Is It Hard to Orgasm Again
Fertil Steril. Author manuscript; available in PMC 2016 November 1.
Published in terminal edited course as:
PMCID: PMC4816679
NIHMSID: NIHMS768150
Delayed Orgasm and Anorgasmia
Abstract
Delayed orgasm/anorgasmia defined as the persistent or recurrent difficulty, filibuster in, or absence of attaining orgasm after sufficient sexual stimulation, which causes personal distress. Delayed orgasm and anorgasmia are associated with significant sexual dissatisfaction. A focused medical history tin can shed calorie-free on the potential etiologies; which include: medications, penile sensation loss, endocrinopathies, penile hyperstimulation and psychological etiologies, amongst others. Unfortunately, there are no excellent pharmacotherapies for delayed orgasm/anorgasmia, and treatment revolves largely around addressing potential causative factors and psychotherapy.
Keywords: delayed orgasm, anorgasmia, delayed ejaculation, retarded orgasm, inhibited orgasm
i. Introduction
Delayed orgasm (Exercise) and anorgasmia (AO) accept been described as 1 end of a spectrum of orgasm timing disorders with the other end being premature ejaculation (1). DO/AO defined equally the persistent or recurrent difficulty, delay in, or absence of attaining orgasm later sufficient sexual stimulation, which causes personal distress. DO has also been termed retarded orgasm, inhibited orgasm, retarded ejaculation and or inhibited ejaculation. We believe that DO is the correct term equally some men fail to ejaculate for medical reasons just still experience orgasm (retroperitoneal surgery, radical prostatectomy). One of the major concerns with Exercise and in particular anorgasmia, young males or men with reproductive involvement, is the failure to inseminate and therefore male infertility. Men with Practise may develop anxiety and frustration, which may pb to other sexual bug such every bit erectile dysfunction (ED) and loss of sexual practice drive. It is critically important to understand that orgasm is an entirely separate process from ejaculation, although they are designed to occur simultaneously.
In the clinical setting, virtually men with failure to ejaculate (retrograde ejaculation, failure of emission both addressed elsewhere in this effect) experience orgasm (although a man with failure to ejaculate for medical reasons may also have Practise or anorgasmia). However, men with anorgasmia volition not ejaculate.
2. Definition
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 absenteeism 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. The Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5) defines delayed orgasm every bit a marked filibuster in ejaculation or a marked infrequency or absence of ejaculation on almost all or all occasions (75–100%) of partnered sexual activity without the individual desiring delay, persisting for at least half-dozen months and causing significant distress to the private (3). The sexual dysfunction is non explained by another non-sexual disorder, medication or significant relation/life distress/stressors.
Practise is further classified equally lifelong/caused, generalized/situational, and mild/moderate/severe. An acquired dysfunction establishes that the patient previously had normal orgasm timing. Situational dysfunction implies the human has problems in a item scenario or scenarios while functioning usually in others.
At that place is no set fourth dimension threshold for what defines Practise. Time threshold for distress is dependent on the partners involved. Some males will attain orgasm with ane partner in 15 minutes and have no distress, only with another partner it may cause astringent distress considering the partner may mutter of pain with prolonged intercourse. A population-based survey established that the median intravaginal ejaculatory latency time (IELT) was 5.4 minutes and ii standard deviations above was approximately 22 minutes (4–6). A provider with a patient complaining of IELT longer than 22 minutes will theoretically qualify him for the diagnosis of DO. One should differentiate betwixt problems with of ejaculation and orgasm.
3. Physiology of orgasm
Orgasm is a complex neurobiological process that comes as a result of sexual activity (physical awareness) and/or arousal (cognitive awareness). The physiology of ejaculation is discussed elsewhere. When ejaculation occurs, the encephalon processes the sensation of the pressure buildup inside the posterior urethra (bladder neck and external urinary sphincter are airtight contemporaneously) leading up to seminal fluid emission and the contraction of the peri-urethral musculature. This processing leads to the triggering of an orgasm.
Advances in functional neuroimaging have been able to evidence the location of increased brain activity during orgasm (vii). PET imaging has demonstrated that sexual stimulation leads to increased activeness in the occipitotemporal, anterior cingulate and insular cortices, equally 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 gyrus), as well as increased activation in the left dentate cerebellar nucleus, left lateral midbrain, and correct pons (8, nine).
four. Prevalence
DSM-v states that only 25% of males routinely achieve orgasm in all sexual encounters. According to the DSM-5, the prevalence remains constant up until historic period 50 and then the rate steadily increases with men in their 80s complaining twice as much every bit men under age 59 (iii). The increment 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 do tolerance and reduced partner tolerance for prolonged sexual intercourse. In one study, the prevalence of primary DO was found to be 1.five in 1000 and secondary DO in men under historic period 65 was 3–4% (10, 11). Masters and Johnson but reported on 17 cases (12), Apfelbaum reported 34 cases(13), and Kaplan reported <50 cases (fourteen). Because this is such an uncommon complaint, the true prevalence is probably underestimated. In a report by Carani et al, they assessed 48 developed men, 14 with hypothyroidism and 34 with hyperthyroidism, and DO was identified in 64% of the hypothyroid patients and 3% of the hyperthyroid patients (15).
5. Pathophysiology
By definition, main anorgasmia begins from the male'southward outset sexual experiences and lasts throughout his life. Whereas, secondary anorgasmia is preceded past a period of normal sexual experiences earlier the problem manifests. A Finnish population-based, twin study found there was no evidence of a genetic influence on DO/AO but there was a moderate familial effect with shared environments, which accounted for 24% of the variance (16). This study included 1,196 twins and their siblings using retrospective self-reported data. Table 1 provides a summary of the different possible causes for DO.
Table 1
Causes of delayed orgasm and anorgasmia
| Endocrine | Testosterone deficiency Hypothyroidism Hyperprolactinemia |
| Medication | Antidepressants Antipsychotics Opiods |
| Psychosexual Causes | |
| Hyperstimulation | |
| Penile sensation loss |
In a written report by Teloken et al, they performed an assay of data on 206 patients who presented with secondary Practise/AO (17). The etiology for their condition were divided into selective serotonin reuptake inhibitor (SSRI) use (42%), low testosterone (21%; mean full testosterone 268±111 ng/dL), abnormal penile sensation (seven%), chronic/idiosyncratic penile (hyper)stimulation (2%) and psychogenic (28%). Age-related hormonal declines (lower testosterone levels) and age-related loss of peripheral nerve conduction may account for the increased onset over age 50 years (three). It has also been suggested that hormonal aberrations such as hypothyroidism and testosterone deficiency may also play a office in DO (1).
5.1 Endocrinopathies
The role of prolactin in men is not fully understood. Even so, it is well understood that prolactin levels above normal, hyperprolactinemia, may result in an inhibitory effect on sexual want (xviii–20). Mild forms of hyperprolactinemia (divers equally >420 mU/Fifty or 20 ng/mL) generally do not accept an impact on sexual role; yet, severe hyperprolactinemia (defined equally >735 mU/L or 35 ng/mL) can have pregnant effects on sexual function, including erectile dysfunction and testosterone product suppression (xviii, 19, 21, 22). Prolactin secretion is positively influenced by prolactin-releasing factors (PRFs): thyroid-releasing hormone, oxytocin, vasopressin, and vasoactive intestinal peptide (23). Serotonin is implicated in the command of prolactin secretion via serotoninergic inputs from the dorsal raphe nucleus stimulating PRFs in the paraventricular nucleus (24). SSRIs are therefore capable of causing hyperprolactinemia and lead to DO/AO (25). Corona et al identified relationships between ejaculation and prolactin, thyroid stimulating hormone (TSH), and testosterone levels (1). Knowing that Exercise and premature ejaculation (PE) stand for ii ends of a linear spectrum, it has been shown that prolactin and TSH levels progressively increased from patients with PE to those with Practice, and the contrary was true for testosterone.
5.2 Hyperstimulation
Some men obtain greater pleasure from masturbation than they exercise with sexual intercourse and may continue deep-rooted habits such as frequent masturbation or using idiosyncratic masturbation techniques. Studies have shown a correlation betwixt DO and men with idiosyncratic masturbation practices (5, 14). Also, with increasing frequency of masturbation the sensitivity of the penis can decline and lead to a fell cycle where the man increases masturbation force to annul 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 (v, 14, 26).
Patients with DO have been shown to have college masturbatory activity, decreased night-time emissions, lower orgasm and intercourse satisfaction scores on the International Index of Erectile Function (IIEF), as well as higher feet and low scores when compared to controls (27). In a study by Xia et al, they compared 24 patients with primary Practise and 24 historic period-matched controls who had no sexual dysfunction complaints (28). They showed that patients with primary Exercise had significantly longer IELT (20 vs five.v minutes), higher frequency of masturbation, lower nocturnal emissions, and college rates of anxiety and depression. They too found that although DO patients had normal glans awareness, they reported penile shaft hyposensitivity and hypoexcitability. The patients with Do were as well found to more commonly use idiosyncratic masturbation methods.
5.3 Penile Sensation Loss
Penile sensation loss has been shown to increase with age (29). In a literature review (13 studies) past Rowland et al, they plotted penile sensory thresholds as a function of age equally well equally sexual functional status (30). They constitute penile awareness loss was more commonly nowadays in those men with increased age and those with sexual dysfunctions.
5.4 Psychosexual Causes
Lifelong DO has been associated with multiple psychological atmospheric condition. Some of these weather condition include fear, anxiety, hostility, and relationship difficulties (31, 32). Fear and anxiety during sexual relations take been examined, and the most common triggers included: hurting the female, impregnating the female person, childhood sexual abuse, sexual trauma, repressive sexual education/religion, sexual anxiety, general anxiety, "spilling of seed," and disharmonize in men in their first sexual relationship afterwards becoming widowed or divorced (xi).
The man may also suffer from a lack in sexual arousal, thus inhibiting his ability to reach orgasm. The man may accomplish an erection without reaching acceptable arousal to proceed with intercourse, such as men who achieve an erection with the assist of erectogenic medications. With the assistance of medication, men are more likely to become an erection without significant psychoemotional arousal or the necessary mental/physical stimulation needed to achieve orgasm (33–35).
DO based on a situational aspect (i.e. difficulties with a specific partner and not another) is more than likely to be due to a psychologic etiology (36). One study looked at stress and anxiety related to timed intercourse demands for fertility treatments and found DO developed in 6% of patients related to elevated feet levels (37). A novel written report 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 office (38). They showed that acute and chronic immobilization stress led to an increment in adrenal glucocorticoids causing an increase in gonadotropin inhibitory hormone which suppresses the HPG axis via inhibition of gonadotropin releasing hormone.
v.v SSRIs/Medications
There are numerous medications that have been implicated in the genesis of Practise including antidepressants (especially SSRIs), antipsychotics, and opioids (3). In a report by Corona et al, approximately 2000 male patients were evaluated for the sexual effects of anti-depressant therapy (39). A seven-fold hazard for Practise was observed in SSRI patients, and they had a two-fold take chances of low libido. In a study by Clayton et al, the furnishings on sexual functioning and antidepressant efficacy of bupropion extended release was compared with escitalopram (forty). The incidence of orgasm dysfunction and worsened sexual role at week eight was statistically significantly higher in the escitalopram (thirty%) vs bupropion (15%) and escitalopram (30%) vs placebo (nine%) groups but not statistically significant in the bupropion (15%) vs placebo (9%) groups.
6. Patient Evaluation
6.1 History and Physical Exam
Management should begin with a expert medical/psychosexual history, social/religious history, medication list, and physical exam. Focusing on the major etiologic factors (as listed higher up) is a useful starting betoken. Medication history should focus on SSRI agents and other psychotropic agents, and define the onset of the use of the medication as it pertains to the timing of onset of Exercise. Asking nearly penile sensitivity is a useful question, particularly in men at run a risk for penile sensation loss such as diabetics. Symptoms and signs of endocrinopathies such equally testosterone deficiency, hypothyroidism and hyperprolactinemia should be sought. Masturbatory style is another useful line of inquiry as frequent masturbation or idiosyncratic masturbatory styles may 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 status is generalized or situational is too disquisitional to agreement the pathophysiology. Asking patients to describe a typical sexual encounter is often a useful ploy to unearth potential contributing factors. Defining the consistency of the problem, that is: "does it happen all the fourth dimension or only some of the time? with sexual intercourse and sexual outercourse with a partner? and how this differs between partner-based relations and masturbation?" For example, men who achieve orgasm with masturbation only accept difficulty with partner-based relations often have i of two factors as causes – loss of penile sensitivity (overcome by vigorous masturbation) or psychological issues (interpersonal conflict, fear, anxiety, or hostility). Inquiring well-nigh how long a man attempts relations before stopping may also provide valuable insight into the problem. Some older men, due to inadequate practice reserve of upper torso force, stop sexual relations sooner than they did when they were younger and thus interpret this as Exercise. Finally, asking about strategies or medications that have been tried previously for this problem will assist in plotting a course of handling.
half dozen.2 Adjunctive Testing
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 exist corrected. As shown by Carani et al, with correction of thyroid hormone levels, patients had significant improvements in DO (15). 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.
In patients lament of loss of penile sensitivity, biothesiometry (Figure 1) and/or pudendal somatosensory evoked potentials (SSEP) might be warranted (5). 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 some other examination that allows the evaluation of sympathetic efferent period 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 (41).
Bio-Thesiometer. Bio-Medical Instrument Visitor, Newbury, Ohio
7. Direction Strategies (Figure two)
Management Algorithm [adjusted from (57)]
Various lifestyle changes include: steps to improve intimacy, reduce masturbation frequency, modify of masturbation style and decreasing alcohol consumption, (5, 11).
seven.1 Psychosexual Counseling
Once the organic causes are ruled out and in some cases contemporaneously, the patient may benefit from a thorough psychosexual evaluation (forth with his partner). There are numerous types of psychotherapy techniques that take been used with Exercise including: masturbation retraining/desensitization, adjustments of sexual fantasies, changes in arousal methods, sexual didactics, sexual anxiety reduction, increased genital stimulation, and office playing an exaggerated orgasm alone and/or with his partner (5, 42). There are numerous strategies that utilize combinations of approaches, but that is beyond the telescopic of this article. Success rates are difficult to determine from literature, and few take had significant testing of their results.
7.ii Pharmacotherapy (Table 2)
Tabular array two
Pharmacotherapeutic Management of Delayed Orgasm
| Drug | As needed dosing | Continuous dosing |
|---|---|---|
| Bupropion | 15 – threescore mg | 150 mg (sustained release) |
| Cyproheptadine | 4 – 12 mg | |
| Amantadine | 100 – 400 mg | 75 – 100 mg bid or tid |
| Yohimbine | twenty – 40 mg | |
| Oxytocin | xx – 24 IU | |
| Anandamide | n/a | north/a |
| Cabergoline | 0.5 mg | |
| Testosterone Supplementation | based on testosterone | |
There are no FDA approved drugs for DO, and those drugs that take been studied often accept limited efficacy or pregnant side issue profiles. 1 could first consider withdrawing whatsoever offending medications if possible, such every bit SSRIs, although it is our clinical practice to liaise with the SSRI-prescribing clinician and take them coordinate the drug manipulation (drug vacation, substitution or cessation) and monitor the patient.
Some medications are used to annul the side furnishings of other medications. Bupropion (open-characterization bupropion-SR 150 mg/mean solar day for 2 months) was trialed in an age-matched group of 19 males with reported lifelong Practice (27). There was a 25% decrease in mean IELT, and the percentage rating control over ejaculation as "fair to good" increased from 0 to 21%. Also, orgasm and intercourse satisfaction domain scores on the IIEF improved significantly from baseline after treatment.
Cyproheptadine, an anti-histamine known to increase brain serotonin levels, has been studied to treat Practice related to SSRI utilise (5, 43, 44). Notwithstanding, there accept been no large randomized controlled studies conducted with this amanuensis to date. In a small report by Ashton et al, improvement was seen in 12/25 men treated with cyproheptadine for SSRI-induced Practice (43). Treatment was express by sedation and reversal of the antidepressant'south furnishings.
Amantadine, an indirect stimulant of central and peripheral dopaminergic nerves, has been used past some investigators to stimulate sexual behavior in rats (41). In a homo written report, Ashton et al used amantadine to treat SSRI-induced DO and establish improvements in viii/19 men (43).
Ashton also used yohimbine and found improvements treating men with SSRI-induced DO. Yohimbine is a product from the bark of the Pausinystalia johimbe tree and functions as an α-2 adrenergic receptor blocker. Yohimbine has been used as a traditional medicine in Africa as an aphrodisiac, and is being studied every bit a possible medication to treat ED. Several groups have studied yohimbine to treat other sexual dysfunctions (45–47). 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 (45). The patients achieved orgasm at a hateful yohimbine dose of 38 mg. In all, 19 men achieved orgasm; however, 3 required the use of penile vibratory stimulation (PVS). Besides, 7 out of viii men with secondary AO were able to accomplish orgasm.
Oxytocin is a 9 amino acid peptide released by the posterior pituitary at college levels during orgasm. Ishak et al reported on one case of oxytocin used successfully for the treatment of anorgasmia (48). The patient was given a 20–24 IU dose of oxytocin intranasally when he was set to orgasm, and a positive response was reported through at least 8 months of follow upwards.
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 (49). Their results were encouraging and constitute that low dose anandamide did lower the ejaculatory threshold in their study grouping. The effects were temporary and the rats no longer displayed the beliefs seven days afterward the initial dosing. There were no effects observed on other sexual behaviors.
seven.3 Endocrine Therapy
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, 51). In one study, patients were treated with cabergoline 0.5 mg for 4 months in a randomized, double-blinded, placebo-controlled trial with 25 patients in the active arm and 25 in the placebo arm. Baseline hyperprolactinemia was establish in 38 of the patients, in add-on, afterwards the treatment catamenia ended both prolactin and testosterone levels normalized in virtually of the patients. Erectile role, orgasmic office, and sexual desire were all enhanced based on IIEF questionnaire scores.
Testosterone plays an of import role in sexual response and motivation with effects at both the key and peripheral levels. Testosterone also plays a facilitative role in the orgasmic response machinery (52). Hackett et al performed a prospective, randomized, double-bullheaded, placebo-controlled trial on 190 men with testosterone deficiency and type ii diabetes using long acting testosterone injections over 30 weeks (53). They constitute patients had improvements in most sexual office areas, including orgasm (based on the orgasm domain of the IIEF questionnaire 5.7±four. vs four±4, p=0.004).
Corona et al performed a meta-analysis examining studies near testosterone supplementation and sexual function (54). Information was available on the effect of testosterone supplementation on orgasmic office in 10 studies totaling 677 patients. They identified an inverse relationship between testosterone levels and the influence treatment caused on the orgasm domain of the IIEF. The hateful divergence in the IIEF orgasm function domain between the treatment groups and placebo was ane.62 (95% Confidence Interval 0.000; 3.229, p=0.05).
7.4 Penile Vibratory Stimulation
Do can successfully be treated in some cases using penile vibratory stimulation (PVS) in patients with penile sensitivity loss. In PVS, a vibrator is applied to the frenular area of the glans penis to produce mechanical stimulation to trigger orgasm. A study by Nelson et al examined the utilize of PVS to restore orgasmic and erectile function (55). They establish that with PVS utilize, 72% of patients reported restoration of orgasm on at least some occasions, and they self-reported that 62% of their attempts at sexual relations resulted in orgasm. The responders had meaning increases in IIEF orgasm and satisfaction domain scores at three months.
7.5 Electroejaculation (EEJ)
In select patients with recalcitrant DO who take failed all other bourgeois methods, EEJ is a viable option to retrieve semen for fertility purposes. Electroejaculation requires placement of a transrectal probe and the commitment of low-level electric electric current in patients without spinal cord injury. EEJ is performed under general anesthesia and routinely leads to the procurement of an ejaculate (56).
8.0 Summary
Delayed orgasm and anorgasmia are associated with significant sexual dissatisfaction. A focused medical history can shed light on the potential etiologies. SSRI medications, penile sensation loss, endocrinopathies, penile hyperstimulation and psychological issues stand for the major etiologies. Unfortunately, there are no fantabulous pharmacotherapies for DO/AO, and handling revolves largely around addressing potential causative factors too as the use of psychotherapy.
Acknowledgments
This enquiry was funded in part through the NIH/NCI Cancer Middle Support Grant P30 CA008748.
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Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4816679/
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