Page 79 - Remedial Andrology

underlying mechanism influencing the reaching of orgasm [855]. As for psychological treatments, these
may include, but are not limited to: increased genital-specific stimulation; sexual education; role-playing on
his own and in front of his partner; retraining masturbatory practices; anxiety reduction on ejaculation and
performance; and, re-calibrating the mismatch of sexual fantasies with arousal (such as with pornography
use and fantasy stimulation compared to reality) [853]. A basic understanding of the sexual cycle for their
respective partners can assist men and women in managing expectations and in evaluating their own sexual
practices. Masturbation techniques that are either solo or partnered can be considered practice for the “real
performance” which can eventually result in greater psychosexual arousal and orgasm for both parties [197].
Although masturbation with fantasy can be harmful when not associated with appropriate sexual arousal and
context, fantasy can be supportive if it allows blockage of critical thoughts that may be preventing orgasm
and ejaculation. Techniques geared towards reduction of anxiety are important skills that can help overcome
performance anxiety, as this can often interrupt the natural erectile function through orgasmic progression.
Referral to a sexual therapist, psychologist or psychiatrist is appropriate and often warranted.

6.3.3.2 Pharmacotherapy
Several pharmacological agents, including cabergoline, bupropion, alpha-1-adrenergic agonists
(pseudoephedrine, midodrine, imipramine and ephedrine), buspirone, oxytocin, testosterone, bethanechol,
yohimbine, amantadine, cyproheptadine and apomorphine have been used to treat DE with varied success
[849]. Unfortunately, there is no FDA or EMA approved medications to treat DE, as most of the cited research
is based on case-cohort studies that were not randomised, blinded, or placebo-controlled. Many drugs have
been used as both primary treatments and/or as antidotes to other medications that can cause DE. A recent
survey of sexual health providers demonstrated an overall treatment success of 40% with most providers
commonly using cabergoline, bupropion or oxytocin [856]. However, this survey measured the anecdotal
results of practitioners and there was no proven efficacy or superiority of any drug due to a lack of placebo-
controlled, randomised, blinded, comparative trials [852]. In addition to pharmacotherapy, penile vibratory
stimulation (PVS) is also used as an adjunct therapy for DE [857]. Another study that used combined therapy
of midodrine and PVS to increase autonomic stimulation in 158 men with spinal cord injury led to ejaculation in
almost 65% of the patients [858].

6.4 Anejaculation
6.4.1 Definition and classification
Anejaculation involves the complete absence of antegrade or retrograde ejaculation. It is caused by failure
of semen emission from the seminal vesicles, prostate, and ejaculatory ducts into the urethra [859]. True
anejaculation is usually associated with a normal orgasmic sensation and is always associated with central or
peripheral nervous system dysfunction or with drugs [860].

6.4.2 Pathophysiology and risk factors
Generally, anejaculation shares similar aetiological factors with DE and retrograde ejaculation (Table 20).

6.4.3 Investigation and treatment
Drug treatment for anejaculation caused by lymphadenectomy and neuropathy, or psychosexual therapy for
anorgasmia, is not effective. In all these cases, and in men who have a spinal cord injury, PVS (i.e., application
of a vibrator to the penis) is the first-line therapy. In anejaculation, PVS evokes the ejaculation reflex [861],
which requires an intact lumbosacral spinal cord segment. If the quality of semen is poor, or ejaculation is
retrograde, the couple may enter an in vitro fertilisation program whenever fathering is desired. If PVS has
failed, electro-ejaculation can be the therapy of choice [862]. When electro-ejaculation fails or cannot be carried
out, other sperm-retrieval techniques may be used [863]. Anejaculation following either retroperitoneal surgery
for testicular cancer or total mesorectal excision can be prevented using unilateral lymphadenectomy or
autonomic nerve preservation [864], respectively.

6.5 Painful Ejaculation
6.5.1 Definition and classification
Painful ejaculation is a condition in which a patient feels mild discomfort to severe pain during or after
ejaculation. The pain can involve the penis, scrotum, and perineum [865].

6.5.2 Pathophysiology and risk factors
Many medical conditions can result in painful ejaculations, but it can also be an idiopathic problem. Initial
reports demonstrated possible associations of painful ejaculation with calculi in the seminal vesicles [866],
sexual neurasthenia [867], sexually transmitted diseases [865, 868], inflammation of the prostate [221, 869], PCa
[870, 871], BPH [219], prostate surgery [872, 873], pelvic radiation [874], herniorrhaphy [875] and antidepressants

78 SEXUAL AND REPRODUCTIVE HEALTH - MARCH 2021