Ejaculation physiology and pathology


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Ejaculation physiology and pathology

  2. 2.  Physiology of ejaculation.  Premature ejaculation  Anejaculation  Retrograde ejaculation
  4. 4. Interactions between autonomic and somatic innervations in the control of male sexual cycle  Sensory input from the genital tract is carried by the pudendal nerve to the S2–S4 segment of the spinal cord.  Contralateral primary sensory area deep in the interhemispheric tissue.  The somatic motor fibers -S2–S4 and supply the pelvic floor muscles and the external anal sphincter.
  5. 5.  Descending parasympathetic innervation exits the spinal cord at the S2–S4 level and reaches the penis.  It is responsible for the corporeal vasodilatation and corporeal smooth muscle relaxation, and hence the penile transformation from the flaccid to the erect state.
  6. 6.  The sympathetic innervation exits the spinal cord at T11–L2 level and reaches the penis.  It is responsible for the emission and ejaculation through coordinated contractions of the vas deferens, ampulla, seminal vesicles, prostate, and the bladder neck.
  7. 7. EJACULATION  Sympathetic nervous system.  Spinal cord reflex arc.  Considerable voluntary inhibitory control over this phase of the sexual response.  Two sequential processes.  A) Emission - deposition of seminal fluid into the posterior urethra. Simultaneous contractions of the ampulla of the vas deferens, the seminal vesicles, and the smooth muscles of the prostate  B)true ejaculation -expulsion of the seminal fluid from the posterior urethra through the penile meatus.
  8. 8. Premature ejaculation  International Society for Sexual Medicine (ISSM) definition  Amsterdam in October 2007  "Premature ejaculation is a male sexual dysfunction characterized by ejaculation which always or nearly always occurs prior to or within about one minute of vaginal penetration; and, inability to delay ejaculation on all or nearly all vaginal penetrations; and, negative personal consequences, such as distress, bother, frustration, and/or the avoidance ofsexual intimacy."
  9. 9. Premature Ejaculation  Between 1 in 3 & 1 in 5 men (20-30%).  Less than 25% men with premature ejaculation seek medical advice  Premature ejaculation is often associated with erectile dysfunction and with rapid loss of erection after ejaculation
  10. 10. CASE 1  A 26 Year old bank employee married for the last 6     months comes to you with complains of premature ejaculation. He has come alone (without his wife) He says fertility is not an immediate concern and this problem is affecting their relationship. He has a normal libido He says his erections are strong enough, but ejaculation occurs within a minute.
  11. 11.  The diagnosis of PE is by history alone.  A detailed sexual history.       Frequency and duration of PE. Relationship with specific partners. Occurrence with all or some attempts Impact of PE on sexual activity Relationship to drug use/ abuse. Partner’s contribution to the history could help.
  12. 12.  Physical examination:  Well androgenised  Flaccid penile length 4.5 cm. Stretched penile length- 7.5 cm  Testicular volume normal.
  13. 13. Ano cutaneous reflex  A noxious or tactile stimulus will cause a wink contraction of the anal sphincter muscles .  Nociceptors in the perineal skin to the pudendal nerve, where a response is integrated by the S2-S4.  Absence of this reflex - interruption of the reflex arc, afferent limb or efferent limb.
  14. 14. Bulbo cavernosus reflex  The test involves monitoring anal sphincter contraction in response to squeezing the glans penis or tugging on an indwellingFoley Catheter.  The reflex is spinal mediated and involves S2-4.
  15. 15. ADDITIONAL TESTS  On an individual basis- Hb, Blood sugar, lipid profile renal function tests.  Hormones- Total testosterone, FSH/LH/TSH/Prolactin – If co existing reduced libido/ erectile dysfunction.
  16. 16.  In patients with PE and ED , ED should be treated first.  The cause of premature ejaculation is unknown; it appears unrelated to performance anxiety, hypersensitivity of the penis or nerve receptor sensitivity
  17. 17.  Psychosexual counselling may help men with less troublesome premature ejaculation but, in most men, the mainstay of long-term treatment is with drugs.
  18. 18.  Selective serotonin uptake inhibitors (SSRIs) are powerful antidepressants but they also have a beneficial effect on premature ejaculation. They are, therefore, used as first-line treatment for this condition and their effectiveness is often maintained for several years.  Dapoxetine is the only SSRI licensed for use in premature ejaculation
  19. 19.  Common side-effects of SSRIs include fatigue, drowsiness, nausea, dry mouth, diarrhoea & excessive perspiration although these are often mild and usually settle after 2-3 weeks.
  20. 20.  Viagra has also been used to help premature ejaculation but their exact role is uncertain; they do, however, improve sexual confidence and reduce performance anxiety by producing better erections (if this is a problem).
  21. 21.  Local anaesthetic cream (lignocaine + prilocaine), applied 20 - 60 minutes before intercourse, can be useful but may numb the vagina unless used with a condom and can occasionally cause irritation of the penile skin.
  22. 22. Psychosexual counselling  "stop-start" technique (developed by Semans),  the "squeeze" technique (pictured, developed by Masters & Johnson)  or the Kegel technique (learning to control the ejaculatory muscles) are also effective.  Improvements are seen in 50-60% of patients but may not be maintained in the long term.
  23. 23. Normal penile length  Adult men with penile length of greater than 4 cm in the unstretched flaccid state or greater than 7.5 cm in the stretched flaccid state or the erect state to have a normal penile length.
  24. 24. Testicular volume  A normal size adult testis has dimensions of 4.1–5.2 cm in length and 2.5–3.3 cm in width.  Adult Volume: 15–30 cm3  The germ cells and seminiferous tubules represent 90% of the testicular volume while Leydig cells contribute to less than 1%.
  25. 25. CASE 2  34 year old man, married for 3 years primary subfertility comes to you with a semen analysis report showing volume 0.5ml and no sperms found in the ejaculate.  Period of abstinence -3 days.  No erectile difficulty, has orgasm, but ejaculate is usually low. He says the volume has been steadily decreasing over the last 3 years.
  26. 26.  Med history: Type 1 diabetic on insulin since the age of 17. Sugars uncontrolled. Has postural hypotension, on treatment  On examination Ht 175 cm, weight 73 kg,BP130/80.Well androgenised.  Stretched penile length-8cm.Testicular volume 20ml bilaterally.  Bulbocavernosus and ano cutaneous reflexes absent
  27. 27.  Repeat semen analysis showed volume 0.4ml and     occasional non motile spermatozoa with abnormal morphology. He was given: 1g NaHCO3 the night before and 1g on the day of the procedure. The man was asked to pass urine without completely emptying the bladder. Produce an ejaculate in to a specimen container. Collect urine in a container with culture media
  28. 28. RETROGRADE EJACULATION  Sympathetic efferent fibers (T10-L3)—  1) emission and 2) expulsion.  During the expulsive phase, it is necessary that the bladder neck (internal urethral sphincter) be closed to prevent the reflux of semen into the bladder as the urethral pressure increases.
  29. 29.  Closure of the bladder neck is also under sympathetic control. Failure of closure of the bladder neck and resulting reflux of semen into the bladder is known as retrograde ejaculation (RE).  This results in a low-volume ejaculate and a low or absent sperm count with subsequent subfertility
  30. 30.  Retrograde ejaculation accounts for less than 2% of cases of subfertility presenting to a fertility clinic.  Etiology : congenital abnormality, spinal trauma, retroperitoneal lymph node dissection, diabetes mellitus, and bladder neck surgery or can be idiopathic.
  31. 31.  Medical management aims at increasing tone of the bladder neck and therefore preventing retrograde flow of semen into the bladder by either stimulating sympathetic activity or blocking parasympathetic stimulation.
  32. 32. Post ejaculatory urine  Live birth rate 17%(IUI)
  33. 33. Hotchkiss technique  Empty the bladder by catherization, instill Ringer’s lactate and flush the bladder, leave behind some Ringer lactate, collect post ejaculatory urine, centifuge,suspend the pellet in the culture medium.  Live birth rate 28%( small sample size).
  34. 34. Ejaculation on a full bladder  Ejaculation on a full bladder and suspend the solution in Baker’s buffer and use for IUI.  Preg rate : 2/3
  35. 35.  PRs for ejaculation on a full bladder (60%) appear to be higher than those using the Hotchkiss technique (24%) or obtaining sperm by centrifugation and suspension of postejaculatory urine (15%).  Small sample size precludes a firm conclusion about relative efficacy.
  36. 36. Medical Management  Sympathomimetic medications-Peudoephedrine hcl, (28%)  Anticholinergics : Brompheniramine maleate(22%),  Combination of sympathomimetics and anticholinergics,: brompheniramine maleate and phenylephedrine hydrochloride( 39%) achievement of antegrade ejaculation
  37. 37. Surgical management  Injecting collagen into bladder neck.  TESA.
  38. 38. CASE 3  47 year old man married for 15 years, has two daughter 12 years and 10 years old. His wife is 37 years old.  They wish to have another baby, but he says he is unable to have an orgasm and ejaculation following a spinal injury a couple of years ago. His erections are normal.  He is otherwise leading a normal life.
  39. 39.  Clinical examination is within normal limits.  Anocutaneous reflex is diminished.  Medical grade Vibrator was used on the ventral surface of the glans penis and a semen sample was produced in 8 minutes, which showed conc 15 million/ml, total motility 25%, progressive motility of 10% and morphology of 4%
  40. 40.  What if he had orgasmic anejaculation?  Rule out- Retrograde ejaculation- post ejaculatory urine sample.  No sperms found- Diagnosis-Orgasmic anejaculation.  Common causes: failure of emission of semen due to a block in the ejaculatory ducts or damage to ejaculatory nerves. Eg: Diabetes, after TURP and following pelvic surgery for prostate, bladder or testicular cancer.
  41. 41. Anejaculation  Anejaculation is the inability to ejaculate semen despite stimulation of the penis by intercourse or masturbation.  The causes can be psychological or physical and anejaculation can be situational or total.
  42. 42.  Situational anejaculation means that a man can ejaculate and attain orgasm in some situations but not in others.  Typically, situational ejaculation is stress induced and occurs selectively.  For example, ―Collection difficulty.‖  In some instances, a man may be able to ejaculate and attain orgasm with one partner but not with another.
  43. 43.  In total or complete anejaculation the man is never able to ejaculate, either during intercourse or through masturbation.  In the absence of spinal cord injury or multiple sclerosis, deep-rooted psychological conflicts may be the cause for this scenario.
  44. 44.  Total anejaculation is further divided into anorgasmic anejaculation and orgasmic anejaculation.  In orgasmic anejaculation, there is failure of emission of semen due to a block in the ejaculatory ducts or damage to ejaculatory nerves
  45. 45.  Treatment depends on the causes and includes psychosexual counseling, drugs such as ephedrine and imipramine, vibrator therapy and electro ejaculation.  The vibrator acts by providing a strong stimulus for a long duration to the penis. Vibrator stimulation results in ejaculation in about 80% of men suffering from a neurological (spinal cord) injury.
  46. 46. Conclusion  Ejaculation is under sympathetic control.  Emission, true ejaculation.  Premature ejaculation is diagnosed by history alone.  If PE+ ED, Treat ED first.  Psychosexual counselling- limited value, drugs mainstay.  Dapoxetene, Sildenafil.
  47. 47.  Retrograde ejaculation is a rare condition <2%.  Low volume ejaculate.  Post ejaculate urine- good success with IUI/IVF/ICSI.  Anejaculation- Situational(not uncommon), true anejaculation ( anorgasmic, orgasmic)  Psychosexual counselling/ vibrator/ electroejaculation.
  48. 48. THANK YOU