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Treatment Options for Patients with Ejaculatory Dysfunction

R. Matthew Coward, M.D., FACS
Assistant Professor of Urology, UNC School of Medicine, Chapel Hill, N.C.
Director of Male Reproductive Medicine and Surgery, UNC Fertility, Raleigh, N.C.

Despite receiving much less attention than erectile dysfunction and other male fertility problems due to its sensitive nature, ejaculatory dysfunction is among the most common sexual disorders worldwide and can be one of the most frustrating sexual symptoms a couple can experience.

What is ejaculation?
The purpose of ejaculation is to deposit sperm into the vagina for reproduction, and most men with these problems seeking an evaluation are younger patients desiring fertility. During normal ejaculation, the neck of the bladder is closed and the semen is expelled through the urethra and out the tip of the penis. Ejaculatory dysfunction can be characterized as premature, delayed, or absent ejaculation. The causes of absent ejaculation may include obstruction, retrograde ejaculation, or anejaculation. This brief review will focus on two common ejaculatory disorders that result in infertility: retrograde ejaculation and anejaculation.

What is retrograde ejaculation?
With retrograde ejaculation, the bladder neck is abnormally relaxed during climax and the semen enters the bladder rather than being expelled through the urethra. It is suspected with a very low volume or completely dry ejaculate, coupled with a normal sensation of climax.

What causes retrograde ejaculation?
Retrograde ejaculation may result from diabetes, neurologic problems, a side effect of certain medications (e.g., tamsulosin, used for treatment of urinary symptoms related to enlarged prostate), previous pelvic or transurethral surgery, or malformations of the bladder neck from birth. The most common cause of retrograde ejaculation is uncontrolled diabetes. Retrograde ejaculation should be ruled out as a first step in the workup of ejaculatory dysfunction, as treatment is often successful without invasive procedures. The evaluation involves examination of a urine sample after ejaculation.

How can retrograde ejaculation be treated?
Retrograde ejaculation can occasionally be normalized with correction of the underlying problem such as treatment of diabetes. Retrograde ejaculation may also be improved with the use of medications such as pseudoephedrine (more commonly used as a decongestant). If conservative measures are unsuccessful, sperm can be harvested from the urine after ejaculation for use with intrauterine insemination (IUI) or in vitro fertilization (IVF).

What is anejaculation?
Anejaculation (or aspermia) is the lack of a visible ejaculate during a normal climax in the absence of retrograde ejaculation, either from a neurologic condition or another sometimes unknown cause. Anejaculation is technically distinct from anorgasmia, which is the lack of climax, but these two entities share many of the same causes and treatment options, and, therefore, are often referred to as a single condition under the umbrella term anejaculation.

How can anejaculation be treated?
Anejaculation can occur with spinal cord injury, erectile dysfunction, hormone problems, or emotional inability. Treatment options to retrieve sperm for men with infertility due to anejaculation or anorgasmia include two different neurostimulatory methods.

Penile vibratory stimulation (PVS) is the recommended first-line treatment for anejaculation because it is simple, non-invasive, cost-effective, and successful in approximately 75% of cases. PVS for neurogenic anejaculation due to spinal cord injury is most effective for men with spinal cord lesions above T10. PVS is performed using a commercially available device which can be purchased online without a doctor’s prescription.

If PVS is unsuccessful or not desired, electroejaculation is more invasive alternative treatment of anejaculation that is almost uniformly successful. Electroejaculation is a minor procedure performed in the office without the need for anesthesia for men with spinal cord injury, in the office with deep sedation, or in the operating room with general anesthesia. Electroejaculation is utilized for men who are unable to ejaculate for any reason, most commonly due to spinal cord injury, previous pelvic surgery, medication side effects, diabetes, erectile dysfunction, multiple sclerosis or other neurologic disorders, or for men or adolescents unable to provide a sperm sample for any other reason. It may be particularly useful in the adolescent population in the setting of fertility preservation prior to cancer treatment if a semen sample cannot be provided. The sperm obtained with electroejaculation may then be frozen (cryopreserved) and stored for later use, or in some cases, may be used as a fresh semen sample for traditional IUI or IVF. During the 15-minute procedure, after anesthesia is induced, a rectal probe is gently positioned over the prostate and seminal vesicles. Activation of the device induces pulsatile electrical stimulation to achieve ejaculation. No external incisions are made, and complication rates are less than 1% and may include minor rectal discomfort or temporary bleeding. More than 95% of men undergoing electroejaculation achieve a semen sample for analysis, and more than 90% of men will have motile sperm for banking or for fresh use with fertility treatments.

When treatments with medications or neurostimulatory methods for ejaculatory dysfunction fail, there always remains an option for surgical sperm extraction. Using sedation or general anesthesia, sperm can be extracted directly from the testicle or epididymis with a minor outpatient procedure. Surgically extracted sperm can then be banked with cryopreservation and later used for IVF.

In summary, ejaculatory dysfunction is a common problem manifested in a variety of different disorders. Fortunately, with a careful evaluation from a male fertility specialist, treatment of ejaculatory dysfunction affords options to couples attempting to achieve pregnancy. There are medications, assistive neurostimulatory methods for ejaculation such as PVS and electroejaculation, and even surgical sperm retrieval, any of which can provide hope for a couple to have a family of their own in spite of one of the most discouraging problems causing male factor infertility.