Treatment of Anejaculatory Orgasm (Anorgasmia)
For men with anejaculatory orgasm (anorgasmia), treatment should begin with identifying and addressing reversible causes—particularly medication adjustments, testosterone optimization if deficient, and behavioral/sex therapy interventions—as no FDA-approved pharmacological treatments exist for this condition. 1
Initial Evaluation and Reversible Causes
The cornerstone of management involves identifying modifiable factors through focused history:
Medication review is critical: Clinicians should replace, adjust dosage, or implement staged cessation of medications contributing to delayed ejaculation/anorgasmia (particularly SSRIs, antipsychotics, and antihypertensives). 1
Testosterone assessment: Check morning testosterone levels, as progressively lower serum testosterone correlates with increased symptoms consistent with delayed ejaculation and anorgasmia. 1
- In men with biochemically low testosterone and symptoms, offer testosterone replacement therapy per AUA guidelines. 1
Comorbid erectile dysfunction: If ED coexists, treat the ED first according to AUA guidelines, as ED and anorgasmia share common risk factors and the chronology matters for treatment sequencing. 1
Behavioral and Psychological Interventions
Behavioral modifications represent the lowest-risk first-line approach:
Sexual practice modifications: Advise men to modify sexual positions or practices to increase arousal, as adequate arousal is essential for optimal ejaculatory function through psychosexual mechanisms. 1, 2
Enhanced stimulation techniques: Incorporate alternative sexual practices, scripts, and sexual enhancement devices to increase physical and psychological arousal. 1, 2
Sex therapy: Cognitive-behavioral therapy and directed behavioral exercises have empirical support, though most evidence comes from female orgasmic disorder literature. 3, 4
- In reported cases, sexual behavioral therapy achieved success in 2 of 3 patients with primary anorgasmia. 3
Partner involvement: Include sexual partners in decision-making when possible, as shared decision-making is fundamental to optimizing outcomes in ejaculatory disorders. 1
Pharmacological Options (All Off-Label)
There is insufficient evidence to definitively recommend oral pharmacotherapy, but several agents have physiologic rationale: 1
The following medications may be considered on an individualized basis with appropriate counseling about weak evidence and off-label use:
Sympathomimetic agents: 1
- Pseudoephedrine 60-120 mg (120-150 minutes prior to sex)
- Ephedrine 15-60 mg (1 hour prior to sex)
- Midodrine 5-40 mg (30-120 minutes prior to sex)
Other agents with potential benefit: 1
- Oxytocin 24 IU intranasal/sublingual during sex
- Bethanecol 20 mg daily
- Yohimbine 5.4 mg three times daily
- Cabergoline 0.25-2 mg twice weekly
- Imipramine 25-75 mg daily
Novel approach: One case report documented first-time orgasm achievement with off-label flibanserin after 28-32 doses over 4 weeks in a 28-year-old with lifelong anorgasmia, though this required further study and was associated with nocturia and insomnia. 5
Bupropion: Has been tried but lacks proven efficacy beyond placebo in controlled settings. 5, 6
Important Caveats
No FDA-approved treatments exist: All pharmacotherapy for anorgasmia is off-label, and patients must understand the weak evidence base and potential for known/unknown side effects. 1
Orgasm and ejaculation are distinct from erection: These functions can be impaired independently—20% of diabetic men with ED experienced orgasmic dysfunction separately, so evaluate and treat these as distinct entities. 7
Multidisciplinary approach often needed: Given the multifactorial nature, treatment frequently requires collaboration between urology, endocrinology, and mental health professionals. 4, 8
Patient-defined success: Patient and partner satisfaction is the primary target outcome, not arbitrary physiological measures. 1