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Causes of delayed ejaculation, from Campbell's

Questions to assess delayed ejaculation, from Campbell's

Algorithm for managing delayed ejaculation, from Campbell's

Delayed ejaculation

• Definition: any disorder resulting in delayed/absent ejaculation 75-100% of sexual interactions
• Most common causes: psychogenic, aging, hypogonadism, hypothyroid, diabetes, SSRI, prior prostate/pelvic surgery, prior radiation
• Cutaneous nerve testing: assess sensory function of the penis, may indicate sensory neuropathy
• Labs: recommended to check testosterone levels, consider evaluating DM or hypothyroid
• Management: switch SSRIs or other meds, psychosexual therapy (helpful to include partner in discussion), consider vibratory stimulation, altering sexual practices
• Medications: options include cabergoline, pramiprexole, amantadine, bupropion, pseudoephedrine, reboxetine, buspirone, cyproheptadine, oxytoxcin, but have limited evidence and are indicated for patient-specific situations

Painful ejaculation

• Location: may be penile, scrotal, perineal
• Causes: infection, stricture, prior vasectomy, prior hernia repair, ejaculatory duct obstruction, seminal vesicle calculi, prior XRT
• Exam: assess location of pain, perform DRE (check for BPH/cancer and pelvic floor dysfunction)
• Pelvic pain during orgasm + anejaculation: may indicate ejaculatory duct obstruction
• Pelvic floor dysfunction: patients may also report pain with urination and bowel movements in addition to sexually-related pain
• Treatment: depends on underlying cause, a-blockers may actually increase pain

Hematospermia

• Causes: infection, stones, prior trauma, constipation, obstruction, cysts, cancer, vascular abnormalities, recent GU instrumentation/surgery
• Malignancy risk: 1.4% if < 40yo, 6.2% if > 40yo, cause is almost always benign
• Evaluation: risk factors, GU exam, DRE, urinalysis, may require STI and Tb testing, consider PSA testing if > 40yo
• Adjunct testing: consider TRUS, semen culture, cystoscopy, pelvic MRI
• Management: often self-limiting, can aspirate or unroof cysts, consider embolization/excision if severe uncontrolled bleeding

Other male sexual dysfunctions

• Ejaculatory anhedonia: minimal pleasure with ejaculation/orgasm, check hormone levels and history, consider psychotherapy or treatment of hormonal causes
• Post-SSRI sexual dysfunction: reported 5-15%, may persist for months/years and spontaneously resolve
• Postorgasmic illness syndrome: rare, may be due to hypersensitivity reaction with their own semen