Ejaculatory disorders, while not receiving the same media exposure as problems with erectile function, are by far the most common sexual problems in men.
Almost half of men over 50 years of age notice some degree of ejaculatory disturbance, and of these men 60% are significantly bothered by these symptoms. Others suffer from lifelong problems including 30—40% of men with premature ejaculation. On the other end of the spectrum, as many as 4% of men suffer from significant problems with delayed ejaculation. These estimates are derived from studies of large populations and we know that a number of disease processes and medications can result in much higher rates of ejaculatory disturbance in certain groups at higher risk. Ejaculatory disturbances can affect both sexual functioning and fertility.
When a man presents with no ejaculation at all, the first question is whether or not he has sensation of orgasm. If so, it is possible that the ejaculation is going back into the bladder. A simple urine test after orgasm would show the presence of large numbers of sperm in the urine and a diagnosis of retrograde ejaculation would be confirmed. On the other hand, if there is no ejaculation, no sensation of orgasm and no sperm in the urine, then absent ejaculation is confirmed.There are a number of medications that can cause absent ejaculation. The more common would be anti-psychotic medications and medications used to treat Parkinson’s disease and depression. Surgical procedures in the pelvis or rectal area can often affect the nerves allowing ejaculation. Prostate cancer surgery removes the prostate as well as the seminal vesicles resulting in no ejaculation.A number of neurological conditions such as multiple sclerosis or spina bifida can impair ejaculation. Diabetes can affect ejaculation in as many as a third of men with long-standing disease. Fortunately, it most often causes retrograde ejaculation that is more easily treated than absent ejaculation.
Generally the same types of medications and neurological problems can cause retrograde ejaculation as cause absent ejaculation. One of the more common medications used for treating prostate enlargement, the alpha-blockers (e.g. Flomax), can frequently result in retrograde ejaculation as the bladder neck is so open to help voiding that it does not close during ejaculation. Prostate surgery (for enlargement, not cancer), while uncommonly performed in men who are at an age where they are concerned about fertility, is notorious for causing retrograde ejaculation in over 70% of men.
Once retrograde ejaculation is established by the presence of sperm in the urine, the initial approach would be to give medication that would help close the bladder neck if possible. Typically one would use an alpha agonist (the opposite of an alpha blocker) such as pseudoephedrine which is present in sinus medications (e.g. Sudafed), and occasionally this can be effective, particularly in diabetic men. If this is not successful then a bladder wash procedure can be performed in which one drains the urine from the bladder and replaces it with a sperm-friendly solution. The fluid in the bladder is collected after ejaculation and then processed and used for intrauterine insemination or in-vitro fertilization. Pregnancies rates in excess of 60% have been reported for treatment of retrograde ejaculation, as often large numbers of healthy sperm can be recovered.
As mentioned earlier, premature ejaculation is an extremely common problem perhaps affecting a third of men and generally being a lifelong problem. There are no normal values as far as the time of ejaculation although the usual time is between two and ten minutes. Generally, research studies on premature ejaculation have included men with ejaculatory times of less than two minutes. One study of otherwise healthy men found that 9% have ejaculation before vaginal penetration at times. This results not only in a disappointing sexual experience, but also potential problems with infertility. The psychological effects of premature ejaculation can be significant as they can erode self-confidence and result in difficulty with relationships and a cessation of intimacy. A number of theories exist as to why some men suffer from premature ejaculation but at this point they remain only theories.
Delayed ejaculation likely affects more men than is generally appreciated. While many of those suffering from premature ejaculation might be envious of this problem, it can cause considerable problems in relationships as often the partner will have feelings of unattractiveness. Delayed ejaculation can result from neurological disease or from medications, particularly high doses of the SSRIs mentioned earlier. When medications cannot be changed, or the problem is a neurological disease or of unknown cause, the use of vibrators as for absent ejaculation can be highly effective. If not, these men also would be candidates for sperm retrieval procedures but obviously this will not benefit their day-to-day sexual functioning. In certain cases, psychological counseling will also be required in cases of delayed ejaculation.
Ejaculatory disorders are the most common sexual dysfunction in men and in their extreme they can cause infertility and sexual disharmony. Effective treatments do exist and are probably underutilized just as the magnitudes of ejaculatory disturbances are probably under appreciated.