Male Anorgasmia

Educational Objectives

The goal of this program is to improve diagnosis and treatment of male anorgasmia. After hearing and assimilating this program, the clinician will be better able to:

1. Trace the anatomic pathways involved in ejaculation.

2. Provide treatment for delayed ejaculation.

Summary

Definitions: delayed ejaculation refers to persistent or recurrent delay in or absence of orgasm after sufficient sexual stimulation; normal median intravaginal ejaculatory latency time (IELT) ≈5 min; delayed ejaculation defined by mean plus 2 standard deviations (IELT ≈25 min); anorgasmia refers to inability to have orgasm; 2% to 11% of men experience these sexual dysfunctions (incidence depends on definition)

Anatomy: ejaculation may occur in absence of erection; sensory input from glans (levels S2-S4) leads to contraction of periurethral muscles; emission regulated by sympathetic inputs (T12-L1) and results in contraction of vas deferens, seminal vesicles, prostate, and bladder neck (to prevent retrograde ejaculation); expulsion depends on somatic inputs (S1-S3) and contraction of bulbocavernosus and bulbospongiosus muscles; signals from sympathetic and sacral centers travel through pudendal nerve; centrally, nucleus paragigantocellularis of pons associated with sexual response

Neurotransmitters and hormones: high levels of norepinephrine and serotonin repress ejaculation; dopamine mitigates their effects; prolactin (PRL) involved in refractory period and prevention of ejaculation; selective serotonin reuptake inhibitors (SSRIs) common cause of sexual dysfunction; in men, anorgasmia most common side effect; serotonin and PRL negatively influence desire, arousal, and orgasm; premature ejaculation may be associated with high or low levels of testosterone; low testosterone linked with delayed ejaculation in some men; high levels of thyroid hormone may lead to premature ejaculation, while low levels may cause delayed ejaculation; PRL may be surrogate of serotonergic activity (high levels of PRL may indicate excessive levels of serotonin); PRL suppresses production of testosterone; oxytocin surges during ejaculation

Etiologies: determinants of IELT genetic, neurophysiologic, behavioral, psychosocial, and cultural; aging, neurologic and endocrine disorders, drugs, and alcohol affect orgasm; clinician should review medication list

Management: includes psychotherapy, sex therapy, and pharmacotherapy; psychosexual therapy recommended in most cases; partner of patient should be encouraged to attend visits; for insufficient stimulation, psychosexual therapy and penile vibratory stimulation (PVS) may be considered; psychic conflict and desire disorders treated mainly with psychotherapy; idiosyncratic masturbation managed with masturbatory retraining and revision of fantasy; sexual tipping-point model examines balance between excitatory and inhibitory stimuli

Pharmacotherapy: no medication currently approved by US Food and Drug Administration for delayed ejaculation; most studies small, underpowered, retrospective, and uncontrolled; differences in outcomes may reflect inclusion of disparate populations

Principles of treatment: in patient with delayed ejaculation and concurrent erectile dysfunction, erectile dysfunction should be treated first; PVS has 70% rate of success; when possible, patients on SSRIs should switch to bupropion

Delayed ejaculation: induced by SSRI — bupropion preferred agent; second choice cyproheptadine; third choice loratadine; not induced by SSRI — cabergoline or oxytocin preferred (depending on level of PRL); survey of members of Sexual Medicine Society of North America — cabergoline, bupropion, oxytocin, and cyproheptadine most popular first-line agents for delayed ejaculation; although these agents supported by strongest evidence of efficacy, quality of evidence not high

Specific agents: bupropion — suicidality most concerning side effect; patient should be managed in cooperation with mental health professional; cabergoline vs oxytocin — for patient not on SSRI, PRL level should be checked; if PRL high or normal, cabergoline preferred (to reduce level of PRL); oxytocin should be considered if level of PRL low or low normal; yohimbine — considered backup agent

Bupropion: Ashton and Rosen studied bupropion for SSRI-induced sexual dysfunction in 47 men; 75 to 150 mg administered as needed before sex; men who did not respond treated with 75 mg 3 times daily for 2 wk; two-thirds of patients responded and few discontinued drug; findings suggested fixed dosing superior to as-needed administration; other studies smaller and had mixed results

Cyproheptadine: serotonin antagonist; study of large cohort of men included ≈100 patients with SSRI-induced sexual dysfunction; 45 men treated with yohimbine, amantadine, or cyproheptadine; yohimbine more effective than other agents; other data supporting cyproheptadine originate from case reports

Cabergoline: dopamine-receptor agonist lowers PRL levels and decreases refractory period in men; speaker retrospectively studied 131 men with orgasmic disorder; patients treated with cabergoline twice weekly; two-thirds reported improvement in orgasm; improvement not related to therapy with testosterone, age, or history of prostatectomy

Oxytocin: may decrease ejaculatory latency period in animals; used in only double-blind placebo-controlled study of drugs for male sexual dysfunction; in this crossover study, 10 healthy men underwent treatment with intranasal oxytocin, followed by washout period; study evaluated catecholamine levels and sexual arousal but did not assess orgasm; findings included increased levels of oxytocin and catecholamines; most men reported increased sexual arousal

Yohimbine: may be used for SSRI-induced delayed ejaculation; drug acts at level of spinal cord adrenergic receptors (bypassing central processes); yohimbine used for erectile and sexual dysfunction; in best study, 29 men treated with 20 mg yohimbine (dose increased to 50 mg if no response observed); two-thirds of men reached orgasm, most without PVS

Summary: data sparse but show that two-thirds of patients respond to medication; orgasmic function depends on interplay of numerous neurohormonal and physical factors; many medications can cause sexual dysfunction, especially SSRIs; treatment should include psychosexual and medical therapies, as appropriate; medical therapies poorly studied and not approved by US Food and Drug Administration

Readings

Abdel-Hamid IA et al: The drug treatment of delayed ejaculation. Transl Androl Urol 2016 Aug;5(4):576-91; Ashton AK, Rosen RC: Bupropion as an antidote for serotonin reuptake inhibitor-induced sexual dysfunction. J Clin Psychiatry 1998 Mar;59(3):112-5; Burri A et al: The acute effects of intranasal oxytocin administration on endocrine and sexual function in males. Psychoneuroendocrinology 2008 Jun;33(5):591-600; Hollander AB et al: Cabergoline in the treatment of male orgasmic disorder-a retrospective pilot analysis. Sex Med 2016 Mar;4(1):e28-33; Keller Ashton A et al: Serotonin reuptake inhibitor-induced sexual dysfunction and its treatment: a large-scale retrospective study of 596 psychiatric outpatients. J Sex Marital Ther 1997 Fall;23(3):165-75; Perelman MA: Psychosexual therapy for delayed ejaculation based on the Sexual Tipping Point model. Transl Androl Urol 2016 Aug;5(4):563-75.

Disclosures

For this program, members of the faculty and planning committee reported nothing to disclose. In his lecture, Dr. Pastuszak presents information related to the off-label or investigational use of a therapy, product, or device.

Acknowledgements

Dr. Pastuszak was recorded at the 23rd Annual Innovations in Urologic Practice, presented by Carden Jennings Publishing Co., Ltd. and Grand Rounds in Urology, and held September 14-16, 2018, in Santa Fe, NM. For information on upcoming CME meetings presented by Grand Rounds in Urology, please visit grandroundsinurology.com. The Audio Digest Foundation thanks the speakers and the sponsors 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:

UR421802

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.