Are there different types of problems with ejaculation What causes them and how are they treated

There are three different types of ejaculatory problems that can occur: premature ejaculation, retrograde ejaculation, and anejaculation.

What is premature ejaculation and what causes it? Premature ejaculation is ejaculation that occurs sooner than desired, either before or shortly after penetration, that causes distress to one or both partners. This condition tends to occur more frequently in younger men. Premature ejaculation is the most common form of sexual dysfunction, occurring in 21% of men ages 18 to 59 years in the United States. The condition may be lifelong (primary) or acquired (secondary). Despite its prevalence, men rarely seek help. Some men with ED may develop secondary premature ejaculation, possibly caused by either the need for intense stimulation to attain and maintain an erection or because of anxiety associated with difficulty in attaining and maintaining an erection. In these patients, treating the erectile dysfunction may lead to resolution of the premature ejaculation.

It appears that men with premature ejaculation may have an increased sensitivity and excitability of the glans penis and the dorsal nerve, which supplies sensation to the penis.

What is retrograde ejaculation and what causes it?

Retrograde ejaculation occurs when the ejaculate flows backward into the bladder instead of forward and out the tip of the penis. There are three potential causes of retrograde ejaculation:

1. Anatomic—that which occurs following surgery on the bladder neck or from a congenital process. Retrograde ejaculation is very common in men who have underdone a transurethral prostatectomy (TURP). A TURP is usually performed to treat benign enlargement of the prostate.

2. Neurologic—resulting from disorders that interfere with the ability of the bladder neck to close during emission such as diabetes mellitus or retroperitoneal surgery.

3. Pharmacologic—caused by paralysis of the bladder neck by certain medications. Such medications include the blood pressure medications phenoxy-benzamine (Dibenzyline), phentolamine, prazosin (Minipress), and the antipsychotic medications thioridazine (Mellaril), chlorpromazine (Thorazine), triflupromazine (Vespein), and mesoridazine (Ser-entil). Tamsulosin (Flomax) was thought to cause

TURP

A surgical technique performed under anesthesia using a specialized instrument similar to the cystoscope that allows the surgeon to remove the prostatic tissue that is bulging into the urethra and blocking the flow of urine through the urethra. After a TURP, the outer rim of the prostate remains.

retrograde ejaculation but it appears to cause anejac-ulation.

Retrograde ejaculation does not cause any harm—one simply urinates out the ejaculate.

What is anejaculation and what causes it?

Anejaculation is the condition in which there is no flow of ejaculate in either direction. This condition occurs in some men with spinal cord injuries and in some men with cancer of the testis who have undergone surgery to remove affected lymph nodes, a procedure called retroperitoneal lymph node dissection. Anejacu-lation may also occur if the outflow of the ejaculate is blocked; this may be caused by a small stone in the ejaculatory duct (the structure through which the ejaculate passes into the urethra), or by prior infection and scarring of the male reproductive tract from sexually transmitted diseases, such as gonorrhea, and other diseases that affect the genitourinary tract, including tuberculosis. In such cases, the ejaculatory duct may be opened surgically. Anejaculation occurs after a radical prostatectomy because the seminal vesicles and prostate gland are removed and the vas deferens is tied off. Congenital disorders such as imperforate anus and their treatment may also cause anejaculation.Tamsulosin is thought to cause reversible anejaculation.

How are the different types of ejaculatory dysfunction treated?

There are two main types of treatment available for the management of premature ejaculation, behavioral therapy and medical therapy (see Table 17). Behavioral therapy starts with education regarding what premature ejaculation is and the possible causes as well as teaching the

Table 17 Pharmacologic Therapies Used to Treat Premature Ejaculation

Type

Oral Therapy

Trade Name

Recommended Dose

Side Effects

Nonselective (SRI)

Clomipramine

Anafranil

25 mg to 50 mg/day or 25 mg 4-24 hrs pre-intercourse

Dry mouth, drowsiness, decreased libido, potential drug-drug interactions, rarely mania and withdrawal sx

Selective (SSRIs)

Fluoxetine

Prozac

5 mg to 20 mg/day or 20 mg 3-4 hrs pre-intercourse

As above

Paroxetine

Paxil

10 mg, 20 mg, or 40 mg/day or 20 mg 2-4 hrs pre-intercourse

As above

Sertraline

Zoloft

25 mg- 200 mg/day or 50 mg 4-8 hrs pre-intercourse

As above

Topical therapy

Lidocaine/prilocaine cream

EMLA

lidocaine 2.5%/ prilocaine 2.5% 20 to 30 min pre-intercourse

Numbness, partner irritation or numbness, prolonged application may lead to loss of erection

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