​Kembara Xtra - Medicine - Ejaculatory Disorders

​Kembara Xtra - Medicine - Ejaculatory Disorders 
Group of dysfunctions involving altered time and control of ejaculation (premature ejaculation [PE], delayed ejaculation [DE]), presence (anejaculation [AE]), direction (retrograde ejaculation [RE]), volume (perceived ejaculate volume reduction [PEVR]), or force (decreased force of ejaculation [DFE]) of ejaculation PE is defined (
Ejaculating between two and five minutes after vaginal penetration is a natural biological response that usually occurs.
Having control over one's ejaculatory function is a learned trait that improves with time and practice.
DE: lengthy time to ejaculate (>30 minutes) despite desire, stimulation, and erection; troublesome for couples trying to conceive Aspermia (lack of sperm in the ejaculate): – AE refers to the absence of emission or contractions of the bulbospongiosus muscle. – RE refers to the partial or complete ejaculation of semen into the bladder. – Obstruction refers to the obstruction of the ejaculatory duct or the occlusion of the urethra. Also:
– Ejaculatory anhedonia: normal ejaculation without orgasm or pleasure – Hematospermia: the presence of blood in the ejaculate (typically not a serious condition) – Painful ejaculation: vaginal or perineal pain during or after ejaculation


Epidemiology Prevalence

PE is quite frequent; the stated frequency among males in the United States ranges from 20–30%.
DE is recorded in 5–8% of males between the ages of 18 and 59, but less than 3% of those men have had the problem for more than six months.
All age groups that are considered sexually mature make up the majority.
Men only make up the majority of the population.

Causes and effects: etiology and pathophysiology 

The parasympathetic nervous system is responsible for the erection, and a normal ejaculation consists of three stages: – Emission phase: the contraction of the prostate, seminal vesicles, and vas deferens deposits sperm into the urethra; this process is controlled by the autonomic sympathetic nervous system. – Ejaculation phase: sperm is violently forced out of the urethra by rhythmic contractions of the bulbospongiosus and ischiocavernosus muscles. The somatic nervous system acts as a mediator on the motor branches of the pudendal nerve to bring about this result. Bladder neck contracture by α-adrenergic receptors ensures anterograde ejaculation.
- Orgasm: a joyful sensation connected with ejaculation (in the cerebral cortex); the contraction of smooth muscle in the accessory sexual organs; and the release of pressure in the posterior urethra.
Hypersensitivity and hyperexcitability of the glans and penis in patients with PE
– The sensitivity of the 5-hydroxytryptamine (5-HT) receptor
- Issues that are caused by the mind (lack of experience, fear or guilt, infrequent sexual activity, difficulties in relationships) - Urologic (such as erectile dysfunction, prostatitis, and urethritis)
- Endocrine conditions (such as hyperthyroidism, obesity, and diabetes)
- A lack of participation in either sexual or physical activities
– Withdrawal and detox from illegal or prescribed medicines DE: – Rarely caused by an underlying painful illness (such as prostatitis or seminal vesiculitis) – Frequently contains a psychogenic component
– Sexual performance anxiety and other psychosocial issues; – No correlation with testosterone levels
– Certain medications, such as MAOIs, SSRIs, beta- and alpha-blockers, thiazides, antipsychotics, tricyclic and quadricyclic antidepressants, NSAIDs, opiates, and alcohol, have been shown to inhibit ejaculatory function.
There was absolutely no ejaculate:
- A congenital structural disorder (such as a wolffian anomaly or a müllerian duct cyst)– Acquired (post-radical prostatectomy neuropathy, post-infectious neuropathy, post-traumatic neuropathy, T10–T12 neuropathy)AE: – Dissection of the retroperitoneal lymph nodes (LN)n Spinal cord damage or other (traumatic) sympathetic nerve injury – Medications (beta- and alpha-blockers, benzodiazepines, SSRIs, MAOIs, TCAs, antipsychotics, aminocaproic acid) – Diabetes mellitus (DM) (neuropathy) n) – Radical prostatectomy RE: – Transurethral resection of the prostate (25%) or another treatment for the removal of the prostates Surgical procedure on the neck of the bladder Extensive pelvic surgical procedurey - Retroperitoneal lymph node dissection for the treatment of testicular cancer (may also result in failure of emission)) - Neurologic disorders (multiple sclerosis [MS], DM) Medications (tamsulosin and other alpha-blockers, selective serotonin reuptake inhibitors (SSRIs), and antipsychotics) - Urethral stricture (perhaps associated with posttraumatic) ● Painful ejaculation: - An infection or inflammation (such as orchitis, epididymitis, prostatitis, or urethritis) in the male reproductive system) Obstruction of the ejaculatory duct Seminal vesicle calculi Obstruction of the vas deferens Other possible causes include:s - Psychological and functional analysisl ● Hematospermia (often impossible to find reason): - In most cases, this is not a significant conditionn - Inflammation or infectious diseasen – Calculi: bladder, seminal vesicle, prostate, urethra. Injury to the genital region (through activities such as cycling, constipation, or masturbation)) – Obstructiohematospermia is seen in one to three percent of cases of prostate cancer. n cyst tumor— Malformation of the arteriovenous systemIatrogenic hypertension is also referred to as s.n


Conditions that are associated with it include: neurologic disorders (such as multiple sclerosis), diabetes, prostatitis, ejaculatory duct obstruction, urethral stricture, psychological problems, endocrinopathies, relationship and interpersonal issues, and so on.


Diagnosis 
founded on an interesting past. To begin, you should inquire as to whether or whether ejaculation takes place prior to the individual's wishes OR does not take place following typical stimulation (including masturbation).

Providing an Account of History 

Detailed sexual history, including: Time frame of the problem Quality of patient's sexual response Sense of ejaculatory control and sexual distress Overall assessment of the relationship Ask specific questions because patients are often reluctant to discuss the issue in an open manner.
A thorough history of recent and currently taken medications A history of any recent injuries or infections A history of any previous operations, paying particular attention to genitourinary (GU) procedures A record of any supplements and alternative therapies that have been attempted
A lot of guys don't realize there's a difference between issues with their erection and their ability to ejaculate at first.
Some men have expectations that are not realistic regarding the reaction and frequency of their ejaculatory output.
During the assessment of systems, elicit any indications of testosterone insufficiency or prolactin excess, especially if anhedonia is present. Include the sexual partner in the interview, especially if the patient expresses a sense that he is not meeting his lover's requirements.

The Patient's Clinical Examination 
● Check vitals. Examine the patient for any focal neurologic signs (such as multiple sclerosis or a spinal cord injury) and any psychological issues.
Extensive exam for the GU, encompassing the following:
- The dimensions and characteristics of the epididymis and testicles
– Confirmation that the vas deferens is present. – Determination of the location of the urethral meatus and whether or not it is patent. – A digital rectal examination to examine the prostate's consistency, size, and any possible midline lesions.

Results From the Laboratory 
It's possible that the results of the laboratory tests are normal.
a glucose or HgbA1c test taken while the patient is fasting to rule out diabetes
A post-gastrointestinal urinalysis will be able to confirm RE. The amount of fructose in sperm, the number of sperm, and the viscosity of the sperm can all be measured.
Patients sometimes report that their urine is hazy.
a fructose negative, sperm negative, and nonviscous postorgasmic urine will be seen in an individual with AE.
Urinalysis and urine culture are required to exclude the possibility of infection in cases of painful ejaculation.
 If there is a suspicion of prostate cancer, a prostate-specific antigen (PSA) test should be performed.
If you suffer from anhedonia, you might think about getting your testosterone, prolactin, glucose, and thyroid levels checked.
It is possible that transrectal ultrasound, often known as TRUS, will be of assistance in cases of hematospermia, painful ejaculation, or when ejaculatory duct occlusion is suspected.

If there is an obstruction in the ejaculatory duct, a transrectal ultrasound-guided aspiration of the seminal vesicle will be performed. If there is a suspicion of anatomical abnormality, a scrotal ultrasound and/or MRI may be performed.

Management 
Helping a patient accept their condition is facilitated by the discovery of any underlying medical cause, even if that cause is irreversible.
● Improve partner communication.
Psychiatric consultation for both the patient and their partner 
Reassure yourself to lower the amount of pressure placed on your performance.
It is possible that the use of a number of different resources, such as psychiatrists, psychologists, sex therapists, vascular surgeons, urologists, endocrinologists, and neurologists, will be required.
In physical education, you will need to participate in sensate focus therapy, which involves a gradual progression from nonsexual interaction to sexual contact.
- Quiet vagina: When the female partner stops moving her vaginal area right before ejaculating.
– Methods to develop ejaculatory control, such as the coronal squeeze technique (which involves squeezing the glans penis until the urge to ejaculate is no longer present) or the start-and-stop technique (which involves ceasing penile stimulation when ejaculation is getting close and restarting stimulation when the ejaculatory feeling is no longer present)

 DE: – Switch to an antidepressant that is less prone to produce DE (citalopram, fluvoxamine, or nefazodone). AE/RE: – Stop taking the medications that are causing the problem.
- Management of diabetes
Urology should be consulted in the event that there is obstruction of the urethra.
Having sexual activity while the bladder is already full may be helpful in treating RE.
- Consider using penile vibratory stimulation (effective in spinal cord injuries more than T10) or electroejaculation (put on monitor if lesions greater than T6 because autonomic dysreflexia may follow) to collect sperm in cases of AE. Both of these methods have been shown to be useful in certain circumstances.
Ejaculation that is excruciating: Seeking professional help might be advantageous.
Urology should be consulted in cases when there is a possibility of seminal vesicle stone formation.

 Hematospermia: - This condition frequently improves on its own, for no apparent reason.
Reassure initially. – May attempt empiric antibiotic, but there is little evidence to support it. – Refer to urologist if the condition persists or if there is a significant degree of suspicion for an abnormality.


Medication Erectile dysfunction (ED), which is a frequent comorbidity, should be treated with PDE5 inhibitors. First-line therapy should consist of:
– The short-acting SSRI dapoxetine is effective when taken "on-demand" in doses ranging from 30 mg to 60 mg one to two hours before sexual activity (2), (3), (4).[A] has the most usefulness but a more expensive price. – Other "ondemand" choices include taking clomipramine between 20 and 50 milligrams four to twenty-four hours before engaging in sexual activity; taking sertraline between 50 milligrams and four to eight hours before engaging in sexual activity; and taking paroxetine between 20 milligrams and three to four hours before engaging in sexual activity (2),(3),(4).[A].
Within one to three weeks of beginning treatment, delaying ejaculation can be accomplished by taking a daily dose of clomipramine 20 to 50 mg, sertraline 25 to 200 mg, fluoxetine 5 to 20 mg, or paroxetine 10 to 40 mg.
- A topical anesthetic gel (for example, 2.5% prilocaine and 2.5% lidocaine [EMLA]), which may or may not be used with a selective serotonin reuptake inhibitor (SSRI). 2.5 grams spread out across the surface of a condom for a period of thirty minutes before to sexual activity (5)[A]
- Taking 5 to 50 milligrams of Tramadol "on demand" two hours before sexual activity has been shown to be helpful in numerous trials (6).– Second line: behavioral/sex treatment, pelvic floor muscle therapy DE: – No "approved" medications; various choices [A]; currently accessible in spray form – Second line: behavioral/sex therapy, pelvic floor muscle therapy
Consider changing your antidepressant medication to one that contains bupropion, nefazodone, or mirtazapine.
- Bupropion and buspirone may be helpful for patients who are required to continue taking SSRIs (2),(7).[B]. – Self-stimulation therapies and sexual therapy There is some evidence that the antidepressants amantadine or cyproheptadine may be useful AE and RE:
- In the first line, take 60 milligrams of pseudoephedrine or 25 to 75 milligrams of imipramine orally three times a day.– Although beta-agonists and antihistamines might be useful, the FDA does not authorize their use.
- As a second line of defense, you can try postejaculation bladder collection of sperm for males with recurrent ejaculatory dysfunction (if fertility is desired); for males with auricular enlargement, you can try midodrine, penile vibratory stimulation, or electroejaculation. For painful ejaculation, you should treat the underlying infection or inflammatory process.
— α-Blockers may have some advantage.


Referral 

Urologists should be consulted whenever there is even a remote possibility that one of the following conditions is present: 
obstructed ejaculatory duct seminal vesicle or prostatic stones obstructed urethra obstructed vas deferens calculi persistent or severe hematospermia urethral obstruction persistent or severe hematospermia urethral obstruction

Surgical Methods and Operations 

Ejaculatory duct obstruction can be treated surgically in a few different ways: Transurethral resection of the ejaculatory ducts

The prognosis usually improves with continued counseling and therapy.

Complications 
The psychological impact includes symptoms such as extreme inadequacy, self-doubt, increased anxiety, and guilt in certain men.

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