Inability to ejaculate (anejaculation)

In the absence of impotence, two types of pathological anejaculation exist:

• Orgasmic anejaculation: The patient is able to hold a penile erection long enough to engage in the sexual act and can derive pleasure and reach a climax or orgasm but is unable to ejaculate semen. The presence of anejaculation does not imply the unviability of the patient’s sperm; after receiving medical attention, they may be able to conceive a child with their partner if desired. This condition can be temporary or permanent and the management of both would vary.
• Anorgasmic anejaculation: Although able to hold a penile erection long enough to engage in sexual intercourse, the patient is unable to reach orgasm or climax even after prolonged or repeated sexual stimulation. As climax is not reached, ejaculation also does not occur. This can be a great source of frustration and emotional trauma for the patient and his partner. The sexual experience for the patient is entirely altered and infertility problems are inevitable due to the lack of semen deposited. However, this type of anejaculation also does not indicate the lack of sperm viability and the patient and his female partner may be able to conceive a baby after treatment.

The patient may experience the following:

• No ejaculate or semen comes out even after prolonged and consistent sexual intercourse while maintaining a penile erection throughout.
• A feeling of orgasm but with no semen (dry orgasm).
• No climax or orgasm even after prolonged and consistent sexual intercourse while maintaining a penile erection throughout.
• Inability to conceive a child even after consistent and regular unprotected sexual intercourse with their female partner.

The causes of anejaculation or inability to ejaculate can either be congenital (some anatomical anomalies of the male reproductive system may be present since birth) or acquired later in life due to diseases, injuries or psychological factors.

• Psychogenic: Anejaculation can result from psychological stress or inhibitions. Sometimes, due to interpersonal relationship strain, other causes of stress or being in an uncomfortable environment, a male patient who is able to orgasm and ejaculate while masturbating or with another partner is unable to do so. Psychosexual counselling can help overcome anejaculation in such cases.
• Congenital anomalies: Defects in the anatomical structure of the components of the male sexual and reproductive tract can impede the flow of semen. Blockages anywhere in the male reproductive tract can prevent ejaculation even after reaching orgasm. Examples include:
  • Müllerian duct anomalies
  • Wolffian duct abnormality
  • Prune belly syndrome
• Surgical complications: Damage to the nerves controlling normal antegrade ejaculation can become damaged following surgery in the region and ejaculate may not be expelled. Retrograde ejaculation is a different condition, in which the semen enters the urinary bladder instead of being let out, and can also result from post-surgery complications. Surgical procedures that can cause anejaculation include:
  • Bladder neck incision
  • Transurethral resection of prostate (TURP): A surgery in which a scope is inserted through the urethra to remove part of the enlarged prostate gland in benign prostate hypertrophy (BPH).
  • Radical prostatectomy: Total surgical removal of the prostate and surrounding tissue is an extensive surgery for prostate cancer.
  • Aortoiliac vascular abdominal surgery for repair of abdominal aortic aneurysm.
  • Para-aortic lymph node resection carried out to remove lymph nodes that drain the cancer being resected.
  • Bilateral sympathectomy: A type of surgery where sympathetic nerves are worked upon to treat hyperhidrosis (excessive pathological sweating) or ventricular tachycardia (a heart rhythm anomaly).
• Neurogenic: Damage to the nerves controlling the ejaculation process (especially T10-L2 spinal nerves) by diseases or injury can prevent the emission of semen. Examples include:
  • Diabetic neuropathy: Diabetes mellitus induced demyelination and damage to nerves of the body.
  • Spinal cord injury: Trauma to the spine can lead to fractures and impingement of the spinal nerves that emerge from the segments of the spine the blow has been made to.
  • Cerebrovascular accident (CVA) or stroke: Paralysis of the areas supplied by the spinal nerves involved in ejaculation can result in anejaculation.
• Infective: Some infections can cause strictures or blockages to form in the male sexual and reproductive tract, preventing the emergence of ejaculate. Infections with an impact on ejaculation include:
  • Urethritis: Infection of the urethra that can heal and form strictures.
  • Schistosomiasis: Blood fluke infection that can present with bloody urine, affect the urinary tract and damage the shared passage of the ejaculate.
  • Genitourinary tuberculosis: Tuberculosis of the male reproductive tract leads to the formation of extensive adhesions that block the semen.
• Endocrine or hormone related: Hormone-related problems can especially hamper sexual functioning and have a negative impact on ejaculation. Hormonal causes are: 
  • Hypogonadism: The deficiency of the male sexual hormone, testosterone can result in anejaculation.
  • Hypothyroidism: Reduced functioning of the thyroid gland results in decreased levels of thyroid hormones that can impact various systems of the body including the male reproductive system.
• Side effects of medicines: Some medicines, taken for other health conditions, can cause ejaculatory dysfunction as a side effect. Drugs causing anejaculation include:
  • Alpha-blockers like alpha methyldopa used for the treatment of enlarged prostate and sometimes for raised blood pressure.
  • Antidepressants: All antidepressants have some untoward effect on the sexual process. Tricyclic antidepressants (TCAs like amitriptyline) and selective serotonin reuptake inhibitors (SSRIs like fluoxetine) impact ejaculation.
  • Thiazide diuretics: Used commonly to treat hypertension, these can cause the adverse effect of anejaculation.
  • Alcohol abuse: Alcohol can impair the ability to ejaculate.

The development of inability to ejavulate may prompt the patient to seek medical care. The doctor will begin by taking a proper medical history, laying emphasis on past surgeries or infections, routine medicine use and pre-existing diseases. Following history-taking, a thorough physical examination is conducted which includes a neurological assessment as well as examination of the genitalia (scrotum, penis and prostate). A digital examination of the prostate gland may be done with lubricated gloved fingers.

While tests may be ordered to diagnose the underlying cause of anejaculation, the diagnosis of anejaculation is clinical. Dry orgasms can occur with retrograde ejaculation, a different condition in which, due to urinary sphincter dysfunction, the sperm is directed to the bladder and expelled in the urine. To differentiate between anejaculation and retrograde ejaculation, a urine test is done.

Urinalysis for sperms: The patient is asked to masturbate and then immediately urinate afterwards to collect a urine sample. The urine is tested for spermatozoa. If serums are present, the most likely cause of dry orgasms is retrograde ejaculation. However, if no sperm is found in the urine, anejaculation is confirmed and the underlying cause is investigated for treatment.

The management of anejaculation depends on the underlying cause and whether it is reversible or not. For example, if the doctor suspects an offending drug to be causing anejaculation as a side effect, the medicine will be stopped and replaced by an appropriate treatment choice. Management of other anejaculation causes include:

• Psychosexual counselling: In cases where anejaculation is caused by undue emotional stress or strain, psychotherapy or counselling is useful to work through those underlying issues. Sexual therapy can additionally involve sex education for a clearer understanding of the arousal process by the affected person. It may help the patient realise their personal needs to elicit a pleasurable reaction to touch and progression toward orgasm and ejaculation.
• Penile vibratory stimulation (PVS): Patients suffering from anejaculation due to spinal cord injury can use an assisted device that helps the penis achieve an erection and ejaculate.
• Electroejaculation (EEJ): Patients with spinal cord injuries who do not respond to penile vibratory stimulation (PVS) can attempt electroejaculation (EEJ) therapy. An electrical current impulse is delivered to the ejaculatiry nerve plexus through the rectum causing artificial ejaculation.
• Surgical sperm retrieval to circumvent absent ejaculation: Patients who are trying to conceive may opt for retrieval of viable sperms from the testes for artificial insemination of the female partner.

While it may not be a major health risk to the patient the following complications can arise:

• Infertility: Lack of semen and spermatozoa deposition in the female partner after sexual intercourse can lead to fertility failure.
• Psychological stress, frustration, anxiety or depression: The inability to reach an orgasm or experience sexual pleasure can be mentally daunting for the male.

Nearly all cases of anorgasmic anejaculation due to psychogenic causes can be treated successfully. With the use of therapies such as penile vibratory stimulation (PVS) and electroejaculation (EEJ), it is possible to retrieve sperm by inducing an artificial ejaculation in most patients. Even patients with irreversible causes such as anejaculation resultant of surgical complications and nerve damage can ejaculate with electrotherapy. When attempting to conceive, most men are successful after receiving treatment for anejaculation, provided their sperm is healthy and viable. If unable to conceive even after medical treatment, assisted reproductive technology (ART) can help the male and his partner in having a baby.