The treatment of retrograde ejaculation depends to some extent on the cause. Anatomic causes are rarely curable, which results in the need for sperm harvesting from the bladder for patients wishing to initiate a pregnancy. Pharmacologic causes are generally reversible by withdrawal of the offending medication. Neurologic causes are difficult to treat if there is complete nerve damage, such as may occur in spinal cord injured patients. In patients with a partial neural injury (diabetes), the use of certain medications (pseudoepohedrine, for example) may convert the patient to an antegrade ejaculator.
The management of premature ejaculation (PE) is best handled in a combined psychotherapy and pharmacologic fashion. Mean ejaculation latency time in healthy men is between 5-6 minutes. Men who have ejaculation latencies within this time period should be reassured. For men with lifelong and acquired premature ejaculation, there are several treatment options. First line therapy generally involves behavioral techniques in combination with psychotherapy. The most commonly used behavioral techniques are the squeeze or stop-start techniques. Topical local anesthetics are often used in combination with behavioral modification. Topical anesthetics are usually applied to the head of the penis (glans) 5-10 minutes prior to planned sexual activity.
Off-label use of selective serotonin reuptake inhibitors (SSRI) and tri-cyclic antidepressant (TCA) such as paroxetine, sertraline and fluoxetine or clomipramine are used in order to take advantage of their side effect profile of delaying ejaculation. Dapoxetine, a short acting SSRI, is the only medication that has been approved in some countries for the sole purpose of treating premature ejaculation.
Treatment of PE with phosphodiesterase type 5 inhibitors (PDE5-I) has been reported, but is best reserved for men with co-morbid erectile dysfunction (ED) and PE.
Delayed ejaculation and anorgasmia are very difficult sexual dysfunctions to treat. There does not exist any FDA approved pharmacologic strategy for these patients. The use of penile vibratory therapy is used as a first line therapy in order to increase penile stimulation and has the ability to help patients achieve orgasm. The results are better in patients in whom there is a delay in orgasm, as opposed to those who have a consistent complete failure to achieve orgasm. Cabergoline, a dopamine receptor agonist used in patients with hyperprolactinemia and Parkinsons disease, has been shown in preliminary studies to decrease ejaculatory latency time and may be useful in the treatment of delayed ejaculation or anorgasmia. Buproprion is another drug that has had some anectdotal success in these patients.
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