What causes anorgasmia or reduced sensation during ejaculation in males?

Causes of Anorgasmia or Reduced Sensation During Ejaculation in Males

The primary causes of anorgasmia or reduced sensation during ejaculation in males include medications (particularly antidepressants and alpha-blockers), neurological conditions, hormonal imbalances, psychological factors, and improper use of topical anesthetics. 1, 2

Medication-Related Causes

• Antidepressants: Particularly serotonin and/or noradrenaline reuptake inhibitors (SNRIs) can frequently induce delayed orgasm or complete anorgasmia 3
• Alpha-blockers: Commonly used in urology, these medications can significantly impact ejaculatory sensation 3
• Antihypertensives: Can affect blood flow and neurological pathways involved in ejaculation 4
• Antiepileptics: Medications like pregabalin have been reported to cause severe anorgasmia when used as add-on therapy 5
• Anticholinergics: Can interfere with the autonomic nervous system control of ejaculation 4

Neurological Causes

• Diabetic neuropathy: Diabetes can cause peripheral nerve damage affecting genital sensation 2
• Spinal cord injuries: Can disrupt nerve pathways essential for ejaculatory sensation 1
• Multiple sclerosis: May affect neural pathways involved in orgasm and ejaculation
• Surgical complications: Particularly from prostate or pelvic surgeries that may damage relevant nerves 6

Hormonal Factors

• Low testosterone levels: The AUA guidelines recommend checking morning testosterone levels in men with delayed ejaculation, as low levels can significantly impact ejaculatory function 1, 2
• Thyroid disorders: Can affect sexual function including ejaculatory sensation

Psychological Factors

• Anxiety and depression: Can significantly impact sexual arousal and orgasmic function 6, 3
• Relationship issues: Conflicts, resentment, or communication problems with partners 6
• Performance anxiety: Excessive focus on performance rather than pleasure
• Past trauma: Previous negative sexual experiences or abuse
• Cultural or religious factors: Guilt or shame associated with sexuality 6

Other Contributing Factors

• Age: Ejaculatory function naturally changes with age, with increased latency and decreased sensation 1
• Improper use of topical anesthetics: Products containing lidocaine/prilocaine used for premature ejaculation can cause excessive numbness when not properly applied and removed 2
• Alcohol and substance abuse: Can impair neurological function related to ejaculation 4

Diagnostic Approach

1. Detailed sexual history:

   • Onset and progression of symptoms
   • Relationship to specific medications or health conditions
   • Whether the issue occurs with masturbation, specific partners, or all sexual activity

2. Medication review:

   • Complete assessment of all medications, including over-the-counter products
   • Timing of symptom onset in relation to medication changes

3. Laboratory testing:

   • Morning testosterone level
   • Basic metabolic panel and HbA1c to screen for diabetes
   • Thyroid function tests if clinically indicated 1, 2

4. Neurological assessment:

   • Focused examination of genital sensation
   • Assessment for peripheral neuropathy

Management Approaches

Management should be targeted to the underlying cause:

1. For medication-induced anorgasmia:

   • Consider dose adjustment or medication substitution when possible 1
   • Staged cessation of medications that may contribute to delayed ejaculation 1

2. For hormonal causes:

   • Testosterone replacement therapy for men with biochemically low testosterone levels and symptoms 1

3. For psychological factors:

   • Referral to a mental health professional with expertise in sexual health 1, 2
   • Behavioral interventions to enhance arousal and trigger orgasmic response 1

4. For topical anesthetic-related numbness:

   • Ensure thorough washing of residual anesthetic before intercourse
   • Adjust application time to minimize risk of numbness 2

5. For neurological causes:

   • Optimize management of underlying conditions (e.g., diabetes control)
   • Consider referral to a neurologist or urologist with expertise in sexual medicine 2

Behavioral Strategies

• Modify sexual positions or practices to increase arousal 1
• Incorporate alternative sexual practices or enhancement devices 1
• Improve communication about sexual needs and desires between partners 1, 2

Important Considerations

• Concurrent erectile dysfunction should be identified and treated first before addressing ejaculatory issues 2
• Partner involvement in the evaluation and treatment process may improve outcomes 2
• Anorgasmia can significantly impact quality of life and sexual satisfaction, requiring comprehensive management 2

Remember that while pharmacological options exist for delayed ejaculation (such as oxytocin, pseudoephedrine, and cabergoline), none have FDA approval for this indication, and their use is considered off-label 1.