Problems on Ejaculation

Dr. Philip Werthman, FACS
Director, Center for Male Reproductive Medicine
Summary: Dr. Philip Werthman is the most recognized vasectomy reversal surgeon and male fertility specialist in the world. After serving as the chief of urology at Century City Hospital, Dr. Werthman founded the Center for Male Reproductive Medicine and Vasectomy Reversal. Dr. Werthman has lectured around the globe, written numerous books and articles and is a clinical assistant professor of Urology at USC School of Medicine.


What is "premature ejaculation"?

Premature ejaculation is a condition where the man has an orgasm before he wants to, or before pleasing his partner. In terms of absolute time, it could be anywhere from under five minutes to specifically under one to two minutes, and it can be distressing to both the male and female partners when this condition occurs.

What causes premature ejaculation?

Premature ejaculation can be caused by a variety of things. It could be a psychological issue, it could be a sensitivity issue. There are probably a variety of reasons that cause it that we don't even know about yet.

How can premature ejaculation be treated?

There are several techniques to treat premature ejaculation. For some men it's decreasing the sensativity, so it's, perhaps, wearing a condom may delay ejaculation. For other men it's using a numbing jelly like lidocaine cream that can decrease sensation of the glans and prolong ejaculation. For other men it's using what's called the sqeeze technique, when they feel like they're about to ejaculate, they pull out and they squeeze and that can delay ejaculation. But, right now, the main stay of premature ejaculation therapy is really using medications. There are a number of medications that belong to the class of drugs known as anti-depressants that can delay or retard ejaculation and thereby it may actually prolong or double the time that someone who ejaculates prematurely can maintain an erection for intercourse.

What is "retrograde ejaculation"?

Retrograde ejaculation is a condition where, when a man ejaculates, instead of the semen coming out through the end of the penis, it actually runs back into bladder. If you look at the male reproductive tract and its anatomy, the sperm come up through the vas deferens and then run through the ejaculatory ducts and the prostate, which is part of the male urethra. The prostate is right next to the bladder. It's probably about a centimeter or two centimeters from the bladder. The penile urethra is usually six to eight centimeters in length, so the path of least resistance for the semen to go is actually back into the bladder, and that is retrograde ejaculation.

What causes retrograde ejaculation?

The causes of retrograde ejaculation are any issues that affect the function of the sphincter at the neck of the bladder. This could be caused by prostate surgery, as it's common when men have prostate surgery for the neck of the bladder to be scraped to facilitate urination, and while scraping this out, muscles that are part of the sphincter are scraped out as well. It used to be very common for men post-surgery to experience retrograde ejaculation. Retrograde ejaculation can also be caused by neurologic conditions. Anything that affects the nerves of the spinal chord in the sacral and lumbar region, and also the nerves that eminate from the spinal chord and go to the prostate and the bladder. Those conditions most commonly include spinal chord injury, abdominal surgery, colon surgery and surgery for testicular cancer. Some men with diabetes will have the problem of the diabetes causing damage to the nerves that control ejaculation and can therefore end up suffering from retrograde ejaculation.

How is retrograde ejaculation treated?

There are several different ways of treating retrograde ejaculation. One is to have the man urinate the sperm out of the bladder. And then the sperm are washed. They're taken out of the urine. The urine is alkalinized by having the man take something like Alka Seltzer or bicarbonate prior, because very acidic urine will kill the sperm. And once those sperm are washed, they can be used for insemination. Certain drugs can be used to help close that sphincter. Certainly in men who have diabetes, and some men who have spinal cord injuries, we use a medication like Sudafed, and that causes those muscles to contract, closing the sphincter. In severe cases of retrograde ejaculation where sperm of good quality can't be obtained through these other means, we can go into the testicle, take the sperm out, and use those sperm with in vitro fertilization.

What is "anorgasmia"?

Anorgasmia is a condition whereby a man is unable to have an orgasm. Usually anorgasmia is psycological condition.

What is "delayed ejaculation"?

Delayed ejaculation is a condition where a man has trouble ejaculating but can ejaculate over a period of time. This can be 15 minutes, a half an hour, an hour, so this is very variable between different men. It's usually due to psychological causes, where the man has decreased sensitivity in the penis and is unable to ejaculate because of that, or through other psychological issues, where they're unable to let go and release and just experience an orgasm.

How is anorgasmia treated?

Anorgasmia is usually treated with psychological counseling or sex therapy.

What causes low libido?

Low libido can be caused by a variety of different things. It can be caused by a low level of the male hormone testosterone. Testosterone, which is made in the testicles, is really the chemical by which a man has sex drive and is aggressive. If testosterone is low, then a man may experience symptoms of lack of desire for sex. Other things include stress, being tired, being overworked, depression; unhealthy lifestyle, being overweight, obese. Some men, a high level of estrogen in their body, even though their testosterone may be normal, can also cause low libido, because it's the balance between testosterone and estrogen in a man's body that affects both sperm production and also libido issues.

How is low libido treated?

Low libido is treated in a variety of different ways. Number one is to assess a man's hormone levels, hormonal status and check his testosterone level and his free testosterone level--which is the part of the testosterone that we call bio-available that's seen by the actual cells in the body. These are two different measurements. If a man has low testosterone then there are a variety of different ways of supplementing testosterone to raise his back to the normal level which should increase his desire and sex drive. For men who have unhealthy lifestyles. . . smoke too much, who are obese, clearly making lifestyle changes, changing their their bad habits can help affect a man's libido. Certainly, we know that when men start working out their testosterone levels increase, their level of estrogen decreases and that can give them a sense of well-being, a sense of better body image and also a sense of sexual desire and increased drive.