What are the treatment options for anejaculation (inability to ejaculate)?

Treatment of Anejaculation

For men with anejaculation (complete inability to ejaculate), the treatment approach depends critically on the underlying cause: neurogenic anejaculation requires assisted ejaculation techniques starting with penile vibratory stimulation, while psychogenic/idiopathic anejaculation requires referral to mental health professionals with sexual health expertise combined with behavioral modifications. 1

Initial Evaluation and Etiology Determination

• Obtain a detailed sexual history focusing on whether the anejaculation is lifelong or acquired, relationship to specific partners, presence of orgasm without ejaculation, and any neurological symptoms or medication use 1
• Assess for neurogenic causes including spinal cord injury, diabetes mellitus, multiple sclerosis, retroperitoneal lymph node dissection, extensive pelvic surgery, or adult myelodysplasia 2, 3
• Consider morning testosterone testing as low serum testosterone levels correlate with ejaculatory dysfunction 1
• Evaluate for medication-induced anejaculation, particularly SSRIs, antipsychotics, and alpha-blockers 1

Treatment Algorithm Based on Etiology

For Neurogenic Anejaculation (Spinal Cord Injury, Post-Surgical)

First-line: Penile Vibratory Stimulation (PVS)

• This is the preferred initial approach because it is noninvasive, inexpensive, and can be performed by the patient at home 2, 4
• PVS successfully induces ejaculation in approximately 75% of spinal cord injury patients with adequate sperm for artificial insemination 3
• The technique can be self-administered, allowing for home insemination as a very low-cost fertility option 4

Second-line: Electroejaculation (EEJ)

• When vibratory stimulation fails, electroejaculation is almost always successful in obtaining an ejaculate 2, 3
• EEJ involves low-current stimulation of ejaculatory organs via a rectal probe 3
• In non-spinal cord injury patients, general anesthesia is required 3
• An ejaculate can be obtained from nearly all patients, with 87% of post-RPLND patients and 75% of SCI patients producing samples adequate for artificial insemination 3
• Overall pregnancy rates of 35% per couple have been achieved using this technique 3

Third-line: Surgical Sperm Retrieval

• When both assisted ejaculation methods fail, consider sperm aspiration from vas deferens or epididymis, or testicular biopsy 2
• For non-SCI anejaculatory men, surgical sperm retrieval with intracytoplasmic sperm injection should be considered first-line therapy 4

For Psychogenic/Idiopathic Anejaculation

First-line: Mental Health Referral

• Refer men with lifelong or acquired delayed ejaculation/anejaculation to a mental health professional with expertise in sexual health 1
• Psycho-behavioral strategies enhance psychosexual arousal and remove barriers interfering with psychosexual excitement 1
• Psychotherapy remains the standard treatment for idiopathic anejaculation, though penile electrovibration may serve as an adjunct 5

Behavioral Modifications

• Advise modifying sexual positions or practices to increase arousal, including incorporation of alternative sexual practices, scripts, and sexual enhancement devices 1
• These low-risk behavioral interventions may help trigger orgasmic response 1

For Medication-Induced Anejaculation

Medication Management

• Replace, adjust dosage, or implement staged cessation of medications contributing to anejaculation 1
• This is a clinical principle that should be attempted before other interventions 1

Pharmacotherapy Options (Off-Label, Limited Evidence)

The following medications have potential efficacy but lack FDA approval for anejaculation treatment 1:

• Sympathomimetics: Pseudoephedrine 60-120 mg taken 120-150 minutes prior to sex, or ephedrine 15-60 mg taken 1 hour prior to sex 1
• Midodrine: 5-40 mg daily, taken 30-120 minutes prior to sex 1
• Oxytocin: 24 IU intranasal/sublingual during sex 1
• Bethanecol: 20 mg daily 1
• Yohimbine: 5.4 mg three times daily 1
• Cabergoline: 0.25-2 mg twice weekly 1
• Imipramine: 25-75 mg daily 1

Critical Caveats

• The evidence basis for pharmacotherapies is very limited and carries risk of treatment-related adverse events 1
• A major obstacle with electroejaculation is severe asthenozoospermia and poor functional sperm quality, which may be caused by the technique itself or prolonged anejaculatory status 3
• Age-related increases in ejaculatory latency may be managed with psychological and behavioral approaches aimed at increasing arousal, avoiding pharmacotherapy risks 1
• Surgical management including injection of bulking agents should be considered experimental and only used in ethical board-approved clinical trials due to risk of permanent penile sensation loss 1, 6