Anejaculation

1. ANEJACULATION
Gaurav Nahar
DNB Urology(Std.)
MMHRC, Madurai

2. EJACULATORY DYSFUNCTION
 An uncommon cause of male infertility.
 CLASSIFICATION:
Premature ejaculation
Delayed ejaculation
Anejaculation
Retrograde ejaculation

3. EJACULATION:
 a complex process requiring coordinated inputs
from both central and peripheral neural
systems to produce expulsion of semen from
urethra.
 Two basic phases of Antegrade Ejaculation:
Emission & Expulsion.

4. Emission:
 The first phase of ejaculation.
 a sympathetic spinal cord reflex.
 Defined as the deposition of seminal fluid into
the posterior urethra.
Expulsion:
 due to the combined action of sympathetic and
somatic pathways.

5. Antegrade ejaculation:
 Requires a synchronized interplay between
periurethral muscle contractions and bladder
neck closure, with relaxation of external urinary
sphincter.
Orgasm:
 Associated with ejaculation.
 A pleasurable sensation resulting from cerebral
processing of the increased pressure in the
posterior urethra and contraction of bulbar
urethra bulb and accessory sexual organs.

6. EJACULATORY REFLEX
 Adequate sensory stimulation of the dorsal
penile nerve and posterior urethral distention
trigger an ejaculatory response.
EMISSION PHASE:
 Emission of seminal fluid is controlled by
sympathetic nervous system activating
propulsive contraction of smooth muscle of the
prostate, vas deferens and seminal vesicles, as
well as prostatic glandular secretion.

7. 1. Emission Phase
 Deposition of seminal
fluid from ampullary
deferens, seminal
vesicles & prostate
into the posterior
urethra.
 Bladder neck closure
occurs concurrently
with emission in
response to
sympathetic
innervations.

8. Applied aspect…
 Interruption of innervation of bladder neck, vas
deferens, and prostate might lead to a
retrograde ejaculation or failure of emission.
 Protection of sympathetic efferents during
surgical procedures in retroperitoneum or
pelvis preserves normal ejaculatory function.

9. EXPULSION PHASE:
 Somatic nervous system (represented by
pudendal nerve) is exclusively responsible for
expulsion phase of ejaculate.
 Synchronous activation of ischiocavernosus,
bulbospongiosus and levator ani muscles as the
perineal striated muscles and the anal and
external urethral sphincters innervated by
pudendal nerve causes expulsion of seminal
fluid from the urethra.

10. 2. Expulsion Phase:
 It involves closure of
bladder neck,
followed by rhythmic
contraction of urethra
by pelvic-perineal &
bulbospongiosus
muscles &
intermittent
relaxation of external
urethral sphincter.

11. Applied aspect…
 Patients with post traumatic sacral spinal cord
injuries (pudendal nerve: S2-4) or patients with
neuropathies (e.g., diabetes, multiple sclerosis)
typically show a dribbling ejaculation due to
missing motor innervation of propulsive pelvic
musculature.

13. ANEJACULATION
 Inability to ejaculate semen despite stimulation
of penis by intercourse or masturbation.
CAUSES:
 Psychological or Physical(organic).
TYPES:
 Situational Vs. Total Anejaculation
 Orgasmic Vs. Anorgasmic Anejaculation

14. SITUATIONAL ANEJACULATION:
 Ejaculation in some situations but not in others.
ex. a man may be able to ejaculate and attain
orgasm with one partner but not with another.
Occurs in case of psychological conflict or
relationship difficulty with one partner.
 Ejaculate normally during masturbation but not
during intercourse.
 Can also occur in stressful situations, as when a
man is asked to collect a sample of semen in
laboratory for infertility treatment.

15. TOTAL ANEJACULATION:
 Man is never able to ejaculate when awake.
 Usual cause- Deep-rooted psychological
conflicts.
 However normal nocturnal (night) sleep
emissions present.

16. ANORGASMIC ANEJACULATION:
 Man is never able to reach an orgasm in the
waking state (either by masturbation or by
intercourse) and does not ejaculate.
 may need a high amount of stimulation before
they reach orgasm, not achieved during
intercourse or masturbation.

17. CAUSES:
 Psychological inhibitions.
 Low serum testosterone level.
 Psychotropic medications.
 Hormonal therapy for the treatment of prostate
cancer .
 Complete or incomplete spinal cord injury.

18. ORGASMIC ANEJACULATION:
 experience orgasm but do not ejaculate semen,
either because there is failure of emission of
semen due to
1. a block in the ejaculatory ducts or
2. damage to ejaculatory nerves.

19. Examples of conditions that cause this situation:
 diabetes,
 after trans-urethral (laser) resection of the
prostate and
 following pelvic surgery for prostate, bladder or
testicular cancer.

20. Retrograde ejaculation may be confused with anejaculation.
 Retrograde ejaculation: flow of semen back into the
bladder due to weakness or surgery of the bladder neck.
 common in diabetics.
 Occurs in men taking medications such as alpha-blockers
that prevent closure of bladder neck during orgasm.
 following trans-urethral resection (TURP) or laser surgery
of the prostate.
 spinal cord lesions and injuries, operations on the spine,
retroperitoneum or pelvic organs.

21.  Anejaculation more likely to occur in complete
trans-urethral resection of prostate including
ejaculatory ducts, which carry semen from
seminal vesicles and testicles.
 A simple analysis of post orgasmic urine
specimen will differentiate between retrograde
and anejaculation.
 Presence of sperm in the urine specimen →
retrograde ejaculation. Total absence of sperm
in urine complete lack of ejaculation or→
anejaculation.

22. TREATMENT
depends upon the cause.
 Psychosexual counselling.
 Medications.
 Penile Vibratory Stimulation(PVS).
 Electroejaculation(EEJ).
 Surgical sperm retrieval to circumvent lack of
ejaculation.

23. Medications
 Anejaculation caused by alpha-blocker
responds to cessation of the offending drug.
 Rarely, medications that help to close the
bladder neck (ephedrine, imipramine) may
convert retrograde ejaculation to antegrade
ejaculation.

25. Penile Vibratory Stimulation(PVS)
 PVS involves direct vibratory stimulation of penile
frenular region using specially designed equipment at
vibration amplitude of 2.5 at 100 Hz.
 Best candidates for PVS- patients with complete SCI who
have an intact ejaculatory reflex system: Specifically,
patients with complete upper motor neuron lesions
above T10 with preservation of sacral efferents,
thoracolumbar sympathetic outflow, and intact
communication between sacral and thoracolumbar
segments exhibit the best response to PVS.

26.  Incomplete spinal cord lesions have poor
response to PVS because of cortical inhibition
of the reflex arc preventing ejaculation, lower
spinal cord lesions or peripheral neural root
injuries are unlikely to respond to PVS.
 First-line therapy for SCI patients, producing
better ejaculate quality than noted with EEJ.

27. Electro ejaculation
 Electro ejaculation(EEJ) is a procedure in which an
electrical current is applied to ejaculatory nerve plexus
through rectum to stimulate ejaculation.
 may be used for SCI men who have failed a trial of PVS.
 effective for any level of SCI, as well as in men with
anejaculation from a variety of other mechanisms
including retroperitoneal nerve injury from prior surgery
such as retroperitoneal lymphadenectomy, diabetic
neuropathy, multiple sclerosis, spina bifida, and
psychogenic anejaculation.

28.  Success rates in retrieving sperm for
insemination are nearly 100% for men with
anorgasmic anejaculation and in men with no
physical defects.
 If nerves are damaged, vibratory stimulation
and electro-ejaculation have an 80% success
rate.

29. Seager Electro Ejaculator

30. Surgical Sperm Retrieval
 Regardless of the etiology of anejaculation,
surgical sperm retrieval via either percutaneous
or open biopsy of epididymis or testis remains
an effective option for management.
 No treatment exists to restore ejaculation
following open or laser prostate surgery.

31. Thank You !!!