Disorders of Orgasm and Ejaculation in Men

IntroductionEjaculatory/orgasmic disorders are common male sexual dysfunctions, and include premature ejaculation (PE), inhibited ejaculation, anejaculation, retrograde ejaculation, and anorgasmia.AimTo provide recommendations and guidelines concerning current state-of-the-art knowledge for management of ejaculation/orgasmic disorders in men.MethodsAn international consultation in collaboration with the major urology and sexual medicine associations assembled over 200 multidisciplinary experts from 60 countries into 25 committees. Committee members established specific objectives and scopes for various male and female sexual medicine topics. The recommendations concerning state-of-the-art knowledge of disorders of orgasm and ejaculation represent the opinion of seven experts from seven countries developed in a process over a 2-year period.Main Outcome MeasureExpert opinion was based on grading of evidence-based medical literature, widespread internal committee discussion, public presentation and debate.ResultsPremature ejaculation management is largely dependent upon etiology. Lifelong PE is best managed with PE pharmacotherapy (selective serotonin re-uptake inhibitor [SSRI] and/or topical anesthetics). The management of acquired PE is etiology specific and may include erectile dysfunction (ED) pharmacotherapy in men with comorbid ED. Behavioral therapy is indicated when psychogenic or relationship factors are present and is often best combined with PE pharmacotherapy in an integrated treatment program. Retrograde ejaculation is managed by education, patient reassurance, pharmacotherapy, or bladder neck reconstruction. Delayed ejaculation, anejaculation, and/or anorgasmia may have a biogenic and/or psychogenic atiology. Men with age-related penile hypoanesthesia should be educated, reassured, and instructed in revised sexual techniques which maximize arousal.ConclusionsAdditional research is required to further the understanding of the disorders of ejaculation and orgasm. Rowland D, McMahon CG, Abdo C, Chen J, Jannini E, Waldinger MD, and Ahn TY. Disorders of Orgasm and Ejaculation in Men.     

Standard Operating Procedures in the Disorders of Orgasm and Ejaculation

IntroductionEjaculatory/orgasmic disorders are common male sexual dysfunctions and include premature ejaculation (PE), inhibited ejaculation, anejaculation, retrograde ejaculation, and anorgasmia.AimTo provide recommendations and guidelines of the current state-of-the-art knowledge for management of ejaculation/orgasmic disorders in men as standard operating procedures (SOPs) for the treating health care professional.MethodsThe International Society of Sexual Medicine Standards Committee assembled over 30 multidisciplinary experts to establish SOPs for various male and female sexual medicine topics. The SOP for the management of disorders of orgasm and ejaculation represents the opinion of four experts from four countries developed in a process over a 2-year period.Main Outcome MeasureExpert opinion was based on grading of evidence-based medical literature, limited expert opinion, widespread internal committee discussion, public presentation, and debate.ResultsPE management is largely dependent upon etiology. Lifelong PE is best managed with PE pharmacotherapy (selective serotonin reuptake inhibitors and/or topical anesthetics). The management of acquired PE is etiology specific and may include erectile dysfunction (ED) pharmacotherapy in men with comorbid ED. All men seeking treatment for PE should receive basic psychosexual education. Graded behavioral therapy is indicated when psychogenic or relationship factors are present and is often best combined with PE pharmacotherapy in an integrated treatment program. Delayed ejaculation, anejaculation, and/or anorgasmia may have a biogenic and/or psychogenic etiology. Men with age-related penile hypoanesthesia should be educated, reassured, and instructed in revised sexual techniques which maximize arousal. Retrograde ejaculation is managed by education, patient reassurance, and pharmacotherapy.ConclusionsAdditional research is required to further the understanding of the disorders of ejaculation and orgasm. McMahon CG, Jannini E, Waldinger M, and Rowland D. Standard operating procedures in the disorders of orgasm and ejaculation. J Sex Med **;**:**–**.     

Delayed Ejaculation and Associated Complaints: Relationship to Ejaculation Times and Serum Testosterone Levels

BackgroundAlthough delayed ejaculation (DE) is typically characterized as a persistently longer than anticipated or desired time to ejaculation (or orgasm) during sexual activity, a timing-based definition of DE and its association with serum testosterone has not been established in a large cohort.AimTo examine in an observational study estimated intravaginal ejaculatory latency time (IELT) and masturbatory ejaculation latency time (MELT) in men self-reporting DE, assess the association of IELT and MELT with serum testosterone levels, and determine whether correlation with demographic and sexual parameters exist.MethodsMen who resided in the United States, Canada, and Mexico were enrolled from 2011 to 2013. Self-estimated IELT and MELT were captured using an Ejaculatory Function Screening Questionnaire in a sample of 988 men screened for possible inclusion in a randomized clinical trial assessing testosterone replacement therapy for ejaculatory dysfunction (EjD) and who self-reported the presence or absence of DE and symptoms of hypogonadism. Additional comorbid EjDs (ie, anejaculation, perceived decrease in ejaculate volume, and decreased force of ejaculation) were recorded. Men with premature ejaculation were excluded from this analysis. IELT and MELT were compared between men self-reporting DE and men without DE. The associations of IELT and MELT with serum testosterone were measured.OutcomesIELT, MELT, and total testosterone levels.ResultsSixty-two percent of screened men self-reported DE with or without comorbid EjDs; 38% did not report DE but did report at least one of the other EjDs. Estimated median IELTs were 20.0 minutes for DE vs 15 minutes for no DE (P < .001). Estimated median MELTs were 15.0 minutes for DE vs 8.0 minutes for no DE (P < .001). Ejaculation time was not associated with serum testosterone levels. Younger men and those with less severe erectile dysfunction had longer IELTs and MELTs.Clinical ImplicationsEstimated ejaculation times during vaginal intercourse and/or masturbation were not associated with serum testosterone levels in this study; thus, routine androgen evaluation is not indicated in these men.Strengths and LimitationsThis large systematic analysis attempted to objectively assess the ejaculation latency in men with self-reported DE. Limitations were that ejaculation time estimates were self-reported and were queried only once; the questionnaire did not distinguish between failure to achieve orgasm and ejaculation; and assessment of DE was limited to heterosexual vaginal intercourse and masturbation.ConclusionIELT and MELT were longer in men with DE, and there was no association of ejaculation times with serum testosterone levels in this study population.Morgentaler A, Polzer P, Althof S, et al. Delayed Ejaculation and Associated Complaints: Relationship to Ejaculation Times and Serum Testosterone Levels. J Sex Med 2017;14:1116–1124.     

Pontine Control of Ejaculation and Female Orgasm

IntroductionThe physiological component of ejaculation shows parallels with that of micturition, as both are essentially voiding activities. Both depend on supraspinal influences to orchestrate the characteristic pattern of activity in the pelvic organs. Unlike micturition, little is known about the supraspinal pathways involved in ejaculation and female orgasm.AimTo identify brainstem regions activated during ejaculation and female orgasm and to compare them with those activated during micturition.MethodsEjaculation in men and orgasm in women were induced by manual stimulation of the penis or clitoris by the participants' partners. Positron emission tomography (PET) with correction for head movements was used to capture the pattern of brain activation at the time of sexual climax.Main Outcome MeasuresPET scans showing areas of activation during sexual climax.ResultsEjaculation in men and orgasm in women resulted in activation in a localized region within the dorsolateral pontine tegmentum on the left side and in another region in the ventrolateral pontine tegmentum on the right side. The dorsolateral pontine area was also active in women who attempted but failed to have an orgasm and in women who imitated orgasm. The ventrolateral pontine area was only activated during ejaculation and physical orgasm in women.ConclusionActivation of a localized region on the left side in the dorsolateral pontine tegmentum, which we termed the pelvic organ‐stimulating center, occurs during ejaculation in men and physical orgasm in women. This same region has previously been shown to be activated during micturition, but on the right side. The pelvic organ‐stimulating center, via projections to the sacral parasympathetic motoneurons, controls pelvic organs involved in voiding functions. In contrast, the ventrolateral pontine area, which we term the pelvic floor‐stimulating center, produces the pelvic floor contractions during ejaculation in men and physical orgasm in women via direct projections to pelvic floor motoneurons. Huynh HK, Willemsen ATM, Lovick TA, and Holstege G. Pontine control of ejaculation and female orgasm. J Sex Med 2013;10:3038–3048.     

Ejaculation Profiles of Men Following Radiation Therapy for Prostate Cancer

ObjectivesRadical prostatectomy (RP) is associated with anejaculation, which for some men is a source of bother and sexual dissatisfaction. Clinical experience has shown us some men after pelvic radiation therapy (RT) also experience anejaculation. This analysis was conducted to define the ejaculation profiles of men after RT for prostate cancer (PCa).MethodsAs a routine part of the sexual health evaluation for post‐RT patients, men provided information regarding their ejaculatory function and orgasm. Analysis was conducted of a sexual medicine database reviewing demographic data, PCa factors, erectile, ejaculatory, and orgasmic function. Men with prior history of RP, cryotherapy, focal therapies, and androgen deprivation therapy (ADT) were excluded. Patients completed the International Index of Erectile Function (IIEF) questionnaire at follow‐up visits commencing with the first posttreatment visit and specific attention was paid to the IIEF orgasm domain.ResultsThree hundred and sixty‐four consecutive patients were included. Two hundred and fifty‐two patients had external beam, and 112 patients had brachytherapy (BT). Mean age was 64 ± 11 (42–78) years and mean follow‐up after RT was 6 ± 4.5 years. Mean prostate size at time of RT was 42 ± 21 g. Of the entire population, 72% lost the ability to ejaculate in an antegrade fashion after prostate RT by their last visit. The proportion experiencing anejaculation at 1, 3, and 5 years after RT was 16%, 69%, and 89%, respectively. For men with at least two IIEF questionnaires completed, the orgasm domain scores decreased dramatically over the follow‐up period; orgasm domain scores (0–10): <12 months post‐RT 7.4, 13–24 months 5.4, 25–36 months 3.2, >36 months 2.8 (P < 0.01). Multivariable analysis identified several factors predictive of failure to ejaculate: older age, ADT, RT dose > 100 Gy, and smaller prostates at the time of RT.ConclusionsThe vast majority of men after prostate RT will experience anejaculation and should be counseled accordingly prior to undergoing therapy. We have identified predictive factors.     

Female Ejaculation Orgasm vs. Coital Incontinence: A Systematic Review

IntroductionWomen may expel various kinds of fluids during sexual arousal and at orgasm. Their origins, quantity, compositions, and expulsion mechanisms depend on anatomical and pathophysiological dispositions and the degree of sexual arousal. These are natural sexual responses but may also represent symptoms of urinary incontinence.AimThe study aims to clarify the etiology of fluid leakage at orgasm, distinguish between associated physiological sexual responses, and differentiate these phenomena from symptoms of illness.MethodsA systematic literature review was performed. EMBASE (OvidSP) and Web of Science databases were searched for the articles on various phenomena of fluid expulsions in women during sexual arousal and at orgasm.Main Outcome MeasuresArticles included focused on female ejaculation and its variations, coital incontinence (CI), and vaginal lubrication.ResultsFemale ejaculation orgasm manifests as either a female ejaculation (FE) of a smaller quantity of whitish secretions from the female prostate or a squirting of a larger amount of diluted and changed urine. Both phenomena may occur simultaneously. The prevalence of FE is 10–54%. CI is divided into penetration and orgasmic forms. The prevalence of CI is 0.2–66%. Penetration incontinence occurs more frequently and is usually caused by stress urinary incontinence (SUI). Urodynamic diagnoses of detrusor overactivity (DOA) and SUI are observed in orgasmic incontinence.ConclusionsFluid expulsions are not typically a part of female orgasm. FE and squirting are two different physiological components of female sexuality. FE was objectively evidenced only in tens of cases but its reported high prevalence is based mostly on subjective questionnaire research. Pathophysiology of squirting is rarely documented. CI is a pathological sign caused by urethral disorder, DOA, or a combination of both, and requires treatment. An in-depth appreciation of these similar but pathophysiologically distinct phenomena is essential for distinguishing normal, physiological sexual responses from signs of illness. Pastor Z. Female ejaculation orgasm vs. coital incontinence: A systematic review.     

Estimations of Typical,Ideal, Premature Ejaculation,and Actual Latencies by Men and Female Sexual Partners of Men During Partnered Sex

BackgroundThe ejaculation latency (ELT) criterion for men with premature ejaculation (PE), including its 2 major subtypes of lifelong and acquired, relies heavily on expert opinion, yet such information represents only one source of data for this determination; furthermore, information regarding ELTs for PE within specific subgroups of men (eg, gay, bisexual) has been lacking.AimTo obtain data regarding men's lived experiences and expectations regarding typical ejaculation, ideal ejaculation, and PE and (for men) self-reported ejaculatory latencies during partnered sex across a variety a groups, including men vs women (ie, sexual partners of men), men with and without PE, and straight vs gay/bisexual men.MethodsWe recruited 1,065 men and sexual partners of men, asking them to estimate typical ejaculation, ideal ejaculation, and PE and (for men) self-latencies through an online survey posted on social media. Demographics, sexual identity, and sexual response data were also collected.ResultsTypical and self-reported ELTs were closely aligned with those reported in the literature, with ideal ELTs generally longer than typical ELTs. Median PE ELTs were consistently estimated around 1.5 min, with nearly all subgroups—men vs women; straight vs gay; PE and non-PE men—showing alignment on this criterion. Men with lifelong PE did not differ from men with acquired PE in either their PE ELT estimation or their self-reported ELT.Clinical ImplicationsThe data support the idea of extending the latency cutoff for establishing a PE diagnosis beyond the current 1-minute threshold.Strengths & LimitationsA large sample size drawn from a multinational population powered the study, whereas the use of social media for recruitment and lack of inclusion of lesbian and asexual individuals may have missed relevant data from some who have had sexual experience with men.ConclusionStraight and nonstraight men do not differ in their ELT estimations. In addition, the use of different ELT criteria for lifelong vs acquired PE may be unnecessary.Côté-Léger P, Rowland DL. Estimations of Typical, Ideal, Premature Ejaculation, and Actual Latencies by Men and Female Sexual Partners of Men During Partnered Sex. J Sex Med 2020;17:1448–1456.     

Latent structures of male sexual functioning

IntroductionStrong debate has been brought out around the upcoming editions of the International Classification of Diseases, the World Health Organization, and the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association) regarding new criteria for sexual dysfunction. Although criteria for male sexual dysfunction have been supported by traditional models of sexual response, recent data suggest that male sexual functioning could be conceptualized differently, offering new directions for diagnostic and assessment tools.AimThe aim of this study was to test, through structural equation modeling, four conceptual alternative models of male sexual response.Main Outcome MeasuresA modified version of the International Index of Erectile Function was used, assessing sexual desire, erectile function, orgasmic function, and premature ejaculation.MethodsA total of 1,558 Portuguese men participated in the study. Participants were divided into two groups according to the presence or absence of sexual difficulties.ResultsFindings suggested different factor solutions for men with and without sexual difficulties. Male sexual response of men with sexual difficulties was best characterized by a two‐factor structure: (i) a general sexual function factor (including sexual desire, erectile function, and orgasmic function); and (ii) premature ejaculation; while a three‐factor solution was the model that best fitted the data regarding men without sexual difficulties: (i) sexual desire; (ii) erectile and orgasmic function (which merged into a single dimension); and (iii) premature ejaculation. Discriminant validity between factors was strongly supported, suggesting that these dimensions measure distinct phenomena in both samples.ConclusionsResults regarding sexually healthy men suggest that erectile function is structurally independent from sexual desire, and that ejaculatory control could be conceptualized as a different phenomenon in relation to the current orgasmic disorders. Additionally, findings related to sexually dysfunctional men suggest the existence of a general sexual distress disorder. Carvalho J, Vieira AL, and Nobre P. Latent structures of male sexual functioning. J Sex Med 2011;8:2501–2511.     

Factors Associated with Low Sexual Desire in 45-Year-Old Men: Findings from the German Male Sex-Study

IntroductionAlthough low sexual desire is 1 of the most common sexual dysfunctions in men, there is a lack of studies investigating associated factors in large, population-based samples of middle-aged men.AimTo survey the prevalence of low sexual desire in a population-based sample of 45-year-old German men and to evaluate associations with a broad set of factors.MethodsData were collected between April 2014–April 2016 within the German Male Sex-Study. Participants were asked to fill out questionnaires about 6 sociodemographic, 5 lifestyle, and 8 psychosocial factors, as well as 6 comorbidities and 4 factors of sexual behavior. Simple and multiple logistic regressions were used to assess potential explanatory factors.Main Outcome MeasuresWe found a notable prevalence of low sexual desire in middle-aged men and detected associations with various factors.Results12,646 men were included in the analysis, and prevalence of low sexual desire was 4.7%. In the multiple logistic regression with backward elimination, 8 of 29 factors were left in the final model. Men having ≥2 children, higher frequency of solo-masturbation, perceived importance of sexuality, and higher sexual self-esteem were less likely to have low sexual desire. Premature ejaculation, erectile dysfunction, and lower urinary tract symptoms were associated with low sexual desire.Clinical ImplicationsLow sexual desire is common in middle-aged men, and associating factors that can potentially be modified should be considered during assessment and treatment of sexual desire disorders.Strengths & LimitationsThe strength of our study is the large, population-based sample of middle-aged men and the broad set of assessed factors. However, because of being part of a prostate cancer screening trial, a recruiting bias is arguable.ConclusionOur study revealed that low sexual desire among 45-year-old men is a common sexual dysfunction, with a prevalence of nearly 5% and might be affected by various factors, including sociodemographic and lifestyle factors, as well as comorbidities and sexual behavior.Meissner VH, Schroeter L, Köhn F-M, et al. Factors Associated with Low Sexual Desire in 45-Year-Old Men: Findings from the German Male Sex-Study. J Sex Med 2019;16:981–991.     

Brain Activity Unique to Orgasm in Women: An fMRI Analysis

BackgroundAlthough the literature on imaging of regional brain activity during sexual arousal in women and men is extensive and largely consistent, that on orgasm is relatively limited and variable, owing in part to the methodologic challenges posed by variability in latency to orgasm in participants and head movement.AimTo compare brain activity at orgasm (self- and partner-induced) with that at the onset of genital stimulation, immediately before the onset of orgasm, and immediately after the cessation of orgasm and to upgrade the methodology for obtaining and analyzing functional magnetic resonance imaging (fMRI) findings.MethodsUsing fMRI, we sampled equivalent time points across female participants’ variable durations of stimulation and orgasm in response to self- and partner-induced clitoral stimulation. The first 20-second epoch of orgasm was contrasted with the 20-second epochs at the beginning of stimulation and immediately before and after orgasm. Separate analyses were conducted for whole-brain and brainstem regions of interest. For a finer-grained analysis of the peri-orgasm phase, we conducted a time-course analysis on regions of interest. Head movement was minimized to a mean less than 1.3 mm using a custom-fitted thermoplastic whole-head and neck brace stabilizer.OutcomesTen women experienced orgasm elicited by self- and partner-induced genital stimulation in a Siemens 3-T Trio fMRI scanner.ResultsBrain activity gradually increased leading up to orgasm, peaked at orgasm, and then decreased. We found no evidence of deactivation of brain regions leading up to or during orgasm. The activated brain regions included sensory, motor, reward, frontal cortical, and brainstem regions (eg, nucleus accumbens, insula, anterior cingulate cortex, orbitofrontal cortex, operculum, right angular gyrus, paracentral lobule, cerebellum, hippocampus, amygdala, hypothalamus, ventral tegmental area, and dorsal raphe).Clinical TranslationInsight gained from the present findings could provide guidance toward a rational basis for treatment of orgasmic disorders, including anorgasmia.Strengths and LimitationsThis is evidently the first fMRI study of orgasm elicited by self- and partner-induced genital stimulation in women. Methodologic solutions to the technical issues posed by excessive head movement and variable latencies to orgasm were successfully applied in the present study, enabling identification of brain regions involved in orgasm. Limitations include the small sample (N = 10), which combined self- and partner-induced stimulation datasets for analysis and which qualify the generalization of our conclusions.ConclusionExtensive cortical, subcortical, and brainstem regions reach peak levels of activity at orgasm.Wise NJ, Frangos E, Komisaruk BR. Brain Activity Unique to Orgasm in Women: An fMRI Analysis. J Sex Med 2017;14:1380–1391.     

ORIGINAL RESEARCH—MEN'S SEXUAL HEALTH: Orgasmic Dysfunction After Open Radical Prostatectomy: Clinical Correlates and Prognostic Factors

IntroductionErectile function after radical retropubic prostatectomy (RRP) is extensively discussed in literature. However, less is known about orgasm after RRP.AimTo analyze sexual function, in particularly orgasmic function, in men before and after RRP.MethodsBetween 1977 and 2007 a RRP was performed in 1,021 men. All men were interviewed by their follow-up physician using a standardized interview about sexual function before and after RRP at regular intervals during a 2-year follow-up. The questions were related to sexual interest, sexual activity, spontaneous erections, and orgasmic function.Main Outcome MeasuresSexual function, in particularly orgasmic function, before and after RRP. Factors potentially influencing orgasmic function, such as patients age, type of operation, pathological stage and continence status were analyzed for their predictive value.ResultsInformation about preoperative and postoperative sexual activity and spontaneous erection was available in 596 and 698 men, respectively. Additional questions were asked on sexual interest (N = 425) and orgasmic function (N = 458).Pre-operatively, sexual interest, sexual activity, spontaneous erections and orgasmic function were normal in 99%, 82.1%, 90.0% and 90% of men, respectively. After operation these values decreased to 97.2%, 67.3%, 29.4% and 66.8%, respectively. Orgasmic function was preserved in 141 of 192 men (73.4%) after a bilateral nerve sparing procedure, in 90 out of 127 men (70.9%) after a unilateral nerve-sparing procedure and in 75 of 139 men (54.0%) after non-nerve sparing technique. Postoperatively, orgasm was present in 123 (77.4%) men below the age of 60 years and in 183 (61.2%) men of 60 years and older (P < 0.0001). Orgasmic function was significantly affected by age ≥60 years, non-nerve sparing procedure and severe incontinence (more than two pads/day).ConclusionsAfter RRP, orgasmic function is still present in the majority of men. A non-nerve sparing operation, age, and severe urinary incontinence are risk factors for orgasmic dysfunction after RRP. Dubbelman Y, Wildhagen M, Schröder F, Bangma C, and Dohle G. Orgasmic dysfunction after open radical prostatectomy: Clinical correlates and prognostic factors.     

Cognitive-Affective Factors and Female Orgasm: A Comparative Study on Women With and Without Orgasm Difficulties

BackgroundOrgasmic difficulties are one of the most common sexual complaints among women. Although models of sexual dysfunction propose that cognitive-affective factors are involved in the development and maintenance of sexual difficulties, there is a need to further examine how these factors are associated with orgasmic difficulties specifically.AimTo analyze differences between women who reported orgasm difficulties and controls in regard to sexual inhibition, sexual excitation, sexual beliefs, as well as negative automatic thoughts and affect during sexual activity.MethodsA total of 500 women, aged 18 to 72 years, completed a Web survey focused on cognitive-affective factors and sexual health. Two hundred fifty women reported orgasm difficulties and were compared with 250 age-matched women who reported no sexual difficulties.OutcomesDifferences between groups regarding sexual inhibition and sexual excitation (Sexual Inhibition/Sexual Excitation Scales–Short Form), sexual beliefs (Sexual Dysfunctional Beliefs Questionnaire), negative automatic thoughts (Automatic Thoughts Subscale of the Sexual Modes Questionnaire), and affect (Positive and Negative Affect Schedule) during sexual activity.ResultsWomen with orgasm difficulties scored higher on sexual inhibition than controls. They also reported more negative automatic thoughts during sexual activity (concerning failure and disengagement, sexual abuse, lack of affection from partner, passivity, body image) and less erotic thoughts. Women with orgasm difficulties reported experiencing higher negative affect and lower positive affect during sexual activity than women who reported no sexual difficulties. No significant differences were found regarding sexual excitation and endorsement of sexual beliefs.Clinical ImplicationsHelping women shift their focus from non-erotic, negative thoughts to erotic stimuli, as well as addressing sexual inhibition, can be relevant targets of interventions aimed at women's orgasm difficulties.Strengths & LimitationsStrengths of the study include the use of a large sample of women who reported orgasm difficulties, offering new insights into the clinical importance of these psychological processes. Limitations include the reliance on self-report measures and a relatively homogeneous sample regarding sexual orientation, education, and age.ConclusionResults highlight the role of cognitive-affective factors on women's orgasm difficulties and emphasize the potential benefit of cognitive-behavioral and/or mindfulness interventions for orgasm difficulties.Moura CV, Tavares IM, Nobre PJ. Cognitive-Affective Factors and Female Orgasm: A Comparative Study on Women With and Without Orgasm Difficulties. J Sex Med 2020;17:2220–2228.     

Brain Functional Biomarkers Distinguishing Premature Ejaculation From Anejaculation by ALFF: A Resting-State fMRI Study

IntroductionPremature ejaculation (PE) and anejaculation (AJ) are 2 opposite disorders of male ejaculatory dysfunction. Recent studies have demonstrated that the process of ejaculation is mediated by certain neural circuits in the brain. However, different mechanisms between PE and AJ are still unclear.AimTherefore, we used resting-state functional magnetic resonance imaging (fMRI) to explore the underlying neural mechanisms in patients with PE and AJ by measuring the amplitude of low-frequency fluctuations (ALFF).MethodsResting-state fMRI data were acquired in 17 PE, 20 AJ patients and 23 matched healthy controls (HC).Main Outcome MeasureDifferences of ALFF values among the 3 groups were compared. We also explored the correlations between brain regions showing altered ALFF values and scores of Premature Ejaculation Diagnostic Tool (PEDT) in the PE group.ResultsThere were widespread differences of ALFF values among the 3 groups, which included left anterior cingulate gyrus, precentral and postcentral gyrus, paracentral lobule, superior temporal gyrus, calcarine fissure, putamen; right postcentral gyrus, paracentral lobule, middle temporal gyrus, putamen. Compared with HC, PE patients had greater ALFF in the right inferior frontal gyrus (opercular part), AJ patients had greater ALFF in the left postcentral gyrus. In addition, PE patients exhibited greater ALFF in the left Rolandic operculum, anterior cingulate gyrus, inferior frontal gyrus (orbital part), putamen, and right putamen when compared with AJ patients, as well as decreased ALFF in the right postcentral gyrus. Moreover, positive correlations were found between ALFF of left postcentral gyrus, inferior frontal gyrus (orbital part), right inferior frontal gyrus (opercular part), and PEDT scores.Clinical ImplicationsThe differences in central pathophysiological mechanisms between PE and AJ might be useful for improving the clinical diagnosis of ejaculation dysfunction.Strength & LimitationsOur results showed that the method of fMRI could identify the differences of ALFF between PE and AJ and that these alterations in ALFF were related to clinical function. However, this was a relatively small sample study, and further multimodal neuroimaging studies with large samples were needed.ConclusionThe findings demonstrated that altered ALFF of frontal, parietal cortex, and putamen might help distinguish premature ejaculation from anejaculation. Abnormal function of these brain regions might play a critical role in the physiopathology of ejaculatory dysfunction of patients.Chen J, Yang J, Huang X, et al. Brain Functional Biomarkers Distinguishing Premature Ejaculation From Anejaculation by ALFF: A Resting-State fMRI Study. J Sex Med 2020;17:2331–2340.     

Relationship Between Use of Videogames and Sexual Health in Adult Males

BackgroundVideogame use is increasingly prevalent in people of all ages, and despite the wide amount of scientific evidence proving a role for electronic entertainment in human health, there is no evidence about the relation between use of videogames and sexual health.AimTo investigate the association between use of videogames and male sexual health.MethodsWe administered the two validated questionnaires, the Premature Ejaculation Diagnostic Tool (PEDT) and the International Index of Erectile Function (IIEF-15), to men 18 to 50 years old recruited through social networks and specific websites. In addition to the questionnaires, volunteers were asked to provide information on their gaming habit and lifestyle.OutcomesAn extended version of the IIEF-15 and PEDT, including data about gaming habits and relevant lifestyles.ResultsFrom June 18, 2014 through July 31, 2014, 599 men 18 to 50 years old completed the questionnaires. One hundred ninety-nine men reported no sexual activity during the previous 4 weeks; four records were rejected because of inherent errors. The remaining 396 questionnaires were analyzed, with 287 “gamers” (playing >1 hour/day on average) and 109 “non-gamers” providing all the required information. We found a lower prevalence of premature ejaculation in gamers compared with non-gamers (mean PEDT score = 3.57 ± 3.38 vs 4.52 ± 3.7, P < .05, respectively). Analysis of the IIEF-15 showed no significant differences between gamers and non-gamers in the domains of erectile function, orgasmic function, and overall satisfaction. Median scores for the sexual desire domain were higher for non-gamers (median score [interquartile range] 9 [8–9] vs 9 [8–10], respectively; P = .0227).Clinical ImplicationsThese results support the correlation between videogame use and male sexual health. Compared with non-gamers, men playing videogames for more than 1 hour/day were less likely to have premature ejaculation but more likely to have decreased sexual desire.Strengths and LimitationsThis is the first study aimed to assess male sexual health in gamers. We identified an association between PEDT and IIEF scores and videogame use; however, these findings require validation through interventional studies. Furthermore, volunteers were recruited through social networks, thus increasing the risk of recruitment bias.ConclusionTo our knowledge, this is the first observational study investigating the link between electronic entertainment and male sexuality, specifically for ejaculatory response and sexual desire.Sansone A, Sansone M, Proietti M, et al. Relationship Between Use of Videogames and Sexual Health in Adult Males. J Sex Med 2017;14:898–903.     

Éjaculation rétrograde et anéjaculation

Ejaculatory disorders are common male sexual dysfunctions. Although premature ejaculation has been extensively studied, anejaculation and retrograde ejaculation are lesser known, though they have been associated with anorgasmia and reproductive disorders. Anejaculation can be congenital or acquired and is mostly seen after prostate surgery and neurological diseases (spinal cord injuries) or is related to psychogenic factors. Generally, the same causes are associated with retrograde ejaculation. The management of these disorders depends on aetiology. Penile vibratory stimulation and pharmacological stimulation, using sympathomimetic drugs, such as midodrine, are increasingly recommended as first-line treatments. Electroejaculation and surgical procedures should only be used when necessary. Behavioural therapy is sometimes indicated when psychogenic or relationship factors are identified. By inducing bladder neck closure, midodrine can prove effective in the treatment of retrograde ejaculation.     

The Relationship Between Self-Reported Sexually Explicit Media Consumption and Sexual Risk Behaviors Among Men Who Have Sex With Men in China

IntroductionPrevious studies have indicated that viewing sexually explicit media (SEM) might be associated with sexual risk behaviors in men who have sex with men (MSM). However, most prior research has not explored this association cross-culturally or the potential influence that important covariates might have on the association.AimTo explore the association between self-reports of viewing SEM depicting various sexual risk behaviors and engagement in sexual risk behaviors after controlling for relevant covariates in MSM in China.MethodsThree hundred fourteen Chinese MSM participated in a web-based survey.Main Outcome MeasuresSEM consumption, sexual risk behavior, and measurements of covariates.ResultsSEM consumption was frequent in MSM in China. Viewing a larger proportion of SEM depicting sexual risk behaviors was associated with a larger number of regular partners with whom MSM reported engaging in sexual risk behaviors, but not with the number of casual partners, after controlling for covariates. HIV-related knowledge and seeking male sex partners were associated with the number of regular partners with whom MSM had engaged in sexual risk behaviors. Seeking sexual sensation, HIV-related knowledge, and seeking male sex partners were associated with the number of casual partners with whom MSM had engaged in sexual risk behaviors.ConclusionFuture research exploring the relation between SEM use and sexual health risk behaviors should consider theoretically important psychological and behavioral covariates.Xu Y, Zheng Y, Rahman Q. The Relationship Between Self-Reported Sexually Explicit Media Consumption and Sexual Risk Behaviors Among Men Who Have Sex With Men in China. J Sex Med 2017;14:357–365.     

Female Sexual Dysfunction—Medical and Psychological Treatments,Committee 14

IntroductionSince the millennium we have witnessed significant strides in the science and treatment of female sexual dysfunction (FSD). This forward progress has included (i) the development of new theoretical models to describe healthy and dysfunctional sexual responses in women; (ii) alternative classification strategies of female sexual disorders; (iii) major advances in brain, hormonal, psychological, and interpersonal research focusing on etiologic factors and treatment approaches; (iv) strong and effective public advocacy for FSD; and (v) greater educational awareness of the impact of FSD on the woman and her partner.AimsTo review the literature and describe the best practices for assessing and treating women with hypoactive sexual desire disorder, female sexual arousal disorder, and female orgasmic disorders.MethodsThe committee undertook a comprehensive review of the literature and discussion among themselves to determine the best assessment and treatment methods.ResultsUsing a biopsychosocial lens, the committee presents recommendations (with levels of evidence) for assessment and treatment of hypoactive sexual desire disorder, female sexual arousal disorder, and female orgasmic disorders.ConclusionThe numerous significant strides in FSD that have occurred since the previous International Consultation of Sexual Medicine publications are reviewed in this article. Although evidence supports an integrated biopsychosocial approach to assessment and treatment of these disorders, the biological and psychological factors are artificially separated for review purposes. We recognize that best outcomes are achieved when all relevant factors are identified and addressed by the clinician and patient working together in concert (the sum is greater than the whole of its parts).Kingsberg SA, Althof S, Simon JA, et al. Female Sexual Dysfunction—Medical and Psychological Treatments, Committee 14. J Sex Med 2017;14:1463–1491.     

When Is Enough Enough? Orgasm's Curvilinear Association With Relational and Sexual Satisfaction

BackgroundCurvilinearity has been found for sexual frequency, but research has not examined whether curvilinear associations exist for other aspects of sexual relationships like orgasm consistency.AimWe examined whether there is curvilinearity and the nature of that curvilinearity between orgasm consistency and sexual and relational satisfaction for men and women.MethodsWith pooled samples of 1,619 and 1,695 men and women from Amazon's Mechanical Turk, we examined the differences of orgasm consistency values and both sexual satisfaction and relationship satisfaction through analysis of variance. We then tested for curvilinearity between orgasm consistency and sexual and relational satisfaction with regression analyses.OutcomesFor men we found no evidence of a curvilinear relationship, but for women we found a curvilinear relationship between orgasm consistency values and both sexual satisfaction and relationship satisfaction.ResultsAcross tests, the overall picture suggests that there is no curvilinear association for men, but there is for women. For women, with each unit increase in orgasm consistency, the increase in sexual satisfaction and relationship satisfaction became progressively smaller. Past the 61-80% threshold for orgasm consistency, there was little gain in sexual satisfaction and no gain in relational satisfaction.Clinical TranslationPhysicians, therapists, and educators can reorient women's orgasm expectations by explaining that having regular orgasms—not necessarily always—is associated with satisfaction in their relationship and sexual experience.Strengths & LimitationsConverging large samples and data analytic techniques evinced the curvilinear association between orgasm consistency and both relational and sexual satisfaction for women. However, this study is cross-sectional and correlational, which limits the conclusions we can draw from it.ConclusionWhile men's orgasm consistency is linearly associated with relational and sexual satisfaction, more consistent orgasms seem to be associated with women's sexual and relational satisfaction, to a point.Leavitt CE, Leonhardt ND, Busby DM, et al. When Is Enough Enough? Orgasm's Curvilinear Association With Relational and Sexual Satisfaction. J Sex Med 2021;18:167–178.     

Female orgasm rates are largely independent of other traits: implications for "female orgasmic disorder" and evolutionary theories of orgasm

IntroductionThe criteria for “female orgasmic disorder” (FOD) assume that low rates of orgasm are dysfunctional, implying that high rates are functional. Evolutionary theories about the function of female orgasm predict correlations of orgasm rates with sexual attitudes and behavior and other fitness‐related traits.AimTo test hypothesized evolutionary functions of the female orgasm.MethodsWe examined such correlations in a community sample of 2,914 adult female Australian twins who reported their orgasm rates during masturbation, intercourse, and other sexual activities, and who completed demographic, personality, and sexuality questionnaires.Main Outcome MeasuresOrgasm rates during intercourse, other sex, and masturbation.ResultsAlthough orgasm rates showed high variance across women and substantial heritability, they were largely phenotypically and genetically independent of other important traits. We found zero to weak phenotypic correlations between all three orgasm rates and all other 19 traits examined, including occupational status, social class, educational attainment, extraversion, neuroticism, psychoticism, impulsiveness, childhood illness, maternal pregnancy stress, marital status, political liberalism, restrictive attitudes toward sex, libido, lifetime number of sex partners, risky sexual behavior, masculinity, orientation toward uncommitted sex, age of first intercourse, and sexual fantasy. Furthermore, none of the correlations had significant genetic components.ConclusionThese findings cast doubt on most current evolutionary theories about female orgasm's adaptive functions, and on the validity of FOD as a psychiatric construct. Zietsch BP, Miller GF, Bailey JM, and Martin NG. Female orgasm rates are largely independent of other traits: Implications for “female orgasmic disorder” and evolutionary theories of orgasm. J Sex Med 2011;8:2305–2316.