Premature Ejaculation Alternative Treatment

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Neurophysiology Ejaculation

The mechanism of ejaculation is conveniently divided into two phases, emission and expulsion. Emission During the emission phase, semen (e.g., sperm and seminal fluids) is deposited into the posterior urethra through contractions of the smooth muscles of the vasa deferentia, seminal vesicles, and prostate. At the same time, the internal sphincter of the urinary bladder is closed, thereby preventing retrograde passage of the semen into the bladder. The closure of the sphincter also prevents urine from mixing with the semen. Emission and bladder neck closure are mediated through the thoracolumbar sympathetic system. It is suggested that the sensation of ejaculatory inevitability parallels the emission phase. Expulsion (or true ejaculation) Emission is immediately followed by expulsion. During expulsion, the semen is forcefully propelled along the urethra and out of the penis by clonic contractions of the striated bulbar

The Ejaculation Distribution Theory of Premature Ejaculation

Waldinger (5,49) formulated a new theory on the etiology and genesis of lifelong premature ejaculation. He postulated that lifelong premature ejaculation is not an Figure 9.2 The IELT (29) measured by stopwatch in a sample of 110 Dutch males with lifelong premature ejaculation. Ninety percent ejaculates within 1 min and 80 ejaculates within 30 s (48). Figure 9.2 The IELT (29) measured by stopwatch in a sample of 110 Dutch males with lifelong premature ejaculation. Ninety percent ejaculates within 1 min and 80 ejaculates within 30 s (48). acquired disorder due to habituation of initial hurried intercourses, as has been suggested by Masters and Johnson. Instead, Waldinger argues that early ejaculation is part of a normal biological variability of the intravaginal ejaculation latency time (IELT) in men, with a possible familial genetic vulnerability (5,23,49). In 1994, Waldinger et al., introduced and defined the IELT as a measure for pharmacological research (29). The IELT is the time...

Lifelong Delayed Ejaculation

According to the classical psychological view, lifelong delayed ejaculation is attributed to fear, anxiety, hostility, and relationship difficulties (85-87). Many different manifestations of anxiety and fear have been hypothesized, including fears of death and castration, fear of loss of self resulting from loss of semen, fear of castration by the female genitals, fear that ejaculation would hurt the female, fear of being hurt by the female, performance anxiety, unwillingness to give of oneself as an expression of love, fear of impregnating the female, and guilt secondary to a strict religious upbringing. The psychological ideas and explanations may have face validity in some individual cases, but there are no well-controlled studies that support a generalization of any of the various psychological hypotheses. The psychological, cultural, and religious factors that may lead to lifelong delayed ejaculation clearly requires further investigations. Waldinger (1,5) postulates that...

Premature ejaculation

Premature ejaculation (PE) refers to the persistent or recurrent discharge of semen with minimal sexual stimulation before, on, or shortly after penetration, before the person wishes it, and earlier than he expects it. In making the diagnosis of PE, the clinician must take into account factors that affect the length of time that the man feels sexually excited. These factors include the age of the patient and his partner, the newness of the sexual partner, and the location and recent frequency of sexual activity. Premature ejaculation (PE) is a common complaint. The available evidence supports the notion that control and modulation of sexual excitement is learned behavior. If someone has learned it incorrectly or inadequately, they can relearn it. PE is only rarely caused by a physical or structural problem in these cases it is usually associated with other physical symptoms, usually pain. In rare cases, PE may be associated with a neurological condition infection of the prostate gland...

Premature Ejaculation and Genetics

In 1943, Schapiro noted that men with premature ejaculation seemed to have family members with similar complaints (19). Remarkably, this interesting observation has never been cited. To investigate the potential familial occurrence of premature ejaculation, I routinely asked 237 consecutively enrolled men with premature ejaculation about the family occurrence of similar complaints (23). Because of embarrassment only 14 men consented to ask male relatives about ejaculation latency. These 14 men reported a total of 11 first degree male relatives with information available for direct personal interview. In fact, 10 relatives fulfilled our strictly defined criterion of an ejaculation time of 1 min or less. In this small selected group of men, the calculated risk of having a first relative with premature ejaculation was 91 (CI 59-99). Therefore, the odds of family occurrence are much higher than the suggested population prevalence rate of 4-39 . Moreover, the high odds ratio indicates a...

Acquired Delayed Ejaculation

The only way to determine the cause(s) of delayed ejaculation is the clinical interview. There are no specific characteristics of psychologically induced acquired delayed ejaculation. Obviously, the ejaculation disturbance has not existed previously. In addition, the onset may be sudden, the delay may be situational and also intermittent. Some factors may be related to the development of acquired delayed ejaculation, such as a psychological trauma (for example, the discovery of the partner's infidelity), or lack of sexual and psychological stimulation (inadequate technique or lack of attention on sexual cues). The onset of ejaculation delay may be sudden or gradual and deteriorates progressively to global unremitting ejaculatory inhibition. A rather normal delay of ejaculation occurs during aging. Androgen deficiency or hypogonadism may be accompanied by loss of sexual desire and delay of ejaculation. Any neurological disease, injury, or surgical procedure that traumatizes the lumbar...

Operational Definition of Premature Ejaculation

For evidence-based research, it is of utmost importance to have a definition of premature ejaculation. However, because of conflicting ideas about the essence of premature ejaculation, sexologists have never reached an agreement on a definition. DSM-IV (47) defines premature ejaculation as persistent or recurrent ejaculation with minimal sexual stimulation before, upon, or shortly after penetration and before the person wishes it. Until recently, any scientific basis for the DSM-IV definition was lacking. For instance, the meaning of persistent, recurrent, minimal, and shortly after is vague and certainly needs further qualification. In order to get an empirically operationalized definition, Waldinger and co-workers investigated 110 consecutively enrolled men with lifelong premature ejaculation (48). In this study, men and their female partners were instructed to use a stopwatch at home during each coitus for a period of 4 weeks (Fig. 9.2). It was found that 10 of these men ejaculated...

Ejaculation Threshold Hypothesis

In the case of a low setpoint of the threshold, men can only sustain a small amount of sexual arousal prior to ejaculation. Whatever these men do or fantasize during intercourse, any control of ejaculation remains marginal and these men ejaculate easily even when they are not fully aroused. The low threshold is assumed to be associated with a low 5-HT neurotransmission and probably a hypofunction of the 5-HT2C receptor and or a hyperfunction of the 5-HT1A receptor, as mentioned earlier. In the case of a higher setpoint, men will experience more control over their ejaculation time. They can sustain more sexual arousal before ejaculating. In these men, 5-HT neurotransmission varies around a normal or averaged level and the 5-HT2C receptor functions normally. The mean and range values of the setpoints that are considered to be normal or averaged are not known. These men have the neurobiological ability to voluntarily decide to get an ejaculation quickly or after a longer duration of...

Retarded Ejaculation

Many people believe that retarded ejaculation is not a real problem for a couple, as they argue that retarded ejaculation enables a man to go on enough time to enable his female partner to be satisfied with one or even multiple orgasms. The reality of this syndrome is different. Many men suffer from delayed ejaculation and their female partners are very frustrated by it. Quite a number of women think they are not attractive to their partner and that he will be able to ejaculate when making love with another woman. Obviously, if coitus goes on too long, it may become painful for her. The failure to conceive is often a reason to seek help.

Combination Therapy The Road To Success


Selection Of Patients For Primary Rplnd

Behind nerve-sparing RPLND in this population is that the surgical removal of metastatic disease is curative 50 to 75 of the time, depending on the amount of metastasis. Similarly, since nerve-sparing technique is used, the morbidity of the procedure does not include the loss of emission and ejaculation. The morbidity of the procedure is essentially that of a laparotomy and includes an approximate 1 to 2 chance of a small-bowel obstruction related to postoperative adhesions and an approximate 2 to 5 chance of developing an incisional hernia.9 In patients with clinical stage II nonseminoma, the main advantage of primary RPLND is that it is therapeutic 50 to 70 of the time (depending upon the volume of metastasis) and that treatment with chemotherapy is thereby avoided. Nerve-sparing techniques can usually be used in clinical stage II patients, and there is therefore no postoperative loss of emission and ejaculation. Furthermore, there is a false-positive rate of 15 to 23 for clinical...

Reproductive biology

Information on the patterns of sigmodontine copulatory behavior is sparse. Calomys, however, is a relatively well known genus in this regard. There is information on three of the 11 species of the genus. They display intravaginal penile thrusting and multiple ejaculations, in combination with single or multiple pre-ejaculatory intromissions. Locks are either rare or absent. In addition, C. musculinus, a non-monogamous species, undergoes a stereotyped precopulatory behavior composed mostly of agonistic behaviors in which the female and the male play the aggressive and submissive roles, respectively (Laconi and Castro-Vasquez, 1998).

Open Simple Prostatectomy

This operation is reserved for BPH where the prostate weighs over 50-75 g. It is also appropriate where there is concomitant benign bladder disease requiring treatment such as a symptomatic diverticulum or a large stone. Potential risks are urinary incontinence, erectile dysfunction, retrograde ejaculation and urinary tract infection. The advantages over TURP are complete removal of the gland (therefore no recurrence) and no risk of dilutional hyponatraemia. However, there is an increased risk of intraoperative haemorrhage and a longer hospital stay. Previous prostatectomy, prior pelvic surgery and prostate cancer are contraindications to the operation.

Male Rat Sexual Behavior

Male rat studies have demonstrated that serotonin (5-HT) and 5-HT receptors are involved in the ejaculatory process. As far as is currently known, 5-HT2C and 5-HT1A receptors determine the speed of ejaculation. For example, studies with D-lysergic acid diethylamide and quipazine, which are nonselective 5-HT2C agonists, suggest that stimulating 5-HT2C receptors delays ejaculation (3). However, which equally stimulates 5-HT2A and 5-HT2C receptors, also increases ejaculation latency (4), whereas the selective 5-HT2A receptor agonist 2,5-dimethoxy-4-methylampheta-mine does not have this effect (3). On the other hand, activation of postsynaptic 5-HT1A receptors by the selective 5-HT1A receptor agonist 8-hydroxy-2-(di-n-propylaminotetralin) in male rats resulted in shorter ejaculation latency (3). On the basis of these male rat studies, Waldinger (1,5) has hypothesized that premature ejaculation is related to a hypofunction of the 5-HT2C receptor and or a hyperfunction of the 5-HT1A...

Plate 85 Spermatic Cord And Ductus Deferens

The ductus (vas) deferens continues from the duct of the epididymis as a thick-walled muscular tube that leaves the scrotum and passes through the inguinal canal as a component of the spermatic cord. At the deep inguinal ring, it continues into the pelvis and, behind the urinary bladder, joins with the seminal vesicle to form the ejaculatory duct. The ejaculatory duct then pierces the prostate gland and opens into the urethra. Mature sperm are stored in the terminal portion (tail) of the ductus epididymis. These sperm are forced into the ductus deferens by intense contractions of the three smooth muscle layers of the ductus deferens following appropriate neural stimulation. Contraction of the smooth muscle of the ductus deferens continues the movement of the sperm through the ejaculatory duct into the urethra during the ejaculatory reflex. The seminal vesicles (see Plate 87) are not storage sites for sperm but, rather, secrete a fructose-rich fluid that becomes part of the ejaculated...

Effects On Fertility

The issue of fertility in the patient with testicular cancer is a complex topic. Patients with testicular cancer often have testicular dysfunction and infertility prior to the diagnosis of the tumor and before the commencement of any therapy. Some (but not all) patients have persistent dysfunction after the completion of treatment. The variables to be considered when discussing this issue are baseline (pretreat-ment) semen characteristics, exposure to chemotherapy, the type and amount of chemotherapy, and the availability of experienced surgeons to perform a nerve-sparing retroperitoneal lymph node dissection (when feasible), to preserve ejaculation. It must also be realized that oligospermia does not translate into Moreover, the impairment in patients who have undergone nerve-sparing RPLND (without chemotherapy) is not always due to an inability to ejaculate as the patients in this series had 98 normal ejaculation after surgery.

Extent Of Postchemotherapy Surgery

Modified Rplnd

Full bilateral-template and operative RPLNDs are shown in Figure 11-1 for the right side and in Figure 11-2 for the left side. The modified bilateral RPLND avoids the contralateral dissection below the level of the origin of the inferior mesenteric artery, in order to try to preserve ejaculation (Figure 11-3). Unilateral

Maternal effects on HPG function and mating behavior

Solicitation behaviors in the female rat are highly dependent on context. In smaller confines, the most common pattern of paracopulatory (or pro-ceptive) behavior is that of hopping, darting, and ear wiggling. However, when a receptive female is tested in a larger area that affords the opportunity to retreat from the male, the approach-withdrawal pattern prevails and reveals the females ability to pace the mating with the male (Erskine, 1989). Female rats pace the rate of male intromissions and thus ejaculation by withdrawal from the male following each intromission. The latency to return to the male is longer after ejaculation than after an intromission, which in turn is longer than after a mount with an intromission (Erskine et al., 2004 Yang and Clemens, 1996). As testing proceeds over the courses of multiple ejaculatory sequences, the interintromission interval increases (Coopersmith et al., 1996). Testing in the pacing chamber revealed considerable differences in sexual behavior...

Anatomical And Morphological Relationships Of The Male Reproductive System

Deatiled Male Reproductive Organ

The male reproductive system comprises the gonads (two testes), excretory ducts (epididymis, vas deferens, and ejaculatory duct), and several accessory structures (prostate, seminal vesicles, bulbourethral glands, and penis). These are illustrated in Figure 12-1. The duct system connects each testis to the urethra and functions to transport the mature spermatozoa during ejaculation. It is composed of the epididymis, ductus deferens, and ejaculatory duct. The vas deferens is a 7- to 8-cm tubule connecting the epididymis with the ejaculatory duct (see Figure 12-1). The passage of sperm through the vas deferens is accomplished by peristaltic contractions of smooth muscle in the duct wall. Vasectomy, which is the bilateral ligation of the vas deferens, has been established as an effective and safe male contraceptive procedure. However, the current success rate for the reversal of vasectomy (as judged by the subsequent production The ejaculatory duct is located at the merger of the vas...

Presentation with Symptoms from Metastases

Aortocaval Compression Image

Complication that is more likely with right-sided tes-ticular tumors and that presents with either bowel obstruction or gastrointestinal bleeding. Ejaculation and antegrade seminal emission in the male are dependent on the sympathetic nervous system and, in particular, the postganglionic nerve fibers that lie anterior to the abdominal aorta and in the aortocaval groove. Patients with testicular GCT have presented with loss of ejaculation and anorgasmia, owing to compression of these nerves (Figure 5-14). Figure 5-14. Computed tomography scan showing a massive retroperitoneal nodal mass from testicular teratoma that initially presented with loss of ejaculation secondary to sympathetic nerve fiber compression. Figure 5-14. Computed tomography scan showing a massive retroperitoneal nodal mass from testicular teratoma that initially presented with loss of ejaculation secondary to sympathetic nerve fiber compression.

Causes and symptoms

Priapism is the occurrence of any persistent erection of more than four hours duration occurring in the absence of sexual stimulation. It is not associated with sexual excitement and the erection does not subside after ejaculation. Priapism can occur at any age, but clusters of occurrence are common between the ages of five and 10 years and between the ages of 20 and 50. In children, priapism is commonly associated with leukemia and sickle cell disease, or occurs secondary to trauma. The most common cause in adults is the intrapenile injection of agents to correct erectile dysfunction. Priapism may also occur secondary to the use of psychotropic sexual anhedonia. Sexual anhedonia is a rare variant of HSDD seen in the male, in which the patient experiences erection and ejaculation, but no pleasure from orgasm. The cause is attributed to penile anesthesia, due to psychological or emotional factors in a hysterical or obsessive person. Psychiatric referral is indicated unless...

Etiologysexual Disorder


Richard S Foster Md Richard Bihrle Md John P Donohue Md

Rplnd Anatomy

Low-stage disease was 5 to 7 days currently, it is 3 to 5 days. Currently, as nerve-sparing technique in conjunction with the complete removal of lymphatic tissue should be mandatory in cases of low-stage disease, loss of emission and ejaculation (such loss being due to the interruption of retroperitoneal sympathetic fibers) should not occur (Figure 10-2). Furthermore, in selected postchemotherapy patients who are candidates for RPLND, nerve sparing is also possible, and emission and ejaculation can be maintained at a level of 70 to 80 . Finally, the perioperative management of pain has improved with the introduction of the intrathecal administration of narcotics and local anesthetics and the routine use of patient-controlled analgesia at the bedside. Therefore, not only has the morbidity of chemotherapy diminished over the last two decades, the morbidity of surgery has decreased while the efficacy of surgical removal of metastatic testicular cancer has been maintained. As noted, this...

Figure Of Renal System Of Female

Renal Fascia Around Kidney

During ejaculation (ejection of the sperm) the sperm are propelled from the epididymis through the vas deferens. The vas deferens, blood vessels, nerves, lymphatic vessels, and the cremaster muscle make up the spermatic cord. Common ejaculatory duct Corpus caverosum Corpus spongiosum Cowper's gland Epididymis Glans penis Prepuce Prostate gland Scrotum Seminal vesicle Symphysis pubis Testis Ureter Urethra Urinary bladder Vas deferens Identify the following structures on the model of the male reproductive system common ejaculatory duct, corpus cavernosum, corpus spongiosum, Cowper's gland, epididymis, glanspenis, prepuce, prostate gland, scrotum, seminal vesicle, spermatic cord, symphysis pubis, testis, ureter, urethra and vas deferens.

The Sexual Response Cycle

Takes place more slowly in women and is characterized by the production of lubricating fluid in the vagina, an increase in the diameter of the clitoris, and increased congestion of the labia with blood. For both sexes, phase II (plateau) is marked by a rise in the blood congestion of the pelvis and a strong feeling of sexual tension. A sex flush colors the forehead, neck, and chest, sometimes extending to the abdominal area. Phase III (orgasm) occurs in two stages in men a preejaculatory contraction of the muscles involved in ejaculation, and actual ejaculation. The same muscles are involved in the orgasms of women as those of men. During phase IV (resolution), which is usually completed more quickly in men than in women, the congestion of the blood vessels that occurred during the previous phases of the sexual response cycle decreases. After a time, the cycle can be repeated. The duration of this recovery, or refractory period, is generally longer for men than for women some women...

Gedske Daugaard Md Mikael R0rth Md

The stage distribution of nonseminomatous germ cell tumor (NSGCT) has changed over the last two decades, apparently as the result of a shift of patients with low-volume disseminated disease to patients with stage I disease.1 About one-half of patients with NSGCT have clinical stage I disease at first presentation. The management of such patients has generated considerable interest and some controversy over the last 20 years. Adjuvant abdominal irradiation and retroperitoneal lymph node dissection (RPLND) after orchiectomy have both been commonly practiced in the past, and the latter is still popular in North America (Table 12-1). Both of these management policies do, however, have disadvantages, including a 10 to 15 failure rate in patients with subclinical thoracic disease and also including specific toxicities, such as bone marrow suppression after radiotherapy and failure of ejaculation after surgery.

Anatomy And Physiology Of Erection

The nervous system of the penis is in three parts. The parasympathetic nerves are branches of spinal nerves S2-S4, which give rise to the so-called pelvic splanchnic nerves that pass around the posterior aspect of the prostate gland, forming the prostatic plexus. Passing forward, they form the cavernous nerves, which branch into the body of the penis. It is this parasympathetic system that is able to elicit an erection. The sympathetic nerves are branches of the sympathetic chain at levels T11-L2. These pass through the inferior mesenteric plexus, the superior hypogastric plexus, and the pelvic plexus and branch off to the organs involved in ejaculation. Overactivity of the sympathetic and becomes fully erect. Further reflex contraction of the ischiocavernous muscles during sexual intercourse or masturbation produces a rigid erection with internal pressures of several hundred millimeters of mercury. The activation of the sympathetic nervous system, which occurs at ejaculation,...

Models For Treating Sexual Dysfunction Sex Therapy

Sex therapy was based on the development of a treatment plan conceptualized from the rapid assessment of the immediate and remote causes of SD while maintaining rapport with the patient (6,7). The sex therapist assigned structured erotic experiences carried out by the couple individual in the privacy of their own homes. These exercises were designed to correct dysfunctional sexual behavior patterns, as well as positively altering cognitions regarding sexual attitudes and self-image. This home play modified the immediate causes of the sexual problem, allowing the individual to have mostly positive experiences and created a powerful momentum for successful treatment outcome. Interventions aimed at correcting or challenging maladaptive cognitions were incorporated into the treatment process (8). The individually tailored exercises acted as therapeutic probes and were progressively adjusted until the individual or couple was gradually guided into fully functional sexual behavior (4,6)....

Biological Theories of the Paraphilias

Early biological hypotheses regarding the paraphilias included Epstein's theory of phylogenetic preparedness of fetishism (120). He observed that a rubber boot, but not leather, evoked penile erection and ejaculation in a chimpanzee, suggesting that the fetishistic attraction to an unusal object is not limited to humans. Epstein speculated that the wet surface of the boot bore a relationship to the female chimpanzee's genitalia during rear mount sexual behavior.

The Azoospermia Phenotype

The complete absence of sperm cells from semen may seem like a simple phenotype, unambiguously ascertained by an examination of semen, but sperm count can be affected by many factors (such as time since the last ejaculation, substance abuse, frequency of hot baths, and even dental caries) and can, thus, vary considerably in a single individual (2). A discussion of this variation lies outside the scope of the present chapter here we note that sperm count can be regarded as a continuous trait (Fig. 1) with azoospermia grading into oligozoospermia (few sperm) and the normozoospermic state, and will not distinguish between the first two, so that the phenotype under consideration here would more accurately be described as azoo- or oligozoospermia. Although azoospermia, in the strict sense, leads to infertility under natural conditions (this can sometimes be overcome by assisted reproduction), the relationship between oligozoospermia and fertility (producing offspring) is complex but can...

Extent Of Local Tumour Spread

Extracapsular Spread Prostate

This is not to be confused with similar looking ejaculatory duct type epithelium which is oriented to loose, vascular connective tissue. Advanced disease manifests spread into seminal vesicle, prostatic urethra and bladder. Presentation can be by an anterior rectal mass or stricture and PSA staining of rectal biopsy material is of use. Frozen pelvis is a clinical term meaning tumour extension to the pelvic wall(s) with fixation and is designated pT4. Optional descriptors are pT4a (bladder neck, external sphincter, rectum) and pT4b (levator muscles, fixed to pelvic wall). Note that the normal prostatic apex may incorporate some striated muscle fibres and cancer lying in relation to these does not necessarily imply extraprostatic disease.

Evidence Based Medicine

For many decades, premature ejaculation was considered to be a psychological disorder that had to be treated with psychotherapy. However, psychological treatments and underlying theories mostly relied on case reports, series of case report studies, and opinions of some leading psychotherapists and sexologists. They were not based on controlled studies. I believe this to be a typical example of authority- or opinion-based medicine (15). In contrast to authority-based medicine, evidence-based medicine (26) has been accepted today as the hallmark for clinical research and medical practice. Particularly in last decade, randomized clinical trials with clomipramine (27,28) and some SSRIs (29-33) have repeatedly demonstrated the efficacy of serotonergic antidepressants to delay ejaculation. In spite of these studies, the belief persists among those involved in sexology that premature ejaculation is a psychological disorder. In order to unravel this dichotomy, it is important to apply...

Accessory sex glands

Seminal vesicles develop as evaginations of the mesonephric (Wolffian) ducts in the region of future ampullae. The wall of the seminal vesicles contains a mucosa, a thin layer of smooth muscle, and a fibrous coat (Fig. 21.26). The mucosa is thrown into numerous primary, secondary, and tertiary folds that increase the secretory surface area. All of the irregular chambers thus formed, however, communicate with the lumen. though prostaglandins were first isolated from the prostate gland (hence the name), they are actually synthesized in large amounts in the seminal vesicles. Contraction of the smooth muscle coat of the seminal vesicles during ejaculation discharges their secretion into the ejaculatory ducts and helps to flush sperm out of the urethra. The secretory function and morphology of the seminal vesicles are under the control of testosterone.

Postmenopausal Dyspareunia


Viclinical Considerations

It produces the following clinical findings underdevelopment of the penis, scrotum (microphallus, hypospadias, and bifid scrotum), and prostate gland. The epididymis, ductus deferens, seminal vesicle, and ejaculatory duct are nonnal. These clinical findings have led to inference that DHT is essential for the development of the external genitalia and prostate gland in gcnotypic XY fetuses. 2. It produces the following clinical findings underdevelopment of the penis and scrotum (microphallus, hypospadias, and bifid scrotum) and prostate gland. The epididymis, ductus deferens, seminal vesicle, and ejaculatory duct are normal. The clinical findings in 17a-HSD deficiency and 5a-reductase 2 deficiency are very similar.

Why Do Women Have Orgasms

An additional function of women's orgasm, which may play a role in the reproductive process, is that if the woman attains orgasm during coitus, the associated contractions of the vagina can facilitate male ejaculation. This would allow the woman to capture the sperm of her chosen inseminator. In addition, as noted earlier, orgasm increases the secretion of prolactin. If prolactin in plasma is able to enter into the vaginal, cervical or uterine fluids, it may influence the entry of calcium into the sperm and this action could play a role in the activation of spermatozoa in the female tract (32).

The Interactional View

The interactional view assumes that vaginistic complaints have a function in maintaining the balance between partners, or in the emotional functioning of the woman herself. In this sense, the complaint can form a solution There are very few authors who explain the phenomenon of vaginismus fully on the basis of this view. However, much of the literature mentions the behavior and the personality structure of the male partner. He comes forward as a low self-confidence, anxious, passive, dependent person who is afraid of failure and for whom sex is a loaded subject (27,38,39). The partners of vaginistic women are believed to often suffer from sexual problems themselves, such as impotence and premature ejaculation (29,35,39,40). Despite these problems, the couple usually look very harmonic on the outside. They give the impression of being very well suited (18,37). In a recent study, rates of parital discord were equal to the general population (3). It speaks for itself that within the...

Epidemiology Of Sexual Dysfunction

Some recent studies went beyond collecting pure epidemiological data and studied the impact of sexual dysfunction on men suffering from various sexual dysfunctions. For instance, Moore et al. (36) described that younger men suffering from erectile dysfunction reported comparatively less relationship satisfaction, greater depressive symptomatology, more negative reactions from partners, and less job satisfaction than older men. They concluded that older men experience less difficulty than younger men adjusting to life with erectile dysfunction. Symonds et al. (37) interviewed men with self-diagnosed premature ejaculation. In their relatively small sample, they found that men with premature ejaculation had a sense that premature ejaculation was causing (not exclusively) Laumann et al. (43) have recently completed a survey of 27,500 men and women aged 40-80 in 29 countries. In Northern European countries, lack of sexual interest was reported in 25.3 of women. Problems with orgasm and...

Secondary Sex Organs

Each ductus deferens and its corresponding seminal vesicle converge to form a short tube called the ejaculatory duct. The ejaculatory duct opens into the urethra within the prostate gland. The ejaculatory duct carries both spermatozoa and seminal vesicle fluid.

Treatment Psychological Treatments


Adverse Effects and Toxicity


Plate 87 Seminal Vesicle

The mucosa rests on a thick layer of smooth muscle that is directly continuous with that of the ductus deferens, from which the seminal vesicle evaginates. The smooth muscle consists of an indistinct inner circular layer and an outer longitudinal layer (compare with the three layers of the ductus epididymis and the ductus deferens, Plate 84), which are difficult to distinguish. Contraction of the smooth muscle coat during ejaculation forces the secretions of the seminal vesicles into the ejaculatory ducts. Beyond the smooth muscle is the connective tissue of the adventitia.

Physical examination for the man

The specimen is routinely obtained by masturbation and collected in a clean glass or plastic container. It is customary to have the man abstain from ejaculation for at least 2 days before producing the specimen. Criteria for a normal semen analysis include a sperm count greater than 20 million sperm mL with at least 50 motility and 30 normal morphology.

Combination Therapy for Sexual Dysfunction Integrating Sex Therapy and Sexual Pharmaceuticals

Combination therapy is the therapeutic modality of choice for any SDs. Combination therapy refers to a concurrent or step-wise integration of psychological and medical interventions. We have previously described developing adherence for this approach to ED, with enthusiasm growing within the FSD treatment community (36). Combination therapy is already being recommended for PE, and is likely to be recommended for the full range of ejaculatory disorders (41). Although desire disorders for men and women have a strong psychosocial cultural component, there is little doubt that sexual desire has biological underpinnings and is likely to be distributed on the same bell-shaped distribution curve as other human characteristics. This simply means that all SDs have a bio-psychosocial basis and that treatment must incorporate medical and psychological dimensions. Without adequate desire, motivation, and realistic expectations, treatment outcome is likely to be disappointing and with high...

Normal Sexual Desire For

An exceptional source of information on men and sexuality (including sexual desire) is the Massachusetts Male Aging Study (MMAS), a survey that involved a random sample of men in the general population aged 40-70, and one in which questions were asked about sexual issues from the viewpoint of both behavior and subjective thinking (9). A total of 1709 men participated in the study. A self-administered questionnaire included 23 items on such sex-related subjects as satisfaction frequency of activity frequency of desire frequency of thoughts, fantasies, or erotic dreams frequency of erections and erectile difficulties orgasm difficulties genital pain frequency of ejaculation and attitudes to sexual changes with age. Reports were divided into two categories behavioral and subjective phenomena. Only the latter will receive

Bladder Bowel and Sexual Disturbances

Sexual symptoms are also common among MS patients. Men most often experience erectile dysfunction, but may also suffer from problems with ejaculation (135,144). These symptoms typically accompany abnormal micturition. Women most typically experience difficulty in achieving orgasm, but may also complain of problems with lubrication (145). Both men and women may also complain of diminished libido. In contrast, a recent case of episodic hyperlibidinism has been reported (146).

Evolution Of Current Treatment Approaches

Start-stop technique for the treatment of rapid ejaculation was first described by Semans in 1956 (10). However, the major use of behavioral techniques to treat sexual problems began after the publication of Human Sexual Inadequacy by Masters and Johnson in 1970 (11). In the 1980s, case reports began appearing in the psychiatric literature about using monoamine oxidase inhibitors and low dose antipsychotic drugs to treat rapid ejaculation (12). However, the use of psychiatric drugs to treat rapid ejaculation became much more common after the introduction of the selective serotonin reuptake inhibitors.

Positron Emission Tomography Scan Studies in Humans

Although male rat studies are of utmost importance for a better understanding of the neurobiology of ejaculation, brain imaging studies in humans are the tools which provide a better understanding of how the human brain mediates ejaculation and orgasm. Brain imaging studies will probably lead to a deeper insight into which parts of the brain mediate ejaculation and which parts are involved in the mechanism of orgasm, how these neural areas are linked to each other, and which parts are disturbed in the different ejaculatory and orgasm disturbances. The first Positron Emission Tomography (PET)-scan study during ejaculation has recently been conducted by Holstege et al. (14). Eleven healthy male volunteers were brought to ejaculation by manual stimulation of their female partner. The PET technique using radioactive water (H 5O) shows increases or decreases in blood flow in distinct parts of the brain, representing increases or decreases of activation of neurons in these areas. It was...

Psychological Therapies for Men with ED

The third group of men includes those with the presence of other psychological morbidity such as dysthymia or mild depression, substance misuse, relational problems, or other sexual problems such as loss of desire or ejaculatory disturbance. These may require a more proactive input from the psychosexual therapist, which may incorporate psychosexual therapy, relationship therapy, often integrated with management from one or more mental health professionals for any associated mental health disorders.

Research and Methodology

Research on lifelong delayed ejaculation is scarce. Most of the literature consists of hypotheses that have not been investigated according to methodological well-designed studies. Several factors may have contributed to this state of affairs. Delayed ejaculation is a relatively rare condition. Both in the general population and in the clinical practice, the prevalence of delayed ejaculation is rather low (84). Furthermore, delayed ejaculation is known as a disorder that is relatively difficult to treat (92). Although controlled studies do not exist, clinical experience suggests that the outcome is rather poor (92). A major problem in the research of lifelong delayed ejaculation is the absence of an empirically derived operational definition of delayed ejaculation.

Chest Radiation

Pelvic radiation can damage the autonomic nerves responsible for erection. As a result, erectile dysfunction is common after radiation for prostate, rectal, and anal cancers.43 Improvement often occurs over the first year after treatment but then stabilizes. As important as evaluating the degree of erectile dysfunction is evaluating how much this bothers the patient some patients are untroubled by complete loss of function while others are extremely distressed by even relatively subtle changes in sexual function such as retrograde ejaculation. Erectile dysfunction can be managed with oral agents like sildenafil, tadalafil, and vardenafil, but sometimes requires external suction devices, penile injection therapy, or implantation ofpenile prostheses. Referral to a urologist specializing in male sexual health can be very helpful.




Waldinger (5,15) distinguishes four periods in the approach to and treatment of premature ejaculation. The First Period (1887-1917) Early Ejaculation In 1887, Gross (16) described the first case of early ejaculation in medical literature. A second report of von Krafft-Ebing (17) followed in 1901. Although publications were rare, it is worth noting that during the first 30 years of its existence in the medical literature, early ejaculation was viewed as an abnormal phenomenon but not significantly as a psychological disturbance. In 1917, Abraham (18) described early ejaculation as ejaculatio praecox and stated that it was a symptom of a neurosis caused by unconscious conflicts. Treatment should consist of classic psychoanalysis. On the other hand, some physicians stated that premature ejaculation was due to anatomical urological abnormalities, such as a too short foreskin frenulum or changes in the posterior urethra, which had to be treated with incision of the foreskin or...


Premature ejaculation is often cited as being the most common male sexual dysfunction. The exact prevalence, however, is unknown as this appeared difficult to determine. Although it has been estimated that as many as 36 of all men in the general population experience premature ejaculation (24), other estimates have been lower. For example, Gebhard and Johnson (25), from a reanalysis of the Kinsey data, determined that 4 of the men interviewed reported ejaculating within 1 min of intromission. The large differences in prevalence numbers are mainly due to the use of various and often totally different definitions of premature ejaculation that have been used. Only by the general use of an empirically defined definition and identical tools to measure the ejaculation time, methodologically correct epidemiological studies can provide reliable prevalence data. Such studies have not been performed yet.


Owing to a congenital or acquired anatomical and or functional failure of closure of the internal sphincter of the bladder ( bladderneck ) during the ejaculatory process, sperm passes into the bladder. Most frequently the cause is a transure-thral prostatectomy, a surgical treatment of benign prostatic hypertrophy. But any traumatic, neurogenic or drug-induced interference with the thoracolumbar sympathetic nervous system may lead to retrograde ejaculation. Spinal cord injury through trauma, birth defect, neoplasm, or surgery and abdominopelvic surgery, retroperitoneal lymph node dissection or total lymphadenectomy, and diabetes may also result in retrograde flow of semen. The medications that may give rise to retrograde ejaculation include alpha-adrenergic blockers (e.g., prazosin, tamsulosin), peripheral sympatholytics (e.g., guanethidine), and antipsychotics (e.g., thioridazine).


Treatments for retrograde ejaculation focus on closing the bladder neck using surgical bladder reconstruction or pharmacotherapy with sympathicomimetic agents (e.g., ephedrine) or anticholinergics (e.g., imipramine). If sperm is needed for procreation and retrograde ejaculation cannot be corrected pharmacologically, vibratory stimulation of the penile shaft and glans penis (93) can be used. For those men who fail vibrator therapy, transrectal stimulation (94) may be used to obtain sperm.

Sexual Functioning

Of all the psychosocial domains affected by testicu-lar cancer and its treatment, sexual function, for understandable reasons, has been among the most frequently studied. Although findings generally indicate that sexual functioning is altered among survivors, careful consideration of this outcome is warranted. The reasons for altered sexual functioning among survivors are varied. Factors such as the physical sequelae of testicular cancer itself, treatment-related side effects, or psychological distress following treatment can affect sexual functioning.38 For example, retroperitoneal lymph node dissection (RPLND), a surgical procedure commonly used in the treatment of testicular cancer, involves the resection of retroperitoneal sympathetic nerves involved in semen emission.38 A common side effect of RPLND is dry ejaculation, which can negatively Schover and colleagues were among the first to describe sexual functioning among survivors of non-seminomatous (n 121) and seminomatous (n 74)...


Reduced fertility is a frequently reported adverse effect of testicular cancer treatment. In fact, estimates indicate that up to 25 of survivors may have reduced fertility.30 It has also been reported that fertility may be reduced prior to diagnosis, suggesting a shared etiologic factor between testicular cancer and reduced fertility.13 Reduced fertility may result from treatment side effects, such as reduced sper-matogenesis following cytotoxic therapy or such as dry ejaculation following RPLND. However, modern therapeutic techniques have greatly reduced these outcomes.38 In addition, the availability of sperm banking has further increased the ability of survivors to father children. The effects of reduced fertility on the QOL of survivors are not fully understood. Limited evidence does suggest that some survivors report an unfulfilled wish to father children33 and more anxiety about fathering children after cancer treatment than before cancer treatment.40

Ductus Deferens

The ductus deferens begins at the inferior pole of the testes, ascends to enter the spermatic cord, transits the inguinal canal, and enters the abdominal cavity by passing through the deep inguinal ring. It is joined by the seminal vesicle at the ampulla of the ductus deferens, to form the ejaculatory duct. The ejaculatory duct passes through the prostate gland and opens into the prostatic urethra at the urethral crest.

Prostate Gland

Prostatic fluid contains citric acid, acid phosphatase, prostaglandins, fibrinogen, and prostate-specific antigen (PSA), which is a serine protease that liquefies semen after ejaculation. Serum levels of acid phosphatase and PSA are used as diagnostic tools to detect prostatic carcinoma.

Surgical Anatomy

Testicles Dissection Human

Formerly, RPLND for low-stage disease included a full bilateral template, which involved the removal of all lymphatic tissue from the crus of the diaphragm to the bifurcation to iliac arteries, from ureter to ureter. This procedure universally resulted in the loss of emission and ejaculation since no effort was made to preserve sympathetic fibers. Because the aorta and the vena cava are in the field of dissection, they must be adequately mobilized in order to completely remove lymphatic tissue that is posterior to these vessels. Therefore, in the course of RPLND, lumbar arteries and veins, which attach the great vessels to the posterior body wall, must be divided. Thus, in full bilateral RPLND, complete mobilization of the great vessels, the renal artery and vein, and the ureters is performed, followed by the removal of lymphatics from the posterior body wall (Figure 10-3). Donohue has called this concept of the mobilization of structures away from the lymphatic tissue and the...

Trichina worm

Classified as animal (mammal) parasites and the causal organism of the disease trichinosis, they are small roundworms that live mainly in rats and other small mammals such as pigs that pick up the worm while rooting for food. Adults have a length of 0.055-0.158 in (1.4-4.0 mm), with males measuring 0.055-0.063 in (l.4-1.6 mm) in length and females 0.118-0.158 in (3.0-4.0 mm) in length. Males and females have distinct features. Females possess a uterus and vulva. The vulva is located near the middle of the esophagus, which is about one-third the length of the body. Males have a single gonad, but no copula-tory spicule, and have an ejaculatory duct. Structures identifiable on both sexes include the muscular esophagus, stichosome, and intestine. Stichosomes are formed by a single short row of stichocytes, following a short muscular esophagus. The color of the external surface of the adult is translucent and white. Both sexes are more slender at the anterior than at the posterior, but do...

Marcel D Waldinger

Ejaculation 218 Neurobiology of Ejaculation 219 Serotonin, 5-Hydroxytryptamine Neurotransmission and Premature Ejaculation 223 The First Period (1887-1917) Early Ejaculation 223 The Second Period (1917-1950) Operational Definition of Premature Ejaculation 227 The Ejaculation Distribution Theory of Premature Ejaculation 227 Ejaculation Threshold Hypothesis 229 Premature Ejaculation and Genetics 230 Drug Treatment for Premature Ejaculation 231 Retarded Ejaculation 233 Lifelong Delayed Ejaculation 235 Treatment of Lifelong Delayed Ejaculation 236 Acquired Delayed Ejaculation 237 Treatment of Acquired Delayed Ejaculation 237 Retrograde Ejaculation 238 Anesthetic Ejaculation (Ejaculatory Anhedonia) 239 Partial Ejaculatory Incompetence 240 Painful Ejaculation 241


In DSM-IV (American Psychiatric Association, 1994), retarded ejaculation is termed Male Orgasmic Disorder and defined as a persistent or recurrent delay in, or absence of, orgasm in a male following a normal sexual excitement phase during sexual activity that the clinician, taking into account the person's age, judges to be adequate in focus, intensity, and duration. In more simple terms, retarded ejaculation means that a man finds it difficult or impossible to ejaculate, despite the presence of adequate sexual stimulation, erection, and conscious desire to achieve orgasm. Some of these men may struggle to ejaculate with such desperation that they may physically exhaust themselves, and sometimes even their partner, in the attempt. Delayed ejaculation may occur in coitus, masturbation (either by the patient or by the partner), as well as during anal or oral intercourse. Throughout the years, a variety of terms have been used to refer to this eja-culatory disorder. Synonyms for delayed...

Figure 2120

Ejaculatory ducts, ductus deferens, epididymis, and efferent ductules are all developed from the mesonephric duct and tubules. The seminiferous tubules, straight tubules, and rete testis develop from the indifferent gonads. The prostate gland develops from the prostatic primordium that originates from the pelvic urethra.

Human whipworm

They derive their name from the characteristic whip-like shape. Adults are 1.2-2.0 in (30-50 mm) in length, with a thread-like anterior end that becomes thicker at the posterior end. Both sexes have two distinct body regions. Males are 1.2-1.8 in (30-45 mm) in length, while adult females are 1.4-2.0 in (35-50 mm) in length. Females are very attenuated on the anterior three-fifths of the body, and become greatly expanded in the posterior two-fifths. Males are similarly shaped, but the swollen posterior is less pronounced. For most of the body's length, there is an area designated as the bacillary band, which is a combination of hypodermal and glandular tissues. The glandular tissue opens up to the exterior through cuticular pores. They have a mouth with a simple opening, and do not have lips. The buccal cavity is tiny and is provided with a minute spear. The esophagus is very long, occupying about two-thirds of the body length and consists of a...


In recent years, much progress has been made in neuroanatomical research of eja-culatory processes. Most knowledge about the functional neuroanatomy of ejaculation is derived from male rat studies. With regard to male rat copulatory behavior, one has to distinguish among brain, brainstem, and spinal cord regions that become activated before and following ejaculation, when sensory information returns from the genitals (Fig. 9.1). The medial preoptic area (MPOA) in the rostral hypothalamus and the nucleus paragigantocellularis (nPGi) in the ventral medulla (6,7) are suggested as being important players in the process leading towards ejaculation. Electrical stimulation of the MPOA promotes ejaculation (8). It is hypothesized that ejaculation is tonically inhibited by serotonergic pathways descending from the nPGi to the lumbosacral motor nuclei. The present hypothesis is that the nPGi itself is inhibited by inhibitory stimuli from the MPOA. Disinhibition of the nPGi is supposed to lead...


The term male menopause is sometimes applied to the structural and functional changes that occur with age-related reductions in the production of testosterone during later life, but there is no scientific justification for this term (Kolodny, Masters, & Johnson, 1979). Changes in the structure and functioning of the sex organs are also typical of older males, but the notion that all men eventually experience a male menopause akin to that in women is inaccurate. Among the changes that occur in older men are a slight shrinkage of the testes, the production of fewer sperm, and an increase in the size of the prostate gland. Older men require longer to achieve an erection, have a softer erection, and lose it more quickly after ejaculation. They experience fewer genital spasms, the force and volume of the ejaculate are less,


The diagnosis is usually readily made on the basis of the patient's history and the presence of the DSM-IV-TR diagnostic criteria. Male orgasmic disorder may be part of a complex of sexual malfunctioning that may include erectile dysfunction, abnormalities in ejaculation (such as premature ejaculation or retrograde ejaculation), and hypoactive sexual desire disorder.

Figure 2122

Differences in smooth muscle function parallel these morphologic differences. In the head and body of the epididymis, spontaneous, rhythmic peristaltic contractions serve to move the sperm along the duct. Few peristaltic contractions occur in the tail of the epididymis, which serves as the principal reservoir for mature sperm. These sperm are forced into the ductus deferens by intense contractions of the three smooth muscle layers after appropriate neural stimulation associated with ejaculation.

What Is Orgasm



Orgasm, premature ejaculation, functional dyspareunia, functional vaginismus, and ego-dystonic homosexuality. In DSM-IIIR, ego-dystonic homosexuality was deleted and sexual aversion disorder was added. The names of certain diagnoses were changed. For example, inhibited sexual desire became hypoactive sexual desire disorder. Sexual arousal disorder and male erectile disorder were substituted, respectively, for inhibited male and female sexual arousal disorders. Throughout, changes in criteria sets have been minimal. In DSM-IV, most of the names and criteria sets resemble DSM-IIIR. The requirement that a disorder be diagnosed only if it causes significant personal distress was added to put a high threshold for diagnosis (45). The DSM based classification remains unclear. For instance, it intermingles terms of sexual dysfunction(s) and sexual disorder(s) in an unclear manner. Current nomenclature includes hypoactive sexual desire disorder, sexual aversion disorder, sexual arousal...

Course of Rapidity

It is generally believed that aging delays ejaculation. This assumption, might be true for men with a normal or average ejaculation time but has never been investigated in men with premature ejaculation. In a stopwatch study (48) of 110 consecutively enrolled men (aged 18-65 years) with lifelong premature ejaculation, 76 reported that throughout their lives, their speed of ejaculation had remained as rapid as at the first sexual contacts in puberty and adolescence, 23 reported that it had become even gradually faster with aging, and only 1 reported that it had become slower. From these data, it is questioned whether the fixed rapidity and even paradoxical shortening of the ejaculation latency time while getting older should be recognized as a part of the pathogenetic process of premature ejaculation. According to Waldinger, early ejaculation is thought of as a part of a normal biological variation of the IELT in men, but its paradoxical or fixed course through life is considered as...

Figure 2127

The prostatic epithelial cells produce enzymes, particularly PAP, fibrinolysin, and citric acid. They also secrete serine protease, clinically known as PSA. This enzyme is secreted into the alveoli and is ultimately incorporated into seminal fluid. The alveolar secretion is pumped into the prostatic urethra during ejaculation by contraction of the fibromuscular tissue of the prostate. The fibrinolysin in the secretion serves to liquefy the semen.

Figure 2124

The ampulla has taller, branched mucosal folds that often show glandular diverticula. The muscle coat surrounding the ampulla is thinner than that of the rest of the ductus deferens, and the longitudinal layers disappear near the origin of the ejaculatory duct. The epithelium of the ampulla and ejaculatory duct appears to have a secretory function. The cells contain large numbers of yellow pigment granules. The wall of the ejaculatory duct does not have a muscularis layer the fibromuscular tissue of the prostate substitutes for it.

Figure 2129

The penis is innervated by somatic, sympathetic, and parasympathetic nerves. Many sensory nerve endings are distributed throughout the tissue of the penis, and sympathetic and parasympathetic visceral motor fibers innervate the smooth muscle of the trabeculae of the tunica albu-ginea and the blood vessels. Both sensory and visceral motor fibers play essential roles in erectile and ejaculatory responses.

Richard Balon


Evolving Models

A 26-year-old male who complains being distressed because ejaculating within 30-60 sec after penetration during sex with his wife, but reports no rapid ejaculation while masturbating technically meets the diagnostic criteria for premature ejaculation. Nevertheless, the diagnosis of premature ejaculation does not fully describe the scope and psychology of his sexual dysfunction. The same could be implied in the case of 67-year-old married male who started to compulsively masturbate about 2 years ago. He thinks about other men being around at times while masturbating, or at times he masturbates just without any thoughts, in various places, for example, while driving. Is his diagnosis sexual disorder not otherwise specified Or obsessive-compulsive disorder Do these diagnoses-labels help the clinician in any way

Sexual maturity

Sexual maturity in many species occurs when body size reaches adult size. However, there are some notable exceptions male least weasels (Mustela nivalis) often seek maternity dens of females and will copulate the newly born females, as soon as 4 hours after birth. At that time, neonates still have their eyes and ears closed, are pink and hairless. This strategy enables females to have a first litter within weeks of birth (least weasels do not exhibit delayed implantation), and then again before the end of their first year. Another example of early sexual maturity is in musk shrews (Suncus murinus) in which mating and repeated ejaculations from males induce puberty and ovulation in virgin females.

Sex Therapy


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