What causes anorgasmia?

What Causes Anorgasmia

Anorgasmia (the inability to achieve orgasm despite adequate sexual stimulation) is caused by four primary categories: medication-induced dysfunction, psychological/psychogenic factors, endocrine abnormalities (particularly low testosterone), and neurological conditions. 1, 2

Medication-Induced Causes

The most common reversible cause of anorgasmia is medication use, particularly SSRIs, antipsychotics, and antihypertensives. 1

• SSRIs and serotonergic antidepressants are the most frequent pharmacological culprits, causing delayed orgasm or complete anorgasmia through their effects on serotonin reuptake 3
• Alpha-blockers (commonly prescribed in urology) frequently induce delayed orgasm or anorgasmia 3
• Antipsychotics (particularly atypical antipsychotics) cause situational anorgasmia through serotoninergic mechanisms 4
• Pregabalin has been documented to cause severe anorgasmia in men with epilepsy 4
• Antihypertensive medications contribute to ejaculatory dysfunction through autonomic nervous system effects 1

The AUA guidelines prioritize identifying and modifying these medications as the first-line intervention, recommending replacement, dose adjustment, or staged cessation. 1

Psychological and Psychogenic Factors

Psychological factors account for approximately 90% of anorgasmia cases and include anxiety, depression, relationship conflict, and inadequate sexual arousal. 3, 4

• Inadequate sexual arousal prevents optimal filling of accessory sex glands during the arousal phase, directly impairing ejaculatory function 5
• Anxiety and low libido significantly impact arousal levels and subsequently affect orgasmic capacity 5
• History of sexual abuse, decreased emotional intimacy, and relationship conflict are associated with ejaculatory disorders 6
• Depression and mood disorders require assessment and possible mental health referral 6

The AUA emphasizes that adequate arousal is essential for optimal ejaculatory function through psychosexual mechanisms, making behavioral modifications a critical first-line approach. 1

Endocrine Causes

Low testosterone is a significant endocrine cause, with progressively lower serum testosterone correlating with increased symptoms of delayed ejaculation and anorgasmia. 1

• The AUA recommends checking morning testosterone levels in all men presenting with anorgasmia 1
• Testosterone replacement therapy should be offered per AUA guidelines for men with biochemically low testosterone and symptoms 1

Neurological and Genitopelvic Causes

Neurological conditions and genitopelvic dysesthesia represent organic causes of anorgasmia, though these are less common than medication-induced or psychological etiologies. 2

• Neurological risk factors should be assessed during clinical interview 3
• Genitopelvic dysesthesia (abnormal sensation in the genital/pelvic region) can impair orgasmic function 2

Comorbid Erectile Dysfunction

Erectile dysfunction commonly coexists with anorgasmia, sharing common risk factors, though these are distinct physiological processes. 1

• 20% of diabetic men with erectile dysfunction experience orgasmic dysfunction separately 1
• The AUA recommends treating erectile dysfunction first according to AUA guidelines when both conditions are present, as the chronology matters for treatment sequencing 1
• Orgasm and ejaculation are distinct from erection and can be impaired independently 1

Clinical Pitfalls

A critical pitfall is failing to recognize that anorgasmia is multifactorial—clinicians must systematically evaluate all four categories (medications, psychological factors, endocrine status, and neurological conditions) rather than assuming a single cause. 2

• The most critical diagnostic tool is a thorough history and physical examination, specifically assessing medication lists, psychological risk factors, testosterone levels, and neurological symptoms 2, 3
• Partner involvement in the evaluation and treatment process is fundamental to optimizing outcomes 1
• Clinicians should avoid wasting time with ineffective treatments when a clear reversible cause (like medication) is identified 1