National Conference of Sexology 2010 Chennai Talk Retarded Ejaculation, Retrograde Ejaculation and Anorgasmia in Aged Men

1. Male Orgasmic Disorders (Retarded, Retrograde, An-ejaculation and Anorgasmia) In Aging Male Author & Presenter :- Dr. Ajay Kumar Gupta Address :- E-28, Shastri Nagar, Jaipur-302016 Phone :- (0141) 2303052, (M) 09829053052 email- ajaygupta.jaipur@gmail.com

2. Introduction :- Male orgasmic disorders are one of the most common sexual disorders in men, and extends from premature ejaculation, through retarded or ( inhibited ) ejaculation to a complete inability to ejaculate i.e. an-ejaculation, and include retrograde ejaculation and anorgasmia. Any psychological or medical disease or surgical procedure that interferes with either central control of ejaculation or the peripheral sympathetic nerve supply to the vas and bladder neck, the somatic efferent nerve supply to the pelvic floor, or the somatic nerve supply to the penis can result in delayed ejaculation, an-ejaculation and anorgasmia. Therefore the causes of orgasmic disorders are manifold.

3. Here we will discuss disorders other than premature ejaculation in aging male. Retarded ejaculation :- May be defined as a persistent or recurrent inability to achieve orgasm despite lengthy sexual contact or while participating in sexual intercourse and which causes personal distress. It means individual affected with this disorder is unable to experience an orgasm following a normal sexual excitement phase. The affected man may regularly experience delays in orgasm, or may be unable to experience orgasm altogether. The prevalence of retarded ejaculation appears to be moderately and positively related to age, which is not surprising in view of the fact that ejaculatory function as a whole tends to diminish as men age.

4. It is important to distinguish orgasm from ejaculation, although in most instances they occur almost simultaneously. Orgasm is a peak emotional and physical experience, whereas ejaculation is simply a reflex action occurring at the lower portion of the spinal cord and resulting in ejection of semen. The evidences strongly suggest that orgasm has more to do with brain than with the body. Electrode stimulation of certain parts of brain will produce sexual pleasure similar to that produced by physical stimulation. The fact that orgasm occurs during sleep is supportive of this evidence.

5. Diagnostic issues :- Some older men who have sex quite frequently complain of being able to reach orgasm occasionally. These type of cases are not best treated, but the patient is simply given assurance that orgasm need not to occur every time they make love. An explanation of normal aging changes in sexual response will often deal with the concerns of this type of patient. Nearly all men who suffer from inhibited orgasm have a history of previously being able to reach orgasm normally.

6. In the majority of men who suffer from retarded ejaculation, this disorder is actually secondary to another sexual problem. The most common presentation is the man with hypoactive sexual desire and inhibited orgasm. These men typically are having sex in response to persuasion from their partners. If a man really does not want to have sex, and is doing so only in response to pressure from a partner, he may not become aroused enough to reach orgasm, even though he is able to maintain an erection. A man with this symptom pattern should not be treated for male orgasmic disorder, as the treatment will usually fail. Instead treatment should focus on his hypoactive sexual desire. Similarly, a man whose inability to reach orgasm coexists with erectile failure, should be treated for erection problem; orgasmic function usually returns when erection problem is solved.

7. Another major diagnostic issue concerns possible physiological and pharmacological etiology of male inhibited orgasm. There is abundant empirical evidence that a large number of medical conditions and medications inhibit male orgasm. Most men complaining of inhibited orgasms do have a medical condition or medication partially causing their problem ( excluding cases of inhibited orgasm secondary to hypoactive sexual desire )

8. Treatment emergent retarded ejaculation ( recent increase in cases):- Some men experience retarded ejaculation as a treatment emergent symptom secondary to PDE-5 inhibitor use. The presence of a pharmaceutically enhanced erection may reduce the need for fantasy or pleasurable stimulation normally required for maintaining the erection and experiencing ejaculation. Instead, these men experience an unpleasant prolonging of ejaculatory interval. Retarded ejaculation secondary to idiosyncratic technique of masturbation ( applicable to young also ):- Some men manifest idiosyncratic way of masturbation. An idiosyncratic masturbation style is defined as technique not easily duplicated by a female partner using her hand, mouth or vagina. Variation frequently involved an unusually high degree of friction and pressure through rapid stimulation of the man’s penis by his own hand.

9. Also there were unusual pattern of taping, pressing or pinching on particular point on penis; to the exclusion of other parts, and this pattern is dissimilar to what they experience with a partner. Almost universally, these men fail to communicate these idiosyncratic preferences to their partner, usually because of shame, embarrassment, or ignorance. In this manner, they preconditioned themselves to difficulty with a partner and experienced secondary retarded ejaculation. Retarded ejaculation also seen in men who along with sexual intercourse with a partner , also have habit of seeing porn movies excessively and have high frequency of masturbatory habit. Most of such men develop problem of ED also.

10. Retarded ejaculation, like other sexual dysfunction, is more prevalent as men age. The progressive loss of fast conducting peripheral sensory axons which begins to be apparent in the third decade of life, and the dermal atrophy, myelin collage infiltration and pacinian corpuscle degeneration observed in older men, may result in a degree of age-related degenerative penile hypoanesthesis and difficulty in achieving the ejaculatory threshold. Causes :- - Psychogenic :- -Inhibited ejaculation ( cultural, religious factors ) - Organic :- - Hormonal- Hypogonadism

11. - Thyroid disorders - Hyperthyroidism - Hypothyroidism - Pitutary conditions - Cushing’s syndrome - Increased Prolactin - Neurological - Strokes - Multiple sclerosis - Diabetic neuropathy - Spinal cord injuries - Anatomic causes -Prostate enlargement - Transurethral resection of prostate - Bladder neck incision - Radical prostactomy

12. - Open prostate surgery - Prostocolectomy - Bilateral sympathectomy - Abdominal aortic aneurismectomy - Para- aortic lymphadenctomy -Radiotherapy of prostate. - Diseases of penis. - Substance abuse including alcohol, marijuana, cocaine - Drug related:- Tricyclic and serotonine-uptake inhibitors - Phenothiazines

13. Physiology of Orgasm & Ejaculation :- Orgasm phase is manifestation of two integrated events: emission and ejaculation. By physiologic studies these reflex events have been shown to be dependent on autonomic nervous system. Emission results from contraction of the smooth musculature of walls of structures of internal genitalia: vas deference , seminal vesicle, prostate, and accessory glands. Antipsychotics - chlorpromazine or trifluoperazine Antihypertensives - Thiazide diuretics - Beta-blockers Alpha-blockers - to treat BPH

14. These emitted secretions are then propelled into posterior urethra through prostatic and ejaculatory duct . Ejaculation of the seminal fluid is provided by contraction of skeletal musculature of ischiocavernosus and bulbocavernosus muscles. In the physiologic state during sexual activity, wherein the bladder neck or internal sphincter is tightly closed, the seminal fluid bolus is ejaculated in an antegrade fashion along the urethra and out through meatus. As we know erectile mechanism is dependent on parasympathetic nervous system & orgasm is entirely an sympathetic component. Afferent impulses from glans penis are transmitted via internal pudendal nerve to spinal cord. Efferent impulses leave the upper lumber cord over lumber rami commuicantes and hypogastric nerves through hypogastric plexus. Stimulation of the structures in turn stimulates the smooth musculature of the internal genitalia and results in emission and closure of bladder neck ( internal urinary sphincter ).

15. Neurotransmitters , biochemical compounds within the CNS , play an important role in control of the autonomic nervous system. Acetylcholine is the transmitter at sympathetic preganglionic receptors. Ganglionic blockade is effected by various drugs competing with acetylcholine at the receptor site of the target structure. In effect, the blocking agent keeps acetylcholine from reaching the receptor and stimulating it to the function. Noradrenaline ( Norepinephrine ) is the neurotransmitter synthesized, stored and released by the nerve terminals of the postganglionic sympathetic nerves. It is classified as alpha adrenergic agent. Noradrenaline stimulates the alpha-adrenergic receptors of the musculature of internal genitalia to bring about emission and ejaculation.

16. Drugs which interfere with synthesis, storage, and release of noradrenaline, or which compete with it and block receptor site, will alter, what may be the desired action of this component of sympathetic nervous system. Thus whereas emission is a balanced interplay between parasympathetic and sympathetic nervous system, orgasm and ejaculation are predominantly under the control of sympathetic nervous system. The mechanism of this system may be blocked by impaired function of brain or of the hormonal, circulatory and neurological system. Additionally certain medicines may block these actions.

17. Retrograde Ejaculation (A directional disorder ):- Retrograde ejaculation occurs, when seminal fluid is propelled posteriorly into the bladder than anteriorly through the distal urethra. The man affected by this disorder is aware of orgasm occurring but notices absence of sensation of fluid spurting through the distal urethra. Normally during ejaculation the bladder neck closes and blocks backward passage of seminal fluid. Conditions that alter the anatomic integrity of bladder neck ( scarring of bladder neck ) or that interfere with its neurogenic tone may produce retrograde ejaculation.

18. Retrograde Ejaculation

19. Retrograde ejaculation

20. Causes of retrograde ejaculation :- 1 . Bladder neck incompetence :- Retrograde ejaculation can follow any form of damage to the bladder neck such as occurring after transurethral resection of prostate, urethrotomy. 2. Damage or removal of sympathetic chain :- Because of the site of the sympathetic chain, any operation that takes place anteriorly or in close proximity to lumbar spine may give rise to disorders of ejaculation. 3. Pelvic surgery :- Operations in the pelvis may also damage the hypogastric nerve plexus and result in ejaculatory disorder. 4 . Urethral obstruction :- Urethral strictures( abnormal urethral pressure system ), Large ectopic urethrocele 5. Diabetes, neurological diseases, increased Prolactin

21. Abnormalities that mimic retrograde ejaculation :- Most important is ejaculatory duct obstruction in which there is exclusion of testicular and seminal vesicle components in ejaculate. Diagnosis of ejaculatory duct obstruction is traditionally relied on semen evaluation: a small ejaculate volume, azoospermia, and absence of fructose. However this description may become more complex if the obstruction is unilateral or partial. Some patients may be severely oligozoospermic as opposed to being azoospermic and fructose may be marginally positive. Nevertheless, absence of fructose in presence of normal FSH, LH and Testosterone and adequate spermatogenesis on testes biopsy should suggest the possibility of ejaculatory duct obstruction.

22. A diagnostic problem may also arise however, in a man, who along with retrograde ejaculation is also azoospermic. In these circumstances diagnosis of retrograde ejaculation is made by measuring one of the more stable seminal markers such as fructose or acid phosphatase in the post coital urine specimen. Ejaculatory failure ( Anejaculation ) - In this condition there is no emission and thus there can be no ejaculation. Retrograde ejaculation, specially, when it is due to neurological cause, can , with time, progress to ejaculatory failure. In this condition, there is no passage of any of the secretions that make up seminal fluid in the posterior urethra, i.e. emission as well as ejaculation has failed. Patient may experience normal or decreased orgasmic sensations with contractions, but no ejaculate is expelled.

23. A detailed history and a non-viscous, fructose negative, and sperm negative post orgasmic urine analysis will confirm diagnosis of an-ejaculation. Anorgasmia ( absent orgasm ):- Anorgasmia is a perceived absence of the orgasm experience, independent of whether or not all of the physiologic concomitants of ejaculation have taken place. It is typically seen in 1. Myopathies. 2. Severe drug abuse.

24. Causes of An-ejaculation :- Although ejaculatory failure can be idiopathic and can be caused by all the neurological diseases, it in fact has two common causes- diabetes mellitus and spinal injury. Diabetes - Ejaculatory failure in diabetic patients may be preceded by retrograde ejaculation. Spinal cord injury - Results in the absence of ejaculation in approximately 90-95% patients. Evaluation : -Evaluation of orgasm phase disorder is best begun by clarification of problem as perceived by patient. In medical parlance, there may be retarded or partially retarded ejaculation, retrograde ejaculation, or anejaculatory orgasm. Orgasm may be totally absent or painful.

25. - Detailed genitourinary history :- A chronologic history of any urologic disease, modalities of diagnosis and teratment. Any ongoing problems are elicited. - Medical history :- List of medications being taken, why & when begun, alcoholic intake, smoking habits, drug usage. Physical examination :- B.P. checking. -Location of any surgical incisions. -Examination of abdomen, inguinal areas, external genitalia. -Digital rectal examination of prostate- its size, shape and texture. - Neurological examination where applicable, checking of reflexes, cutaneous sensations and motor strength .

26. Laboratory investigations :- -Blood sugar. -Urine analysis for microscopic sediments. -C/S of prostatic secretions. -Microscopic examination of urine voided after ejaculation for presence of spermatozoa to differentiate between retrograde and anejaculatory orgasm. -If there is associated problem of desire or ED, then endocrinological evaluation including Testosterone, Prolactin and LH.

27. Treatment :- Treatment of orgasmic disorders is rarely needed in this age group. Simple explanation of the problem and assurance is sufficient. Treatment is given when the problem is because of any side effect of drug or fertility is a concern. First of all control blood sugar and correct any hormonal abnormality e.g. hypogonadism, thyroid disorder. Drug therapy for SSRI-induced dysfunction :- Drug Symptom Doses Daily ( as needed ) 75-100mg Amantadine Anorgasmia 100-400mg BD or TD Decreased libido ( for 2 days ED prior to coitus) Bupropion Anorgasmia 75-150 mg 75mg BD or TD

28. Buspirone Anorgasmia 15-60mg 5- 15mg BD Decreased libido ED Cyproheptadine Anorgasmia 4-12mg on demand Decreased libido ED If ejaculatory dysfunction is result of administration of any medication, this agent should be altered or stopped if possible. In some patients whose ejaculatory dysfunction is either neurological or not associated with bladder neck scarring, sympathomimetic agents may partially or completely convert the patient to antegrade ejaculation.

29. Some alpha-adrenergic sympathomimetic agents act through increased closure pressure at the internal urinary sphincter via a release of norepinephrine from terminal nerve endings and stimulation of adrenergic receptor site. Others ( for example imipramine hydrochloride, a tricyclic antidepressant ) block the reuptake of norepinephrine at nerve terminals, potentiating the adrenergic activity. In anejaculatory patients injections of Human Chorionic Gonadotrophin increases incidence of nocturnal emission. In paraplegic patients application of a vibrator to penis will lead to ejaculation, in others electroejaculation may be necessary to produce spermatozoa. Ejaculatory duct obstruction can be treated endoscopically .

30. References:- 1. Retarded Ejaculation : Michael A, Perelman, PhD, Current Sexual health reports 2004,1:95-101 2. Disorders of Orgasm and Ejaculation in men : Chris G. MCmahon,MB,BS, in Sexual Dysfunction in male and female, by T F Lue, R.Basson,R.Rosen 3. Male infertility: By Anne M. Jequier 4. The Evaluation of Sexual Disorders : Psychological and Medical Aspects. By Helen Singer Kaplan, M.D.,PhD 5. Male Infertility :By F.H.Comhaire 6. Text Book of Sexual Medicine : Robert C.Kolodny,William H. Masters, Virginia E. Johnson 7. Assessment of aging man with sexual dysfunction: By Sidney Glina in Men’s Health and Aging by Bruno Lunenfeld Louis JG Gooren,Alvaro Morales

31. This presentation can be downloaded from our institutional web site: www.shcrc.org

32. Thank You