Treatment Options for Patients with Ejaculatory Dysfunction

Despite much less attention than erectile dysfunction and other male fertility problems, ejaculatory dysfunction can be one of the most frustrating sexual symptoms a patient can experience.

The purpose of ejaculation is to deposit sperm into the vagina for reproduction, and most men with these problems seeking an evaluation are younger patients desiring fertility. Ejaculatory dysfunction can be characterized as premature, delayed, or absent ejaculation, obstructed, retrograde ejaculation, or anejaculation; this brief review will focus on retrograde and anejaculation.

With retrograde ejaculation, during climax the semen enters the bladder rather than being expelled per urethra. It is suspected in patients with a very low ejaculate volume or completely dry ejaculate coupled with a normal sensation of climax, occurring after the failure of the bladder neck to close during the ejaculatory reflex. Retrograde ejaculation may result from diabetes or other neurologic problems, a side effect of certain medications, or previous pelvic surgery. Retrograde ejaculation should be ruled out as a first step in the workup of ejaculatory dysfunction, as treatment is often successful without invasive procedures. The evaluation involves examination of the urine after ejaculation. Antegrade ejaculation can sometimes be induced with medications, but sperm can also be harvested from the urine after ejaculation for insemination or in vitro fertilization. In these situations, medications to change the pH or alkalinize the urine may improve semen quality.

Anejaculation is the lack of a visible ejaculate during a normal climax in the absence of retrograde ejaculation, either from a neurologic condition or is sometimes unknown. This is different from anorgasmia, which is the lack of climax. Anejaculation can occur with spinal cord injury, erectile dysfunction, hormone problems, diabetes, or for emotional reasons. Treatment with medications that stimulate the sympathetic nervous system such as over the counter sudafed or phenylephrine will sometimes increase ejaculate volume or change retrograde ejaculation to antegrade ejaculation. Treatment options include two different neurostimulatory methods. Penile vibratory stimulation (PVS) is the recommended first line treatment for anejaculation because it is simple, non-invasive, cost-effective, and successful in a certain percentage of cases. Penile vibratory stimulation for neurogenic anejaculation due to spinal paralysis is most effective with spinal cord injuries above T10. PVS is performed using a commercially available device such as the FertiCare or Viberect. If PVS is unsuccessful or not desired, electroejaculation is the gold standard treatment of anejaculation because it is almost uniformly successful. Under general anesthesia, a rectal probe is positioned over the prostate and seminal vesicles to induce pulsatile electrical stimulation to achieve ejaculation.

When treatments with medications or neurostimulatory methods for ejaculatory dysfunction fail, there always remains an option for a surgical sperm extraction. Using sedation or general anesthesia, sperm can be extracted directly from the testicle or epididymis with a minor outpatient procedure. Surgically extracted sperm can then be later used for in vitro fertilization.

In summary, ejaculatory dysfunction is a common problem manifested in a variety of different disorders. Fortunately, with a careful evaluation from a male fertility specialist, treatment of ejaculatory dysfunction is almost always possible to result in pregnancy. There are medications, assistive devices, and even surgical sperm retrieval, any of which can provide hope for a couple with such a discouraging problem to have a family of their own.

Matthew Coward, MD

Assistant Professor of Urology

Clinical Assistant Professor of Reproductive Endocrinology and Infertility

Matthew Coward received his medical degree with distinction from the University of North Carolina at Chapel Hill School of Medicine, where he later completed his residency in Urologic Surgery. Dr. Coward then went on to complete a prestigious microsurgical fellowship in Male Reproductive Medicine and Surgery at the Baylor College of Medicine with Dr. Larry Lipshultz. After completing his fellowship, Dr. Coward joined the UNC Department of Urology as an Assistant Professor in 2013. In 2014, he was appointed Clinical Assistant Professor of Reproductive Endocrinology and Infertility.

Dr. Coward's practice offers comprehensive Men's Reproductive and Sexual Health services. He is an expert in sexual medicine, penile prosthesis implantation, and Peyronie's disease, and he also specializes in male infertility, vasectomies, and microsurgical vasectomy reversals. Dr.

Coward is also the newest partner at UNC Fertility, a brand new, state-of-the-art IVF facility in Raleigh, NC. Complete diagnostic and treatment services offered by Dr. Coward on-site at UNC Fertility include advanced semen studies and hormone evaluations performed in UNC Fertility's Andrology laboratory, diagnostic ultrasound, sperm cryopreservation, and a full array of surgical sperm extraction procedures under anesthesia in the on-site procedural suite.

Dr. Coward's research interests include hypogonadism, male infertility, vasectomy and vasectomy reversal, penile prostheses, and urologic imaging. At UNC Fertility, he is a co-investigator with the Reproductive Medicine Network, an NIH-funded group of centers of excellence that carries out multi-centered clinical trials of male and female infertility.