Fig. 4.1
Physiology of ejaculation. Sympathetic innervation originates from segments T10-L2 and reaches the pelvic plexus via the hypogastric nerve. Parasympathetic innervation arises from segments S2 to S4 and reaches the pelvic plexus via the pelvic nerve. The pudendal nerve (segment S4) innervates the external sphincter, bulbospongiosus, and ischiocavernosus muscles and provides sensory fibers to the dorsal nerve of the penis
Seminal Emission
It is the deposition of seminal fluid to the posterior urethra. It involves muscular contraction of vas deferens, seminal vesicles, and prostate.
Bladder Neck Closure
Following emission bladder neck closes to prevent retrograde passage of semen to the urinary bladder. Both phases are under sympathetic α1 adrenergic nervous stimulation through superior and inferior hypogastric plexus (T10-L2 spinal centers).
Seminal Expulsion (Antegrade Ejaculation)
It is the forward expulsion of semen through the urethra. This is done through contraction of the bulbocavernosus muscle. The nervous control of this phase is by somatic nerve fibers from spinal segments S2–S4 and begins once the ejaculate has reached the urethra [3]. Here the external urethral sphincter relaxes while rhythmic peristaltic contractions of the periurethral and pelvic floor muscles move the ejaculate through the urethra and cause a pulsatile projectile ejaculation.
Ejaculatory Disorders
The well-known classification of ejaculatory disorders is the following:
Premature ejaculation : The most common and highly debatable male sexual dysfunction. Recently defined by International Society of Sexual Medicine in 2013 as a male sexual dysfunction characterized by ejaculation which always or nearly always occurs prior to or within 1 min of vaginal penetration, and the inability to delay ejaculation on all or nearly all vaginal penetrations, and negative personal consequences, such as distress bother, frustration, and/or avoidance of sexual intimacy [4, 5]. PE can either present from the first sexual experience or following a new bothersome change in ejaculatory latency.
Delayed ejaculation : Repeated or persistent difficulty in obtaining ejaculation following proper sexual stimulation [6].
Retrograde ejaculation (RE) : Failure of antegrade ejaculation due to retrograde passage of semen to the urinary bladder caused by failure of simultaneous closure of bladder neck with ejaculation [7].
Low ejaculate volume : This may be due to ejaculatory disorder like partial RE or anatomical obstruction of the ejaculatory duct (ED).
From the clinical point of view another classification for ejaculatory failure may be adopted to help in differential diagnosis:
- 1.
Anorgasmic Anejaculation :
This condition is characterized by persistent or recurrent absence of attaining orgasm after sufficient sexual stimulation. This may be situational or complete.
- (a)
Situational anejaculation :
The patient cannot ejaculate during certain conditions only, e.g., during semen sample collection for in vitro fertilization (IVF) . This may be due to inability to masturbate, erectile dysfunction, or psychological stress [8].
- (b)
Complete anejaculation :
The patient here never ejaculates with either masturbation or intercourse. It can be primary or secondary. By definition, primary anorgasmia begins from the male’s first sexual experiences and lasts throughout his life. However, secondary anorgasmia is preceded by a period of normal sexual experiences before the problem manifests [9].
The main cause for this condition is psychogenic due to fear and anxiety during sexual relations. The most common triggers for this anxiety are hurting the female, impregnating the female, childhood sexual abuse, sexual trauma, repressive sexual education/religion, sexual anxiety, or general anxiety or depression [5, 9].
- (a)
- 2.
Orgasmic Anejaculation:
In this condition, the patient reaches orgasm but doesn’t ejaculate. This can be subclassified into the following:
- (a)
Failure of emission :
This may be caused by different neurological disorders most commonly diabetes mellitus, spinal cord injury and multiple sclerosis, surgeries including retroperitoneal lymph node dissection (RPLND), or iatrogenic causes including the intake of some medications, e.g., tamsulosin. Ejaculatory duct obstruction may also lead to failure of deposition of semen in the posterior urethra. Ejaculatory duct obstruction (EDO) may be caused by a variety of reasons including congenital bilateral absent vas deferens, prostatic cysts, inflammatory (post-prostatitis), ED stones, and traumatic or iatrogenic injury of the ED [9, 10].
- (b)
Failure of bladder neck closure :
This will lead to retrograde ejaculation. It may be partial leading to low ejaculate volume or complete leading to anejaculation. It shares the neurological causes of failure of emission. Additionally it may be caused by iatrogenic injury of the external urethral sphincter during bladder neck surgeries or transurethral resection of the bladder.
- (c)
Failure of seminal expulsion :
This condition may be caused by urethral obstruction or failure of bulbocavernosus muscle contraction due to neurological causes.
- (a)
Diagnosis of Ejaculatory Failure
The first step in the management of ejaculatory failure is to reach a diagnosis of the condition as further management plan will be fashioned accordingly. This can be done through proper history taking, clinical examination, and investigations.
History Taking
A detailed sexual history is required to clarify the actual sexual activity. Special emphasis on the history of orgasm, history of ejaculation, and its physical characteristics is important to differentiate orgasmic from anorgasmic AE. Details of sexual preference, sexual stimulus, and erectile function are also necessary to differentiate situational from complete anorgasmic AE. A thorough psychological assessment may be further needed in cases with anorgasmic AE. Looking for etiologic factors for ejaculatory dysfunction such as chronic comorbidities (such as diabetes mellitus, spinal cord aliments, neuropathies) and previous surgeries (pelvic and retroperitoneal) may help in choosing correct therapeutic approaches.
Clinical Examination
General physical examination may help in identifying features of hypogonadism. Genital examination is crucial to assess penile sensations and to look for anatomical abnormalities, e.g., congenital absence of vas deferens. Digital rectal examination may recognize dilatation of seminal vesicles or presence of prostatic abnormalities.
Investigations
Serum testosterone levels will assess the patient’s gonadal state. Semen analysis showing low ejaculate volume, acidic pH, and negative fructose is diagnostic for ejaculatory duct obstruction. Postorgasmic urine analysis is needed to diagnose RE where sperm can be found in the postorgasmic urine sample differentiating it from AE. Imaging may also be needed. Transrectal ultrasound or MRI will help in the diagnosis of EDO.
Sperm retrieval in Ejaculatory Failure
The method used to retrieve sperm in cases presenting with ejaculatory failure depends mainly on the etiology. Usually the management takes stepwise approach starting with noninvasive methods ending by surgical sperm retrieval. As ejacultory failure can be a chronic condition, it is advised to do cryopreservation of the retrieved sperm to be used for future IVF trials.
Situational Anejaculation
The history guides our management in these cases. Usually these cases can be anticipated by having previous history of failure of ejaculation during semen collection procedures either for semen analysis or during IVF procedures.
If the patient has erectile dysfunction then he can benefit from using phosphodiesterase five inhibitors (PDE5i), usually short-acting PDE5i like sildenafil or vardenafil, or intracorporal injection of vasoactive agents, mostly prostaglandin E2 being the safest. For patients who cannot masturbate, coitus interruptus or sexual intercourse using spermicidal free condoms can solve the problem. Psychological stress of obtaining a semen sample can also be alleviated by instructing the patient to get the semen sample at home and deliver it to the laboratory within convenient time.
In case of failure of ejaculation despite use of these previous measures, vibratory stimulation, electroejaculation, or surgical sperm retrieval may be tried. These measures will be discussed in details later in this chapter.
Anorgasmic Complete Anejaculation
These cases are the most difficult to treat. Once a reversible cause is identified such as presence of hyperprolactinemia or hypogonadism or use of SSRI, it should be appropriately addressed initially.
Conditions associated with psychological disturbances may need prolonged psychotherapy and behavioral therapy with very limited success rates [11].
Pharmacological treatment usually has very limited success rates in these cases. Although there is no FDA-approved medication for anorgasmia, sympathomimetics may be tried [12, 13].
Orgasmic Anejaculation due to Ejaculatory Duct Obstruction
Surgical treatment of EDO is the classical treatment in cases associated with prostatic cysts or post-inflammatory EDO. This includes transurethral resection of the ejaculatory duct (TUR-ED) with deroofing of the cyst if present. In up to 75% of patients, sperm will return to the ejaculate and 25% of them can achieve normal pregnancy. The patients should be informed that complications rate can reach up to 20% and varies from transient hematuria and hematospermia to chronic epididymitis due to reflux of urine with chances of secondary epididymal obstruction [16].
In case of failure of TUR-ED or in cases where reconstruction is not feasible (e.g., congenital bilateral absent vas deferens), surgical sperm retrieval may be used successfully including percutaneous epididymal sperm aspiration , testicular aspiration , or biopsy.
Retrograde Ejaculation
RE had been managed through different approaches throughout history. Surgical approaches aimed at restoration of bladder neck integrity included bladder sphincter and/or neck reconstruction operations [17, 18]. However, there is limited data available regarding the success rate of such procedures. Injection of collagen into the bladder neck was another method described by Reynolds et al. [19] who reported success in achieving antegrade ejaculation, two subsequent pregnancies, and one live birth. However, again limited reports are available.
Many studies have reported achieving pregnancy in RE patients by IVF using sperm recovered from postorgasmic urine [20]. However, these sperm may often be of poor quality and may be unusable due to the acidity and osmolarity of urine [21]. Therefore, prior preparation of urine is needed. Some authors instilled sperm preparation media into the bladder by a catheter prior to ejaculation; however there are many complications for catheterization and even the K-Y gel used during catheterization may be lethal to sperm [21]. Others used pharmacological treatment to alkalinize urine by using NaHCO3 tablets on the days prior to sperm retrieval. NaHCO3 is dissolved in 500 mL of water to adjust both the pH and osmolarity of urine [7, 22]. Results of all these trials are contradictory and insufficient, but due to the simplicity and cost-effectiveness of this procedure, it is frequently tried for sperm retrieval in men with RE.
Medical treatment aiming at restoring ejaculation in men with RE is based on either increasing the sympathetic activity or decreasing the parasympathetic activity of the bladder neck. Alpha-adrenergic agonists and antihistaminic and anticholinergic medications such as pseudoephedrine, imipramine, chlorpheniramine, milodrin, and brompheniramine were previously used. The main drawbacks of these medications are their side effects which include elevated blood pressure, restlessness, sleep disturbances, dizziness, lethargy, dry mouth, and nausea [20, 23]. A meta-analysis of studies investigating the use of alpha-agonists, anticholinergics, and antihistamines for treatment of RE reported a success rate of 50% in achieving antegrade ejaculation. Moreover, spontaneous pregnancy was reported in 34% of patients seeking fertility during treatment [20]. Arafa and El Tabie reported a superior role for using combination of pseudoephedrine 120 mg and imipramine 25 mg twice daily in achieving antegrade ejaculation in diabetic patients with RE with a success rate of 62% and spontaneous pregnancy in 12% of cases [24]. Although the overall success rate of medical treatment is still not well studied, this treatment modality has to be considered the first choice. Second-line therapies include the use of penile vibrator and sperm recovery from postorgasmic urine or electroejaculation.
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