5. Interactions between autonomic and somatic
innervations in the control of male sexual cycle
Sensory input from the genital tract is carried by the
pudendal nerve to the S2–S4 segment of the spinal
cord.
Contralateral primary sensory area deep in the
interhemispheric tissue.
The somatic motor fibers -S2–S4 and supply the
pelvic floor muscles and the external anal sphincter.
6. Descending parasympathetic innervation exits the
spinal cord at the S2–S4 level and reaches the penis.
It is responsible for the corporeal vasodilatation and
corporeal smooth muscle relaxation, and hence the
penile transformation from the flaccid to the erect
state.
7. The sympathetic innervation exits the spinal cord at
T11–L2 level and reaches the penis.
It is responsible for the emission and ejaculation
through coordinated contractions of the vas
deferens, ampulla, seminal vesicles, prostate, and the
bladder neck.
8. EJACULATION
Sympathetic nervous system.
Spinal cord reflex arc.
Considerable voluntary inhibitory control over this phase
of the sexual response.
Two sequential processes.
A) Emission - deposition of seminal fluid into the
posterior urethra. Simultaneous contractions of the
ampulla of the vas deferens, the seminal vesicles, and the
smooth muscles of the prostate
B)true ejaculation -expulsion of the seminal fluid from
the posterior urethra through the penile meatus.
9. Premature ejaculation
International Society for Sexual Medicine
(ISSM) definition
Amsterdam in October 2007
"Premature ejaculation is a male sexual dysfunction
characterized by ejaculation which always or nearly
always occurs prior to or within about one minute of
vaginal penetration; and, inability to delay
ejaculation on all or nearly all vaginal penetrations;
and, negative personal consequences, such as
distress, bother, frustration, and/or the avoidance
ofsexual intimacy."
10. Premature Ejaculation
Between 1 in 3 & 1 in 5 men (20-30%).
Less than 25% men with premature ejaculation seek
medical advice
Premature ejaculation is often associated with
erectile dysfunction and with rapid loss of erection
after ejaculation
11. CASE 1
A 26 Year old bank employee married for the last 6
months comes to you with complains of premature
ejaculation.
He has come alone (without his wife)
He says fertility is not an immediate concern and this
problem is affecting their relationship.
He has a normal libido
He says his erections are strong enough, but
ejaculation occurs within a minute.
12. The diagnosis of PE is by history alone.
A detailed sexual history.
Frequency and duration of PE.
Relationship with specific partners.
Occurrence with all or some attempts
Impact of PE on sexual activity
Relationship to drug use/ abuse.
Partner’s contribution to the history could
help.
13. Physical examination:
Well androgenised
Flaccid penile length 4.5 cm. Stretched penile length-
7.5 cm
Testicular volume normal.
14. Ano cutaneous reflex
A noxious or tactile stimulus will cause a wink
contraction of the anal sphincter muscles .
Nociceptors in the perineal skin to the pudendal
nerve, where a response is integrated by the S2-S4.
Absence of this reflex - interruption of the reflex arc,
afferent limb or efferent limb.
15. Bulbo cavernosus reflex
The test involves monitoring anal sphincter
contraction in response to squeezing the glans penis
or tugging on an indwellingFoley Catheter.
The reflex is spinal mediated and involves S2-4.
16. ADDITIONAL TESTS
On an individual basis- Hb, Blood sugar, lipid profile
renal function tests.
Hormones- Total testosterone,
FSH/LH/TSH/Prolactin – If co existing reduced
libido/ erectile dysfunction.
17. In patients with PE and ED , ED should be
treated first.
The cause of premature ejaculation is unknown; it
appears unrelated to performance anxiety,
hypersensitivity of the penis or nerve receptor
sensitivity
18. Psychosexual counselling may help men with
less troublesome premature ejaculation but,
in most men, the mainstay of long-term
treatment is with drugs.
19. Selective serotonin uptake inhibitors (SSRIs)
are powerful antidepressants but they also have a
beneficial effect on premature ejaculation. They are,
therefore, used as first-line treatment for this
condition and their effectiveness is often maintained
for several years.
Dapoxetine is the only SSRI licensed for use in
premature ejaculation
20. Common side-effects of SSRIs include fatigue,
drowsiness, nausea, dry mouth, diarrhoea &
excessive perspiration although these are often mild
and usually settle after 2-3 weeks.
21. Viagra has also been used to help premature
ejaculation but their exact role is uncertain; they do,
however, improve sexual confidence and reduce
performance anxiety by producing better erections
(if this is a problem).
22. Local anaesthetic cream (lignocaine +
prilocaine), applied 20 - 60 minutes before
intercourse, can be useful but may numb the vagina
unless used with a condom and can occasionally
cause irritation of the penile skin.
23. Psychosexual counselling
"stop-start" technique (developed by Semans),
the "squeeze" technique (pictured, developed by
Masters & Johnson)
or the Kegel technique (learning to control the
ejaculatory muscles) are also effective.
Improvements are seen in 50-60% of patients but
may not be maintained in the long term.
24. Normal penile length
Adult men with penile length of greater than 4 cm in
the unstretched flaccid state or greater than 7.5 cm
in the stretched flaccid state or the erect state to have
a normal penile length.
25. Testicular volume
A normal size adult testis has dimensions of 4.1–5.2
cm in length and 2.5–3.3 cm in width.
Adult Volume: 15–30 cm3
The germ cells and seminiferous tubules represent
90% of the testicular volume while Leydig cells
contribute to less than 1%.
26. CASE 2
34 year old man, married for 3 years primary
subfertility comes to you with a semen analysis
report showing volume 0.5ml and no sperms found
in the ejaculate.
Period of abstinence -3 days.
No erectile difficulty, has orgasm, but ejaculate is
usually low. He says the volume has been steadily
decreasing over the last 3 years.
27. Med history: Type 1 diabetic on insulin since the age
of 17. Sugars uncontrolled. Has postural
hypotension, on treatment
On examination Ht 175 cm, weight 73 kg,BP130/80.Well androgenised.
Stretched penile length-8cm.Testicular volume 20ml
bilaterally.
Bulbocavernosus and ano cutaneous reflexes absent
28. Repeat semen analysis showed volume 0.4ml and
occasional non motile spermatozoa with abnormal
morphology. He was given:
1g NaHCO3 the night before and 1g on the day of the
procedure.
The man was asked to pass urine without completely
emptying the bladder.
Produce an ejaculate in to a specimen container.
Collect urine in a container with culture media
29. RETROGRADE EJACULATION
Sympathetic efferent fibers (T10-L3)—
1) emission and 2) expulsion.
During the expulsive phase, it is necessary that the
bladder neck (internal urethral sphincter) be closed
to prevent the reflux of semen into the bladder as the
urethral pressure increases.
30. Closure of the bladder neck is also under
sympathetic control. Failure of closure of the
bladder neck and resulting reflux of semen into the
bladder is known as retrograde ejaculation (RE).
This results in a low-volume ejaculate and a low
or absent sperm count with subsequent subfertility
31. Retrograde ejaculation accounts for less than 2% of
cases of subfertility presenting to a fertility clinic.
Etiology : congenital abnormality, spinal trauma,
retroperitoneal lymph node dissection, diabetes
mellitus, and bladder neck surgery or can be
idiopathic.
32. Medical management aims at increasing tone of the
bladder neck and therefore preventing retrograde
flow of semen into the bladder by either stimulating
sympathetic activity or blocking parasympathetic
stimulation.
34. Hotchkiss technique
Empty the bladder by catherization, instill Ringer’s
lactate and flush the bladder, leave behind some
Ringer lactate, collect post ejaculatory urine,
centifuge,suspend the pellet in the culture medium.
Live birth rate 28%( small sample size).
35. Ejaculation on a full bladder
Ejaculation on a full bladder and suspend the
solution in Baker’s buffer and use for IUI.
Preg rate : 2/3
36. PRs for ejaculation on a full bladder (60%) appear to
be higher than those using the Hotchkiss technique
(24%) or obtaining sperm by centrifugation and
suspension of postejaculatory urine (15%).
Small sample size precludes a firm conclusion about
relative efficacy.
37. Medical Management
Sympathomimetic medications-Peudoephedrine hcl,
(28%)
Anticholinergics : Brompheniramine maleate(22%),
Combination of sympathomimetics and
anticholinergics,: brompheniramine maleate and
phenylephedrine hydrochloride( 39%) achievement
of antegrade ejaculation
39. CASE 3
47 year old man married for 15 years, has two
daughter 12 years and 10 years old. His wife is 37
years old.
They wish to have another baby, but he says he is
unable to have an orgasm and ejaculation following a
spinal injury a couple of years ago. His erections are
normal.
He is otherwise leading a normal life.
40. Clinical examination is within normal limits.
Anocutaneous reflex is diminished.
Medical grade Vibrator was used on the ventral
surface of the glans penis and a semen sample was
produced in 8 minutes, which showed conc 15
million/ml, total motility 25%, progressive motility
of 10% and morphology of 4%
41. What if he had orgasmic anejaculation?
Rule out- Retrograde ejaculation- post ejaculatory
urine sample.
No sperms found- Diagnosis-Orgasmic
anejaculation.
Common causes: failure of emission of semen due to
a block in the ejaculatory ducts or damage to
ejaculatory nerves. Eg: Diabetes, after TURP and
following pelvic surgery for prostate, bladder or
testicular cancer.
42. Anejaculation
Anejaculation is the inability to ejaculate semen
despite stimulation of the penis by intercourse or
masturbation.
The causes can be psychological or physical and
anejaculation can be situational or total.
43. Situational anejaculation means that a man can
ejaculate and attain orgasm in some situations but
not in others.
Typically, situational ejaculation is stress induced
and occurs selectively.
For example, ―Collection difficulty.‖
In some instances, a man may be able to ejaculate
and attain orgasm with one partner but not with
another.
44. In total or complete anejaculation the man is
never able to ejaculate, either during intercourse or
through masturbation.
In the absence of spinal cord injury or multiple
sclerosis, deep-rooted psychological conflicts may be
the cause for this scenario.
45. Total anejaculation is further divided into
anorgasmic anejaculation and orgasmic
anejaculation.
In orgasmic anejaculation, there is failure of
emission of semen due to a block in the ejaculatory
ducts or damage to ejaculatory nerves
46. Treatment depends on the causes and includes
psychosexual counseling, drugs such as ephedrine
and imipramine, vibrator therapy and electro
ejaculation.
The vibrator acts by providing a strong stimulus for
a long duration to the penis. Vibrator stimulation
results in ejaculation in about 80% of men suffering
from a neurological (spinal cord) injury.
47. Conclusion
Ejaculation is under sympathetic control.
Emission, true ejaculation.
Premature ejaculation is diagnosed by history alone.
If PE+ ED, Treat ED first.
Psychosexual counselling- limited value, drugs
mainstay.
Dapoxetene, Sildenafil.
48. Retrograde ejaculation is a rare condition <2%.
Low volume ejaculate.
Post ejaculate urine- good success with
IUI/IVF/ICSI.
Anejaculation- Situational(not uncommon), true
anejaculation ( anorgasmic, orgasmic)
Psychosexual counselling/ vibrator/
electroejaculation.
