Disorders of Ejaculation Affecting Sexual Function and Fertility

By John E. Grantmyre, MD

Fall 2007

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.

 

Ejaculation delivers sperm from its storage location in the epididymis (behind the testicle), through the vas deferens and ejaculatory duct and out into the urethra. From the urethra the sperm are ejected into the vagina, penetrate the cervical mucus, and then swim through the uterus to hopefully find a receptive egg higher in the fallopian tubes. In many ways this is an incredible feat - we split our genetic blueprint in two, stick the chromosomes in a tadpole (sperm), propel millions of tadpoles out of our body and then mix our DNA with someone else’s. And then, incredibly, a unique person begins. All this, quietly, in the dark, over and over since our species began.

 

The process of ejaculation begins with genital stimulation in combination with erotic impulses from the brain. Ejaculation can occur with or without erection. Once a critical level of stimulation is achieved, sperm are emptied from the epididymis and then mixed with the secretions of the seminal vesicles and the prostate. These secretions compose the vast majority of the ejaculate volume and provide energy sources for the sperm. At the time of ejaculation the bladder neck closes and muscular contraction results in propulsion of the semen outwards.

 

The main reflex which co-ordinates the ejaculation process is located in the mid-portion of the spinal cord. The nerves and the neurotransmitters involved in the process are complex and only partially understood, but it is clear that the neurotransmitter serotonin is one of the main inhibitors of ejaculation and, at least in rodents, the neurotransmitter dopamine has a major effect on facilitating ejaculation.

 

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.

 

Spinal cord injury affects approximately 36,000 Canadians, most of whom are men and most of whom have not completed their family at the time of injury. Although some men with incomplete spinal cord injury do have ejaculatory function, complete spinal cord injury is rarely associated with spontaneous ejaculation or pregnancy.

 

Evaluation of men with absent ejaculation initially involves a routine hormone evaluation including FSH, LH, Testosterone and Prolactin. These are the hormones that are involved in sperm production and serve as a screening test to prove that the production within the testicle is normal. A genital exam confirms normal anatomy and helps define any nerve damage or disease.

 

The treatment of absent ejaculation, if it is caused by medication, obviously involves changing the offending drug but frequently this is not possible. Most often, a sperm retrieval procedure will be required. Initially this could be vibratory stimulation of ejaculation using a commercially available vibrator (e.g. Ferticare vibrator). This is frequently successful in patients with an incomplete neurological injury and in men with a complete injury that is above the ejaculatory centre in the mid-portion of the spinal cord. Men with high spinal injuries are at risk of autonomic dysreflexia (sudden elevation in blood pressure) and should initially try this treatment in the clinic. Vibratory stimulation is also effective in patients who have a psychological failure of ejaculation.

Vibratory stimulation has a success rate as high as 85% depending on the reason for the ejaculatory failure. Sperm retrieved by this method can be used for in-vitro fertilization, intrauterine insemination or for home insemination by some couples. Home insemination at the time of ovulation significantly decreases the costs associated with the procedure.

 

When vibratory ejaculation is unsuccessful, electro-ejaculation can often succeed. This procedure involves placing a probe within the rectum and then increasing an electrical current, which causes a contraction of the pelvic muscles expelling the sperm. The procedure has a sperm recovery rate over 90% but quality of the sperm retrieved in this manner is not as good as with vibratory stimulation. Clearly this is not a procedure that can be done at home and, because of the medical personnel and equipment required, it could often be difficult to co-ordinate the procedure with a fresh intrauterine insemination. More commonly, sperm are frozen and used for in-vitro fertilization at a later date. This approach leads to higher costs and a risk of multiple births. Alternatively, or if induced ejaculation is ineffective, sperm can be retrieved percutaneously using a small needle placed in the vas deferens, the epididymis or the testicle. Only small numbers of sperm are retrieved by this method and they can be used frozen or fresh but only for in-vitro fertilization.

 

One acute and potentially disastrous problem with ejaculatory failure occurs when a man is suddenly unable to ejaculate at the time of IVF treatment. His partner has already received numerous, expensive medications and has undergone an egg retrieval but try as he may, nothing happens. Although a number of treatments have been advocated the most practical is the use of a vibrator that can salvage the situation. Aspiration of sperm is possible if trained staff is available. Individuals who are on medications known to affect ejaculation or who have had difficulty obtaining specimens in the past should probably freeze sperm ahead of time to avoid this difficult situation.

 

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.

 

Treatment of premature ejaculation can involve behavioural approaches such as the ‘start and stop’ techniques and squeeze techniques that were popularized by psychologists such as Masters and Johnson. These techniques can be effective, at least in the short term, but do require an interested partner and a trained therapist. One fairly easy treatment is the use of numbing creams such as Lidocaine or Prilocaine applied to the penis twenty minutes before sexual activity. Most studies have shown significant improvement with this approach although they require the use of a condom to prevent numbness of the vagina. Condoms with numbing creams already applied are now widely available in the contraceptive section of drug stores.

 

The most popular approach to treatment of premature ejaculation has been the use of antidepressant medications. These drugs help depression by increasing the levels of serotonin in the brain. One side effect is an inhibitory effect on ejaculation. The drug most popular currently is paroxetine (Paxil). The class of this type of drug, called the SSRIs (selective serotonin reuptake inhibitor), can cause dry mouth, fatigue, and, at times, erectile dysfunction. A new drug called dapoxetine is anxiously awaited by the market, as this medication appears to be more effective than the other SSRIs and can be used on an as-necessary basis instead of with daily dosing. This drug is yet to be approved by the FDA or Health Canada. Some men are reluctant to take a medication that has effects on the brain and prefer to try one of the Viagra-type drugs. This can be effective particularly in older men who also have some degree of difficulty achieving a full erection. In younger men it can allow a second erection quickly after initial ejaculation and circumvent the problem. Currently, the use of the SSRI medications or the Viagra-type drugs is not an ‘approved’ use and it is important that the patients consider the possible side effects carefully before taking any medication, particularly if the indication is largely to improve a recreational activity.

 

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 underappreciated.

 

Dr. Grantmyre is a Professor of Urology at Dalhousie University in Halifax. His Infertility and Andrology training was completed at Baylor College of Medicine in Houston, Texas. He has initiated new programs in microsurgical reconstruction, induced ejaculation, and other forms of sperm retrieval for treatment of male infertility at Dalhousie. He is the past Secretary/Treasurer of the Canadian Andropause Society, a past member of the Executive of the Canadian Urology Association and Past President of the Canadian Fertility and Andrology Society.