Page 35 - Remedial Andrology

4.3 Other ejaculatory disorders
4.3.1 Delayed ejaculation
Due to its rarity and uncertain definitions, the epidemiology of delayed ejaculation (DE) is not clear [190]. However,
several well-designed epidemiological studies have revealed that its prevalence is around 3% among sexually
active men [181, 191]. According to data from the NHSLS, 7.78% of a national probability sample of 1,246 men
aged 18-59 years reported inability achieving climax or ejaculation [181]. In a similar stratified national probability
sample survey completed over 6 months among 11,161 men and women aged 16-44 years in Britain, 0.7%
of men reported inability to reach orgasm [192]. In an international survey of sexual problems among 13,618
men aged 40–80 years from 29 countries, 1.1-2.8% of men reported that they frequently experience inability to
reach orgasm [193]. Another study conducted in the United States, in a national probability sample of 1,455 men
aged 57-85 years, 20% of men reported inability to climax and 73% reported that they were bothered by this
problem. [194]. Considering the findings of these epidemiological studies and their clinical experiences, some
urologists and sex therapists have postulated that the prevalence of DE may be higher among older men [195-
197]. Similar to the general population, the prevalence of men with DE is low among patients who seek treatment
for their sexual problems. An Indian study that evaluated the data on 1,000 consecutive patients with sexual
disorders who attended a psychosexual clinic demonstrated that the prevalence of DE was 0.6% and it was more
frequent in elderly people with diabetes [198]. Nazareth et al. [199] evaluated the prevalence of International
th
Classification of Diseases 10 edition (ICD-10) diagnosed sexual dysfunctions among 447 men attending 13
general practices in London, UK and found that 2.5% of the men reported inhibited orgasm during intercourse.
Similar to PE, there are distinctions among lifelong, acquired and situational DE [200]. Although the evidence is
limited, the prevalence of lifelong and acquired DE is estimated at 1 and 4%, respectively [201].

4.3.2 Anejaculation and Anorgasmia
Establishing the exact prevalence of anejaculation and anorgasmia is difficult since many men cannot
distinguish between ejaculation and orgasm. The rarity of these clinical conditions further hampers the
attempts to conduct epidemiological studies. In a report from the USA, 8% of men reported unsuccessfully
achieving orgasm during the past year [181].
According to Kinsey et al. [202], 0.14% of the general population have anejaculation. The most
common causes of anejaculation were spinal cord injury, diabetes mellitus and multiple sclerosis. Especially
in most cases of spinal cord injury, medical assistance is the only way to ejaculate. While masturbation leads
to the lowest rates of ejaculation, higher response rates can be obtained with penile vibratory stimulation or
acetylcholine esterase inhibitors followed by masturbation in patients with spinal cord injury [203].

4.3.3 Retrograde ejaculation
Similar to anejaculation, it is difficult to estimate the true incidence of retrograde ejaculation (RE). Although
RE is generally reported in 0.3-2% of patients attending fertility clinics [204], diabetes may increase these
rates by leading to autonomic neuropathy. Autonomic neuropathy results in ED and ejaculatory dysfunctions
ranging from DE to RE and anejaculation, depending on the degree of sympathetic autonomic neuropathy
involved [205]. In 54 diabetic patients with sexual dysfunction, RE was observed with a 6% incidence [206]. In
a controlled trial, RE was observed in 34.6% of diabetic men [207]. A more recent trial reported the rate of RE
among 57 type-1-diabetes mellitus patients (aged 18-50 years) was at least 8.8% [208]. Retrograde ejaculation
was also reported in studies of patients who had undergone transurethral resection of prostate (TURP) or
open prostatectomy due to disrupted bladder neck integrity. A study of the effect of prostatectomy on QoL in
5,276 men after TURP, found that 68% reported post-surgical RE [209]. However, with the development of less
invasive techniques, the incidence of RE decreases following the surgical treatment of LUTS [210-214].

4.3.4 Painful ejaculation
Painful ejaculation is a common but poorly understood clinical phenomenon, which is associated with
sexual dysfunction. Several studies demonstrated its prevalence to range between 1 and 10% in the general
population [215-217]; however, it may increase to 30-75% among men with chronic prostatitis/chronic pelvic
pain syndrome (CP/CPPS) [218-222]. It should be noted that the design of most of these studies was not
scientifically sound and the condition was probably under-reported due to the lack of an evidence-based
definition and well-defined prognostic criteria.

4.3.5 Haemospermia
The exact incidence and prevalence of haemospermia are difficult to elucidate due to a number of factors
including its covert presentation, usually self-limiting nature and patient embarrassment. The symptom
represents 1-1.5% of all urological referrals and occurs in all age groups, with a mean age of 37 years [223,
224]. In a PCa screening study of 26,126 men, aged ≥ 50 years or older than 40 with a history of PCa or of
black ethnicity, haemospermia was found in 0.5% on entry to the trial [225].

34 SEXUAL AND REPRODUCTIVE HEALTH - MARCH 2021