Ejaculatory physiology and dysfunction

Neurons for Ejaculation and Factors Affecting Ejaculation

Simple Summary

Sexual dysfunctions are rarely discussed in our current society. Males experience different sexual dysfunctions, including erectile, infertility, and ejaculatory dysfunctions. In this review only the ejaculatory dysfunction will be discussed. Ejaculation is defined as the ejection of contents collectively from the vas deferens, seminal vesicle, prostate and Cowper’s glands. It is completely controlled by a population of neurons present in the lumbar spinal cord. The presence of lesion in these neurons ceases the ejaculatory behavior in males. This population of neurons was first identified in rats; however, recently it was confirmed that these neurons are present in human males as well. The issues are known as ejaculatory dysfunction. The following are the different types of ejaculatory dysfunctions: early ejaculation, ejaculation into the urinary bladder, late ejaculation and no ejaculation.

Abstract

Ejaculation is a reflex and the last stage of intercourse in male mammals. It consists of two coordinated phases, emission and expulsion. The emission phase consists of secretions from the vas deferens, seminal vesicle, prostate, and Cowper’s gland. Once these contents reach the posterior urethra, movement of the contents becomes inevitable, followed by the expulsion phase. The urogenital organs are synchronized during this complete event. The L3–L4 (lumbar) segment, the spinal cord region responsible for ejaculation, nerve cell bodies, also called lumbar spinothalamic (LSt) cells, which are denoted as spinal ejaculation generators or lumbar spinothalamic cells [Lst]. Lst cells activation causes ejaculation. These Lst cells coordinate with [autonomic] parasympathetic and sympathetic assistance in ejaculation. The presence of a spinal ejaculatory generator has recently been confirmed in humans. Different types of ejaculatory dysfunction in humans include premature ejaculation (PE), retrograde ejaculation (RE), delayed ejaculation (DE), and anejaculation (AE). The most common form of ejaculatory dysfunction studied is premature ejaculation. The least common forms of ejaculation studied are delayed ejaculation and anejaculation. Despite the confirmation of Lst in humans, there is insufficient research on animals mimicking human ejaculatory dysfunction.

Insights Into the Vaginismus Treatment by Cognitive Behavioral Therapies: Correlation With Sexual Dysfunction Identified in Male Spouses of the Patients

Objective: To examine retrospectively sexual dysfunction in the male spouses of 425 female patients who had presented to our clinic and were diagnosed with primary vaginismus.

Materials and methods: Seven questions related to age, profession, educational status, number of marriages, personality structure, sexual experience, and sexual dysfunction history were directed to the spouses of the 425 female patients presenting to our clinic for vaginismus treatment between 2015 and 2018. Men reporting sexual dysfunction were evaluated by a urologist, and the necessary treatment was initiated. Cognitive-behavioral couple therapy was started for all patients.

Results: Of the 425 men, 73.9% stated that they did not have any sexual problems. Of the 111 men (26.1%) stated that they had one or more sexual problems, 77 (18.1%) were diagnosed with premature ejaculation, 25 (5.8%) erectile dysfunction, 36 (8.4%) hypoactive sexual desire, and one (0.2%) had delayed ejaculation. Premature ejaculation and erectile dysfunction were identified in nine patients, premature ejaculation and hypoactive sexual desire in seven, and erectile dysfunction and hypoactive sexual desire in four patients. There was an increased rate of sexual dysfunction in men in cases where the duration of marriage without coitus was longer than three years.

Conclusion: In the treatment of vaginismus, male sexual dysfunction should not be ignored. Spouses should be questioned for sexual dysfunction and included in the treatment process.

Ejaculation-sparing versus non-ejaculation-sparing anatomic GreenLight laser enucleo-vaporization of the prostate: first comparative study

PURPOSE

To present the step-by-step description of an ejaculation-sparing anatomic photo-selective vaporization of the prostate (PVP) technique. To report the results of a series of ejaculation-sparing versus non-ejaculation-sparing anatomic PVPs.

METHODS

Sexually active, benign prostatic hyperplasia (BPH) patients undergoing an anatomic PVP between 11/2018 and 2/2020 were included. Patients were divided into group A (ejaculation-sparing surgery) and group B (control group). Baseline, peri-operative and 6-months follow-up data were evaluated. Lower urinary tract symptoms (LUTS) and sexual function were assessed through internationally validated questionnaires. Groups were matched by an inverse probability of treatment weighting (IPTW) analysis. Logistic univariable regression analysis was performed to detect predictors of antegrade ejaculation preservation.

RESULTS

Overall, 76 patients were included, among which 15 in group A and 61 in group B. Median (inter-quartile range, IQR) age was 72 (66.5-77) years, median (IQR) prostate volume 63.5 (54.5-98.5) cc. No differences about peri-operative outcomes were detected, included high-grade complications. At 6-months follow-up, no differences in urinary or erectile function were detected between groups, while ejaculation-sparing patients showed better Male Sexual Health Questionnaire (MSHQ) scores [7 (1-13) vs. 1 (1-1), p < 0.001] and higher rates of antegrade ejaculation (60% vs. 13.1%, p < 0.001). The ejaculation-sparing technique was identified as a predictor of post-operative antegrade ejaculation (OR 19.3, CI 95% 7.2-51.2, p < 0.001).

CONCLUSION

The ejaculation-sparing anatomic PVP showed superiority over the control group in post-operative ejaculatory function scores and antegrade ejaculation rates. Besides, preliminary results suggested similar effectiveness in LUTS relief at a short-term follow-up.

The impact of ejaculatory dysfunction upon the sufferer and his partner

Ejaculatory function cannot be evaluated outside the dyadic process and without taking into account the men’s and women’s cognition of the condition and how their subjective perception impacts on the evaluation of the relationship and sexual quality. Although the distress of the sufferer and his partner has been a motivating factor in leading men with ejaculatory dysfunction to seek medical help, few objective or prospective evaluations of the effects on the couple have been reported. Specialized literature has been dealing with ejaculatory disorders in a heterogeneous manner. Comparatively, there are far more studies on premature ejaculation (PE) than on delayed ejaculation (DE) and even fewer studies on other male orgasm disorders. Therefore, the review focuses on the literature of the two most studied ejaculatory disorders. The matter presented in this article can also be considered for other ejaculatory disorders, since all of them relate to a failure of control, changing the intravaginal ejaculatory latency time (IELT), with consequences for men and their partners. There are multiple psychological explanations as to why a man develops PE or DE. Unfortunately, none of the theories evolve from evidence-based studies. The common final pathway of these factors is the irrational fear of ejaculating intravaginally. These sexual disorders may also cause personal distress for the sexual partner and decreased sexual satisfaction for the couple. An association between pre-existing anxiety disorders and sexual performance anxiety has been found in men and couples with ejaculatory dysfunction. This could reflect a process in which pre-existing anxiety triggers sexual dysfunction, causing performance anxiety and leading to a vicious cycle: anxiety, sexual dysfunction, more anxiety. Men with DE are similar to men with other sexual dysfunctions. They show the same elevated level of sexual dissatisfaction and they also show lower levels of coital frequency. To a lower extent, they use more masturbatory activity relative to controls. The burden of PE for the patient is revealed in three different levels: the emotional burden, the health burden, and the burden on the relationship. In terms of the emotional burden, there is often a sense of embarrassment and shame at not being able to satisfy their partner, and patients often have low self-esteem, feelings of inferiority, anxiety, anger, and disappointment. Men feel frustrated about their PE and how it affects their intimacy with their partners and the sexual relationship. In conclusion, ejaculatory dysfunction has a negative impact on both the man and his female partner and, consequently, it has implications for the couple as a whole. Additionally, ejaculatory dysfunction extending beyond a year elevates the risk of depression in these patients. Although partner perceptions of PE generally indicated less dysfunction than those of subjects, partner outcomes measures play a part in the assessment of PE. Ejaculatory dysfunction involves the integration of physiological, psychobehavioral, cultural, and relationship dimensions. All these elements need to be considered in the treatment.

Normal male sexual function: emphasis on orgasm and ejaculation

Orgasm and ejaculation are two separate physiological processes that are sometimes difficult to distinguish. Orgasm is an intense transient peak sensation of intense pleasure creating an altered state of consciousness associated with reported physical changes. Antegrade ejaculation is a complex physiological process that is composed of two phases (emission and expulsion), and is influenced by intricate neurological and hormonal pathways. Despite the many published research projects dealing with the physiology of orgasm and ejaculation, much about this topic is still unknown. Ejaculatory dysfunction is a common disorder, and currently has no definitive cure. Understanding the complex physiology of orgasm and ejaculation allows the development of therapeutic targets for ejaculatory dysfunction. In this article, we summarize the current literature on the physiology of orgasm and ejaculation, starting with a brief description of the anatomy of sex organs and the physiology of erection. Then, we describe the physiology of orgasm and ejaculation detailing the neuronal, neurochemical, and hormonal control of the ejaculation process.

Prevalence and factor association of premature ejaculation among adult Asian males with lower urinary tract symptoms

Purpose

To determine the prevalence of premature ejaculation (PE) among adult Asian males presented with lower urinary tract symptoms (LUTS) and characterize its association with other clinical factors.

Methods

A cross-sectional study was conducted at a tertiary medical center to determine the prevalence of PE among adult male participants with LUTS during the Annual National Prostate Health Awareness Day. Basic demographic data of the participants were collected. All participants were assessed for the presence and severity of LUTS using the International Prostate Symptom Score (IPSS), and for the presence of PE using the PE diagnostic tool. Digital rectal examination was performed by urologists to obtain prostate size. LUTS was further categorized into severity, storage symptoms (frequency, urgency, and nocturia), and voiding symptoms (weak stream, intermittency, straining, and incomplete emptying) to determine their association with PE. Data were analyzed by comparing the participants with PE (PE diagnostic tool score ≥11) versus those without PE, using the independent t test for continuous data, Mann–Whitney U test for ordinal data, and Chi-square test for nominal data. The statistical significance was set at P < 0.05.

Results

A total of 101 male participants with a mean ± standard deviation age of 60.75 ± 10.32 years were included. Among the participants, 33% had moderate LUTS, and 7% severe LUTS. The most common LUTS was nocturia (33%). The overall prevalence of PE was 27%. There was no significant difference among participants with PE versus those without PE in terms of age, marital status, prostate size, or total IPSS score. However, significant difference between groups was noted on the level of education (Mann–Whitney U, z = −1.993, P = 0.046) where high educational status was noted among participants with PE. Likewise, participants with PE were noted to have more prominent weak stream (Mann–Whitney U, z = −2.126, P = 0.033).

Conclusions

Among the participants consulted with LUTS, 27% have concomitant PE. Educational status seems to have an impact in the self-reporting of PE, which may be due to a higher awareness of participants with higher educational attainment. A significant association between PE and weak stream that was not related to prostate size suggests a neuropathologic association.

Comparison of alpha blockers in treatment of premature ejaculation: a pilot clinical trial

Background:

Premature ejaculation (PE) is the most common sexual disorder in men and studies reported prevalence up to 30% (1, 2). PE is not a life-threatening medical condition but it influences the quality of life (QoL).

Objectives:

The aim of this study was to compare the efficiency, and safety of alpha blocker drugs in the treatment of patients with premature ejaculation (PE). Additionally we investigated the quality of life (QoL) in patients with PE who were treated with alpha blocker drugs.

Materials and Methods:

This study was a pilot clinical trial. Prospectively documented 108 patients with PE were treated and were followed-up in urology outpatient clinic. All patients were divided into 5 groups according to used alpha blocker agents which were determined by simple randomization. Silodosin 4mg (Group 1, n = 21), tamsulosin hydrochloride 0.4mg (Group 2, n = 23), alfuzosin 10mg (Group 3, n = 22), terazosin 5mg (Group 4, n = 21), doksazosin mesylate 4mg (Group5, n = 21), were used for treatment. The demographic parameters of patients, pre and post treatment intravaginal ejaculation latency time (IELT), PE Profile (PEP), and QoL index were recorded and evaluated. Effectiveness of treatment was evaluated by measuring IELT. Additionally, side effects of drugs were recorded. P < 0.05 was considered statistically significant.

Results:

All alpha blocker drugs were statistically effective for preventing PE. Notably, silodosin seemed to be more effective for preventing PE than other alpha blockers (P < 0.05). However all alpha blockers provided development in QoL scores, silodosin was a little better than other drugs in statistical analyses. Furthermore statistical increase in IELT and decrease in PEP were provided more in Group 1 than other groups (P < 0.05).

Conclusions:

Silodosin seems to be able to even more prevent PE. Silodosin may provide development in QoL than other alpha blocker agents. Additionally, lower systemic adverse events and more effectivity are the prominent features of silodosin in PE.This study was a pilot clinical trial. Prospectively documented 108 patients with PE were treated and were followed-up in urology outpatient clinic. All patients were divided into 5 groups according to used alpha blocker agents which were determined by simple randomization. Silodosin 4mg (Group 1, n = 21), tamsulosin hydrochloride 0.4mg (Group 2, n = 23), alfuzosin 10mg (Group 3, n = 22), terazosin 5mg (Group 4, n = 21), doksazosin mesylate 4mg (Group5, n = 21), were used for treatment. The demographic parameters of patients, pre and post treatment intravaginal ejaculation latency time (IELT), PE Profile (PEP), and QoL index were recorded and evaluated. Effectiveness of treatment was evaluated by measuring IELT. Additionally, side effects of drugs were recorded. P < 0.05 was considered statistically significant.

[Ejaculatory disorders except premature ejaculation, orgasmic disorders]

INTRODUCTION

Disorders of ejaculation and orgasm apart from premature ejaculation are pretty uncommon.

METHODS

Medical literature was reviewed and combined with expert opinion of the authors.

RESULTS

The semiology of these disorders is essential: aspermia, hypospermia, retrograde ejaculation, delayed or absent ejaculation with or without orgasm. Whether this is a lifelong or acquired condition, it is essential to assess the side-effects of medications i.e. psychotropic drugs, including antidepressant, neuroleptics, tramadol, alphablockers: tamsulosin and silodosin must always be surveyed.

CONCLUSION

The management is often difficult, especially with a parenthood perspective. The management of lifelong disorders must rely on psychosexual therapies.

Neurological rehabilitation: sexuality and reproductive health

Sexuality is the embodiment of sexual and reproductive activities involving complex interactions among biological, psychological, and social systems. An individual's perception of their sexuality, as well as society's perception, can have an inestimable impact on self-esteem, and hence willingness to openly address these issues Earle S (2001). Disability, facilitated sex and the role of the nurse. J Adv Nurs 3: 433-440. Such barriers to communication represent a real challenge to practicing clinicians. However, advances in treatment options obligate the clinician providing care to those with neurogenic sexual/reproductive dysfunction to learn to communicate effectively about these issues, provide effective therapies, and refer patients to appropriate specialists. This chapter will address counseling, an overview of male and female sexual and reproductive physiological responses in the case of an intact nervous system, and a description of the impact of disorders of the nervous system on sexual function and reproductive health. Treatment options are also reviewed.

Characterization of the effects of various drugs likely to affect smooth muscle tension on isolated human seminal vesicle tissue

OBJECTIVES

To investigate the effects of different classes of drugs on the isometric tension of isolated human seminal vesicle (SV) tissue. The contractility of human SV contributes to the process of seminal emission during ejaculation. Different endogenous compounds, such as serotonin (5-HT), adenosine triphosphate (ATP), and nitric oxide, have been suggested to be involved in the control of contraction and relaxation of human SV smooth muscle. However, only limited data are available regarding the effects of compounds known to affect smooth musculature on SV contractile activity.

METHODS

Using the organ bath technique, the effects of increasing concentrations (10 nm-1 microm/10 microm) of norepinephrine (NE), phenylephrine, endothelin 1, ATP, and 5-HT on human SV tissue at basal tension were studied. In another set-up, SV strip preparations were preincubated with prazosin (alpha-adrenergic blocker), nifedipine and verapamil (Ca(2+)-channel blockers), 2-aminoethoxydiphenyl borate [inositol 1,4,5-trisphosphate (IP(3)) antagonist], cromakalim (K(+)-channel opener), or Y-27632 (ROK inhibitor) (1 microm each, for 10 minutes), followed by the application of NE (0.1 microM, 1 microM, and 10 microm).

RESULTS

SV smooth muscle was most effectively contracted by NE (mean = 75% of calibrated scale), phenylephrine (mean = 82% of calibrated scale), and endothelin 1 (mean = 70% calibrated scale), whereas only minor responses to ATP (mean = 10.65% calibrated scale) and 5-HT (mean = 6.3% calibrated scale) were observed. The contraction induced by NE was significantly inhibited after pre-exposure of the tissue to prazosin (-92.4%), cromakalim (-83.7%), 2-aminoethoxydiphenyl borate (-43.1%), Y-27632 (-42.8%), and nifedipine (-32.7%).

CONCLUSIONS

alpha-adrenoceptor antagonism, activation of potassium channels, and inhibition of Rho-kinase decrease the sympathetic contraction of SV smooth muscle. This might be of significance with regard to the identification of new pharmacologic avenues to affect the male ejaculatory system.

Measurement of benign prostatic hyperplasia treatment effects on male sexual function

Benign prostatic hyperplasia (BPH) is the leading cause of lower urinary tract symptoms among the aging male population. Epidemiological, pathophysiological and clinical studies indicate that many of these men also suffer from declining sexual function, especially those undergoing treatment for their BPH-related urinary symptoms. Although urinary symptoms and quality of life may improve with BPH therapy, the resulting effects on sexual function vary by medical, surgical and minimally invasive approaches and have not been consistently reported. As comprehensive, validated instruments to measure male sexual function are now available for routine use in the clinical setting, urologists and primary care providers caring for patients with BPH have the opportunity to monitor both urinary and sexual function before, during and after BPH therapy. Herein, we describe the relationship between BPH and its treatments on male sexual function, the role of new measures for sexual functioning and opportunities for future work to improve the care of men suffering from both maladies.

Role of the neurokinin-1 receptors in ejaculation in anesthetized rats

INTRODUCTION

Several lines of evidence indicate a role for substance P in the control of ejaculation, although its mode of action needs to be clarified.

AIM

The effects and sites of action of a selective antagonist for the substance P-preferred receptor (neurokinin-1 receptor subtype; NK1) were investigated in a pharmacological model of ejaculation.

METHODS

Ejaculation was induced in anesthetized rats by intracerebroventricular (i.c.v.) delivery of the dopamine D3 receptor preferring agonist 7-hydroxy-2-(di-N-propylamino)tetralin (7-OH-DPAT). The effects of the selective NK1 antagonist RP67580 on 7-OH-DPAT-induced ejaculation were measured following intraperitoneal (i.p.), i.c.v., or intrathecal (i.t.) (third lumbar spinal segment; L3) administration.

MAIN OUTCOME MEASURES

Intraseminal vesicle pressure (SVP) and electromyogram of the bulbospongiosus muscle (BS) were recorded as physiological markers of emission and expulsion phases of ejaculation, respectively.

RESULTS

Upon i.p., i.c.v., or i.t. administration, RP67580 significantly reduced the occurrence of ejaculation elicited by 7-OH-DPAT. A mild decrease in the occurrence of SVP and BS responses was observed in rats treated ip with RP67580, whereas only SVP responses were moderately affected following i.c.v. or i.t. administration.

CONCLUSION

These results show the multilevel regulation of 7-OH-DPAT-induced ejaculation by NK1 receptors.

Sacrolumbar intersegmental reflex circuit in men and its relation to the ejaculatory process

OBJECTIVE

We aimed to investigate electrophysiologically the intersegmental reflex circuit from sacral to lumbar cord segments in normopotent adult men, in patients with spinal cord injury and in patients with premature ejaculation.

METHODS

Reflex EMG activity of the cremasteric (CM) and bulbocavernosus (BC) muscles was recorded simultaneously by needle electrodes during electrical stimulation of the upper lumbar and sacral dermatomes, respectively. Thirty-three healthy male volunteers, 16 patients with spinal cord injury (SCI) at the thoracic or cervical levels, and 26 men with premature ejaculation (PME) were included in the study.

RESULTS

In controls, upper lumbar dermatomal stimulation (ULS) at the inner side of thigh only elicited a reflex response from the CM muscle and did not produce a regular response from the lower sacral myotomes such as in the BC muscle. However lower sacral dermatomal stimulation (LSS) at the dorsal nerve of penis consistently evoked reflex responses from both CM and BC muscles. These basic electrophysiological features were not different in patients with SCI. LSS did not elicit a reflex response from the CM muscle in about 39% of patients with PME, while the BC reflex was obtained from all patients with PME.

CONCLUSIONS

The neurophysiological pattern in BC and CM muscles during sacral or lumbar dermatomal stimulation reflects the sacrolumbar intersegmental reflex linkage that may be related to the ejaculatory process in men. The intersegmental sacrolumbar reflex circuit may be functionally disturbed in some patients with PME.

SIGNIFICANCE

Interaction between the reflex activity of sacral to lumbar dermatomes could prove useful in defining electrophysiological mechanisms related to ejaculation in men.

Trazodone and ejaculatory inhibition

Sexual adverse effects are common with psychotropics. Rational polypharmacy may confound etiology. This case report describes development of ejaculatory inhibition in a male patient with co-morbid psychiatric diagnoses treated with fluoxetine, divalproex sodium, lamotrigine, trazodone, and clonazepam. Detailed psychotropic history with time-line of adverse effect onset implicated trazodone. Within 48 hours of trazodone discontinuation, ejaculatory inhibition was resolved. Clinicians should be aware that trazodone may cause ejaculatory inhibition, understand that determination of sexual adverse effects necessitates directed and periodic questioning as these symptoms may increase in severity over time, and appreciate that religious patients may find discussing this issue difficult.

Assessment of penile vibratory stimulation as a management strategy in men with secondary retarded orgasm

OBJECTIVES

To evaluate the effectiveness of penile vibratory stimulation for the management of retarded orgasm. Retarded orgasm, a condition characterized by difficulty achieving orgasm and ejaculation, is one of the most recalcitrant of the male sexual dysfunctions. Currently, no evidence-based treatments have been proven to ameliorate this condition.

METHODS

Men who had a complete inability to achieve an orgasm during sexual relations in the previous 3 months were instructed in the use of penile vibratory stimulation. The men's responses were measured by self-report of orgasm function and using the orgasm and satisfaction domains of the International Index of Erectile Function. The responses were assessed at baseline (admission into the study) and at 3 and 6 months.

RESULTS

A total of 36 men met the inclusion criteria, and 72% reported the restoration of orgasm. These responders reported that orgasm during sexual relations occurred 62% of the time. A statistically and clinically significant increase occurred in the orgasm and satisfaction domains of the International Index of Erectile Function between the baseline visit and the 3-month follow-up visit. These gains were sustained at 6 months.

CONCLUSIONS

Penile vibratory stimulation is an effective treatment for retarded orgasm. Penile vibratory stimulation should be integrated into current cognitive-behavioral sex therapy techniques to achieve maximal effectiveness and satisfaction.

Ejaculatory urine incontinence after radical prostatectomy

OBJECTIVES

Urinary incontinence and erectile dysfunction remain the long-term complications that affect most patients' lives after radical prostatectomy. Previous reports evaluating incontinence have focused on volumes of urine loss and daily pad use to assess these issues. We have observed that small volumes of urinary incontinence during sexual activity can be just as disconcerting to patients. We attempt to further describe and assess the phenomenon of urinary incontinence with ejaculation in a series of patients.

METHODS

We reviewed the experience of one physician who received referrals for the treatment of erectile dysfunction after radical prostatectomy from July 2002 to March 2005 and identified 26 men experiencing urine leak predominantly during ejaculation. Questionnaires assessing urinary incontinence were sent to all these patients.

RESULTS

The mean age was 62 years (range 54 to 73). Sixteen patients underwent bilateral nerve-sparing, five unilateral nerve-sparing, and five nonnerve-sparing radical retropubic prostatectomy. At a median follow-up of 42 months (range 15 to 118), all patients had experienced urine leakage (volume 0.5 teaspoon to 1 cup) during ejaculation. The incontinence questionnaire revealed that most patients had mild incontinence; however, they experienced ejaculatory urine incontinence "most, or all of the time" and considered it a "big problem."

CONCLUSIONS

Although the prevalence of ejaculatory urine incontinence is unclear, in our experience it occurs often enough to be considered a part of the routine postprostatectomy evaluation. A better understanding of the pathophysiology of postprostatectomy incontinence will lead to targeted therapy and an improved quality of life for the patient.

Retarded ejaculation

Retarded ejaculation (RE) has a relatively low prevalence (<3%), yet this condition results in considerable distress, anxiety, and lack of sexual confidence for those suffering from it. Furthermore, men with partners often experience impairment of both the sexual and nonsexual aspects of their relationships, with such negative effects compounded when procreation is a consideration. The definition of RE is ambiguous, due to the variability and paucity of data regarding normal coital ejaculatory latency. RE is influenced by both biogenic and psychogenic components, which may vary over time both between and within individuals. While specific pathophysiology can often be identified, further elucidation of the biogenic components of this dysfunction will require greater understanding of the physiological mechanisms underlying ejaculation. Yet, the most useful strategies for understanding RE will integrate rather than isolate the various biogenic and psychogenic aspects of this dysfunction. Evidence based evaluation and treatment protocols for this disorder are lower than for other sexual dysfunctions, but reports suggest better treatment efficacy when the etiology is predominantly psychogenic. As with erectile dysfunction (ED) and premature ejaculation (PE), if safe and efficacious oral pharmaceuticals are eventually developed for this condition, the treatment algorithm is likely to undergo significant alteration. Even then, however, the most effective treatments are likely to result from a combination treatment that integrates sex coaching with pharmacotherapy.

Comparison between tamsulosin and alfuzosin on the expulsion phase of ejaculation in rats

OBJECTIVE

To investigate the effects of acute intravenous (i.v.) delivery of tamsulosin and alfuzosin on the contractions of bulbospongiosus muscles (BS) induced by central delivery of a serotonin agonist, 8-hydroxy-2-(di-n-propylamino)tetralin (8-OH-DPAT), in anaesthetized rats, as an experimental model of the expulsion phase of ejaculation.

MATERIALS AND METHODS

Under urethane anaesthesia, adult male rats were implanted with a cannula into the lateral cerebral ventricle for intracerebroventricular (i.c.v.) injection, and with recording electrodes in the BS for electromyogram (EMG) monitoring. Tamsulosin (1 microg/kg) and alfusozin (10 microg/kg) were injected i.v. and 15 min later 8-OH-DPAT (20 microg) was delivered i.c.v. BS-EMG recording was continued for 30 min after i.c.v. 8-OH-DPAT. The area under the curve (AUC) of the BS cluster of contractions was determined as reflecting the energy of BS contractions.

RESULTS

After i.c.v. delivery of 8-OH-DPAT, there were rhythmic BS contractions in the form of clusters of bursts in vehicle-, tamsulosin- and alfuzosin-treated rats. The number of BS clusters was not altered by the alpha1-blockers as compared with vehicle, but the AUC was significantly less in tamsulosin-treated rats than in vehicle- or alfuzosin-treated (both P < 0.05) rats.

CONCLUSION

Systemic injection of tamsulosin impaired BS contractile capacity whereas alfuzosin did not. This might explain anejaculation in men treated with tamsulosin.

Definition and current evaluation of subfertile men

Male infertility affects 10% of reproductive aged couples worldwide and is treatable in many cases. In addition to other well-described etiologies, genetic causes of male infertility are now more commonly diagnosed. Using principles of evidence-based medicine, this review outlines diagnostic and treatments options to inform clinical management. In order of importance, randomized controlled clinical trials, basic scientific studies, meta-analyses, case-controlled cohort studies, best-practice policy recommendations and reviews from peer-reviewed literature were incorporated that provide organized and timely guidelines to the current management of male infertility. The strength of evidence for treatment recommendations is also classified when appropriate.

Terazosin in the treatment of premature ejaculation: a short-term follow-up

AIM

The aim of the present study was to evaluate the efficacy of terazosine in patients with premature ejaculation and lower urinary tract symptoms (LUTS), after excluding other sexual disorders and chronic prostatitis.

METHODS

A total of 90 patients with premature ejaculation and LUTS were enrolled to the study after excluding sexual disorders, prostatitis and benign prostatic hyperplasia. The patients were divided into two groups. Sixty patients in group 1 were treated with terazosine 5 mg daily for a month. Patients were followed monthly and questioned for their ejaculation problem. The results were classified as cure, improvement and ineffective. If patients showed improvement and ineffectiveness, the treatment was continued with 10 mg daily for the following month. Group 2 was included 30 patients, and placebo was applied for a month. At the end of this period, in patients who did not show any improvement, terazosine 10 mg was started.

RESULTS

In the treatment group, at the 1st month follow-up, 21 patients (35%) were cured, 20 (33.3%) showed improvement. In 19 (31.7%) patients, the treatment was ineffective. In group 2, 9 (30%) patients showed improvement and the rest had no-changes after one-month follow up. There was statistically significant difference between two groups (Pearson chi2 test = 0.000). Later, terazosine 10 mg was given to the patients in group 2 and to the patients who showed improvement or unsuccessful result with terazosine 5 mg. With terazosine 10 mg, 10 (14.5%) patients were cured, 29 (42.2%) patients were improved. Finally, terazosine treatment in patients with premature ejaculation was found to be effective in 60 patients (66.7%).

CONCLUSION

Alpha blockers seem to be physiological medical agents in the treatment of premature ejaculation since ejaculation is under sympathetic control. Moreover, these agents are effective in lower urinary tract and they should be used in patients with premature ejaculation and lower urinary tract symptoms.

Practical approaches to the diagnosis and management of male infertility

Male infertility affects 10% of couples of reproductive age worldwide, and is treatable in many cases. In addition to well-established etiologies, genetic causes of male infertility are now diagnosed more commonly, as our knowledge of genomic medicine advances. Using principles of evidence-based medicine, this review outlines diagnostic and treatment algorithms that guide clinical management. In order of importance, randomized controlled clinical trials, basic scientific studies, meta-analyses, case-controlled cohort studies, best-practice policy recommendations and reviews from peer-reviewed literature were incorporated into algorithms that provide organized and timely guidelines to the current management of male infertility. The strength of the evidence for treatment recommendations is also classified when appropriate.

D2-Like Receptors Mediate the Expulsion Phase of Ejaculation Elicited by 8-Hydroxy-2-(di-N-propylamino)tetralin in Rats

The mechanism of action by which 8-hydroxy-2-(di-N-propylamino)tetralin (8-OH-DPAT) facilitates ejaculation in conscious rats is not clearly established. The serotonin (5-HT) 1A agonist 8-OH-DPAT may actually act on cerebral dopaminergic receptors to exert its proejaculatory effect. The present work was undertaken to clarify this issue by testing various compounds i.c.v. delivered in an experimental model of the expulsion phase of ejaculation in anesthetized Wistar rats. Intracerebroventricular delivery of 8-OH-DPAT dose-dependently (ED(50) = 17 microg) induced rhythmic contractions of bulbospongiosus (BS) muscles, which are of paramount importance for the expulsion of semen, occurring in the form of cluster of bursts evidenced by the recording of BS muscle electrical activity. The 5-HT1A antagonist WAY100635 (N-[2-[4-(2-methoxyphenyl)-1-piperazinyl]ethyl]-N-2-pyridinylcyclohexanecarboxamide) (20 microg) i.c.v. coadministered with 8-OH-DPAT (20 microg) was unable to inhibit the effect of 8-OH-DPAT on BS muscle contractile activity. Conversely, raclopride (40 microg) and spiperone (10 microg), both dopamine D2-like receptor antagonists, i.c.v. coinjected with 8-OH-DPAT (20 microg), abolished BS muscle contractions. The involvement of D2-like receptors was further supported by the fact that the D2-like agonist quinelorane (20 microg i.c.v.) also induced BS muscle rhythmic contractions. Our data demonstrate that D2-like receptors mediate the induction by 8-OH-DPAT of rhythmic BS muscle contractions and suggest that i.c.v. delivery of D2-like receptor agonists to anesthetized rats represents a relevant experimental model to study the expulsion phase of ejaculation.

Effects of sildenafil citrate on ejaculation latency, detumescence time, and refractory period: placebo-controlled, double-blind, crossover laboratory setting study

OBJECTIVES

To evaluate whether sildenafil citrate (SC) prolongs ejaculation latency and detumescence time and shortens the refractory period in a laboratory setting.

METHODS

Two successive double-blind, placebo-controlled, crossover laboratory studies were performed with 30 different healthy volunteers in each study (total of 60). In the first study, the subject ingested placebo or SC. Real-time penile tumescence and rigidity monitoring and audiovisual sexual stimulation was performed. When the subject had his best erection, he applied vibratory stimulation until he ejaculated, and then audiovisual sexual stimulation was stopped. Monitoring was continued until he lost rigidity. The test was repeated with the second medication in 7 to 15 days. In the second study, another group of 30 volunteers were tested, as in the first study, and audiovisual sexual stimulation was continued for an additional hour after ejaculation.

RESULTS

In the first study, the time to ejaculation with vibratory stimulation was 2.23 and 3.89 minutes (P = 0.01) and the time to minimal tip rigidity after ejaculation was 1.93 and 3.1 minutes (P <0,001) in the placebo and SC groups, respectively. In the second study, the time to ejaculation with vibratory stimulation was 2.23 and 4.91 minutes (P = 0.006), the time to best tip rigidity after ejaculation was 19.10 and 15.66 minutes (P = 0.242), and the area under the curve of tip rigidity in 3 minutes after ejaculation was 73.61 and 144.05 (P <0.001) in the placebo and SC groups, respectively.

CONCLUSIONS

In this laboratory setting, SC seemed to prolong the ejaculation latency time. The detumescence time was also longer, with better quality. However, we did not show that SC shortens the refractory period after ejaculation.

Selecting therapy for maintaining sexual function in patients with benign prostatic hyperplasia

In the first of these mini-reviews the selection of therapy for the maintenance of sexual function in patients with BPH is outlined, along with an explanation of how altered regulation of neurotransmitters, especially noradrenaline, may underlie the syndrome of LUTS and sexual dysfunction. Other mini-reviews outline the current status of robotic surgery to treat renal and adrenal disorders, and its future applications, and the potential use of the nitric oxide/cGMP pathway as a potential target to treat BOO associated with benign prostatic enlargement. Finally, the capacity to be creative in academic departments is extolled as a core property of academicians, and its surfacing described as having the potential to revitalize individuals and departments.

Male infertility in spinal cord trauma

Every year there are 10 thousand new cases of patients victimized by spinal cord trauma (SCT) in the United States and it is estimated that there are 7 thousand new cases in Brazil. Eighty percent of patients are fertile males. Infertility in this patient group is due to 3 main factors resulting from spinal cord lesions: erectile dysfunction, ejaculatory disorder and low sperm counts. Erectile dysfunction has been successfully treated with oral and injectable medications, use of vacuum devices and penile prosthesis implants. The technological improvement in penile vibratory stimulation devices (PVS) and rectal probe electro-ejaculation (RPE) has made such procedures safer and accessible to patients with ejaculatory dysfunction. Despite the normal number of spermatozoa found in semen of spinal cord-injured patients, their motility is abnormal. This change does not seem to be related to changes in scrotal thermal regulation, frequency of ejaculation or duration of spinal cord damage but to factors related to the seminal plasma. Despite the poor seminal quality, increasingly more men with SCT have become fathers through techniques ranging from simple homologous insemination to sophisticated assisted reproduction techniques such as intracytoplasmic sperm injection (ICSI).

Sexual Dysfunction and Lower Urinary Tract Symptoms (LUTS) Associated with Benign Prostatic Hyperplasia (BPH)

Sexuality is an essential aspect of a couple's relationship and has a significant impact on life satisfaction. Benign prostatic hyperplasia (BPH) is a condition that commonly affects older men and is often associated with lower urinary tract symptoms (LUTS) and sexual dysfunction. Men with moderate-to-severe LUTS are at increased risk for sexual dysfunction, including moderate-to-severe erectile dysfunction (ED), ejaculatory dysfunction (EjD), and hypoactive desire (HD). The results of several recent large-scale studies have shown a consistent and strong relationship between LUTS and both ED and EjD. It appears that the pathophysiological mechanisms of LUTS and the related prostatic enlargement of BPH as well as certain treatments for this condition may have an impact on both the erection and ejaculation components of the sexual response. Validated questionnaires that assess sexual function provide clinicians with valuable information to help guide treatment selection decisions. Effective medical therapies for LUTS associated with BPH include alpha(1)-adrenergic receptor antagonists (i.e., alfuzosin, doxazosin, tamsulosin, and terazosin) and 5alpha-reductase inhibitors (i.e., finasteride and dutasteride). The side effects of these medications, including sexual dysfunction, are important distinguishing features. The successful management of patients with LUTS associated with BPH should include assessments of sexual function and monitoring of medication-related sexual side effects. For men with LUTS and sexual dysfunction, an appropriate integrated management approach, based on each patient's symptoms and outcome objectives, is warranted.

Psychosexual factors that differentiate men with inhibited ejaculation from men with no dysfunction or another sexual dysfunction

AIM

Inhibited or retarded ejaculation (IE) is an uncommon male sexual dysfunction that may result in a lack of sexual fulfillment for both the man and his partner. In this study, we attempted to identify factors that differentiate men with IE from sexually functional controls or from men with other sexual dysfunctions and to specify whether such factors predict self-reported sexual arousal during psychophysiological assessment.

METHODS

Each patient underwent psychophysiological assessment and a structured clinical interview based on a standardized questionnaire that included demographic information, psychosexual and medical history, and assessment of current sexual, erectile, and ejaculatory function, including relationship quality and characteristics.

RESULTS

Men with IE resemble men with other dysfunctions but are differentiated from controls, in their lower level of relationship satisfaction, greater level of distress, and higher level of health-related problems. Men with IE were further characterized by lower levels of self-reported subjective sexual arousal, despite exhibiting strong penile response during psychophysiological testing and reporting high quality erections across a variety of situations. Also notable, however, were the many factors on which men with IE did not differ from controls.

CONCLUSIONS

Taken together, this research helps specify directions for future investigations of men with IE.

Sexual response in men with inhibited or retarded ejaculation

Inhibited ejaculation (IE) is a poorly understood male sexual dysfunction having both somatic and psychological etiologies. This study investigated sexual response in 25 IE men with no probable somatic cause. Using a standard psychophysiological assessment procedure, these men were compared with sexually functional and other dysfunctional groups on two measures of sexual response: erectile response and self-reported sexual arousal. Within the sample of IE men, sexual response was investigated as a function of both diagnostic classification and relationship factors. Differences occurred between IE men and the other groups on erectile response and self-reported sexual arousal during psychosexual stimulation in the lab, with IE men reporting lowest levels of sexual arousal. Within the IE group, diagnostic classifications and relationship variables were also related to self-reported sexual arousal. These findings suggest that inhibited arousal may be fairly common among IE men having no apparent somatic etiology, and further that several specific relationship factors may provide potential strategies for enhancing arousal in these men.

A comparison of the effects of tamsulosin and alfuzosin on neurally evoked increases in bladder neck and seminal vesicle pressure in rats

OBJECTIVE

To assess the effects of the alpha 1-adrenoceptor antagonists alfuzosin and tamsulosin on the physiological events associated with ejaculation in the rat, because when these drugs are used for treating symptomatic benign prostatic hyperplasia in men they may affect ejaculation by impairing bladder neck closure and seminal vesicle contraction.

MATERIALS AND METHODS

In clinical trials the incidence of ejaculatory disorders in men is typically < 1% with alfuzosin and 4-18% with tamsulosin. The effects of tamsulosin and alfuzosin on bladder neck and seminal vesicle pressures (BNP and SVP) in the rat were analysed. Increases in BNP and SVP were induced in urethane-anaesthetized. Wistar rats by electrical stimulation (ES) of the hypogastric nerve (HN) before and after an intravenous injection with vehicle, 3 or 10 micrograms/kg of tamsulosin or alfuzosin (10 rats/group). The mean amplitude and area under the curve (AUC) of the BNP and SVP were expressed as the percentage of the response to ES of HN before the treatment.

RESULTS

The amplitude and AUC of the SVP were significantly decreased by both doses of tamsulosin, and marginally decreased by the same doses of alfuzosin. The amplitude of the BNP was significantly decreased by 3 and 10 micrograms/kg of tamsulosin and 10 micrograms/kg alfuzosin, and marginally decreased by 3 micrograms/kg alfuzosin. The AUC of the BNP was significantly decreased by both doses of tamsulosin, but barely affected by alfuzosin at the same doses.

CONCLUSION

Over the doses assessed, alfuzosin had significantly less deleterious effect on increases in BNP and SVP induced by ES of the HN than had tamsulosin.

Phosphodiesterase 5 Inhibitors in Rapid Ejaculation

Rapid (premature) ejaculation (RE) is a very common sexual disorder. This condition may be primary or secondary to underlying disease. Control of RE has been primarily focused on behavioural therapy, topical anaesthetics, tricyclic antidepressants and selective serotonin reuptake inhibitors; however, an approved treatment does not exist. Recently, a number of clinical trials have studied the potential effectiveness of the phosphodiesterase (PDE)-5 inhibitor sildenafil in the treatment of RE. Results of most of these studies have been encouraging. Available data indicate that there is clinical, anatomical, physiological, pharmacological and genetic evidence to explain the efficacy of PDE5 inhibitors in RE. The rationale for the use of PDE5 inhibitors in the treatment of RE could be due to possible peripheral and central mechanisms. Possible peripheral ejaculation retarding capabilities may include modulation of the contractile response of the vas deferens (VD), seminal vesicles (SV), prostate and urethra, induction of a state of peripheral analgesia, and prolongation of the total duration of erection. Possible central mechanisms may involve lessening of the central sympathetic output. Furthermore, there is evidence from knockout mice to explain the efficacy of PDE5 inhibitors in RE. Mice lacking the gene for endothelial nitric oxide synthase develop a condition similar to RE. On the other hand, mice lacking the gene for heme oxygenase-2 develop a condition similar to delayed ejaculation. This review also discusses the findings against the use of these agents in RE. In conclusion, a review of the literature suggests the potential usefulness of PDE5 inhibitors as a promising line of therapy in RE but further studies are needed.

Medical therapy for benign prostatic hyperplasia: sexual dysfunction and impact on quality of life

Therapies for benign prostatic hyperplasia (BPH) may either improve or exacerbate sexual function with an ensuing impact on quality of life. Here we review a total of 73 papers on medical therapies for BPH with a focus on the effects of different pharmacological agents on sexual function. For example, certain alpha(1)-adrenergic receptor blockers may improve erectile function; however, ejaculatory dysfunction with one of these agents, tamsulosin, occurs at a rate of 4-18%, rising to 30% with long-term use. In addition, treatment with the 5 alpha-reductase inhibitor finasteride is associated with problems of ejaculation (2.1-7.7%), erection (4.9-15.8%), and libido (3.1-5.4%). Such significant and undesirable complications in relation to sexual function produce a well-documented negative impact on quality of life. Thus, optimal treatment for men with BPH requires the use of agents that demonstrate efficacy and safety with fewer sexual side effects.

Treatment of premature ejaculation after traumatic brain injury

Premature ejaculation (PE) is the most common male sexual disturbance occurring in the general community. Surveys of sexual dysfunction after traumatic brain injury (TBI) have identified that between 17-36% of males report a number of different post-injury ejaculatory problems, including PE. Whilst there are a number of studies that document effective treatment of PE in the general population, there have been no reports of treatment interventions for this problem amongst males with TBI. This paper reports on the assessment and successful treatment of PE in a young male with severe TBI. The treatment programme trialed combined pharmacotherapy (namely, the application of a topical anaesthetic), behavioural and educational approaches. The case report suggests that existing sex therapy techniques, albeit with modifications to compensate for motor sensory, cognitive and affect related injury sequelae, provide one option for the treatment of PE after TBI.

Control of canine membranous urethra, bulbocavernosus and ischiocavernosus muscles by lumbosacral sympathetic pathways

The membranous urethral muscles, bulbocavernosus muscle (BCM) and ischiocavernosus muscle (ICM) play a significant role on expulsion at ejaculation. Projection of the sympathetic pathways in the retroperitoneum to these muscles was investigated in the dog. Intraluminar pressure of the membranous urethra and contractions of the BCM and ICM to electrical stimulation of the lumbar splanchnic nerve (LSN) or the lumbosacral sympathetic chain (LSC) were examined. Stimulation of the LSN was performed after transection of the unilateral hypogastric nerve (HGN) to clarify its cross-innervation. Stimulation of each of the 2nd to 4th LSNs elicited elevation of the intraluminal pressure of the membranous urethra. In eight dogs whose right HGNs were transected, 15 of the 19 right LSNs, and 12 of the 16 left LSNs examined elicited elevation of the membranous urethral pressure, respectively. In five dogs whose left HGNs were transected, 6 of the 9 right LSNs and 10 of the 12 left LSNs stimulated elicited elevation of the pressure. Stimulation of the HGN caused no detectable contractions of the BCM and ICM in all six dogs examined. Stimulation of the LSC elicited responses of the BCM and ICM in all six dogs examined and the membranous urethra in three of six dogs. The maximum value of the response of the BCM was greater than that of the ICM. After consecutive transection of the ipsilateral pelvic nerve, stimulation of the LSC showed no significant changes in the responses of the BCM and ICM. The above results indicate the following: (1). each of the L2-L4 LSNs sends signals to the membranous urethra via two routes, passing through the ipsilateral or contralateral HGN; (2). the above nerve does not send effective signals to the BCM and ICM; (3). the LSC sends signals to the membranous urethra, BCM and ICM; (4). the signals from the LSC mainly pass through the pudendal nerve to the BCM and ICM; and (5). the signals were dominant to the BCM compared with the ICM.

Diagnosis and treatment of ejaculatory dysfunction

The normal ejaculatory process requires complex coordination and integration of neurologic, physiologic, anatomic, and psychologic events. An understanding of these processes is critical to evaluate properly and manage patients with ejaculatory dysfunction. With the advent of improved techniques to treat patients, some men with ejaculatory dysfunction are being offered the opportunity to reproduce. Further research on the ejaculatory process and associated dysfunctional states should continue to improve treatment for patients presenting with ejaculatory disorders.