Ejaculation disorders are sexual dysfunction, expressed in a permanent or episodically recurring disorder of the ejaculation process. Ejaculation disorders include accelerated, delayed, retrograde ejaculation and lack of ejaculation (anejaculation). Ejaculation disorders may be accompanied by male anorgasmia or combined with erectile dysfunction. Diagnostic tactics for ejaculation disorders include a complete clinical, instrumental and laboratory examination of the patient: examination, functional tests, ultrasound of the male genitals, examination of prostate and urine secretions, urethroscopy, etc. Treatment may include psychotherapy, behavioral therapy, medication and physiotherapy of inflammatory processes of the urogenital tract, according to indications – surgical intervention.
Ejaculation disorders are a concept that combines various types of ejaculatory disorders (premature ejaculation, delayed ejaculation, aneaculation, retrograde ejaculation). Among the various forms of sexual dysfunction in men, ejaculation disorders account for about 40%. Depending on the underlying causes of ejaculation disorders, specialists from the field of urology, andrology, neurology, endocrinology, psychology, and sexology can be involved in solving the problem.
Ejaculation (ejaculation of seminal fluid through the external opening of the urethra) is a complex reflex act that plays an important role in a man’s sexual life and provides the possibility of natural procreation. Ejaculation is a natural result of stimulation of the penis or occurs involuntarily (emission). It is believed that normally in men who have sex, ejaculation occurs 2-3 minutes after the beginning of the frictional period, but this indicator can vary significantly depending on the age, sexual experience, psychological and physical condition of the man.
The ejaculation process includes several successive stages: emission, pre-ejaculation and ejaculation proper, accompanied by orgasm. During the emission phase, the contents of the epididymis (spermatozoa), the secretion of the prostate gland and seminal vesicles are released into the prostatic urethra. Almost simultaneously, the neck of the bladder contracts, preventing retrograde discharge of seminal fluid into the bladder (pre-ejaculation). This is followed by the expulsion phase – the ejection of seminal fluid from the urethra outside as a result of a series of rhythmic contractions of the bulbo-spongiose, sciatic-cavernous and other perineal muscles. The ejaculation process is provided by multilevel nervous regulation, including the ordered interaction of the sympathetic (emission and pre-ejaculation), parasympathetic, somatic nervous system, central nervous system (ejaculation and orgasm). Disorders that occur at one of the levels of regulation cause ejaculation disorders that differ in their manifestations and severity.
According to the time of occurrence, there are primary (arising with the onset of sexual life) and secondary ejaculation disorders (developed after a period of normal sexual function). Depending on the clinical form and mechanisms of dysfunction, the following forms of ejaculation disorders are distinguished:
- premature ejaculation (true and false)
- painful ejaculation
- asthenic ejaculation
- delayed ejaculation
- absence of ejaculation (anejaculation, anejaculatory syndrome) associated with emission disorders, aspermia, and other factors
- retrograde ejaculation.
The causes of ejaculation disorders may be organic and psychogenic in nature. Thus, accelerated ejaculation of organic genesis is observed in urological diseases (prostatitis, urethritis, colliculitis, prostate adenoma, hypersensitivity of the glans penis), anatomical anomalies (short frenulum of the foreskin), neurological pathology (pelvic fractures, spinal cord injury). Psychogenic premature ejaculation is most often found in sexually inexperienced men, with rare sexual contacts, excessive sexual arousal, stressful situations, fear of failure, etc.
Psychological factors leading to delayed ejaculation and aneaculation may be sexual complexes and restrictions, low sexual attractiveness of a sexual partner, depression, problems in interpersonal relationships with a woman. The organic substrate that causes ejaculation disorders can be neurological (Parkinson’s disease, multiple sclerosis, stroke, polyneuropathy), endocrine (hypothyroidism, hypogonadism), urological (STDs, penile injuries, prostate surgery, etc.) pathology.
The causes of retrograde ejaculation are usually pathological conditions accompanied by a violation of the innervation of the neck of the bladder. The development of such disorders is possible against the background of congenital anomalies of the posterior urethra and bladder, sclerosis of the bladder neck, diabetic neuropathy, after surgery on the bladder and prostate. Asthenic ejaculation is usually associated with pathology of the urethra (valves or stricture of the urethra, etc.) or neurogenic causes (spinal cord injuries, sympathectomy, retroperitoneal lymphadenectomy, colon surgery). Violation of ejaculation by the type of painful ejaculation occurs in chronic prostatitis, chronic pelvic pain syndrome, urethritis, obstruction of the vas deferens.
Various ejaculation disorders are often a side effect of certain medications (antihypertensive, diuretics, antidepressants, adrenoblockers), develop when taking alcohol and drugs. In some cases, men are diagnosed with idiopathic ejaculation disorder, the etiological factor of which cannot be established.
According to WHO criteria, premature ejaculation is considered to have occurred before sexual intercourse or less than 1 minute after its beginning and does not lead to sexual satisfaction of one or both sexual partners. With delayed ejaculation, on the contrary, a man is unable to achieve ejaculation, despite prolonged sexual stimulation. A delay in ejaculation is usually said if it does not occur 20-30 minutes after the start of frictions, contrary to the mutual desire and desire of partners to complete sexual intercourse. With retrograde ejaculation, the ejaculate is not ejected antegrade (from the urethra outside), but enters in the opposite direction (into the bladder). In this case, the seminal fluid is not released at all or the volume of the ejaculate is too small. Such a violation of ejaculation can also be suspected by the release of cloudy urine after sexual intercourse. Delayed, retrograde ejaculation and aneaculation can act as factors of male infertility.
Asthenic ejaculation (“ejaculatory jelly”, partial ejaculatory dysfunction) is based on a violation of rhythmic muscle contractions of smooth muscles, providing a jolt-like ejaculation of seminal fluid from the urethra. This violation of ejaculation is accompanied by erased orgasmic sensations, but the quality of the ejaculate does not change, and the fertility of the man does not suffer. Painful ejaculation is often combined with dysuric disorders. In this case, a violation of ejaculation is characterized by pain along the urethra and in the perineum. Various ejaculation disorders can cause the development of decreased libido and impotence. The consequence of ejaculation disorders can be conflicts in a couple, refusal of sex and even a breakup of a relationship.
A patient who has turned to a urologist or andrologist with complaints of ejaculation disorders should be carefully examined to exclude neurological, endocrine, urological and other pathologies. During the initial examination, a thorough clarification of complaints, anamnesis, concomitant diseases, psychosexual status is carried out; examination of the external genitals and prostate gland. According to the indications, the patient is recommended to consult specialists: neurologist, endocrinologist, venereologist, sexologist.
To detect partial or complete retrograde ejaculation, a post-ejaculatory urine test is performed. An important role among the methods of laboratory examination of patients with ejaculation disorders is played by the study of prostate secretion (after preliminary prostate massage), bacteriological seeding of a urethral smear, ELISA and PCR diagnostics of infections. As necessary, the laboratory complex is supplemented with instrumental studies: ultrasound of the prostate gland and scrotum organs, determination of evoked potentials of the dorsal nerve of the penis, urethroscopy, cystoscopy, uroflowmetry, etc. In case of ejaculation disorders, various functional tests can be carried out aimed at clarifying the organic or psychogenic nature of the dysfunction.
General principles of treatment of various forms of ejaculation disorders include etiotropic and symptomatic drug therapy, psychosexual counseling, behavioral psychotherapy, physiotherapy. In the case of a pharmacoinduced ejaculation disorder, medication is canceled or adjusted. If an etiologically significant concomitant pathology is detected (diabetes mellitus, sexual infections, nonspecific urogenital inflammation, neurological pathology, etc.), appropriate treatment is prescribed. In case of premature ejaculation, local anesthetic drugs are used, prolonging sexual intercourse and delaying intravaginal ejaculation. With retrograde ejaculation, sexual intercourse is recommended to be performed with a full bladder. Additional methods of therapy for ejaculation disorders include acupuncture, general baths, electrical stimulation, massage, vibration stimulation, etc.
Surgical methods of treating premature ejaculation may include denervation-renervation of the glans penis, plastic surgery of the short frenulum of the penis. In the case of infertility caused by a violation of ejaculation, it is possible to consider the use of assisted reproductive technologies (IVF).
Most cases of ejaculation disorders can be cured with the help of adequate pharmacotherapy, psychotherapy and other methods of influence. An integrated and individualized approach allows to normalize a man’s sexual function and harmonize sexual relations. In cases of ejaculation disorders caused by organic causes, the prognosis of sexual function restoration largely depends on the possibility and success of correction of the concomitant pathological condition. It is very important that sexual partners who are faced with the problem of ejaculation disorders overcome the difficulties that have arisen together.