A 57-year-old diabetic man recently consulted me about his inability to ejaculate during intercourse. He reported good erectile function and achieved an orgasm at all times during intercourse. He was concerned about his fertility and his partner was concerned that he was being unfaithful.

CAN A MAN HAVE INTERCOURSE AND ORGASM, BUT NOT EJACULATE?

Yes. Aspermia refers to the inability to ejaculate during sexual intercourse, despite being able to achieve an orgasm. This is quite different from azoospermia, where a man may ejaculate but the semen contains no sperm. The problem may be lifelong (congenital) or recently acquired.

WHAT PHYSIOLOGICAL PROCESSES GOVERN NORMAL EJACULATION?

Ejaculation is the ejection of semen through the urethra or central tube within the penis, when a man has an orgasm.

The process of ejaculation is regulated by two components of the nervous system. It consists of two phases: emission and ejaculation. Emission occurs when semen is loaded in the urethra, close to the prostate during intercourse. The second phase of ejaculation is the forcible expulsion of semen from the urethra. The expulsion occurs in spurts with rhythmic contraction of the pelvic muscles.

Ejaculation is a reflex process and once the reflex is stimulated there is a ‘point of no return’.

Any interruption of the nervous system governing ejaculation may result in ejaculatory dysfunction.

WHAT MAKES UP EJACULATE?

The ejaculate consists of fluid from the seminal vesicles, prostate and a small percentage from accessory reproductive glands. The first part of the ejaculate contains the most sperm, prostatic enzymes and zinc.

WHAT ARE THE CAUSES OF LACK OF EJACULATION?

Lack of ejaculation may be due to either:

1. Lack of emission of semen;

2. Retrograde ejaculation — where the semen is emitted but instead of going down the urethra and out through the penis, it enters the bladder.

WHAT CAUSES LACK OF EMISSION?

Some men may not emit semen because of lack of seminal glands and a prostate, as seen after radical surgery for prostate cancer. It may also occur after injury to the nerves that control the process of ejaculation or with use of some drugs to treat non-cancerous enlargement of the prostate. If the ejaculatory ducts are blocked, little or no semen will be released. Also, men with low testosterone may produce very low volumes of semen. Some psychological disturbances may also affect emission.

This condition may be treated with either medication or a process called electro-ejaculation, where ejaculation is electrically stimulated by placing a probe in the rectum under anaesthesia to obtain semen. Alternatively, penile vibratory stimulation may be used to induce ejaculation.

WHAT CAUSES RETROGRADE EJACULATION?

Semen may be absent because of nerve-related conditions. Up to 32 per cent of diabetics do not ejaculate. This is because diabetes affects the peripheral nerves in the body. Other less common nerve-related conditions include spinal cord injury and multiple sclerosis.

Many drugs have the ability to cause this, including some medications to treat high blood pressure, psychiatric medications and prostate medications for non-cancerous enlargement. Surgery on the prostate for benign conditions, radiation and major pelvic surgery may also lead to retrograde ejaculation.

Retrograde ejaculation may be diagnosed by noticing sperm cells in the analysed urine that is obtained from the bladder immediately after intercourse. It may be treated by stopping the offending medication or administering specific medication to allow normal flow of semen. If medication do not work, sperm may be harvested from the bladder and assisted fertility treatment utilised.

The lack of ejaculation is not uncommon. It is a distressing complaint for both patient and partner. It does not necessarily signify infidelity. There are many medical reasons for lack of ejaculation which can be identified and treated.

Dr Belinda F Morrison is a consultant urologist and lecturer at the University of the West Indies and Mona Institute of Medical Sciences, Mona, Kingston 6. Please send questions and comments to – belinda.morrison02@uwimona.edu.jm