What is anejaculation?

Anejaculation: Definition and Clinical Understanding

Anejaculation is defined as the absence or lack of ejaculation despite normal sexual arousal and stimulation. 1, 2 It represents a specific type of ejaculatory dysfunction that can significantly impact a man's sexual health, quality of life, and fertility.

Types of Anejaculation

Anejaculation can be classified into several types:

1. Retrograde ejaculation (51.2% of cases) - Semen flows backward into the bladder rather than out through the urethra 3
2. Impaired sperm emission into the urethra (27.9% of cases) 3
3. Aspermatism/anorgasmic anejaculation (20.9% of cases) - Absence of ejaculation despite normal sexual arousal 3

Etiology and Risk Factors

Anejaculation can result from various causes:

Neurological Causes

• Spinal cord injury 4
• Multiple sclerosis 4
• Peripheral neuropathy 3
• Diabetes mellitus (18.6% of cases) 3

Surgical/Anatomical Causes

• Retroperitoneal lymph node dissection for testicular cancer 4
• Prostate and bladder neck surgery (25.6% of cases) 3
• Extensive pelvic surgery 4

Medication-Related Causes

• Alpha-blockers 2
• Serotonin and/or noradrenaline reuptake inhibitor antidepressants 2
• Antipsychotics 5
• Certain antihypertensives 5

Psychological Factors

• Fear, guilt, resentment, and passivity 6
• Relationship issues 6
• Primary psychological anejaculation 2

Other Causes

• Primary absence of ejaculation (congenital) 4
• Low testosterone levels 5

Diagnostic Approach

The diagnosis of anejaculation requires:

1. Detailed sexual history:

   • Onset and progression of symptoms 5
   • Relationship to specific medications or health conditions 5
   • Whether the issue occurs with masturbation, specific partners, or all sexual activity 5

2. Physical examination:

   • Focused neurological examination 5
   • Genital and prostate examination 5
   • Assessment for signs of hormonal disorders 5

3. Laboratory tests:

   • Morning testosterone levels 5
   • Post-ejaculation urinalysis to check for retrograde ejaculation 5

Treatment Options

Medication Management

• Review and adjust current medications that may contribute to anejaculation 5

• Pharmacological options for delayed ejaculation/anejaculation:

  Medication	Dosage	Timing
  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
  Oxytocin	24 IU intranasal/sublingual	During sexual activity
  Bethanecol	20 mg daily	-
  Yohimbine	5.4 mg three times daily	-
  Cabergoline	0.25-2 mg twice weekly	-
  Imipramine	25-75 mg daily	-
  1, 5

• Testosterone therapy if total morning testosterone is <300 ng/dL (unless contraindicated) 5

Non-Pharmacological Interventions

• Lifestyle modifications: smoking cessation, weight loss, increasing physical activity, avoiding excess alcohol 5
• Sexual technique modifications: changing positions or practices to increase stimulation 5
• Vibratory therapy: particularly effective for neurological causes 5
• Pelvic floor physical therapy: to improve pelvic floor function and sensation 5
• Electroejaculation: for men with neurogenic anejaculation who wish to father children 4, 7

Psychological Approaches

• Sex therapy and couples counseling 5
• Improved communication about sexual needs between partners 5

Treatment Considerations and Cautions

1. Use sympathomimetic drugs with caution due to potential side effects including hypertension, anxiety, and insomnia 5

2. Avoid surgical interventions as they should be considered experimental 5

3. Treat comorbid erectile dysfunction according to AUA Guidelines if present 5

4. Set realistic expectations about improvement rather than complete resolution 5

5. Evaluate response after 4-12 weeks of any intervention 5

6. Consider combined approaches (psychological and pharmacological), which typically yield better results than either alone 5

7. Partner involvement in evaluation and treatment may improve outcomes 5

8. Referral to specialists if no improvement after initial management:

   • Sexual health specialist
   • Mental health professional with expertise in sexual health 5

Anejaculation can significantly impact quality of life and fertility, but with proper diagnosis and a structured treatment approach, many men can experience improvement in their condition.