Retrograde Ejaculation

1. Lebanese International Fertility Summit
2 – 3 October 2015
Hilton Beirut Habtoor Grand
LIFE 2015
LIFE 2015

2. Ejaculatory Dysfunction
Stéphane Droupy MD, PhD
Professor of Urology, CHU de Nimes-Université Montpellier 1

3. Physiology of
ejaculation

4. LIFE 2015
Male sexual response
Excitation
Plateau
Orgasme
Résolution
Excitation/
Erection
Tumescence
Stimulation
Ejaculation et
orgasme
Détumescence
Penetration
Phase réfractaire

5. LIFE 2015
The two phases of ejaculation
• 1st phase: Emission
¡ Peristaltic contractions
of epididymis and vas
deferens
¡ Secretion of spermatic
liquid by prostate and
seminal vesicles
¡ Contraction of
seminal vesicles,
prostate and bladder
neck
¡ Propulsion of
spermatozoa and
seminal/prostatic fluid
into posterior urethra

6. LIFE 2015
The two phases of ejaculation
• 2nd phase: Expulsion
¡ Rhythmic
contractions of
striated pelvic floor
muscles
(bulbospongiosus
muscle)
¡ Bladder neck closure
and relaxation of
external urinary
sphincter
¡ Propulsion of semen
out of urethral
meatus

7. LIFE 2015
Sympathic
TL centers
LSt cells
Parasympathic
Sacral nucleus
BS
Muscle
Prostate
IMG
N Pelv.
N Hypog.
MPG
T12-L1
L3-L4
L5-S1
DM
(VH)
LumbarSpinothalamic
neurons (L3-L4) (galanin-
NK1) are connected with
BS, prostate and SV.
LSt neurons coordinate
both emission and
expulsion phases of
ejaculation.
Emission is not a
prerequist for expulsion.
N Pud.
Ves Sem
Spinal generator of
ejaculation: LSt

8. LIFE 2015
BRAIN CONTROL
of
SEXUAL RESPONSE
INHIBITION / ACTIVATION
OF SPINAL CONTROL
Des influx nerveux activateurs avec
comme neuromédiateur la DOPAMINE
et Inhibiteurs comme la SEROTONINE
vont converger vers le centre spinal
de l’éjaculation.
1- Influx activateurs via
l’hypothalamus (aire préoptique
médiane (MPOA) et noyau
paraventriculaire (PVN))
2- Influx inhibiteurs via le noyau
paragigantocelluaire (NPGi) du tronc
cérébral.

9. LIFE 2015

Department of Urology University of Copenhagen
Physiology of Ejaculation
Serotonergic  Dopaminergic
(Inhibitory) (Excitatory)
Spinal innervation
of ejaculation

10. LIFE 2015
Ejaculatory dysfunctions
¡ « Dry ejaculation »
¡ Anejaculation
¡ Aspermia
¡ Retrograde ejaculation
¡ Anorgasmia
¡ Partial ejaculations : hypospermia, asthenic ejaculation
¡ Emission or expulsion dysfunction
¡ Delayed ejaculations (> 25 min)
¡ Premature ejaculation (<3 min) (ante portas)
¡ Painfull ejaculation
¡ Orgasmuria

11. LIFE 2015
Anejaculation
• Complete absence of antegrade or retrograde
ejaculation = Aspermia
• Failure of semen emission from the seminal
vesicles, prostate and ejaculatory ducts into the
urethra
• Anejaculation associated with a normal
orgasmic sensation.
¡ Central or peripheral nervous system dysfunction
¡ Drugs
¡ Iatrogenic / surgery

12. LIFE 2015
Retrograde ejaculation
• Total, or partial, absence of antegrade
ejaculation as a result of semen passing
backwards through the bladder neck into the
bladder. Aspermia or hypospermia
• Patients experience a normal or decreased
orgasmic sensation.
• The causes :
¡ neurogenic,
¡ pharmacological,
¡ urethral
¡ bladder neck incompetence

13. LIFE 2015
Delayed ejaculation
• Prolonged stimulation of the erect penis is
needed to achieve orgasm with ejaculation
• Mild form of anorgasmia.
• The causes
¡ Psychological,
¡ Organic: SCI
¡ Iatrogenic penile nerve damage,
¡ Pharmacological: selective serotonin re-uptake
inhibitors (SSRIs), antihypertensives, or antipsychotics

14. LIFE 2015
Etiologies
MALE INFERTILITY - UPDATE MARCH 2014
Colorectal and anal surgery
Parkinson´s disease
Urethral Bladder neck incompetence
Ectopic ureterocele Congenital defects/dysfunction of hemitrigo
Urethral stricture Bladder extrophy
Urethral valves or verumontaneum hyperplasia Bladder neck resection (transurethral resect
prostate)
Congenital dopamine b-hydroxylase deficiency Prostatectomy
3L.1.5 Asthenic ejaculation
Asthenic ejaculation is characterised by an altered propulsive phase, with a normal emission phase [
The orgasmic sensation is reduced and the typically rhythmical contractions associated with ejacula
missing. Asthenic ejaculation does not usually affect semen quality.
3L.1.6 Premature ejaculation
The International Society for Sexual Medicine (ISSM) has adopted the first evidence-based definition
premature ejaculation (PE): “Premature ejaculation is a male sexual dysfunction characterised by eja
which always or nearly always occurs prior to or within about one minute of vaginal penetration; and
to delay ejaculation on all or nearly all vaginal penetrations; and negative personal consequences, su
distress, bother, frustration and/or the avoidance of sexual intimacy”. Premature ejaculation may be
organic (e.g., prostatitis-related) or psychogenic, partner-related or non-selective, and can be assoc
EAU guidelines

15. Ejaculatory
dysfunction after
surgery

16. LIFE 2015
Iatrogenic after surgery
• Cystoprostatectomy
¡ Bladder cancer
• Radical prostatectomy
¡ Prostate Cancer
• Endoscopic and simple prostatectomy
¡ BPH
• Retroperitoneal
¡ Lymphadenectomies
¡ Aortic surgery
¡ Sigmoid and rectal surgery
• EBR, Brachytherapy (Prostate cancer)
¡ Anejaculation 90% at 5 y
¡ IIEF-O: 7,4 to 2,8/10 at 3 y
Sulivan JF et al J Sex Med 2013

17. LIFE 2015
Retroperitoneal
lymphadenectomy
L1 L2 L3
VCI
Ao
Rein Dt Psoas
Uretère
VRG

18. LIFE 2015
Sexual dysfunctions after
rectal surgery
0
10
20
30
40
50
60
70
80
90
100
Tous
AAP
Résection Antérieure
Excison trans-anale
Hendren et al Ann Surg 2005

19. LIFE 2015
Sexual dysfunctions after
rectal surgery
0
10
20
30
40
50
60
70
80
90
100
Tous
AAP
Résection Antérieure
Excison trans-anale
Hendren et al Ann Surg 2005

20. Drug side effects
on ejaculation

21. LIFE 2015
Drug induced ejaculatory
dysfunction
• Delayed or suprressed ejaculation
¡ Alphablokers
¡ Antiandrogens
¡ Antidepressants
¡ Analgesic, Baclofen
¡ Antipsychotics, lithium
¡ Antihypertensive (alpha or betablockers and central)
¡ Cytotoxics (methotrexate, vincristine)
¡ Antiparkinsonians (bromocryptine)
¡ Recreational rugs except amphetamin and heroïne
¡ Alcoolism

22. LIFE 2015
Alpha-blockers
• Anejaculation
¡ Silodosin> Tamsulosin> Alfusosin
¡ Anejaculation:
¡ 100% of healthy volunteers with silodosin
(Kobayashi et al. J Sex Med 2008)
¡ 20-30% of treated pts in pivotal studies(Marks et
al J Urol 2009)
0
40
80
120
Vehicle 3 10
*p <0.001
3 10
Tamsulosine
(µg/kg)
Alfuzosine
(µg/kg)
Pression de la vésicule séminale
*
*

23. LIFE 2015
Sexual side effects of drugs
Classe&
Thérapeutique&
Priapisme/ES
P/HS&
Tr.&Libido& DE& Tr.&
Orgasme/Ej&
Les&médicaments&conseillés&
Neuroleptiques& +" +" ±" +" Clozapine*(Leponex®),*Olanzapine*
(Zyprexa®),*Quiétapine*
(Seroquel®),*Arispiprazole*
(Abilify®)"
Antidépresseurs& +" +" +" +" Mirtazapine*(Norset®),*Tianeptine*
(Stablon®),*Moclobémide*
(Moclamine®),*Agomelatine*
(Valdoxan®),*Duloxetine*
(Cymbalta®)"
Antiépileptiques& " +" " +" "
Antalgiques& " +" +" ±" "
Anxiolytiques& +" " +" +" Bupropion*et*Buspirone"
*Classes thérapeutiques impliquées dans la survenue de dysfonctions sexuelles iatrogènes
et médicaments conseillés afin d’éviter ou de limiter la survenue de ces effets indésirables.
(ESP : Excitation sexuelle persistante, HS : hypersexualité, Tr. EJ : troubles de l’éjaculation,)
S Droupy EMC 2005. Épidémiologie et physiopathologie de la dysfonction érectile
¶
18-720-A-10

24. LIFE 2015
Corona and Ricca equally contributed to the article.
© 2009 International Society for Sexual Medicine J Sex Med 2009;6:1259–1269
Results. Higher prolactin was observed only in patients using SSRIs, whereas no other
found after adjustment for confounders. Use of SSRIs was associated with a twofold risk for
desire and with a higher impairment of reported erectile function. However, no differenc
observed. A very high risk (sevenfold) for delayed ejaculation (DE) was observed in SSR
association with the mild, but not severe, form of DE was observed also in subjects using
(3.35 [1.48–7.59]; P < 0.005). Different life stressors and relational parameters were also
SSRI users reported less enjoyment with masturbation and decreased partner desire and
of significant association was observed among BDZ or non-SSRI antidepressant users an
life-stressors and relational parameters.
Conclusions. SSRIs can negatively affect all the steps of the male sexual response cycle (de
orgasm). SSRI-associated sexual dysfunction has a deleterious effect on both auto- and co
Conversely, other antidepressants and BDZ are less often associated with sexual impairm
Bandini E, Mannucci E, Lotti F, Boddi V, Rastrelli G, Sforza A, Faravelli C, Forti G,
serotonin reuptake inhibitor-induced sexual dysfunction. J Sex Med 2009;6:1259–1
Key Words. Erectile Dysfunction; Hypoactive Sexual Desire; Delayed Ejaculation; SS
NCEP-ATPIII = National Cholesterol Education Program-Third Adult Treatment Pane
Corona and Ricca equally contributed to the article.
© 2009 International Society for Sexual Medicine J Se
• Delayed ejaculation x7
• SSRI: younger and PRL
• HSD: risk x2
• Less sexual intercourse
• ED: idem non-SSRI
• Deleterious effect
– Autoerotisme
– Partner
P = notsignificant).Accordingly,nodifferencewas
observed in SIEDY scale 1 score after adjustment
for confounders (Figure 3).
As expected, a higher risk for MMDE and
ASDE was observed in subjects reporting the
use of SSRIs. Interestingly, the association with
MMDE, but not with ASDE, was observed also in
subjects using non-SSRI antidepressants (3.35
ponent of ED) were o
SSRIs even after adjust
asage,useofBDZ,oro
sants, patient’s HSD, te
and S MHQ (Figure 3)
between the use of BDZ
sants, and all the aforem
relational parameters, w
Figure
sympt
logica
patien
select
tor (S
risk (a
hood
being
of SS
been
founde
age,
non-S
hypoa
ostero
J Sex Med 2009;6:1259–1269

25. LIFE 2015
Management of sexual
dysfunctions / SSRI
• Inform and anticipate to prevent drug stop
• Remplacement
• Mirtazapine (Norset), Tianeptine (Stablon), Moclobémide
(Moclamine), Zyban
• ED : PDE5i
• Ejaculation:
• Periactine (cyproheptamine): 2 to 16 mg/d or on demand
• Amantadine: 100mg 5h before SI
Strategies for managing sexual dysfunction induced by antidepressant
medication.
Lisa R, Matthew JT, Keith H. Cochrane Database Syst Rev. 2004
Labbate et al. J Clin Psychiatry. 2003
Nurnberg et al.JAMA. 2003 and J Clin Psychiatry. 2003

26. ED and spinal
cord injury

27. LIFE 2015
Sexuality in SCI patients
• 1 à 2 news case/ day
• Young men
• Quality of reinsertion is dependant of
management of sexual dyfunctions
Phelps Arch Sex Behav 2001
Why consider genital and
sexual rehabilitation ?
f
27%
13%
Anderson J. Neurotrauma 2004
Why consider genital and
sexual rehabilitation ?
f
27%
13%
Anderson J. Neurotrauma 2004
Anderson et al. J Neurotrauma 2004

28. LIFE 2015
Spinal cord injury
• Thoracolumbar Sympathic :
¡ Emission,
• Sacral somatic and parasympathic
¡ Reflexogenic Erections, sensitivity
¡ Expulsion (perineal muscles contractions)
• Level of the spinal lesion
• Infralesional syndrom
• Complete vs incomplete Ejaculation
Erection
Sensibilité

29. LIFE 2015
ED in SCI
• Ejaculation depends on the intergrity the spinal
cord between T12 et L2,
• In SCI > T12, ejaculatory reflex remains intact and
automatic ejaculation can be optain.
• In SCI between T12 and L2 et complete, no
ejaculation.
• In SCI < L2, and integrity of sacral roots,
psychogenic ejaculation is sometimes possible.

30. LIFE 2015
Management of ED in SCI
• Urinary function
• Anorectal function
• Spasticity
• Pain
• Skin
• Associated treatments
• Reeducation of erection and recreative sexual life

31. LIFE 2015
Penile Vibratory stimulation
• 22 studies since1954
• 2257 patients
• 15% (0 et 52%) of patients are able to ejaculate
without medical assistance
• Vibratory stimulation of the penis: Ferticare

Department of Urology University of Copenhagen
Principle of PVS
Spinal
Cord
PVS
Pudendal
nerve
T12-L1
S2-S4
Seminal emission
Projectile ejaculation
Vibratory amplitude (N=66)
2.5 mm: 80% success rate
1.0 mm: 25% success rate
Sønksen et al 1994
Sønksen et al 2001
Above T10
Intact BC reflex
Sonkesen et al 1994 et 2001
Consequence of Amplitude S
 Development of t
first medical vibra
home use.
 FDA 510K registr
 Currently in use i
more than 30 cou
including US.
University of
Copenhagen
&
Multicept A/S
Denmark

32. LIFE 2015
Ferticare®
• Brackett, SØnksen. J. Urol, 1988. (653 essais chez 211
patients)
¡ C3-C7 66%
¡ D1-D5 54%
¡ D6-D10 41%
¡ D11-L3 36%
• Efficacy 50 to 80% if Sci > T10
• First line treatment for ED in SCI
• Home use for intravaginal inseminations
• Association with:
¡ Midodrine :Gutron® (alpha +)
¡ iPDE5 to improve erection and sensitivity
Courtois et al 2008, Soler et al 2008
Department of Urology
Clinical
Department of Urology
Clinical use of PVS

33. LIFE 2015
Home insemination

Department of Urology University of Copenhagen
TMS (millions): 31 (1-426)
74/170couples: 100 pregnancies
Outcome: 91 healthy babies
(1 set of twins)
Time to pregnancy: 1.2 years (0.1-8.2)
Spontaneous abortion: 10 in 9 couples (10%)
Results
PVS and Home Insemination

34. LIFE 2015
Electroejaculation : 100%

Department of Urology University of Copenhagen
Electroejaculation
Procedure

35. Partial
ejaculation

36. LIFE 2015
Obstruction of seminal tract
• CBAVD, at least one mutation of the CF gene in
82%. Dysgenesis of seminal vesicles.
• Unilateral agenesis or a partial defect
¡ Contralateral seminal duct anomalies 80%
¡ Renal agenesis in 26%
• Ejaculatory duct obstruction: 1-3% of OA
¡ Cystic obstruction: Mullerian cyst (central)
¡ urogenital sinus/ejaculatory duct cysts
¡ Post-inflammatory obstruction
¡ Lithiasis
¡ Painful ejaculation

37. LIFE 2015
Ejaculatory duct
obstruction
Phosphates amorphes de Calcium Carbonatés
+ Protéines

38. LIFE 2015
MRI
Curran S et al. AJR 2007;188:1373-1379

39. LIFE 2015
Treatment of Mullerian cyst
• Mullerian cyst:
¡ US guided transrectal aspiration.
¡ TUR of cyst., laser resection
¡ Cryopreservation
• Risks:
¡ Rectal perforation
¡ Retrograde ejaculation
¡ Urine reflux seminal tract
¡ Recurrence
Goldstein - Surgery of Male Infertility – 1995,
Fish World J Urol 2006, XU BJUInt 2011

40. LIFE 2015
Ejaculatory duct obstruction
¡ Stenosis /calculi of ejaculatory ducts
¡ Endoscopic incision (laser),
¡ Colliculus seminalis resection
¡ Per operative sperm retrieval
¡ Peroperative US
¡ Antibiotics, antiinflammtory a, repeated
ejaculations
¡ Dilation 9 french vesiculoscopy
free, and the scarred portion was removed, a drop of vasal fluid was
examined for the presence of sperm. All patients were found to have
sperm in the proximal vas bilaterally. Assisted laparoscopy was needed
if the distal vas end was retreated into the pelvis and inaccessible at the
inguinal area or if the distal (pelvic) vas end was found and dissected
near the internal ring, but the defective vas was too long to anastomose
with the proximal end of the vas. This procedure is similar to Shaeer
pelviscrotal VV.4
A three-port transperitoneal approach is placed after
artificial pneumoperitoneum. The initial 10 mm port was placed at the
inferior umbilical crease and housed the laparoscope. Ports number
2 (5 mm) and number 3 (5 mm) were placed one fingerbreadth outside
the lateral border of the rectus muscle and two fingerbreadths below
the umbilicus. After an incision of the peritoneum on the internal ring,
the distal end of the vas was easily identified and dissected distally, and
7–8 cm length of distal vas was dissected free. Another 5 mm trocar
was placed on the external ring and created a new canal by penetrating
the abdominal wall into the peritoneal cavity adjacent to the outside
of the obliterated umbilical artery fold. This canal was a shortcut for
a tension-free VV (Figure 3). The distal vas were delivered intact and
then trimmed under direct vision of the microscope. The scarred end
of the vas was cut-off until the vasal lumen appeared healthy. The distal
vas was near the proximal vas, and VV was performed (the procedure
used was similar to the previously reported technique5
). The patients
started to ejaculate 3 weeks after surgery.
Microscopic vasoepididymostomy
Patients who were presumptively diagnosed with vasal or epididymal
obstruction underwent scrotum exploration under spinal anesthesia.
The vas was transected at the site near the epididymis. The patency
of the distal vas lumen was checked by injecting 10 ml of saline into
the cannulated vas deferens. If saline could not pass through the vas
Hong‐Tao Jiang et al. Asian Journal of Andrology (2014) 16, 912–916

41. LIFE 2015
Ballistic problems
• Normal ejaculatory sensation : no intravaginal
semen emission
• Hypospadias
• Urethral stenosis
• Congenitale or acquired penile curvature
• Ejaculation prématurée ante-portas
• Vaginism

42. Premature
ejaculation

43. LIFE 2015
Premature ejaculation
PE
Normal
response
Etiology of PE remains largely unknown
Steep excitement
phase
Rapid ejaculation
and associated
orgasm
Short plateau phase

44. LIFE 2015
Pathophysiology of PE
Adapted from Perelman, Atlas of Male Sexual Dysfunction, 2004
Biological
Factors
Psychological
Factors
Penile Hypersensitivity
Hyperexcitability
Genetic predisposition
Central 5-HT sensitivity
Early sexual experience
Sexual conditioning
Anxiety
Psychodynamic
Variable expression

45. LIFE 2015
Definitions
Primary PE(1) Acquired PE Naturally variable
PE(2)
Pseudo-PE (2)
Délai pour éjaculer
après la pénétration
vaginale: 1minute ou
moins toujours ou
presque.
Incapacité de retarder
l’éjaculation lors de
toutes ou presque les
pénétrations
vaginales.
Conséquences
personnelles
négatives: souffrances,
gêne, frustration,
évitement de l’intimité
sexuelle
Diminution
significative du délai
pour éjaculer après la
pénétration vaginale:
3 minutes ou moins
toujours ou presque.
Incapacité de retarder
l’éjaculation lors de
toutes ou presque les
pénétrations
vaginales.
Conséquences
personnelles
négatives: souffrances,
gêne, frustration,
évitement de l’intimité
sexuelle
Éjaculations précoces
occasionnelles.
Incapacité totale ou
partielle à retarder une
éjaculation imminente.
Ejaculation parfois
dans des délais
normaux
Perception subjective
d’une éjaculation
précoce lors des
rapports sexuels.
Ejaculation précoce
imaginaire
Le temps de latence
pour éjaculer est dans
la fourchette normale
(3 à 25 min).
La capacité à retarder
l'éjaculation
imminente est
diminuée ou absente.
2- Waldinger MD. Recent advances in the classification,
neuro- biology and treatment of premature ejaculation.
Adv Psycho- som Med 2008;29:50–69.
1- McMahon CG, Althof SE, Waldinger MD, et al. An
evidence-based definition of lifelong premature
ejaculation: report of the Interna- tional Society for Sexual
Medicine (ISSM) ad hoc committee for the definition of
premature ejaculation. J Sex Med 2008;5:1590–606.

46. LIFE 2015
Management of PE
1. Althof SE, et al. International Society for Sexual Medicine’s Guidelines for the Diagnosis and Treatment of Premature Ejaculation. J Sex Med 2010;7:2947-2969.
Ejaculation Prématurée
OUI
EP secondaire à une DE ou autre
dysfonction sexuelle
OUI
Prise en charge de
la cause primaire
EP acquise EP primaire
Traitement
Comportemental/Psychothérapie
Pharmacothérapie
Traitement combiné
Traitement
Pharmacothérapie
Comportemental/Psychothérapie
Traitement combiné
Préférence
du patient
Tentative d’arrêt progressif du traitement pharmacologique selon les
patients
NON

47. LIFE 2015
Psycho-sexological approach
§ Sexothérapies comportementales 2, 3
Ø Technique Stop and Go
Ø Squeeze
Ø Sensate Focus
Ø Thérapies cognitivo-comportementales
Ø Jeux de rôle
§ Hypnose, relaxation, sophrologie 3
§ Sexothérapies corporelles
§ Thérapie de couple 4
Ø Développer la communication
Ø Gérer les émotions (négatives)
§ Thérapie psychodynamique 3
Ø Problèmes psychologiques et relationnels en amont du symptôme
sexuel
2. Mohee A, et al. Medical therapy for premature ejaculation. Ther Adv Urol 2011;3(5):211︎-222.
3. Porto R, et al. L’éjaculation prématurée. Prog Urol 2013;23:647-656.
4. AIHUS. Recommandations aux médecins généralistes pour la prise en charge de première intention de la dysfonction érectile. 2010.

48. LIFE 2015
Pharmacological approach
n=1,437(
n=1,486(
n=1,455(
1.6
2.5
3
0
1
2
3
4
5
Fold
increase
Placebo Priligy30 mg Priligy60 mg
n=1,437(
n=1,486(
n=1,455(
Traitements
per
os
An#dépresseurs
hors
AMM
traitement
quo#dien
fluoxé#ne,
paroxé#ne,
citalopram,
clomipramine
Dapoxé#ne
à
la
demande
PriligyR
Tramadol
hors
AMM
à
la
demande
seul
ou
associé
(antalgique)
Anesthésie
locale
Anesthésique
local
lidocaïne-­‐prilocaïne
crème
(EmlaR)
hors
AMM
Pryor et al. Lancet 2006; 368: 929-937. McMahon et al. (2008) Presented at ESSM/ISSM

49. Delayed
ejaculation
male orgasmic dysfunction
Median time: 5.4 min (0,55- 44)
+ 2DS = 25 min

50. LIFE 2015
Delayed ejaculation
• Persitant or recurrent difficulty or delay to reach an orgasm
and obtain an ejaculation after suficient sexual stimulation.
• > 25 minutes
• Primairy (1,5/1000) or secondary (3-4%)
• Permanent or situationnal
• Seems interesing for the female partner
• In fact: penible pour both

51. LIFE 2015
Causes
• Inadequate stimulation
¡ Psychogenic
¡ Disparity fantasma /reality
¡ Affinity /partner
¡ Physical
¡ Masturbatory idiosyncrasism:
¡ Every day 35%
¡ auto-erotism > partner

52. LIFE 2015
Causes
• Psychic conflicts: fear of semen, vagina, to hurt
the partner or to have a child
• Relational conflicts
• Hyspoactive sexual desire / dysorgasmia
• Organic:
¡ SSRi
¡ Hypogonadism : Testosterone
¡ Diabetes, hypothyroidism

53. LIFE 2015
Treatment of delayed
ejaculation: Off-label
• Alpha adrénergics sympathomimétics
• Midodrine 5 to 30 mg 30 à 60 minutes before ejaculation.
• Imipramine: 25mg x2-3 /jour.
• Dopaminergiques agonists
• Cabergoline (dostinex)
• Apomorphine (Ixense, Uprima)
• Periactine (cyproheptamine): 2 à 16 mg/jour ou à la demande (patients sous
SSRI)
• Amantadine: 100mg 5h avant le RS
• Ocytocine (nasal)
• Buspirone (buspar)
• Bupropion (Zyban)
• SSRI: efficacy 66%
• Improve orgasm men and women

54. Painful orgasms / radical prostatectomy
¡ Pain: 14%
¡ Penis: 63%
¡ Rectum:24%
¡ Abdomen:9%
¡ elsewhere: 4%
¡ always: 33%
¡ Frequent: 13%
¡ sometimes: 35%
¡ Rare 19%
¡ Duration : <1min:55% , 1-5min: 33%, > 5min: 12%, >1H: 2,5%
Barnas et al BJU Int 2004, 2005
Pathophysiology
• Vas deferens obstruction
Treatment:
Alphablockers
Silodosin

55. LIFE 2015
Climacturia, orgasmuria
• Following radical prostatectomy
• Urinary incontinence during sexual IC:
¡ 20 to 93%
¡ Techniques ou modalité d’évaluation ?
¡ Associated to painful orgasms and penile
shortening
¡ A bothered problem for 50% patients
• Prevention: preservation of bladder neck and nerve
sparing technique .
• Information, condoms
Barnas et al BJU Int 2004, Lee et al J Urol 2006, Choi et al J Urol 2007

56. LIFE 2015
Conclusion
• Ejaculatory dysfunctions are frequent in infertile
men
¡ Cause of infertility
¡ Consequence of Infertility or ART
• Aspermia or hypospermia need further
investigations
¡ Clinical and Imaging (TRUS, MRI)
• Surgical treatment of reversible cause of infertility
• Psychological management of infertile men