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Try out PMC Labs and tell us what you think. Learn More. Delayed orgasm and anorgasmia are associated with ificant sexual dissatisfaction.
A focused medical history can shed light on the potential etiologies; which include: medications, penile sensation loss, endocrinopathies, penile hyperstimulation and psychological etiologies, amongst others. Delayed orgasm DO and anorgasmia AO have been described as one end of a spectrum of orgasm timing disorders with the other end being premature ejaculation 1. DO has also been termed retarded orgasm, inhibited orgasm, retarded ejaculation and or inhibited ejaculation. We believe that DO is the correct term as some men fail to ejaculate for medical reasons but still experience orgasm retroperitoneal surgery, radical prostatectomy.
One of the major concerns with DO and in particular anorgasmia, young males or men with reproductive interest, is the failure to inseminate and therefore male infertility. Men with DO may develop anxiety and frustration, which may lead to other sexual problems such as erectile dysfunction ED and loss of sex drive.
It is critically important to understand that orgasm is an entirely separate process from ejaculation, although they are deed to occur simultaneously. In the clinical setting, most men with failure to ejaculate retrograde ejaculation, failure of emission both addressed elsewhere in this issue experience orgasm although a man with failure to ejaculate for medical reasons may also have DO or anorgasmia. However, men with anorgasmia will orgasm forum ejaculate.
The best definition is probably that of the World Health Organization 2nd Consultation on Sexual Dysfunction defines DO as the persistent or recurrent difficulty, delay in, or absence of attaining orgasm after sufficient sexual stimulation, which causes personal distress 2. The International Consultation on Sexual Medicine defines anorgasmia as the perceived absence of orgasm, independent of the presence of ejaculation.
An acquired dysfunction establishes that the patient ly had normal orgasm timing. Situational dysfunction implies the man has problems in a particular scenario or scenarios while functioning normally in others. There is no set time threshold for what defines DO. Time threshold for distress is dependent on the partners involved.
Some males will reach orgasm with one partner in 15 minutes and have no distress, but with another partner it may cause severe distress because the partner may complain of pain with prolonged intercourse. A population-based survey established that the median intravaginal ejaculatory latency time IELT was 5.
A provider with a patient complaining of IELT longer than 22 minutes will theoretically qualify him for the diagnosis of DO. One should differentiate between problems with of ejaculation and orgasm. The physiology of ejaculation is discussed elsewhere. When ejaculation occurs, the brain processes the sensation of the pressure buildup within the posterior urethra bladder neck and external urinary sphincter are closed contemporaneously leading up to seminal fluid emission and the contraction of the peri-urethral musculature. This processing le to the triggering of an orgasm. Orgasm forum in functional neuroimaging have been able orgasm forum show the location of increased brain activity during orgasm 7.
PET imaging has demonstrated that sexual stimulation le to increased activity in the occipitotemporal, anterior cingulate and insular cortices, as well as bilateral activation in the substantia nigra 8. During orgasm there is a decrease in regional cerebral blood flow across the prefrontal cortex right medial orbitofrontal, left lateral orbitofrontal, left dorsolateral and in the left temporal lobe fusiform gyrus, superior temporal gyrusas well as increased activation in the left dentate cerebellar nucleus, left lateral midbrain, and right pons 89.
According to the DSM-5, the prevalence remains constant up until age 50 and then the rate steadily increases with men in their 80s complaining twice as much as men under age 59 3. The increase with age is likely multifactorial and may be related to a combination of: changes in penile sensitivity, increased prevalence of testosterone deficiency, increased use of offending medications, decreased exercise tolerance and reduced partner tolerance for prolonged sexual intercourse.
In one study, the prevalence of primary DO was found to be 1. Because this is such an uncommon complaint, the true prevalence is probably underestimated. Whereas, secondary anorgasmia is preceded by a period of normal sexual experiences before the problem manifests. This study included 1, twins and their siblings using retrospective self-reported data. Table 1 provides a summary of the different possible causes for DO. Age-related hormonal declines lower testosterone levels and age-related loss of peripheral nerve conduction may for the increased onset over age 50 years 3.
It has also been suggested that hormonal aberrations such as hypothyroidism and testosterone deficiency may also play a role in DO 1. The role of prolactin in men is not fully understood. However, it is well understood that prolactin levels above normal, hyperprolactinemia, may result in an inhibitory effect on sexual desire 18 — Prolactin secretion is positively influenced by prolactin-releasing factors PRFs : thyroid-releasing hormone, oxytocin, vasopressin, and vasoactive intestinal peptide Serotonin is implicated in the control of prolactin secretion via serotoninergic inputs from the dorsal raphe nucleus stimulating PRFs in the paraventricular nucleus Corona et al identified relationships between ejaculation and prolactin, thyroid stimulating hormone TSHand testosterone levels 1.
Knowing that DO and premature ejaculation PE represent two ends of a linear spectrum, it has been shown that prolactin and TSH levels progressively increased from patients with PE to those with DO, and the opposite was true for testosterone.
Some men obtain greater pleasure from masturbation than they do with sexual intercourse and may continue deep-rooted habits such as frequent masturbation or using idiosyncratic masturbation techniques. Studies have shown a correlation between DO and men with idiosyncratic masturbation practices 5 Also, with increasing frequency of masturbation the sensitivity of the penis can decline and lead to a vicious cycle where the man increases masturbation force to counteract the declining sensitivity, therefore leading to worsening DO.
Vaginal intercourse or orogenital stimulation may not be able to replicate the stimulation achieved through idiosyncratic masturbation and this may result in reduced penile stimulation leading to difficulty achieving an orgasm 514 Patients with DO have been shown to have higher orgasm forum activity, decreased night-time emissions, lower orgasm and intercourse satisfaction scores on the International Index of Erectile Function IIEFas well as higher anxiety and depression scores when compared to controls In a study by Xia et al, they compared 24 patients with primary DO and 24 age-matched controls who had no sexual dysfunction complaints They also found that although DO patients had normal glans sensation, they reported penile shaft hyposensitivity and hypoexcitability.
The patients with DO were also found to more commonly use idiosyncratic masturbation methods. Penile sensation loss has been shown to increase with age In a literature review 13 studies orgasm forum Rowland et al, they plotted penile sensory thresholds as a function of age as well as sexual functional status They found penile sensation loss was more commonly present in those men with increased age and those with sexual dysfunctions.
Lifelong DO has been associated with multiple psychological conditions. Some of these conditions include fear, anxiety, hostility, and relationship difficulties 31 The man may also suffer from a lack in sexual arousal, thus inhibiting his ability to reach orgasm. The man may achieve an erection without reaching adequate arousal to proceed with intercourse, such as men who achieve an erection with the assistance of erectogenic medications.
DO based on a situational aspect i. A novel study by Kirby et al used a rat model to show how stress can suppress the hypothalamic-pituitary-gonadal HPG axis which is important in healthy normal sexual function They showed that acute and chronic immobilization stress led to an increase in adrenal glucocorticoids causing an increase in gonadotropin inhibitory hormone which suppresses the HPG axis via inhibition of orgasm forum releasing hormone. There are numerous medications that have been implicated in the genesis of DO including antidepressants especially SSRIsorgasm forum, and opioids 3.
In a study by Corona et al, approximately male patients were evaluated for the sexual effects of anti-depressant therapy In a study by Clayton et al, the effects on sexual functioning and antidepressant efficacy of bupropion extended release was compared with escitalopram Focusing on the major etiologic factors as listed above is a useful starting point. Medication history should focus on SSRI agents and other psychotropic agents, and define the onset of the use of the medication orgasm forum it pertains to the timing of onset of DO. Asking about penile sensitivity is a useful question, especially in men at risk for penile sensation loss such as diabetics.
Symptoms and s of endocrinopathies such as testosterone deficiency, hypothyroidism and hyperprolactinemia should be sought. Masturbatory style is another useful line of inquiry as frequent masturbation or idiosyncratic masturbatory styles orgasm forum lead to DO. Defining relationship status, satisfaction and the role external stressors may be playing in the DO genesis is also important.
Furthermore, identifying the onset of the DO is critical, whether lifelong or acquired. Next, understanding whether the condition is generalized or situational is also critical to understanding the pathophysiology. Asking patients to describe a typical sexual encounter is often a useful ploy to unearth potential contributing factors. Inquiring about how long a man attempts relations before stopping may also provide valuable insight into the problem. Some older men, due to inadequate exercise reserve of orgasm forum body strength, cease sexual relations sooner than they did when they were younger and thus interpret this as DO.
Finally, asking about strategies or medications that have been tried ly for this problem will aid in plotting a course of treatment. The role of laboratory testing, such a testosterone and TSH levels, is optional and is applied depending upon patient symptoms.
If laboratory values are abnormal, endocrine function should be corrected. As shown by Carani et al, with correction of thyroid hormone levels, patients had ificant improvements in DO After thyroid hormone treatment and normalization of lab values, half of the hypothyroid patients reported their DO improved, and IELT improved from 22 to 7 minutes. Biothesiometry examines the sensory threshold of vibratory tactile stimulation.
Pudendal SSEP evaluates the afferent activity from the dorsal nerve of the penis towards the brain. Sympathetic skin testing is another test that allows the evaluation of sympathetic efferent flow to the skin of the genitals. Lastly, sacral reflex arc testing examines the motor and sensory branches of the pudendal nerve and nerve roots S2, S3, and S4 Management Algorithm [adapted from 57 ]. Various lifestyle changes include: steps to improve intimacy, reduce masturbation frequency, change of masturbation style and decreasing alcohol consumption, 5 Once the organic causes are ruled out and in some cases contemporaneously, the patient may benefit from a thorough psychosexual evaluation along with his partner.
There are numerous strategies that utilize combinations of approaches, but that is beyond the scope of this article.
Success rates are difficult to determine from literature, and few have had ificant testing of their. There are no FDA approved drugs for DO, and those drugs that have been studied often have limited efficacy or ificant side effect profiles. One could first consider withdrawing any offending medications if possible, such as SSRIs, although it is our clinical practice to liaise with the SSRI-prescribing clinician and have them coordinate the drug manipulation drug holiday, substitution or cessation and monitor the patient. Some medications are used to counteract the side effects of other medications.
Also, orgasm and intercourse satisfaction domain scores on the IIEF improved ificantly from baseline after treatment. Cyproheptadine, an anti-histamine known to increase brain serotonin levels, has been studied to treat DO related to SSRI use 543 However, there have been orgasm forum large randomized controlled studies conducted with this agent to date. Amantadine, an indirect stimulant of central and peripheral dopaminergic nerves, has been used by some investigators to stimulate sexual behavior in rats Yohimbine has been used as a traditional medicine in Africa as an aphrodisiac, and is being studied as a possible medication to treat ED.
Several groups have studied yohimbine to treat other sexual dysfunctions 45 — Adeniyi et al performed a study using yohimbine in 29 patients with anorgasmia who presented to their clinic with complaints of infertility or orgasmic dysfunction The patients achieved orgasm at a mean yohimbine dose of 38 mg. In all, 19 men achieved orgasm; however, orgasm forum required the use of penile vibratory stimulation PVS. Also, 7 out of 8 men with secondary AO were able to achieve orgasm. Oxytocin is a nine amino acid peptide released by the posterior pituitary at higher levels during orgasm.
Ishak et al reported on one case of oxytocin used successfully for the treatment of anorgasmia The patient was given a 20—24 IU dose of oxytocin intranasally when he was ready to orgasm, and a positive response was reported through at least 8 months of follow up. A rat model sexually sluggish male rats has been used to study low dose endocannabinoid anandamide effects on the CB1 cannabinoid receptor to lower the ejaculatory threshold Their were encouraging and found that low dose anandamide did lower the ejaculatory threshold in their study group.
The effects were temporary and the rats no longer displayed the behavior 7 days after the initial dosing. There were no effects observed on other sexual behaviors. The dopamine agonist cabergoline has been shown to augment plasma prolactin levels and was studied for its utility in treating psychogenic erectile dysfunction ED 50 In one study, patients were treated with cabergoline 0. Baseline hyperprolactinemia was found in 38 of the patients, in addition, after the treatment period ended both prolactin and testosterone levels normalized in most of the patients.
Erectile function, orgasmic function, and sexual desire were all enhanced based on IIEF questionnaire scores. Testosterone plays an important role in sexual orgasm forum and motivation with effects at both the central and peripheral levels. Testosterone also plays a facilitative role in the orgasmic response mechanism Hackett et al performed a prospective, randomized, double-blind, placebo-controlled trial on men with testosterone deficiency and orgasm forum 2 diabetes using long acting testosterone injections over 30 weeks They found patients had improvements in most sexual function areas, including orgasm based on the orgasm domain of the IIEF questionnaire 5.
Corona et al performed a meta-analysis examining studies about testosterone supplementation and sexual function Data was available on the effect of testosterone supplementation on orgasmic function in 10 studies totaling patients.Orgasm forum
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Delayed Orgasm and Anorgasmia