426 Sexual Dysfunctions
terns; men who require highly ritualized ac tivity to ejaculate during partnered sexual
activity). Another medical illness or injury ma y produce delays in ejaculation independent
of psychological issues. For example, inability to ejaculate can be caused by interruption of
the nerve supply to the genitals , such as can occur after traumatic surgical injury to the
lumbar sympathetic ganglia, abdominoperitoneal surgery, or lumbar sympathectomy.
Ejaculation is thought to be under autonomic nervous system control involving the hypo-
gastric (sympathetic) and pudendal (parasym pathetic) nerves. A number of neurodegen-
erative diseases, such as multiple sclerosis and diabetic and alcoholic neuropathy, can
cause inability to ejaculate. Delayed ejaculat ion should also be diffe rentiated from retro-
grade ejaculation (i.e., ejaculation into the bladder), which may follow transurethral pros-
tatic resection.
Substance/medication use. A number of pharmacological agents, such as antidepres-
sants, antipsychotics, alpha sympathetic drugs, and opioid drugs, can cause ejaculatory
problems.
Dysfunction with orgasm. It is important in the history to ascertain whether the com-
plaint concerns delayed ejaculation or the sensation of orgasm, or both. Ejaculation occurs
in the genitals, whereas the experience of orga sm is believed to be primarily subjective.
Ejaculation and orgasm usually occur together  but not always. For example, a man with a
normal ejaculatory pattern may complain of decreased pleasure (i.e., anhedonic ejacula-
tion). Such a complaint would not be coded as delayed ejaculation but could be coded as
other specified sexual dysfunction or  unspecified sexual dysfunction. 
Comorbidity