What are the treatment options for anejaculation?

Treatment Options for Anejaculation

For patients with anejaculation, first-line treatment should be determined by the underlying cause, with psychosexual counseling recommended for psychological causes and pharmacological or mechanical interventions for organic causes. 1

Classification and Diagnosis

Before initiating treatment, it's essential to determine the type of anejaculation:

• Situational anejaculation: Occurs in specific situations but not others (e.g., can ejaculate during masturbation but not during intercourse) 2
• Organic anejaculation: Results from physical causes such as spinal cord injury, multiple sclerosis, diabetes, or surgical complications 3

Treatment Algorithm

1. Psychological Causes

For situational or psychogenic anejaculation:

• Psychosexual counseling/therapy should be the first-line treatment 2
  • Addresses performance anxiety, relationship issues, and psychological barriers
  • Particularly effective for partner-specific anejaculation
  • May require several sessions over weeks to months

2. Pharmacological Options for Organic Anejaculation

• Alpha-1 adrenergic agonists:

  • Midodrine (7.5-15 mg daily) has shown effectiveness in over 50% of patients with organic anejaculation (excluding spinal cord injury) 4
  • Dosing should start at 7.5 mg and increase in a stepwise approach if needed
  • Most effective in patients with multiple sclerosis; less effective in those with bilateral sympathectomy 4

• Other medications with varying success rates:

  • Imipramine (tricyclic antidepressant)
  • Pseudoephedrine
  • Ephedrine 5

3. Mechanical/Procedural Interventions

• Penile vibratory stimulation (PVS):

  • Non-invasive option that may be effective even after unsuccessful psychotherapy 6
  • Can produce ejaculate adequate for insemination in some cases

• Electroejaculation (EEJ):

  • Highly effective for neurogenic anejaculation, especially after spinal cord injury or retroperitoneal lymph node dissection 3
  • Requires specialized equipment and sometimes general anesthesia (in non-spinal cord injury patients)
  • Success rates for obtaining sperm: 75% in spinal cord injury patients, 87% in post-retroperitoneal lymph node dissection patients 3

• Prostatic massage: May be considered in select cases 5

Important Considerations

• Fertility concerns: If the goal is conception, sperm retrieval methods may be combined with assisted reproductive techniques
• Medication side effects: Monitor for adverse effects of alpha-agonists, particularly cardiovascular effects (hypertension)
• Treatment expectations: Patients should understand that:
  • Success rates vary significantly based on etiology
  • Some treatments may restore ejaculation but not necessarily normal orgasmic sensation
  • Treatment may need to be ongoing rather than curative

Treatment Selection Based on Etiology

1. Psychogenic anejaculation: Begin with psychosexual counseling 2
2. Neurogenic anejaculation: Consider electroejaculation or vibratory stimulation as first-line 3
3. Medication-induced: Consider medication adjustment if possible
4. Post-surgical: Alpha-1 agonists may be beneficial, but mechanical methods often needed 4

Caution

• Midodrine therapy should be discontinued if significant adverse events occur (6.3% discontinuation rate reported) 4
• Electroejaculation requires specialized expertise and equipment
• Poor sperm quality is common in anejaculatory patients and may limit fertility outcomes even with successful sperm retrieval 3

The choice of treatment should prioritize the least invasive option first, progressing to more invasive techniques if initial treatments fail.