Treatment of Male Anorgasmia
The most effective treatment approach for male anorgasmia combines psychological/behavioral interventions with pharmacological treatments tailored to the underlying cause, as none of these treatments alone have FDA approval or strong evidence of consistent efficacy. 1
Diagnostic Evaluation
Before initiating treatment, a thorough evaluation is essential to determine the cause:
- Assess if anorgasmia began after starting specific medications
- Determine if it occurs with all sexual activities or only certain ones
- Rule out underlying causes:
- Hormonal factors (check morning testosterone levels)
- Neurological conditions
- Medication side effects
- Psychological factors 1
Treatment Algorithm
Step 1: Address Modifiable Factors
Lifestyle modifications:
- Smoking cessation
- Weight loss
- Increasing physical activity
- Avoiding excess alcohol consumption 2
Medication review:
Step 2: Hormonal Assessment and Treatment
- Check morning testosterone levels
- If total morning testosterone is <300 ng/dL, testosterone therapy may relieve symptoms of orgasm problems 2
- Testosterone therapy should not be used if contraindicated by primary oncologic diagnosis (e.g., prostate cancer) 2
Step 3: Behavioral and Psychological Interventions
- Modify sexual positions or practices to increase stimulation
- Improve communication about sexual needs between partners
- Consider vibratory therapy to enhance arousal 1, 3
- Pelvic physical therapy (pelvic floor muscle training) may improve sexual function 2
- Referral to sex therapy and couples counseling as appropriate 2
Step 4: Pharmacological Interventions (Off-label)
No medications have FDA approval for treating anorgasmia, but the following may be considered:
Sympathomimetics:
- Pseudoephedrine (60-120 mg, 120-150 minutes before sex)
- Ephedrine (15-60 mg, 1 hour before sex)
- Midodrine (5-40 mg, 30-120 minutes before sex) 1
Other medications:
For ejaculation problems:
- SSRIs (paroxetine, sertraline, citalopram, fluoxetine) dosed daily or clomipramine dosed on-demand may help with ejaculation issues 2
Special Considerations
Medication-Induced Anorgasmia
- Identify and adjust offending medications when possible
- SSRIs are a common cause - consider dose reduction or medication switch
- For PDE5 inhibitor-induced issues, consider dose adjustment or alternative dosing schedules 1
Age-Related Considerations
- Ejaculatory dysfunction becomes increasingly common with age and may require more comprehensive management 1
- Older men may benefit from combined approaches rather than single interventions
Treatment-Resistant Cases
- For treatment-resistant cases, consider referral to a sexual health specialist
- Combined approaches (psychological + pharmacological) typically yield better results than either alone 1
- Intranasal oxytocin has shown success in treatment-resistant cases 4
- Vibratory therapy has shown success in 26 out of 30 patients with primary anorgasmia in one study 3
Monitoring and Follow-up
- Evaluate response after 4-12 weeks of any intervention
- Adjust treatment based on response
- Partner involvement in evaluation and treatment may improve outcomes 1
- Set realistic expectations about improvement rather than complete resolution
Cautions
- Use sympathomimetic drugs with caution due to potential side effects (hypertension, anxiety, insomnia)
- Avoid surgical interventions as they should be considered experimental 1
- PDE5i is contraindicated in patients taking oral nitrates due to dangerous blood pressure decreases 2
By following this structured approach and addressing the underlying causes of anorgasmia, most patients can experience significant improvement in their condition and quality of life.