By: Ayman Rashed,MD ejaculatory disorders are always bothering. premature, delayed ejaculation, or anejaculation are all challenging both in diagnosis or treatment

1. Ejaculatory Disorders

2. Sexual Response Cycle
DESIRE
ORGASM
RESOLUTION AROUSAL

3. Terminology
 Desire:
This is what we call Libido
 Arousal:
Is the sexual excitation
 Orgasm: "Sexual Climax”
Is the peak of sexual Excitation featured with rhythmic contraction of
pelvic ms. Including bulbospongiousus and ischiocavernosus ms.
 Ejaculation: “Resolution”
Is the discharge of the seminal fluid at end of the sexual cycle,
normally through external meatus

4. Classification of Ejaculatory Disorders
 Anejaculation “Dry Ejaculation”
• This include absent production or negligible ejaculation
• May be due to organic or iatrogenic, reasons or even psychogenic associated
with “anhedonia”
• Most common (90%) with RPLND and SCI
 Retrograde Ejaculation
 Dys-ejaculation
 Delayed Ejaculation
• More than 25 to 30 minutes of IELT considered delayed ejaculation by some
investigators
 Premature Ejaculation
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5. What is the Ejaculate consists of ?
 Spermatozoa
From the vas deference and constitutes 10% of the ejaculate
 Seminal vesicle secretion
It constitutes > 75% of the ejaculate. Its fructose containing fluid
alkalinizes the ejaculate
 Prostatic secretion
It constitutes 10% of the ejaculate containing acid phosphatase,
citric acid and zinc
 Cowper's gld. & Periurethral glds.
They produce < 5% of the ejaculate

6.  Ejaculatory process is mediated mainly by autonomic nervous
system.
 It consists of two main phases, namely:
Emission and Expulsion phases
Physiology

7. Physiology
 This the phase includes production and discharge of the seminal
fluid
 Organs involved in this phase include: Vas deference, Epididymis,
Seminal Vesicles, Bladder neck, Prostate and Prostatic Urethra
 These organs have dense sympathetic and parasympathetic
innervation mainly from pelvic plexus
Emission Phase

8.  This is the phase where the ejection of the seminal fluid takes
place from the external urethral meatus through the urethra
 Organs involved in this phase include: Bladder neck, Urethra and
Pelvic striated muscles
 It is a spinal cord reflex that occurs when the ejaculate discharged
at the bulbous urethra. "Point of NO RETURN"
Expulsion Phase Physiology

9. Control of Ejaculation Process
 The ejaculation process is under physiologic control of:
• Neuronal
• Neurochemical transmitters
• Hormonal
Physiology

10. Neurogenic Control of Ejaculation
 The organs involved in emission and expulsion are heavily
innervated with sympathetic and parasympathetic nerves
 Both Peripheral and Central nervous systems are integrated to
provoke normal ejaculatory function
Physiology

11.  Peripheral Nervous System
• Afferents: are through sensory Dorsal nerve of the penis to the
upper and lower segments of the sacral spinal cord
• Efferents:
• Sympathetic: T12-L1
• Parasympathetic: via Hypogastric n. which join the pelvic n. to
form Pelvic Plexus
• Motor: Located in Onuf’s nucleus in Sacral spinal cord through
pudendal n. to reach pelvic ms. Including bulbospongiosis and
ischiocavernosus ms.
Neurogenic Control of Ejaculation Physiology

12. Neurogenic Control
 Central Nervous System
 Spinal Ejaculatory Generator (SEG) :
• Located in L3-4 proved to play important role in integration of
peripheral and central inputs and outputs to the pelvi-perineal
structures in addition to the aforementioned peripheral network
• This proved by the ability of peripheral stimuli to induce
ejaculation in patients with spinal cord injury
 Cerebral Network:
• Studies using PET during ejaculation in animals proved that
certain areas in the brain have a role in normal ejaculation

13. Neurochemical Mediators
 Dopamines
• There are two families of dopamines;
D1- like (D1& D5) and D2 – like (D2,3,4)
• D2 – like agonists are known to stimulate ejaculation and blockage of their
receptors inhibits it
 Serotonins (5HT)
• Selective 5HT reuptake inhibitors increases 5HT tone resulting in
ejaculatory impairment centrally
• While, Peripherally these inhibitors have stimulatory effect
 Nitric Oxide (NO)
• It has inhibitory effect on ejaculatory process
• PDE-5 inhibitors found to increase NO & C-GMP. This decreases
peripheral sympathetic tone and inhibition of ejaculation

14. Hormonal Control
 Androgens
• Low s. Testosterone level is associated with delayed ejaculation and vice
versa. This is because the emission phase depends upon NO/PDE-5
system
 Estrogens
• E2 plays an important role in emission phase through epididymal
contraction and increasing sperm concentration.
• Furthermore, L. E2 / L. Testosterone contribute in decreased libido and ED
 Prolactin
• Hyperprolactinemia is known to have negative effect on Libido
• On the other hand, low s. Prolactin is associated with premature
ejaculation as suggested by some studies

15. Hormonal Control
 Oxytocin
• This hormone released from post. Pituitary
• Some studies proved that oxytocin receptor antagonists inhibit ejaculation
• It has been suggested that intra-nasal inhalation of oxytocin may facilitates
orgasm in anorgasmic patients
 Thyroid Hormones
• It has been proven that 50% of patients with hyperthyroidism had premature
ejaculation, and, only 15% of them still has premature ejaculation after ttt
• Studies showed that administration of L-thyroxin in rats would increase
bulbospongiousus contractions
 Glucocorticoids
• Replacement of cortisol in Addison's disease is associated with improvement of
overall sexual function including orgasm

16. Premature Ejaculation
 The absence of a consensus medical definition for PE urges
a “patient-dependent” definition and a “patient-decided”
diagnosis
 This is a risky approach, because diagnosis and possible
therapy would then be based exclusively on subjective
parameters, which are clearly influenced by culture, religion,
policy, society, and the media. all aspects that greatly deviate
from a medical definition

17. Epidemiology
 PE is most frequently reported by adolescents or young adults, and
affects about 30% of men
 PE affects more men from East Asia and fewer men from
Middle Eastern and African countries than in other regions.
The European prevalence seems to lie between that of East
Asia and Middle Eastern and African countries.
 Still, epidemiological data on PE have been difficult to define
due to the lack of a globally accepted definition of the disorder

18. Premature Ejaculation
2nd
2nd
 The ISSM has adopted a completely new definition of
PE which is the first evidence-based definition
PE (lifelong and acquired) is a male sexual dysfunction
characterized by the following:
1. Ejaculation that always or nearly always occurs prior to
or within about 1 min. of vaginal penetration (lifelong
PE) or a clinically significant and bothersome reduction
in IELT, often to about 3 mins. or less (acquired PE)
2. The inability to delay ejaculation on all or nearly all
vaginal penetrations
3. Negative personal consequences, such as distress,
bother, frustration, and/or the avoidance of sexual
intimacy.

19. Pathophysiology of PE
 The pathophysiology of PE can be differentiated into five
distinct areas:
Psycho-relational, neurobiological, urological, hormonal and
andrological
Consequently, this will suggests five different therapeutic approaches,
each according to the pathology behind

20. Conclusions
 Understanding the physiology of ejaculation is essential issue in
tracking the ejaculatory pathogenesis
 Ejaculation is a complex process involving several anatomical structures
and under extensive neurogenic, neurochemical and hormonal
regulation in addition to psychogenic component
 Extensive history taking, clinical assessment and investigation work up
according to the history and clinical data e.g. Hormonal assay in
deceased libido, will assist greatly in diagnosis and hence the proper
treatment of the patient
 Orgasm, although associated with ejaculation, is a distinct physiological
process, different from ejaculation.

24.  Ejaculation before Penetration: Ante portas “before the gates” ejaculation that
occurs before vaginal penetration
 Other PE-like Sexual Concerns: Two other experiences of ejaculation have
been described that are sometimes mistaken for PE, which have been termed
Natural Variable PE and Subjective PE; neither is a sexual dysfunction. Natural
Variable PE is characterized by early ejaculations which occur irregularly and
inconsistently with some subjective sense of diminished control of ejaculation.
This subtype is considered a variant of normal experience. Subjective PE is
characterized by preoccupation with an imagined early ejaculation or lack of
control of ejaculation when, in reality, the period of time from vaginal penetration
to ejaculation is five minutes or longer.

25.  The ISSM has adopted a completely new definition of
PE which is the first evidence-based definition
PE (lifelong and acquired) is a male sexual dysfunction
characterized by the following:
1. Ejaculation that always or nearly always occurs prior to
or within about 1 min. of vaginal penetration (lifelong
PE) or a clinically significant and bothersome reduction
in IELT, often to about 3 mins. or less (acquired PE)
2. The inability to delay ejaculation on all or nearly all
vaginal penetrations
3. Negative personal consequences, such as distress,
bother, frustration, and/or the avoidance of sexual
intimacy.