Anejaculation and Anorgasmia

Overview

Anejaculation is defined as the inability to ejaculate semen; the word itself means “no ejaculation.” With this condition, a man can produce sperm but cannot expel them during normal ejaculation even though he may have normal orgasm sensation. Anorgasmia refers to the lack of orgasm (or sensation of pleasure). Anorgasmia can occur without ejaculation, or occasionally with normal ejaculation. Normal ejaculation without pleasure/orgasm is called “orgasmic anhedonia.”

Symptoms

Anejaculation can be divided into several categories:

  • Situational anejaculation: Situational anejaculation is when a man can ejaculate in some situations but not in others. Frequently, this type of anejaculation is caused by stress in situations such as being in the fertility clinic where some men become tense when they know they have to give a semen sample “on demand.” Additionally, if a man can ejaculate during intercourse but cannot ejaculate through masturbation (or vice versa) then this is considered situational.
  • Total anejaculation: Total anejaculation is when a man is never able to ejaculate semen either during intercourse or by masturbation, at home or in the clinic. Total anejaculation also can be divided into:
    • Anorgasmic anejaculation - a man who can never achieve an orgasm while awake, but may or may not be able to reach orgasm, and ejaculation, while asleep. In these cases, psychological factors rather than physical ones are likely causing the condition.
    • Orgasmic anejaculation - a man can reach and achieve orgasm but cannot ejaculate semen. This failure to release semen can be due to a block in the tubes or damage to the nerves, or possibly due to retrograde ejaculation where semen is going backwards into the bladder rather than leaving the penis through its tip.

Anejaculation and anorgasmia can also be classified as primary or secondary.  Primary anejaculation/anorgasmia is when ejaculation/orgasm has never been experienced in a man's entire lifetime and secondary anejaculation/anorgasmia is when a man is unable to ejaculate/orgasm after he has been experiencing normal sexual functioning.

Causes

In cases where retrograde ejaculation has been ruled out (see section on retrograde ejaculation), anejaculation occurs when the prostate and seminal ducts fail to release semen into the urethra.  This problem can be due to several causes:

  • Spinal cord injuries
  • Conditions that affect the nervous system (such as Parkinson's disease, multiple sclerosis, diabetes, spina bifida, etc.)
  • Traumatic injury or infection to the pelvis/groin area
  • Surgical treatment for testicular cancer or other cancers requiring the removal of lymph nodes located in the groin
  • Surgeries that may cause damage to the pelvic area (such as prostate, bladder or abdominal surgery that can damage or traumatize nerves)
  • Medications such as alpha blockers that are commonly used to treat urinary symptoms

Sometimes hormonal and psychological factors can play a role (e.g. anxiety, marital problems, fear of causing pregnancy). It has been found that situational anejaculation can be due to psychological factors such as stress.

Many of these conditions and problems can also lead to anorgasmia.

Men with anejaculation can often still have children. Most men with anejaculation still produce sperm even though they cannot ejaculate semen.  Medical procedures can induce ejaculation or retrieve sperm in other ways, following which artificial insemination or in vitro fertilization (IVF) can help a couple conceive. 

Diagnosis

Anejaculation and anorgasmia are diagnosed during the history-taking process. The provider may ask under which circumstances the patient experiences these issues. The provider will also try to assess whether the patient is experiencing orgasm or not. Medical and surgical history and all medications will be reviewed to assess for any possible causes.

Treatment

Treatment options for men with anejaculation depend on that patients’ goals. For men who are interested in having a child, sperm can be retrieved for artificial insemination. For those who are interested in restoring ejaculation for other reasons, several treatments have been proposed.

Situational anejaculation can often be prevented or treated by simple methods that make the man feel more comfortable (such as the clinic being quiet with no waiting lines, or the man collecting a semen sample at home). If situational anejaculation is due to psychological causes it can often be treated by simple measures such as psychological or sexual counseling. You should talk to your doctor about what is right for you.

When the cause of anejaculation is due to a physical problem then you will have to consult with your doctor to find out exactly what is happening and what action can be taken. Treatment can be as easy as changing to a different type of medication after consultation with your doctor. You may want to reduce or stop drinking alcohol or taking other non-prescription drugs.

For other physical causes of anejaculation, treatment is the use of a vibrator (called penile vibratory stimulation). With this treatment, vibrations travel along the sensory nerves to the spinal cord to cause ejaculation. A specially designed vibrator applies vibrations to the tip of the penis and the immediate surrounding area. Vibrator stimulation results in ejaculation in about 60% of men. In men with spinal cord injuries, depending on the level of injury, this technique may or may not work.

If vibrator therapy fails, electroejaculation can be performed. This involves the direct electrical stimulation of the nerves by inserting a lubricated probe, called an electroejaculator, into the rectum and applying electrical stimulations.  This procedure is carried out under general anesthesia. The semen specimen is then collected, processed and analyzed for sperm quality.  If sperm quality is high enough, then the sperm can be used for artificial insemination. Although about 90% of men successfully ejaculate with electroejaculation, retrograde ejaculation occurs in about a third. If insufficient amounts of semen are obtained, urine is checked for the presence of sperm. If present, the semen is then extracted from the bladder for artificial insemination.

The major downfall with electroejaculation is that semen quality is often poor, although semen quality often improves after repeated ejaculations. Therefore, electroejaculation is usually the second-choice treatment only after repeated sessions of vibratory stimulation fail. When electroejaculation also fails, or if the quality of the sperm obtained from this procedure is too poor, many couples resort to in vitro.

If there is a blockage due to infection or scar tissue, this can sometimes be cleared by surgery and sexual function can be regained.

If the above measures are not successful and fertility is the main concern, it is possible for a trained physician to extract sperm from the testicles and in vitro fertilization (IVF) (egg-sperm fertilization in a test tube and then inserted into uterus of mother) or single sperm injection can be attempted.

Drug treatment for anejaculation has shown low success rates compared to vibrator stimulation and electroejaculation stimulation and therefore is not a preferred treatment option. For the treatment of anorgasmia, several drugs have been proposed including cabergoline, oxytocin, bupropion and amphetamine/dextroamphetamine salts (Adderall).

Condition overview written by Petar Bajic, MD

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