Paediatrics Urology Unit
Prostate Growth And Greenlight Method
Premature Ejaculation (Early-Fast-Rapid Ejaculation)
Penile Prosthesis İmplantation
Sexually Transmitted Diseases (Venereal Diseases)
Testicle And Epididymis İnfection
• Assoc. Prof. Ömer ÖGE, MD
• Işık H. ÖZGÜ, MD
• Uğur SARAÇOĞLU, MD
Orgasm disorders are often due to psychological causes. In addition to this, it can be considered as symptom and of some diseases retaining nervous system and drug side effects. The state of absence of any ejaculation is called as "anejuculation".
Orgasm should be investigated in patient applying for with anejaculation. The state of absence of orgasm is called as "anorgasmia". Sperm presence in post orgasm urine is investigated in patients with no orgasm problem. If sperm is found out in urine sample, this case is defined as "retrograde ejaculation" and the absence is "real anejaculation". Real anejaculation is called as "aspermia".
Anejaculation is often a symptom of another disease; underlying real problem can be distinguished with a good clinic story and physical examination. Delayed ejaculation and retrograde ejaculation should not be confused with one another. Delayed ejaculation is the least encountered and understood disorder among male sexual dysfunctions. In retrograde ejaculation, semen is not thrown out but escapes back to bladder and orgasm is experienced.
Factors leading to anejaculation
Anejaculation may arise depending on retention of autonomous nervous system in patients such as with diabetes and multiple sclerosis. Treatment of patients in this case is difficult. These patients can only have a child by using auxiliary reproduction techniques. One of the methods is the approach of electrical stimulation (rectal probe electroejaculation) applied from rectal way with the help of probe. Furthermore, seminal duct and calcification in ejaculator ducts and thus, clogging may occur in patients with long term diabetes. In such case, muscle contractions with electrical stimulus and forward transfer of sperm are not possible; in this case, it is attempted to obtain live sperm with epididymal or testicular sperm aspiration. If success is not achieved, obtaining sperm is resorted with testis biopsy.
Spinal traumas are other causes of another anejaculation. Treatment mode varies according to level of trauma. Ejaculation may be provided with the method of stimulating penis with vibration and in patients whereby this treatment is not successful, ejaculation may be provided with rectal probe electroejaculation system. Alternative other methods to be used for the patients that this method is not successful is to obtain surgical sperm with sperm aspiration and testis biopsy from epididymis or testis.
Surgical interventions conducted to the main arteries causing retrograde ejaculation may reveal anejaculation depending on extent of nervous damage occurred during pelvis surgery and operations performed in localizations close to spine in rear section of abdomen. Other than that, functional anejaculation case occurs due to removal of prostate and seminal vesicles following radical prostatectomy operation conducted for early stage prostate cancer treatment.
Other operations causing ejaculation disorder are spine surgery performed with large abdominal surgery and spinal surgery conducted with the reason of colon cancer. Recovery and treatment of such ejaculation disorder depending on sympathic nervous damage occurred during operation.
Drugs causing retrograde ejaculation may cause anejaculation as well. It is recommended to cut off the drug causing in the treatment.
Ageing, decreased penile sensitivity, reduction in sensitivity of ejaculatory reflex, disorders alcohol and sexual hormones also can cause delayed ejaculation or anejaculation.
Treatment is started with the drugs showing generally adrenergic effects. Sometimes this treatment transforms anejaculation status into retrograde ejaculation. Success of treatment of these drugs depends on the number and strength of nerves reaching seminal vesicles, seminal duct and bladder neck. If medical treatment is unsuccessful, sperm to be used in auxiliary reproduction techniques may be obtained with rectal probe electroejaculation method. This method is rhythmically applied under light general anesthesia. Ejaculator reflex is stimulated by providing voltage gradually increasing. (0-25 V).
Semen escapes to bladder depending on insufficiency in closure of bladder neck during semen ejaculation in some portion of patients with normal orgasm function but without ejaculation and this case is defined as "retrograde ejaculation". It is difficult to identify real frequency of retrograde ejaculation and this is seen in approximately 14-18 % of patients applying for with complaint of failure of ejaculation. It is required to see sperm cell in urine sample obtained following masturbation with story of failure of ejaculating semen following organism for diagnosis purpose.
Factors leading to anejaculation
It has a wide range of causes such as systemic diseases, nervous system diseases, post operative interventions or cases caused by drugs.
Retrograde ejaculation may be rarely due to some congenital development disorders; this emerges after various prostate operations conducted via transurethral route for the purpose of treating the most frequently benign prostate enlargement.-as an expected complication of these operations-. Bladder neck is cut off in these operations; this disrupts integrity of muscles in this bladder neck and deteriorates function; it may not prevent back escape of semen due to this case.
The drugs used in treatment of benign prostate enlargement also cause retrograde ejaculation with a similar mechanism and when drug is discontinued, this side effect emerged vanishes. Many patients confuse retrograde ejaculation complication developed prostate post operations with lack of orgasm or impotence. While this case emerges with 80 % likelihood following transurethral prostatectomy (TURP), this emerges with 35 % likelihood following bladder neck incision operation (TUIP) performed with the same purpose.
Diabetes related autonomic nervous system disorder is another cause of retrograde ejaculation. This occurs as a result of autonomic nervous system disorder (diabetic neuropathy) in those with especially long term diabetes. Functional insufficiency in nerves reaching muscles closing bladder neck during ejaculation in diabetic neuropathy causes retrograde ejaculation. Retrograde ejaculation is seen in fairly high ratio such as 32 % in diabetic patients. Vanishing case of seminal duct and seminal vesicles contraction functions as a result of disrupted function of this complication in nervous system in more severe way can progress to anejaculation.
This can emerge following sympathic nervous system damage occurred during pelvis, abdominal and spine operations or injuries.
Retrograde ejaculation or anejaculation occurs following large surgical interventions such as lymphadenectomy performed due to testis cancer and colon operations performed due to intestine diseases characterized by cancer or inflammation and surgical interventions performed with abdominal way for benign diseases of spine and affecting sympathic nervous system.
High rate of retrograde ejaculation or anejaculation occurs with surgical interventions performed for congenital anomalies occurred in pelvis area in childhood age. Ejaculation disorders of these patients may depend on type of congenital anomaly (cloacal exstrophy, imperforate anus) or surgical intervention required for correcting anomaly (exstrophy / epispadias repair, bladder neck reconstruction).
Purpose in medical treatment is to ensure closing bladder neck by administering adrenergic drugs. Adrenergic drugs are the main drugs used in the treatment. If drug treatment fails, auxiliary reproduction techniques may be used together with obtaining sperm for having a child.
This is the case where you cannot have any pleasure or have inability to have orgasm despite occurrence of physiological ejaculation. Note that ejaculation and orgasm are two separate phenomena despite their being co-existence at the same time. While ejaculation is realized with sexual organs, even if orgasm is a case depending on ejaculation, this is a case realized in brain. It is high importance to conduct a thorough physical examination of medical and sexual story of patient and to evaluate the same by a sex therapist. Level of serum testosterone hormone in all patients should be measured. FSH, LH and serum prolactin serum levels should be investigated in patients considered as insufficiency in testis functions. Today, it is not possible to explain this problem with neuro, psychological and endocrinological mechanisms. Several organic problems such as chronic diseases, thyroid gland diseases and pituitary gland disorders may cause loss of desire. Again note that these drugs used for depression treatment may cause such side effects.
Orgasm is defined as reaching peak of sexual pleasure or peak of pleasure in sexual contact. Anorgasmia is the inability to reach orgasm. Anorgasmia can occur in different ways. Persons may have never experienced organism at any time of their lives or they may have delayed and had difficulty in reaching peak during sexual activity during their life time. This can be characterized as men having normal orgasm lose these abilities in time.
Congenital anorgasmia known as primary or psychological is a conscious anejaculation cause seen rarely in the same time. In the event of availability of especially night emissions (semen discharge with nocturnal automatic ejaculation), primary anorgasmia depends on psychological reasons such as growing u under pressure due to most frequently social, cultural or religious causes and accompanies with reduction in normal sexual response to stimuli; This reasons is contemplated to be fairly in relation with educations received in childhood age. This emerges as a result of the fact that parents have expectations from the child and parents have weak communication with the child. Treatment of primary anejaculation is difficult. These patients perceive sensory stimulation of their bodies insufficiently. Treatment is only required when couples want to have a child. Psychotherapy can be effective. Sexual education starts with informing. This is followed by cognitive behaviour treatment containing systematic relaxation and sensory concentration exercises. Children having problems can be resolved following one or more treatments with techniques such as prostate massage, collecting nocturnal emission and using for vaccination, stimulation with penile vibrator, rectal probe electroejaculation and micro surgical sperm aspiration.
This uncommon clinical condition may emerge depending on psychological and organic causes (such as acute and chronic prostate infections). Pain before or after ejaculation in the rate of 69 % in 163 patients having prostate infection story has been reported. Particularly acute prostate infection should be treated; but there is a possibility chronicity and recurrence in prostate infections. Ejaculatory canal clogging leading pain and bloody ejaculate, inflammation and renal calculus can be treated with endoscopic resection.
Low Ejaculate Volume
This emerges in evaluation of men often having problem of having a child. Investigation is required in volume existence lower than especially 1 ml. Seminal fluid formation is dependent on sufficient amount of reproduction hormones such as LH and FSH secreted from brain with male hormones; if secretion of the mentioned hormones is insufficient or drugs are used for suppressing these hormones, reduction and sometimes anejaculation may emerge in semen volume. Partial nervous system disorders may cause this case following undergone surgical interventions and diabetes and congenital anomalies of seminal vesicles (absence of seminal duct etc.), urethral stricture and ejaculatory duct obstruction,