In addition to detailed developmental and sexual history, full physical exam with neurologic exam should be performed. In patients who are not sure about the ability to achieve orgasm, we perform an ultrasonographic (US) orgasmic/ejaculatory study using transperineal ultrasound. The patient is allowed to self-stimulate using audiovisual adult materials after adequate erection is achieved via intracavernosal injection if needed. During ultrasound, the change in cross section of bulbous urethra (BU) (measure of arousal) is assessed and the patient is allowed to stimulate for up to 30 minutes. If the patient achieves progressive distention of BU and reaches central nervous system (CNS) threshold level for ejaculation, the rhythmic contractions of bulbocavernosal muscle (BCM) (regulated by spinal cord motor generator) are measured and
indicate that subject achieved necessary arousal to initiate cascade of ejaculatory events. For those patients who suffer from retrograde ejaculation (RE), postorgasmic urine analysis will show sperm in men who have normal sperm production. Lack of sperm in urine does not exclude RE, as men with nonobstructive azoospermia (NOA) will not have sperm in ejaculate despite RE. If NOA is anticipated, then transrectal ejaculatory study with power Doppler allows one to clearly visualize flow of semen through the ejaculatory ducts and confirms RE or verifies a disorder of emission (Fig. 55.1).

Men who do not achieve adequate increase in size of BU and never reach orgasm suffer from disorder of arousal; one needs to achieve adequate arousal to have orgasm and to ejaculate.

Biothesiometry may help to identify men with decreased penile sensitivity (age-related penile hyposensitivity), which can be often treated with penile vibratory stimulation (11) (Fig. 55.2).

Corona et al. (12) and study of our own patients have shown that hypogonadism is associated with anejaculation and DE. Thus, correcting hypogonadism and improving erectile function is a first step in treatment of men with anejaculation or DE (arbitrary defined as >30 minutes of intravaginal stimulation). Erectile dysfunction is clearly associated with ejaculatory delay and anejaculation (13). Treatment with tadalafil has been shown to improve ejaculatory function (14). Review of our own experience indicates that testosterone level >650ng per dL
may be needed to improve ejaculatory function but more research is needed in this area. Men with elevated prolactin (PRL) should have magnetic resonance imaging (MRI) of pituitary to exclude prolactinoma. Anecdotal reports indicate that empiric treatment with low-dose 0.25 to 0.5 mg of Dostinex has been associated with ability to ejaculate.

Medical therapy has been used for over three decades in men with anejaculation. Sympathomimetic agents have been a mainstay of medical therapy. They may work better in men who have RE, as they increase bladder neck resistance and direct flow of semen toward meatus. Pseudoephedrine in doses of 30 to 120 mg taken 1 to 2 hours prior to sexual intercourse can be used together with 5PDE inhibitor to improve erectile function. Imipramine has also been successfully used in RE (15). Midodrine has been successful in 50% of patients with anejaculation and RE but midodrine can result in very high blood pressure and is only approved for treatment of severe orthostatic hypotension (16,17).

Oxytocin analogs have been proposed as treatment of anejaculation, but clinical experience is at best limited. Recently, trazodone has been successfully used in men with disorders of orgasm and ejaculation secondary to selective serotonin reuptake inhibitors (SSRIs) (18). Trazodone may be considered in men who have nonorganic sexual dysfunction (19). SSRI weekend “vacation” buspirone, amantadine, and pramipexole (Mirapex) have all been proposed as potential treatment of anejaculation but no prospective trials exist to assess their efficacy (20).

Penile vibratory stimulation (PVS) has been used for therapeutic treatment of anorgasmia and to achieve ejaculation and help with erections (21,22) (Fig. 55.3).

Success of PVS depends on residual neuromotor control of ejaculatory centers. In complete upper motor neuron lesions, reflex erections can be achieved in 93% of men but antegrade ejaculation only in 5% of men (23). PVS has been successfully used as initial form of therapy in diabetic men with anejaculation and resulted in 50% of pregnancy rate. There seems to be a decrease in quality of semen parameters with nocturnal emission yielding highest concentration, followed by PVS and electroejaculation (EEJ) yielding lowest sperm concentration (24). PVS combined with at home vaginal self-insemination has resulted in 43% of pregnancies in men with spinal cord injury (SCI) (25).

Although testicular sperm extraction and epididymal aspiration of sperm in men with SCI and anejaculation combined with intracytoplasmic sperm injection is a feasible procedure, nonsurgical approaches should be initially tried (26).