What is a puborectalis rupture in men and how does it cause or contribute to sexual dysfunction such as erectile difficulty, reduced libido, premature or delayed ejaculation, or difficulty achieving orgasm?

Sexual Dysfunction in Men and Puborectalis Rupture

Critical Clarification: Puborectalis Rupture is Not a Recognized Medical Entity

There is no medical condition called "puborectalis rupture" that causes sexual dysfunction in men. The puborectalis is a pelvic floor muscle that forms part of the levator ani complex and functions primarily in fecal continence—not sexual function. This term does not appear in any sexual medicine literature, guidelines, or anatomical texts related to male sexual dysfunction 1, 2, 3.

You may be confusing this with:

• Pelvic floor muscle dysfunction (which can contribute to chronic pelvic pain and ejaculatory disorders)
• Pudendal nerve injury (which can cause erectile dysfunction and orgasmic difficulties)
• Perineal trauma (which can damage neurovascular structures involved in sexual function)

---

Male Sexual Dysfunction: Overview

Male sexual dysfunction encompasses several distinct disorders that can occur independently or together 1, 4:

Erectile Dysfunction (ED)

• Impaired ability to achieve or maintain erections sufficient for sexual activity
• Most common sexual dysfunction, affecting >50% of men aged 40-70 4
• Risk factors include diabetes, hypertension, cardiovascular disease, depression, and anxiety 4

Ejaculatory Disorders

Premature Ejaculation (PE)

Lifelong PE is defined as ejaculation within approximately 2 minutes of penetration with poor ejaculatory control and associated bother, present since sexual debut 1, 2. The normal median ejaculatory latency time is 5-6 minutes in Western countries 2.

Acquired PE is characterized by consistently poor ejaculatory control with markedly reduced ejaculatory latency compared to prior sexual experience, typically falling under 2-3 minutes or reduced by 50% from baseline 1.

Management approach:

• Behavioral therapy combined with pharmacotherapy provides superior outcomes compared to either modality alone 2
• Primary pharmacologic treatment is selective serotonin reuptake inhibitors (SSRIs), used off-label 1, 2
• All men should receive basic psychosexual education 5
• Surgical interventions (dorsal nerve neurotomy, radiofrequency ablation, hyaluronic acid augmentation) should be considered experimental only, performed in ethical board-approved trials due to risk of permanent penile sensation loss 2

Delayed Ejaculation (DE) and Anorgasmia

DE is characterized by lifelong or acquired, consistent, bothersome inability to achieve ejaculation or excessive latency (beyond 25-30 minutes) despite adequate stimulation and desire to ejaculate 2, 3. Men who cease sexual activity due to partner's request, fatigue, or ejaculatory futility qualify for this diagnosis 2.

Pathophysiology is multifactorial:

• Organic factors: medications (SSRIs, antipsychotics, antihypertensives), low testosterone, neurological conditions, age-related penile hypoanesthesia 3, 6
• Psychosocial factors: history of sexual abuse, decreased emotional intimacy, relationship conflict, depression, anxiety 3, 6
• Comorbid erectile dysfunction (20% of diabetic men with ED experience orgasmic dysfunction separately) 3

Treatment algorithm:

1. Address reversible causes first:

   • Replace, adjust dosage, or implement staged cessation of offending medications (particularly SSRIs, antipsychotics, antihypertensives) 3
   • Check morning testosterone levels and offer testosterone replacement therapy per AUA guidelines for men with biochemically low testosterone and symptoms 3
   • If comorbid ED is present, treat the erectile dysfunction first according to AUA guidelines, as the chronology matters for treatment sequencing 3

2. Behavioral modifications (lowest-risk first-line approach):

   • Modify sexual positions or practices to increase arousal 3
   • Incorporate alternative sexual practices, scripts, and sexual enhancement devices 2, 3
   • Include sexual partners in decision-making when possible 2, 3

3. Mental health referral:

   • Referral to a mental health professional with sexual health expertise should be considered for all men with lifelong or acquired DE, as psycho-behavioral strategies enhance psychosexual arousal and remove barriers to sexual excitement 2, 3

4. Pharmacotherapy (all off-label, weak evidence):

   • Sympathomimetic agents: pseudoephedrine 60-120 mg (120-150 minutes prior to sex), ephedrine 15-60 mg (1 hour prior), midodrine 5-40 mg (30-120 minutes prior) 2, 3
   • Other agents: 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 2, 3
   • No FDA-approved treatments exist for DE/anorgasmia; all pharmacotherapy is off-label with weak evidence base 2, 3

Retrograde Ejaculation

• Ejaculate enters the bladder instead of exiting through the urethra
• Diagnosed by finding spermatozoa and fructose in centrifuged post-ejaculatory voided urine 7
• First-line treatment for men seeking fertility is sympathomimetic medications, with pseudoephedrine 60-120 mg taken 120-150 minutes prior to ejaculation showing highest success rates 2
• Alternative options include imipramine, urine alkalinization with urethral catheterization, and assisted reproductive techniques 2

---

Post-Ejaculatory Pain

Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) is the leading cause of post-ejaculatory pain, characterized by pain in the perineum, suprapubic region, testicles, or penile tip specifically exacerbated by ejaculation 8.

Assessment should include:

• Pain location (perineal, urethral, penile tip, testicular, suprapubic, or diffuse pelvic) 8
• Associated urinary symptoms (frequency, urgency, dysuria, incomplete emptying) 8
• Medication history and surgical history 8
• Screening for psychological health issues (anxiety, depression, sexual trauma) 8

Treatment approach:

• Treat CP/CPPS-related pain according to chronic prostatitis protocols 8
• Multimodal therapy: pelvic floor physical therapy, anti-inflammatory agents, neuromodulators 8
• Alpha-1 adrenergic antagonists may provide benefit for associated LUTS and potentially ejaculatory pain 8
• For medication-induced pain, consider switching or discontinuing offending antidepressants if clinically appropriate 8
• Refer patients with psychogenic pain to mental health professionals with expertise in sexual disorders 8

---

Critical Clinical Pitfalls

• Orgasm and ejaculation are distinct from erection; these functions can be impaired independently 3
• Bother must be present for diagnosis—either to the patient, partner, or relationship 1
• Patient and partner satisfaction is the primary target outcome, not arbitrary physiological measures 3
• Age is one of the most significant factors in DE, combining psychological and physiological processes 2
• Depression and mood disorders significantly impact arousal levels and subsequently affect orgasmic capacity 3
• Shared decision-making is fundamental in managing ejaculatory disorders, with involvement of sexual partners when possible to optimize outcomes 2, 3