Delayed ejaculation or anejaculation

Specialty: Nephrology and urology.

• delayed ejaculation
• inability to ejaculate
• non-retrograde dry orgasm

Why it occurs

• Adverse effect of psychotropic drugs (especially selective serotonin reuptake inhibitors - SSRIs - for continuous use such as fluoxetine or sertraline, tricyclic antidepressants, or antipsychotics that reduce sensitivity and sympathetic response)
• Peripheral or autonomic neuropathy (damage to the pudendal afferent/efferent pathways secondary to long-standing decompensated diabetes mellitus)
• Partial or total spinal cord injury (incomplete lesions of the conus medullaris that alter the sympathetic and parasympathetic ejaculation reflex pathways)
• Post-surgical sequelae of retroperitoneal lymphadenectomy, radical prostatectomy or major colorectal surgery (due to inadvertent injury to the superior hypogastric plexus responsible for seminal emission)
• Basic psychological factors (phobias about conception, extreme religious inhibition, serious interpersonal conflicts or habituation to intensive masturbation that cannot be replicated in intercourse)

Initial workup

Determination of basal blood glucose and glycosylated hemoglobin (HbA1c); complete hormonal profile in peripheral blood (total testosterone, prolactin, TSH); post-coital urine analysis to confirm the presence or absence of sperm (essential to accurately differentiate real anejaculation from retrograde ejaculation); electromyography of the pelvic floor or conduction studies of the pudendal nerve in suspected neurological pathology.

Standard management

• Cabergoline — 0.25-0.5 mg twice weekly if significant background hyperprolactinemia is documented
• Adjust the regimen of the offending antidepressant — for example, reduce the dose of SSRI, switch to a drug with a lower profile of sexual side effects such as Bupropion, or schedule weekend breaks in taking the psychotropic drug under close psychiatric supervision.
• Pseudoephedrine (60 mg orally 1 to 2 hours before sexual activity, empirically tested for its alpha sympathomimetic effect to promote semen emission, monitoring blood pressure).