What are the treatment options for decreased ejaculation?

Treatment Options for Decreased Ejaculation

The treatment of decreased ejaculation should follow a stepwise approach starting with non-pharmacological interventions and progressing to pharmacotherapy when needed, with a focus on addressing underlying causes and enhancing sexual arousal. 1

Initial Assessment and Management

Identify and Address Underlying Causes

• Medication review: Many medications can cause delayed ejaculation

  • Consider replacement, dose adjustment, or staged cessation of contributing medications 2
  • Common culprits include SSRIs, antipsychotics, and certain antihypertensives

• Hormonal evaluation:

  • Check morning testosterone levels, as low testosterone can contribute to ejaculatory dysfunction 2
  • Consider testosterone replacement therapy for men with biochemically low testosterone levels 2

• Comorbid conditions:

  • Treat erectile dysfunction according to AUA Guidelines if present 2
  • Evaluate for depression, as it can be both a cause and consequence of ejaculatory disorders 3

Non-Pharmacological Interventions

Psycho-behavioral Strategies

• Modification of sexual practices to enhance arousal:

  • Change sexual positions or incorporate alternative sexual practices 2, 1
  • Incorporate sexual enhancement devices 2
  • Improve communication about sexual needs and desires between partners 1

• Referral to specialists:

  • Sexual health specialist or mental health professional with expertise in sexual health 2, 1
  • Pelvic floor physical therapy can improve pelvic floor function and sensation 1

• Vibratory therapy:

  • Particularly effective for neurological causes of anorgasmia 1
  • Can be used as home-based therapy with proper instruction

Pharmacological Interventions

When non-pharmacological approaches are insufficient, consider pharmacotherapy:

First-line Pharmacological Options

• Oxytocin: 24 IU intranasal/sublingual during sexual activity 2, 1
• Pseudoephedrine: 60-120 mg taken 120-150 minutes before sex 2, 1
• Ephedrine: 15-60 mg taken 1 hour before sex 2, 1
• Midodrine: 5-40 mg taken 30-120 minutes before sex 2, 1

Second-line Pharmacological Options

• Bethanecol: 20 mg daily 2, 1
• Yohimbine: 5.4 mg three times daily 2, 1
• Cabergoline: 0.25-2 mg twice weekly 2, 1, 4
• Imipramine: 25-75 mg daily 2, 1
• Bupropion: Has shown efficacy in some studies 4, 5

Important Considerations and Caveats

• Limited evidence base: There are no FDA-approved medications specifically for delayed ejaculation 2, 4

  • Most evidence consists of case reports and small non-randomized trials 4
  • Patients should be counseled on the weak evidence and potential side effects 2

• Combined approach: Psychological and pharmacological approaches typically yield better results than either modality alone 1, 5

• Avoid surgical interventions: These should be considered experimental due to lack of evidence 1

• Monitor response: Evaluate treatment response after 4-12 weeks 1

• Partner involvement: Including the partner in evaluation and treatment may improve outcomes 2, 1

• Age consideration: Ejaculatory dysfunction is increasingly common with age and may require more comprehensive management 2

• Caution with medications: Be aware of potential side effects of sympathomimetic drugs (pseudoephedrine, ephedrine, midodrine) including hypertension, anxiety, and insomnia 2

By following this stepwise approach and addressing both psychological and physiological factors, most men with decreased ejaculation can experience significant improvement in their condition.