Diagnosis
The diagnosis of IE is based largely on history obtained from the patient. A thorough review of the patient’s medical history is essential. The onset of ejaculatory dysfunction and any temporal associations with medical, surgical, or psychosocial issues should be assessed. Physicians must be sensitive to the fact that patients often have difficulty differentiating erectile dysfunction, ejaculatory dysfunction, and orgasmic dysfunction. Careful questioning regarding each of these components of male sexual health is essential. Distinguishing “pre-ejaculate” from true antegrade ejaculation is also important in delineating the patient’s underlying function. Prior medical problems, surgeries, and medications should be discussed. In particular, the use of antidepressants and alpha-antagonists should be assessed. During the physical examination, testicular volume and consistency, as well as vasal and epididymal presence or absence, should be assessed. Serum testosterone levels should be checked because the accessory sexual glands (prostate, seminal vesicles, and bulbourethral glands) are androgen-dependent structures, and secretory function may be impaired by markedly diminished serum testosterone levels. Urinalysis testing should be performed because the presence of elevated urine glucose levels may signify the presence of DM. If the patient is able to provide an antegrade semen sample, semen analysis should be performed. For patients with no antegrade ejaculate or low ejaculate volumes <1.0 mL, postejaculate urinalysis should be performed immediately after ejaculation to assess for the presence of sperm in the urine.
Treatment
For men with IE thought to be due to medications, the suspected agents can be withheld and change in ejaculatory function then assessed.
Alpha agonist administration is potentially beneficial in some patients with IE, particularly those with autonomic dysfunction. While the goal of this therapy is to optimize seminal emission and bladder neck closure, the severity of the underlying autonomic dysfunction is often so profound that this therapeutic maneuver is unsuccessful . Alpha agonists can cause numerous adverse side effects, including hypertension, tachycardia, dry mouth, and urinary retention, and these must be closely considered before dosing. Alpha agonists should be administered with care, particularly in patients with DM, as these individuals are at increased risk of cardiovascular disease.
Numerous reports of psychological and behavioral therapies for IE have been published, but the overall efficacy of such approaches is unclear. Most studies are case report format and lack controls, hampering the assessment of the effectiveness of this treatment modality. While psychological and behavioral therapies are certainly a reasonable option and should be considered for men with a suspected psycho-genic cause of ejaculatory dysfunction, additional work is needed to better characterize this therapeutic approach.
Vibratory stimulation devices can also be employed, with the enhanced stimulatory input providing benefit for some affected patients. The best vibratory stimulation devices allow both frequency and amplitude modulation, although some patients may benefit from less expensive and more accessible commercially available vibratory devices.