Ejaculation disorders - Failure to launch
EJACULATION is not as well understood as the other physiological processes of sexual functions. Ejaculation disorders are common yet may be difficult to treat adequately.
There are two sequential processes in ejaculation which, when associated with emotional and psychological processes, is termed orgasm. The first process is called emission and involves the deposition of seminal fluid in the posterior urethra. Simultaneous contraction of the vas deferens, seminal vesicles and the muscles of the prostate leads to the formation of the ejaculate fluid, the majority of the volume coming from the seminal vesicles. The sperms are added from the vas deferens close to the prostate.
The second process is true ejaculation and involves contraction of the perineal muscles which forcibly expels the ejaculate from the urethral opening (meatus). Ejaculation is controlled by the nervous system at the level of the spinal cord and the brain.
Premature ejaculation (PE) is the most common male sexual dysfunction in men below the age of 40 years. PE is associated with psychological distress like anxiety and depression.
It is necessary to establish whether the PE is life-long or acquired and to assess the severity of the problem. The physical examination would focus on the male’s secondary sex characteristics, urological and neurological examination. Laboratory and other investigations may be indicated. Any medical problem (such as diabetes or cardiovascular problems) need to be treated.
Treatment is primarily medical which may be topical or systemic. The former involves the use of a condom or local anaesthetic to decrease the sensitivity of the penile tip. Local anaesthetic gel or cream applied 15 to 30 minutes prior to intercourse have been shown to increase the time to ejaculation in more than 75% of men treated.
The selective serotonin reuptake inhibitors (SSRI) used in the treatment of depression are associated with retarded or absent ejaculation. This side effect is unwanted in patients treated for depression but it is a desirable one in those with PE.
The choice of SSRI may vary but they are prescribed as a daily dose until ejaculation returns to normal and then as needed. SSRIs have side effects with the potential to cause harm. As such, it is essential that they are taken under medical supervision. Self medication can be dangerous.
Retrograde ejaculation is a condition in which part or all of the ejaculate is deposited in the bladder instead of out of the body through the penis. The affected male still experiences an orgasm but the volume of the ejaculate out of the penis is decreased; sometimes the volume is zero. The condition is due to deficient closure of the bladder neck.
There are many causes of this condition including diabetes, spinal cord injury, some medicines and prostate surgery. It is estimated that 30% of diabetics and 25% to 30% of men after transurethral resection of the prostate have this problem. The diagnosis is made when a large amount of sperm is found in the urine sample taken soon after ejaculation.
The condition can cause infertility but is otherwise harmless. No treatment is necessary unless infertility is an issue. Treatment is challenging. About a third of men improve after treatment with medicines that close the bladder neck, such as pseudoephedrine, phenylephrine, chlorpheniramine, brompheniramine and imipramine. These medicines are given an hour or two prior to intercourse or daily. Most of the medicines increase the heart rate and blood pressure, so its use in men with heart disease or hypertension can be harmful. If infertility is an issue and medicines are not helpful, the male’s sperms can be collected and artificial insemination carried out. Surgery has been described but is rarely successful.
Haematospermia is a common condition in which there is blood in the ejaculate, which is usually painless, brown or dark. In most instances, especially in younger men, it is of no significance but in some patients, it is an indicator of urological conditions like prostatitis, seminal vasculitis, prostatic stones and rarely, prostatic cancer. If there is pain, the usual cause is prostatitis but it may be due to duct obstruction or prostatic cancer.
In general, evaluation is required if there are 10 or more instances of haematospermia. The physical examination includes checking the blood pressure because severe hypertension is associated with haematospermia and a urological examination. Laboratory and other examinations may also be necessary.
The extent of the evaluation and treatment is influenced by the patient’s age, the duration and recurrence, and the presence of blood in the urine (haematuria). Reassurance and allaying the anxiety of the affected person is vital, especially in younger men. The treatment would depend on the cause identified.
Dr Milton Lum is a member of the board of Medical Defence Malaysia. This article is not intended to replace, dictate or define evaluation by a qualified doctor. The views expressed do not represent that of any organisation the writer is associated with.
There are two sequential processes in ejaculation which, when associated with emotional and psychological processes, is termed orgasm. The first process is called emission and involves the deposition of seminal fluid in the posterior urethra. Simultaneous contraction of the vas deferens, seminal vesicles and the muscles of the prostate leads to the formation of the ejaculate fluid, the majority of the volume coming from the seminal vesicles. The sperms are added from the vas deferens close to the prostate.
The second process is true ejaculation and involves contraction of the perineal muscles which forcibly expels the ejaculate from the urethral opening (meatus). Ejaculation is controlled by the nervous system at the level of the spinal cord and the brain.
Premature ejaculation (PE) is the most common male sexual dysfunction in men below the age of 40 years. PE is associated with psychological distress like anxiety and depression.
It is necessary to establish whether the PE is life-long or acquired and to assess the severity of the problem. The physical examination would focus on the male’s secondary sex characteristics, urological and neurological examination. Laboratory and other investigations may be indicated. Any medical problem (such as diabetes or cardiovascular problems) need to be treated.
Treatment is primarily medical which may be topical or systemic. The former involves the use of a condom or local anaesthetic to decrease the sensitivity of the penile tip. Local anaesthetic gel or cream applied 15 to 30 minutes prior to intercourse have been shown to increase the time to ejaculation in more than 75% of men treated.
The selective serotonin reuptake inhibitors (SSRI) used in the treatment of depression are associated with retarded or absent ejaculation. This side effect is unwanted in patients treated for depression but it is a desirable one in those with PE.
The choice of SSRI may vary but they are prescribed as a daily dose until ejaculation returns to normal and then as needed. SSRIs have side effects with the potential to cause harm. As such, it is essential that they are taken under medical supervision. Self medication can be dangerous.
Retrograde ejaculation is a condition in which part or all of the ejaculate is deposited in the bladder instead of out of the body through the penis. The affected male still experiences an orgasm but the volume of the ejaculate out of the penis is decreased; sometimes the volume is zero. The condition is due to deficient closure of the bladder neck.
There are many causes of this condition including diabetes, spinal cord injury, some medicines and prostate surgery. It is estimated that 30% of diabetics and 25% to 30% of men after transurethral resection of the prostate have this problem. The diagnosis is made when a large amount of sperm is found in the urine sample taken soon after ejaculation.
The condition can cause infertility but is otherwise harmless. No treatment is necessary unless infertility is an issue. Treatment is challenging. About a third of men improve after treatment with medicines that close the bladder neck, such as pseudoephedrine, phenylephrine, chlorpheniramine, brompheniramine and imipramine. These medicines are given an hour or two prior to intercourse or daily. Most of the medicines increase the heart rate and blood pressure, so its use in men with heart disease or hypertension can be harmful. If infertility is an issue and medicines are not helpful, the male’s sperms can be collected and artificial insemination carried out. Surgery has been described but is rarely successful.
Haematospermia is a common condition in which there is blood in the ejaculate, which is usually painless, brown or dark. In most instances, especially in younger men, it is of no significance but in some patients, it is an indicator of urological conditions like prostatitis, seminal vasculitis, prostatic stones and rarely, prostatic cancer. If there is pain, the usual cause is prostatitis but it may be due to duct obstruction or prostatic cancer.
In general, evaluation is required if there are 10 or more instances of haematospermia. The physical examination includes checking the blood pressure because severe hypertension is associated with haematospermia and a urological examination. Laboratory and other examinations may also be necessary.
The extent of the evaluation and treatment is influenced by the patient’s age, the duration and recurrence, and the presence of blood in the urine (haematuria). Reassurance and allaying the anxiety of the affected person is vital, especially in younger men. The treatment would depend on the cause identified.
Dr Milton Lum is a member of the board of Medical Defence Malaysia. This article is not intended to replace, dictate or define evaluation by a qualified doctor. The views expressed do not represent that of any organisation the writer is associated with.
MOHD ADHA MOHD ZAIN (ADHA ZAIN)
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