Practical Pathway for the Patient with Anejaculation

Educational Objectives

The goal of this program is to improve the management of anejaculation. After hearing and assimilating this program, the clinician will be better able to:

1. Formulate a diagnostic approach and treatment algorithm for patients with anejaculation.

Summary

Definition of anejaculation: failure to produce antegrade ejaculate in presence of orgasm; failure to achieve orgasm referred to as anorgasmia; delayed orgasm — majority caused by use of selective serotonin-reuptake inhibitors or serotonin-norepinephrine-reuptake inhibitors, loss of penile sensation (eg, in patients with diabetes mellitus), markedly low level of testosterone, hyperstimulation (eg, vigorous, frequent masturbation), or psychogenic causes (most commonly erectile dysfunction)

Causes of anejaculation: retrograde ejaculation (semen enters bladder); failure of emission of semen into prostatic urethra; causes cannot be distinguished by history and physical examination

Physiology of ejaculation: bladder neck and sphincter closed at time of orgasm; pressure in prostatic urethra increases; semen deposited into prostatic urethra; sphincter opens; periurethral muscular contraction (ischiocavernosus and bulbospongiosus) resulting in antegrade ejaculation; retrograde ejaculation caused by failure of bladder neck to close, with flow of semen into bladder

Etiologies of anejaculation: pharmacologic — α-blocking agents can cause both retrograde ejaculation and failure of emission; if patient on tamsulosin (powerful uroselective α-blocking agent), switching to alfuzosin often resolves problem; neurogenic — caused by interference with nerves responsible for contraction of bladder neck or emission, eg, from diabetes mellitus, multiple sclerosis, and retroperitoneal surgery; chemotherapy — causes autonomic neuropathy; mechanical — from surgery of bladder neck (eg, repair of bladder exstrophy); results in lifetime anejaculation

Evaluation: ask patient what bothers him about anejaculation; homosexual men more commonly bothered by condition; however, 30% of heterosexual men with anejaculation profoundly bothered (interferes with sense of manhood); consider concern for fertility; identify possible causative factors; obtain thorough medical, surgical, medication, and sexual history; postorgasmic semen analysis — cornerstone of diagnostic workup; distinguishes retrograde ejaculation from failure of emission; requires abstinence from sexual activity for 2 to 4 days, normal consumption of liquids before test (avoid overhydration), collection at sperm bank, and voiding before test; ejaculation with masturbation collected in cup 1 (usually empty), followed by voiding 10 to 15 min later into cup 2; failure of emission defined as absence of sperm in urine

Treatment strategies: discontinue any α-blocking agents; administer trial of α-agonist agent; fertility — in men with retrograde ejaculation, alkalinization of urine permits harvesting of sperm; electroejaculation is suitable in patients with failure of emission

Alpha-agonist agents: recommended dose of pseudoephedrine 60 mg 4 times daily; causes increase in blood pressure; rate of success 40% to 60% (based on case reports); rates of success in men with retrograde ejaculation higher; rate of success in men with failure of emission low; ineffective in men following retroperitoneal lymph node dissection; patients with failure of emission respond poorly to medical therapy

Electroejaculation: rate at which semen retrieved 95%; general anesthesia required; paralytic agents (including succinylcholine) may not be administered because they paralyze ejaculatory contraction apparatus in seminal vesicles and vasal ampulla); technique — position patient in supine position; empty bladder; insert sperm transport medium into bladder; position patient in lateral decubitus position; perform digital rectal examination and anoscopy to confirm that rectal mucosa intact; insert 20- to 30-volt probe transanally; most common complication urinary tract infection, so single dose of antibiotic administered; presence of sperm indicates success of procedure; in patients who fail electroejaculation, testicular sperm extraction recommended; electroejaculation recommended for patients who are otherwise unable to produce semen specimen before undergoing chemotherapy or testicular radiation; not useful in patients producing azoospermic specimen

Readings

Althof SE, McMahon CG: Contemporary management of disorders of male orgasm and ejaculation. Urology 2016 Jul;93:9-21; Mehta A, Sigman M: Management of the dry ejaculate: a systematic review of aspermia and retrograde ejaculation. Fertil Steril 2015 Nov;104(5):1074-81.

Disclosures

For this program, members of the faculty and planning committee reported nothing to disclose. In his lecture (“Practical Pathway for the Patient with Anejacultion”), Dr. Mulhall presents information related to the off-label or investigational use of a therapy, product, or device.

Acknowledgements

Dr. Mulhall was recorded at the 3rd Annual Conference: Practical Urology, presented by the University of Southern California Institute of Urology and held February 1-3, 2018, in Los Angeles, CA. For information on other CME programs from the Keck School of Medicine of USC, please visit usc.edu/cme. The Audio Digest Foundation thanks the speakers and the University of Southern California Institute of Urology for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0 CE contact hours.

Lecture ID:

UR411302

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.