroxatral), tamsulosin (Flomax), and silodosin (Rapaflo). Prazosin, doxazosin, terazosin, and alfuzosin are considered to be non-selective alpha-blockers, meaning that they are less able to affect the types of alpha receptors primarily found within the prostate. These non-selective alpha-blockers tend to have fewer ejaculatory side effects. Prazosin, doxazosin, and terazosin, however, cause higher rates of orthostatic hypotension (a drop in blood pressure on standing) and dizziness because of their effect on alpha receptors within blood vessels.
Selective alpha-blockers (tamsulosin and silodosin) are associated with higher rates of ejaculatory dysfunction. Rates of ejaculatory dysfunction with tamsulosin and silodosin have generally been found to be in the 10–30 percent range. In one study, almost 90 percent of patients taking tamsulosin were found to have decreased ejaculate volumes, as compared to 21 percent of patients taking alfuzosin. [Couteau N. JClinMed 2021]
Surgical Treatments for BPH
Any surgical procedures that can open up the urinary channel can also damage the bladder neck, resulting in retrograde ejaculation.
Such surgical treatments include:
1) Transurethral resection of the prostate (TURP)
2) Laser vaporation of the prostate (eg Greenlight)
3) Microwave treatment of the prostate
4) Transurethral needle ablation of the prostate (TUNA)
5) Transurethral incision of the prostate (TUIP)
6) Holmium laser enucleation of the prostate (HoLEP)
7) Open prostatectomy (for very large glands)
Urolift is a newer BPH treatment in which sutures are placed transurethrally within the prostate to mechanically open the prostate. Though the data are preliminary, sexual and ejaculatory side effects are reported to be minimal.
Rezum (water vapor treatment) is another treatment for BPH which also preserves sexual and ejaculatory function in the majority of men (and may be better than Urolift for men with a large obstructing median lobe of the prostate). [AUA Update 2019]
In general, the more invasive the procedure, the higher the chances of ejaculatory dysfunction (primarily retrograde ejaculation) afterwards. Very high rates are seen with standard TURP (standard or laser) and HoLEP procedures. Procedures with minimal tissue removal (e.g. TUIP, Urolift and water vapor treatments) tend to have the least amounts of post-procedure ejaculatory dysfuntion. Retrograde ejaculation resulting from surgery is typically not reversible. A trial of alpha agonists (see below) could be attempted, but success rates can be expected to be very low.
[Bearelly P. FertSteril 2021] [Couteau N. JClinMed 2021]
Diabetic Neuropathy
Advanced diabetes can result in nerve damage throughout the body. This nerve damage can affect the bladder neck, leading to retrograde ejaculation. Good blood sugar control can help prevent retrograde ejaculation in diabetic patients. [Feder J. Andrology 2013]
Other Neurologic Disorders
Any neurologic disease affecting the pelvic nerves can result in bladder neck dysfunction and subsequent retrograde ejaculation. Examples of neurologic problems that can lead to retrograde ejaculation include spinal cord injury, spina bifida, and transverse myelitis. In patients with multiple sclerosis (MS), about 50 percent have ejaculatory dysfunction and around 35 percent have orgasmic disorders. These neurologic problems can also lead to complete anejaculation (see below).
Pelvic or Abdominal Surgery
Rectal and aortic surgery are two examples of pelvic procedures that can damage the nerves controlling bladder neck function and result in retrograde ejaculation. Retroperitoneal lymph node dissection (RPLND) for advanced testicular cancer is another surgery that can lead to retrograde ejaculation. These surgeries can also lead to complete anejaculation (see below). [Jeffreys A. FertSteril 2012]
Congenital Abnormalities
Some men are born with anatomic abnormalities of the bladder neck that can lead to retrograde ejaculation later in life—for example, bladder exstrophy.
Diagnosis of Retrograde Ejaculation
The diagnosis of retrograde ejaculation is made with a post-ejaculatory urinalysis (PEU). A PEU is performed by having the man provide a urine sample into a separate cup right after giving a semen analysis specimen. In men with neurologic problems who cannot voluntarily urinate (such as spinal cord injuries), the urine may be collected by urinary catheterization following ejaculation. The lab can then evaluate the urine for the presence of sperm. Small numbers of sperm in the urine are normal, as a few sperm can be left behind in the urethra and picked up by the urine on its way out. However, more than 10–15 sperm per high power field (hpf) on microscopic evaluation is consistent with the presence of retrograde ejaculation.
Treatment of Retrograde Ejaculation
Discontinue Alpha-Blocker Medications
Tamsulosin (Flomax) and silodosin (Rapaflo) seem to be the alpha-blockers that are most likely to cause ejaculatory problems. If the urinary problems are not severe, then stopping the alpha-blocker until pregnancy is achieved is usually the most effective approach. In men with more severe urinary voiding problems, switching to a less selective alpha-blocker, such as alfuzosin (Uroxatral), can often resolve the ejaculatory problems. [Jeffreys A. FertSteril 2012]
Alpha Agonists
Alpha agonists work by increasing the strength of bladder neck closure during ejaculation. In men without bladder neck scarring (for example, those who have not had prior prostate surgery), the success rate in reversing retrograde ejaculation is about 20–30 percent. If alpha agonists are used on a regular basis, their effect on bladder neck function tends to wear off over time. Therefore, intermittent short courses of treatment are recommended. Examples of alpha agonists include pseudoephedrine (Sudafed), phenylpropanolamine, ephedrine sulfate, and imipramine. [Shoshany O. Andrology 2017]
The most commonly used alpha agonist is pseudoephedrine (Sudafed) which is commonly used to treat nasal congestion and sinusitis. It’s effectiveness and relatively low side effect profile make it an attractive choice for the management of retrograde ejaculation. Potential side effects include dizziness, dry mouth, nausea, restlessness, and sleep disturbances, but it is usually fairly well tolerated if dosages are kept within the recommended amount of no more than 240mg daily. [Shoshany O. Andrology 2017] There is a potential for a modest increase blood pressure with Sudafed, so men with blood pressure problems should check with their primary care physician before they use this medication. Not all formulations sold under the brand name Sudafed contain pseudoephedrine, so check the ingredients to make sure that it does. Pseudoephedrine sales are tightly monitored due to its use in the production of illegal methamphetamine. Some states require a doctor’s prescription for Sudafed, but most still require only a photo ID and the signing of a sales log.
The length of treatment time for maximal effectiveness with Sudafed is controversial, with some studies suggesting that up to 7 days of treatment may be best. [Ohl D. UrolClNAm 2008]. However, other authors have found that a 2 day protocol with Sudafed offers similar outcomes, with 70% of men showing improvements in their retrograde ejaculation and 38% achieving total sperm counts of 39 million sperm or higher. [Shoshany O. Andrology 2017]. I personally aim for somewhere in the middle and a 4 day treatment protocol details are listed below.
Pseudoephedrine can be used in the following manners:
1) Prior to semen analysis (to assess response to treatment). See protocol below for details.
2) In conjunction with timed intercourse. If pseudoephedrine is found to be effective in reversing retrograde ejaculation, then the man can take 60 mg three times a day starting on day 9 of the woman’s cycle and continuing the medication for nine days, with planned intercourse every other day during this period (so intercourse on days 9, 11, 13, 15, and 17 of her cycle). Of course, if the woman’s cycle is irregular, this schedule may need to be modified.
3) In conjunction with intrauterine insemination (IUI)- The man starts the 4 day Sudafed protocol (described below) starting 3 days prior to the expected day of ovulation. On ovulation day the man collects his antegrade semen specimen and then collects the post-ejaculatory urinalysis in a separate container after. This sperm collected from the urine is then washed and added to the antegrade specimen for insemination. Live birth rates as high as 15–20 percent per cycle have been reported using this type of IUI protocol if no other significant fertility risk factors are present.
Urine is normally acidic, and this acidity is damaging to urine. Therefore the urine must be alkanalized prior collection for use with an IUI. Often alkalinization is added to a standard semen analysis with PEU to get an idea of the quality (in terms of motility) of the sperm going backward into the bladder when a couple is considering moving forward with an IUI. [Braude PR. BrJObsGyn 1987]
Alkalinization of the urine can be achieved by one of the following methods:
1) Baking soda (not baking powder): mix 1–2 tablespoons in a glass of water and drink it the night before, and take the same dose one to two hours before ejaculation
2) Alka-Seltzer tabs: dissolve 2 tablets in a glass of water and drink it the night before, and take the same dose one to two hours prior to ejaculation
3) Sodium bicarbonate tablets or capsules: 650 mg by mouth the night before, and take the same dose one to two hours prior to ejaculation
4) Urocit K 10 mg tabs: 2 tabs by mouth the night before, and take the same dose one to two hours prior to ejaculation
4 Day Post-Ejaculatory Urinalysis Protocol
You will need 5 tablets of Sudafed (each containing 120mg pseudoephedrine) and baking soda (not baking powder)
1) 3 days before semen analysis (SA) or intrauterine insemination (IUI): take 1/2 tab of Sudafed (60mg) with breakfast and 1/2 tab of Sudafed (60mg) with dinner.
2) 2 days before SA or IUI: take 1/2 tab of Sudafed (60mg) with breakfast and 1/2 tab of Sudafed (60mg) with dinner.
3) The day before SA or IUI: take 1/2 tab of Sudafed (60mg) with breakfast. Right before bedtime, take 1 tab of Sudafed (120mg) and one tablespoon of baking soda in a glass of water.
4) One hour prior to SA or IUI, take 1 tab of Sudafed (120mg) and one tablespoon of baking soda in a glass of water.
Come to the fertility lab well-hydrated but not with a very full bladder.
Delayed Ejaculation
Delayed ejaculation used to describe the situation when a man has trouble reaching orgasm during sexual intercourse. [Jenkins LC. FertSteril 2015] Retarded ejaculation is another (really bad) term that is also sometimes used to describe this clinical situation.
Potential causes of retarded ejaculation include:
1) Hypogonadism (low testosterone levels)
2) Medications, especially antidepressants such as SSRIs (Prozac, Paxil, Zoloft) or more uncommonly PDE5 inhibitors (sildenafil, tadalafil, etc.)
3) Diabetes or neurologic disorders, resulting in poor nerve function and/or sensation in the genital region
4) Psychological or relationship issues
[Wincze JP. FertSteril 2015][Althof SE. Urol 2016]
When I see a patient with delayed ejaculation, I check a hormone profile to look for low testosterone levels. I also conduct a medication review, looking for drugs that could be contributing to these problems.
Treatment of delayed Ejaculation
Once a possible cause for the delayed ejaculation has been determined, it may be able to be treated with the following options:
1) Hypogonadism can be treated if present.
2) If SSRIs may be having an impact on ejaculation, considering reducing the dosage, weaning off them, or changing to another type of medication, such as bupropion (Wellbutrin), that may have less of an impact. Animal studies have shown neurochemical stimulatory effects on ejaculation, and human case reports of reversible premature ejaculation in men taking buproprion have been reported as well. [Abdel-Hamid IA. TransAndrolUrol 2016]
These types of medication changes should always be done in close consultation with your primary care physician or psychiatrist.
3) Counseling can be an effective means of addressing difficulty achieving orgasm thought to be due to stress, anxiety, or other psychological issues. For guidance on finding a local sex therapist, check the website of American Association of Sexuality Educators, Counselors and Therapists at www.aasect.org.
4) Several small studies have shown improvement in ejaculatory and orgasmic function in men taking low-dose tadalafil (Cialis), 2.5 to 5 mg daily. These studies have found improvements in about two-thirds of men taking Cialis, as opposed to only about one-third of men on placebo medications in the studies. See “PDE-5 Inhibitors,” above, for more information.
5) Cabergoline (Dostinex) is a medication usually used to treat elevated prolactin levels. Anecdotally, low-dose cabergoline has been used successfully in the treatment of some men with ejaculatory dysfunction who have normal prolactin levels. [Hollader AB. SexMed 2016] The usual dose is 0.5 mg twice a week. If the treatment is going to be successful, most men see a response within the first few months. Potential side effects may include nausea, constipation, dry mouth, gastric irritation, headache, sleep disturbances, vertigo, depression, dyskinesia (involuntary muscle movements), hallucinations, hypotension (low blood pressure), swelling of the hands or feet, arrhythmia (irregular heartbeat), heart palpitations, or angina (chest pain). If you develop any of these side effects, stop the medication and contact your physician. And use cabergoline with caution if you have any of the following medical issues: severe hepatic dysfunction, peptic ulcer disease or a history of GI bleeding, or Raynaud’s disease.
[Shindel AW. JUrol 2022][Abdel-Hamid IA. TransAndrolUrol 2016]
Anejaculation
Anejaculation occurs when a man experiences the feelings of orgasm but no seminal fluid comes out, either antegrade (out the penis) or retrograde (into the bladder).
Potential causes of anejaculation include:
1) Alpha-blocker (prostate) medications. As described in “Retrograde Ejaculation,” above, alpha-blocker medications can cause anejaculation as well as retrograde ejaculation. Higher rates of ejaculatory dysfunction are seen with tamsulosin (Flomax) and silodosin (Rapaflo).
2) Antidepressant medications. Antidepressants (especially SSRIs, such as Paxil) can cause ejaculatory failure in some men.
3) 5-alpha reductase inhibitors (finasteride, dutasteride). There is some evidence of mildly increased levels of ejaculatory dysfunction associated with their use. It is unclear if low-dose finasteride (Propecia) can also cause this problem.
4) PDE5 inhibitors (sildenafil, tadalafil, etc.)- These medications can be used in the premature ejaculation, but on occasion can cause reversible ejaculatory failure in some men.
5) Diabetic neuropathy. Advanced diabetes mellitus can result in nerve damage throughout the body. This nerve damage can cause paralysis of the reproductive smooth muscle, resulting in complete anejaculation. Diabetes can also cause retrograde ejaculation (see above).
6) Neurologic disorders. Any neurologic disease impacting the pelvic nerves can result in paralysis of the smooth muscle of the reproductive tract, leading to anejaculation or failure of emission (sperm deposition within the urethra). Examples include spinal cord injury, spina bifida, transverse myelitis, and multiple sclerosis, all of which can also result in retrograde ejaculation as well (see above).
7) Pelvic or abdominal surgery. Rectal and aortic surgery are two examples of pelvic procedures that can damage the nerves responsible for controlling smooth muscle contractions of the reproductive tract. Retroperitoneal lymph node dissection (RPLND) for advanced testicular cancer is another surgery that can cause anejaculation. These surgeries can lead to complete retrograde ejaculation as well (see above).
8) Hypogonadism. Low testosterone levels may contribute to ejaculatory failure in a small percentage of men.
[Phillips E. UrolClNAm 2014]
Evaluation of Anejaculation
Evaluation of patients with anejaculation should include checking a hormone profile as well as a review of their medications. A good medical and surgical history can also look for other risk factors, including diabetes or other neurologic problems, as well as previous surgical procedures in the abdomen or pelvis which may have impacted nearby nerves. [Mehta A. FertSteril 2015] [Phillips E. UrolClNAm 2014]
Treatment of Anejaculation
Once a possible cause for the anejaculation has been determined, it may be able to be treated using the following potential options: [Hsiao W. BJUI 2012][Mehta A. FertSteril 2015]
1) Treat hypogonadism if it is present.
2) Modify medications that could be impacting ejaculation. Stop alpha-blocker medications, or change to a less selective type such as alfuzosin (Uroxatral.) Consider lowering the dosage of any SSRIs, weaning off them, or changing to another type of medication, such as bupropion (Wellbutrin) that may have less of an impact. These types of medication changes should always be done in close consultation with your primary care physician or psychiatrist.
3) Alpha agonists are medications work by increasing sympathetic nerve stimulation, resulting in contractions of the seminal vesicles, vas deferens, and prostate. Commonly used alpha agonists include pseudoephedrine, ephedrine sulfate, and imipramine (see “Retrograde Ejaculation,” above). In situations involving a failure of emission that is due to disruption of sympathetic nerve function, these alpha agonists can sometimes reinitiate emission of sperm. Alpha-blockers can also be used effectively in some men with diabetes who have anejaculation. Note, however, that some of these men can still have retrograde ejaculation, so a post-ejaculatory urinalysis (PEU) should always be done (see “Retrograde Ejaculation”).
4) Several small studies have shown improvement in ejaculatory and orgasmic function in men taking low-dose tadalafil (Cialis), 2.5 to 5 mg daily. Men with more severe cases resulting from issues such as spinal cord injury or previous pelvic surgery will probably not respond to Cialis. However, patients with certain medical problems, such as hypogonadism, may benefit from a trial of low-dose daily Cialis if testosterone replacement by itself is not effective. See “PDE-5 Inhibitors,” above, for more information.
5) Electroejaculation. See “Spinal Cord Injury” section of this website for more information.
6) Sperm extraction combined with IVF/ICSI. See “Azoospermia” section for more information on sperm extraction techniques.
Congenital Anorgasmia
With congenital anorgasmia, a man has never been able to have an orgasm during his entire life. Most often this is due to psychological issues, which in some men can be related to an overly strict childhood upbringing. Men with congenital anorgasmia often lack a sensual awareness of their bodies. Effective treatment includes sexual therapy with a trained counselor. For guidance on finding a local sex therapist, a potential resource is the website of the American Association of Sexuality Educators, Counselors and Therapists, www.aasect.org. If this is not effective, other treatment options include electroejaculation combined with IUI, or sperm extraction combined with IVF/ICSI (see the above links for "Spinal Cord Injuries" and "Azoospermia" for more information). [Althof SE. Urol 2016]
Note: a case report series reported several cases of acquired anorgasmia with the use of gabapentin. Symptoms resolved upon stopping the medication. [Hui E. Andrology 2022]
Painful Ejaculation
Pain with ejaculation can have multiple possible causes, including:
1) Seminal vesicle inflammation
2) Ejaculatory duct obstruction
3) Seminal vesicle or prostate stones
4) Prostatitis, urethritis, or epididymitis
5) Psychological issues
[Althof SE. Urol 2016]
Evaluation of painful ejaculation typically consists of a thorough evaluation by a urologist to look for problems such prostatitis, urinary tract infections, and poor bladder emptying. Further potential tests include cystoscopy and transrectal ultrasound (to look for evidence of problems with the seminal vesicles, prostate, and ejaculatory ducts). Semen analysis testing can be performed to look for signs of ejaculatory duct obstruction as well as pyospermia which can also be a sign of prostatitis or epididymitis (see “Interpreting Semen Analysis Testing" and "Reversible Semen Analysis Factors" sections for more information on diagnosing and managing pyospermia).
Specific Medical Problems That Can Affect Ejaculation
Spinal Cord Injuries and male infertility
Spinal cord injury patients typicaly have ejaculatory and erectile dysfunction problems. Please see "Spinal Cord Injury" section of this website for more detailed information.
Diabetes and male infertility
Diabetes is one of the most common causes of neurologic abnormalities, and up to 40 percent of diabetic men have some form of ejaculatory dysfunction.
The impact of diabetes on ejaculation depends upon the degree of nerve involvement, and can take one of several forms, including:
1) Retrograde ejaculation (from incomplete closing of the bladder neck)
2) Anejaculation (from paralysis of smooth muscle in the reproductive tract, which is replaced by fibrotic tissue)
3) Failure of emission (sperm not deposited into urethra)
4) Erectile dysfunction (impacts approximately 35–75 percent of men with type 1 diabetes)
5) Calcification of the seminal vesicles (makes them unable to contract and propel sperm into the urethra; EEJ does not work well in
these patients)
Management of Diabetes-Related Ejaculatory Problems
Good blood sugar control can help to prevent worsening of ejaculatory problems. The use of alpha agonists (see “Retrograde Ejaculation,” above) can convert a failure of emission into retrograde ejaculation, and can also be used to treat retrograde ejaculation itself. In cases of acontractile seminal vesicles, testicular sperm extractions combined with IVF are typically the only option if a couple wants to have a biologically related child.
Post-Surgical Changes and male infertility
The sympathetic nerves that are responsible for normal ejaculation run alongside the aorta in the deep pelvic and retroperitoneal areas. Surgery in this region (and especially near the aortic bifurcation) can disrupt these nerves and result in problems with ejaculation.
Examples of such surgeries include:
1) Low colorectal resection (up to 47 percent of these patients have ejaculatory problems)
2) Inflammatory bowel disease surgery
3) Surgery on the aorta or other great vessels (up to 60 percent risk of ejaculatory problems)
4) Retroperitoneal lymph node dissection (less than 5 percent risk of ejaculatory problems if a nerve-sparing approach can be used)
5) Transabdominal anterior spinal surgery (up to 20 percent risk of ejaculatory problems)
Damage to the sympathetic nerves in this region can cause retrograde ejaculation, anejaculation, or failure of emission. The severity of symptoms depends upon whether there was total or incomplete disruption of the sympathetic nerve chains.
Management of Surgery-Related Ejaculatory Problems
In rare cases, the use of alpha agonists (see “Retrograde Ejaculation,” above) can convert a failure of emission into retrograde ejaculation, and can also be used to treat retrograde ejaculation itself. Electroejaculation can directly stimulate the pelvic nerves to induce ejaculation. Sperm extraction combined with IVF/ICSI is another treatment option. More information on electroejaculation can be seen in the "Spinal Cord Injury" section and sperm extraction information can be found in the "Azoospermia" section.
Seminal Megavesicles and male infertility
Enlarged cystic seminal vesicles can sometimes be seen in men with polycystic kidney disease. The cystic changes can render the seminal vesicles unable to contract. These men therefore have semen characteristics consistent with ejaculatory duct obstruction, and evaluation shows enlarged seminal vesicles without evidence of obstruction. As with other problems associated with seminal vesicle dysfunction, brown-colored semen can be found in about 25 to 50 percent of these patients. If a patient with seminal megavesicles is azoospermic, the only effective option for achieving a pregnancy is typically sperm extraction combined with IVF/ICSI.
Premature Ejaculation
Premature ejaculation (PE) is defined as ejaculation which occurs during sexual intercourse sooner than the man would like. The average intravaginal latency time (IELT) in men found during studies is around 5.4 minutes [Waldinger MD JSexMed 2005]. Most clinicians usually consider premature ejaculation to be an IELT of less than 1-2 minutes. [Shindel AW Juroll 2022]. PE obviously does not have a negative impact on a couple’s overall fertility but can be bothersome to some men who may wish to seek treatment for this while they are trying to conceive. One risk factor for PE is hypogonadism, so treatment of low testosterone can sometimes improve symptoms. [Jannini EA. FertSteril 2015] Some treatments for PE including medications such as paroxetine which can have a negative impact on sperm transport in some men. [Bejma JP AUAUpdate 2007] Topical anesthetics such as lidocaine cream or Promescent spray do not have a negative impact on male fertility. In contrast with lidocaine cream, the potential advantage of Promescent is that it is quickly absorbed by the skin with minimal transfer to the female during intercourse. Another option is the use of PDE5i medications (such as sildenafil, tadalafil, vardenafil) which can cause increased ejaculatory latency in some men and therefore can be used as a treatment for PE that does not decrease male fertility. [Nacchia A. Urology 2024]. Referral to a mental health professional with expertise in sexual health can be helpful as well to some with PE. [Shindel AW Jurol 2022]