Male Anorgasmia: Evaluation and Treatment
Direct Recommendation
Start by identifying and stopping offending medications (especially SSRIs, antipsychotics, and antihypertensives), then check morning testosterone levels and treat if low, followed by behavioral modifications as first-line therapy before considering off-label pharmacotherapy. 1, 2
Step 1: Identify and Address Reversible Causes
Medication Review
- Immediately review and modify medications contributing to anorgasmia, particularly SSRIs, antipsychotics, and antihypertensives through replacement, dosage adjustment, or staged cessation. 2
- Alpha-blockers commonly used in urology and serotonin/noradrenaline reuptake inhibitor antidepressants frequently induce delayed orgasm or anorgasmia. 3
- This represents the highest-yield intervention with the strongest evidence base from the 2022 AUA/SMSNA guidelines. 1
Hormonal Assessment
- Check morning testosterone levels in all men with anorgasmia, as progressively lower serum testosterone correlates with increased symptoms of delayed ejaculation and anorgasmia. 1, 2
- Offer testosterone replacement therapy per AUA guidelines for men with biochemically low testosterone and symptoms. 1, 2
- The androgenic milieu has direct influence on ejaculation and orgasm function. 1
Comorbid Erectile Dysfunction
- If erectile dysfunction coexists, treat the ED first according to AUA guidelines, as ED and anorgasmia share common risk factors (medications, endocrine conditions, penile sensation loss, psychological factors). 1, 2
- Define the chronology: when anorgasmia precedes ED, focus on anorgasmia etiologies; when ED precedes anorgasmia, address common etiological factors and secondary psychological sequelae. 1
- Twenty percent of diabetic men with ED experience orgasmic dysfunction independently. 2
Step 2: Behavioral and Psychological Interventions (First-Line)
Behavioral Modifications
- Advise men to modify sexual positions or practices to increase arousal, as adequate arousal is essential for optimal ejaculatory function through psychosexual mechanisms. 2
- Incorporate alternative sexual practices, scripts, and sexual enhancement devices to increase both physical and psychological arousal. 2
- This represents the lowest-risk first-line approach with no adverse effects. 2
Partner Involvement
- Include sexual partners in decision-making when possible, as this is fundamental to optimizing outcomes in ejaculatory disorders. 1, 2
- Shared decision-making should guide all management of ejaculatory disorders. 1
Psychological Assessment
- Assess for history of sexual abuse, decreased emotional intimacy, and relationship conflict, which are associated with ejaculatory disorders. 2
- Evaluate for depression and mood disorders, as these significantly impact arousal levels and orgasmic capacity. 2
- Consider mental health referral for patients with no organic risk factors or when psychological factors predominate. 3, 2
Step 3: Pharmacological Options (All Off-Label)
Critical Caveat
No FDA-approved treatments exist for anorgasmia—all pharmacotherapy is off-label, and patients must understand the weak evidence base and potential for known/unknown side effects. 1, 2
Sympathomimetic Agents (Strongest Physiologic Rationale)
- Pseudoephedrine 60-120 mg taken 30-120 minutes prior to sexual activity. 1, 2
- Ephedrine 15-60 mg or midodrine 5-40 mg as alternatives. 1, 2
- These agents may be considered on an individualized basis with appropriate counseling about weak evidence. 2
Alternative Pharmacologic Options
- Oxytocin 24 IU intranasal or sublingual. 1, 2
- Yohimbine 5.4 mg three times daily. 1, 2
- Cabergoline 0.25-2 mg twice weekly. 1, 2
- Bethanecol 20 mg daily. 1, 2
- Imipramine 25-75 mg daily. 1, 2
The evidence base consists primarily of case reports and non-randomized, non-placebo-controlled case series—patients must weigh potential benefits against risks through individualized decision-making. 1
Step 4: Mechanical Interventions (Historical Evidence)
- Electrovibrator therapy showed positive results in 26 of 30 patients with primary anorgasmia in older studies, particularly when medicaments and psychotherapy failed. 4, 5
- This approach requires simultaneous intensive psychological guidance and instruction about normal sexual behavior. 4
- While historical data exists, this is not prominently featured in current AUA guidelines. 4, 5
What NOT to Do
Invasive Procedures
Do not use any invasive procedures (pudendal nerve release, intracavernosal injections, platelet-rich plasma, surgical interventions) for anorgasmia outside ethical board-approved clinical trials, given the risks and potential expense without published peer-reviewed supporting data. 1
Treatment Target
Patient and partner satisfaction is the primary outcome—not arbitrary physiological measures like specific ejaculatory latency times. 2 The goal is to restore sexual satisfaction and reduce distress for both the man and his partner(s). 1
Common Pitfalls
- Failing to distinguish orgasm from ejaculation and erection—these are distinct functions that can be impaired independently. 2
- Not checking testosterone levels—this is a reversible cause that should never be missed. 1, 2
- Treating anorgasmia before addressing comorbid ED—the chronology matters for treatment sequencing. 1, 2
- Overlooking medication-induced causes—this is the most common reversible etiology. 2, 3