Most of my discussions with patients about ejaculation centers around education. Many individuals confuse an orgasm with an ejaculation. The two are extremely different. Generally, an ejaculation is a reflex event of a highly limited length of time and represents numerous levels of neural input.
Ejaculations from a nervous system standpoint can happen in two ways. The first is purely a central nervous system standpoint, as with a young man who has a nocturnal emission, or a wet dream. This is a combination of erotic stimulation during sleep combined with some limited amount of friction.
The majority of contribution is from the central nervous system and results in an ejaculation.
This generally occurs in younger patients and oftentimes in an older man who, for a variety of reasons, is not having active intercourse or ejaculating on a regular basis.
The impulse goes into the spinal cord and then into the brain where the automatic nervous system stimulates the sympathetic portion of the autonomic nervous system, which results in a contraction of the male accessory sexual organs including the vas deferens, the prostate, and the bladder neck.
This is a fancy way to say that the brain stimulates the sympathetic nervous system into creating the ejaculate to be squeezed and expelled. This process is a seminal emission, in which the semen, the fluid from both the prostate fluid and the seminal vesicles, is deposited into the back part of the urethra.
An ejaculation occurs when this fluid is propelled out of the penis. This occurs when there is a contraction of the bulbocavernosus muscles, or more commonly referred to as an orgasm. An orgasm is the actual contraction of these muscles expelling the fluid.
It is possible to have an orgasm without the expelling of fluid. It is also possible to have the fluid go backward into the bladder, which is called a retrograde ejaculation. This is most commonly seen in men who have had prostate surgery or men who have had surgery to damage the sympathetic nerves.
Additionally, some men will have a failure of emission. In other words, the fluid will not be deposited, and therefore, the ejaculate is dry. A typical ejaculate is between 2 and 5 ccs, or roughly one tablespoon.
There is a great deal of ignorance about exactly what an ejaculation is and what can cause it.
Problem with ejaculation: types of ejaculatory disorders
Ejaculatory disorders have numerous causes.
The most common ejaculatory diagnosis is premature ejaculation. Many times, simply discussing premature ejaculation and the physiology associated with it convinces the patient that it is not a problem to worry about. I always use the analogy of our ancient predecessors: Early man would not have evolved had he not been a premature ejaculator.
In other words, if reproduction took long periods of penile-vaginal penetration before an ejaculation occurred, humankind would not have evolved. It is much more important from a survival standpoint to have a quick ejaculation with multiple partners for preservation of our species.
Also, partner education is important to explain the importance of timing and the frequency of sexual intercourse. I always try to educate at this juncture since so many men have learned their ejaculatory physiology from pornographic movies in which it is common to see men with sustained erections for long periods of time and ejaculations that appear to constitute a gallon of fluid.
Neurologic lesions at any level can also cause ejaculatory dysfunction. Men with spinal cord lesions caused by an injury or surgical damage can have an inability to ejaculate, such as in men who have had colon surgery or abdominal aortic surgery. Because the sympathetic nerves lie so close to the structures that control sexual functioning, they can easily be damaged at the time of surgery.
Y.M. was brought to the clinic by his wife for evaluation. She said he was a premature ejaculator, and it was impossible to have relations with him because of this problem. A careful history revealed that he ejaculated even before he was able to penetrate, and when he did his wife became so angry that there would be a long period before he would be allowed to attempt intercourse again.
Creating this atmosphere of hostility greatly exacerbated his problem. The use of serotonin uptake inhibitors provided dramatic results in this situation.
Delayed ejaculation: when man can’t or has a problem to ejaculate
Other problems, such as diabetes and multiple sclerosis, are other causes of ejaculatory problems. Many drugs can cause a lack of emission, which is a failure of deposition of the seminal fluid into the posterior or back part of the urethra, and result in a failure of ejaculation.
Hypertensives and cold medications potentially fall into this category. Damage to the structures that propel the fluid from the penis outward, such as bladder neck damage, is also a cause of ejaculatory disorders.
The most common form of this is in men who have had prostate surgery, particularly a transurethral resection of the prostate (TURP) where the bladder neck is destroyed and the resulting condition is retrograde ejaculation.
Perhaps the most common form of ejaculatory dysfunction is premature ejaculation. But an accurate diagnosis requires a satisfactory definition.
The definition of premature ejaculation varies for every individual and depends on the person. I have seen many persons who are able to sustain intercourse for five and ten minutes and yet complain of premature ejaculation. I’ve also seen many men who ejaculate before even penetrating the vagina.
Other ejaculatory dysfunction problems, although less common, are men who can sustain erection and are able to penetrate for long periods of time but often do not ejaculate. This may sound like a wonderful thing, but in fact it is not.
Ejaculation with blood
The most troubling situation for men is a bloody ejaculation. This is usually a benign, self-limited condition called hematospermia. It typically relates either to inflammation of the seminal vesicles (the structure that stores fluid prior to ejaculation), the colon, or the prostate. Observation and antibiotics will easily treat this condition, and it is rarely associated with a malignancy.
A careful examination by a doctor can easily rule out this possibility. The most appropriate measure is that of reassurance. Then it typically ceases to be much of a problem.
When I examine men who have had an ejaculatory dysfunction, I take a careful history focusing on the frequency of sexual intercourse. Infrequent intercourse is the most common cause of premature ejaculation. I also focus on changes in sexual functioning, particularly about the time of ejaculation, and on things such as painful ejaculation, blood in the ejaculate, decreased ejaculate volume, and sudden decreases in the volume of the ejaculate versus a chronically low ejaculatory volume.
Again, the physical examination is important to carefully examine the prostate and collecting structures.
J.F. had substantial problems sustaining intercourse. Apparently, his wife told him (at that time) that they were allowed to have intercourse at a rigidly set period of time. If he was unable to sustain an erection for a period that would provide her with satisfaction, she would then terminate the event.
This created an intense problem for the partner, and he was basically unable to perform and became a premature ejaculator. This problem was resolved when he terminated the relationship.
The treatment of ejaculatory disorders has undergone a renaissance. We are now able to effectively treat most problems with targeted medications, depending upon the diagnosis. Before the advent of these medications, mental health individuals and sexual therapists saw most of these patients.
Premature ejaculation treatment
Premature ejaculation was commonly believed to be a psychological problem. Treatment involved only behavioral therapy, which required intense motivation from both partners and which typically did not achieve the success rate as reported in the standard literature of the time. This therapy involved sexual foreplay to the point of ejaculation, without allowing ejaculation to occur, then slowly increasing the length of time between activity and the point of ejaculation.
Previous medical therapy used local anesthetics, a non-prescriptive cream found in drugstores. Men would apply roughly one-half teaspoon of this anesthetic jelly to the penis and wear a condom. Approximately thirty minutes later, sexual relations were initiated. Treatment could be successful, but an obvious side effect was vaginal anesthesia. Before the advent of serotonin uptake blockers, another treatment involved giving the patient penile injections to create an erection that would not go away after premature ejaculation, thus allowing the individual to get over the fear of premature ejaculation.
The advent of serotonin uptake blockers has changed the treatment of ejaculatory disorders dramatically. It has been found that men who are on selective serotonin reuptake inhibitors (SSRIs) to treat depression have difficulty ejaculating, and many patients complained about this side effect. This observation led many physicians to use this side effect as a treatment in men with premature ejaculation. These medications, including fluoxetine and sertraline, prolong ejaculatory latency and increase the time it takes to ejaculate by up to thirty minutes.
It is extremely important to note that these drugs are not currently indicated for this treatment, and their usage must be done with caution and only by informed individuals since this is an off-label use of these medications. I recommend using the lower-strength dosage roughly four hours prior to anticipated sexual relations. I have found it to have a high success rate.