Ejaculation is a highly integrated process that involves both the sympathetic and parasympathetic neural pathways. Numerous studies reveal that ejaculatory dysfunction is a common disorder and the source of significant bother for many of those affected. Ejaculatory dysfunction is comprised of several different, more specific abnormalities including: premature ejaculation, inhibited ejaculation (consisting of delayed and absent ejaculation), and painful ejaculation. The evaluation of affected patients should include a comprehensive medical history, physical examination, and laboratory testing. Numerous thera-peutic options are available to treat ejaculatory disorders, with many of these leading to marked improvement in patients’ symptoms and associated bother.
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Introduction
The normal male sexual cycle consists of four stages: desire, arousal, orgasm, and resolution.
As Masters and Johnson originally reported, each of these stages is associated with distinct physiological changes in the male. Ejaculation, which normally occurs during the orgasm phase, is a highly complex, integrated process essential for the normal delivery of semen into the female reproductive tract during intercourse. Ejaculation disorders can lead to impaired reproductive potential in men and may necessitate the use of a variety of advanced diagnostic and therapeutic maneuvers. The impact of ejaculatory dysfunction is not confined to detrimental effects on men trying to achieve a pregnancy, as a recent study by Rosen et al. showed In a survey of 12,815 US and European men aged 50 years or older, the authors found that ejaculatory disorders are common, affecting 30.1% of men between 50 and 59 years of age. A majority (50.2%) of these affected men reported bother due to their ejaculatory problems. The authors noted that despite the pervasive focus among many clinicians on erectile dysfunction when assessing a patient’s sexual health, ejaculatory problems are almost as common and should also be considered. For these reasons, physicians should be capable of identifying and treating the broad spectrum of ejaculatory disorders; this is essential in order to effectively care for the large numbers of affected men.
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The Physiology of Ejaculation
Ejaculation in human men occurs simultaneously with orgasm. The concurrent timing of ejaculation with the rewarding sensory experience of orgasm, from an evolutionary perspective, serves to facilitate sexual behavior and human reproduction. Despite the close temporal link between orgasm and ejaculation, these are two distinct and unique physiologic events. Orgasm is largely a central nervous system process that can be generated by cerebral stimulation without any accompanying genital input. Thus, it is possible for men to experience orgasm in the absence of ejaculation. Clinically, this is illustrated in men who have undergone radical retropubic prostatectomy, with surgical extraction of their ampullary vas deferens, seminal vesicles, and prostate gland. Despite the absence of these accessory sex glands that play a central role in ejaculation, patients who have undergone radical prostatectomy are typically capable of achieving orgasm postoperatively.
Ejaculation consists of two phases: emission and expulsion. Each phase is coordinated by anatomical structures functioning together in a highly integrated fashion and is separately discussed below.