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Idiopathic anejaculation treated by vibratory stimulation
FERTILITY AND STERILITY Copyright 0 1988 The American Fertility Society
Vol. 50, No. 2, August 1988 Printed in U.S.A.
Idiopathic anejaculation treated by vibratory stimulation
JohnS. Wheeler Jr., M.D.*t:j: James S. Walter, Ph.D.*§ Daniel J. Culkin, M.D. II John R. Canning, M.D.*t Loyola University Medical Center, Maywood, Hines Veterans Administration Hospital, Hines, Illinois, and Louisiana State University Medical Center, Shreveport, Louisiana
Anejaculation, the inability to ejaculate even with an adequate erection, is a rare cause of sexual dysfunction and infertility. 1 The cause of anejaculation is usually organic in nature; however, if there is no cause, then it is considered idiopathic. Vibratory stimulation to the penis has been successful for treating patients with organic anejaculation. For idiopathic anejaculation, the usual mode of treatment has been psychotherapy. 1- 3 Recently, two patients presented with idiopathic anejaculation who wand expeditious treatment of their infertility and underwent vibratory stimulation for ejaculation, in addition to psychotherapy. CASE REPORTS
Patient 1, a healthy 30-year-old white male, was referred for infertility. He has been married for 12 years, having regular sexual intercourse with normal erections, but has never had a coital orgasm. He admits to a diminished libido and has never successfully masturbated, although he has had periodic nocturnal emissions. His past medical hisReceived January 18, 1988; revised and accepted April 22, 1988. *Department of Urology, Loyola University Medical Center. t Department of Surgery, Hines Veterans Administration Hospital. :j: Reprint requests: JohnS. Wheeler Jr., M.D., Department of Urology, Loyola University Stritch School· of Medicine, 2160 South First Avenue, Maywood, Illinois 60153. § Rehabilitation Research and Development Center, Hines Veterans Administration Hospital. II Department of Urology, Louisiana State University Medical Center. Vol. 50, No. 2, August 1988
tory was normal. He is of East Indian descent and admits to a slow and naive adolescent sexual development. His wife is normal gynecologically. The physical examination is normal, except that he is uncircumcised with a sensitive glans penis. Our diagnosis was anejaculation, probably psychosocial or idiopathic in etiology. He was already undergoing psychotherapy. Because this was a slow process and the patient was anxious about fertility, he underwent penile vibratory stimulation. A vibrator (Ling, Dynamic Systems, Inc., Yalesville, CT) was adapted with a 2-cm domed plate on a 2-inch stem and a handle for self-stimulation. Vibration parameters were 80 HZ with a 2.5-mm wave length to the penile frenulum intermittently for 45 minutes. The resultant ejaculate was of adequate volume and quality for insemination. A random semenanalysis done early in his vibration therapy showed a sperm count of 300 million, motility 30%, and morphology 24%. He still uses the vibrator for insemination into his wife, requiring less stimulation time with each ejaculation, but is unable to have intravaginal orgasm. He continues with psychotherapy, and to date, there is no pregnancy. Patient 2, a healthy 32-year-old white male was referred for infertility and anejaculation. He has been married for 10 years, having intercourse weekly with a normal libido and normal erection, but he has never had a coital orgasm. He has never been able to masturbate, but he averages one nocturnal emission per month. He has recurrent low back pain but denies any other illnesses. He has been undergoing psychotherapy for 6 months but claims to be well adjusted psychologically. He is of Wheeler et al.
Communications-in-brief
377
British descent and was born into a strictly religious family that inhibited adolescent sexual awareness development. His wife is normal gynecologically. Physical examination shows normal genitalia, but he is uncircumcised with a sensitive glans penis. His prostate was normal, but the expressed fluid showed more than 10 white blood cells per high-powered field, indicative of prostatitis, for which he underwent a 1 month course of trimethoprim/sulfa. Because of the anxiety about fertility, he underwent vibratory stimulation similar to patient 1. He claims to have had a sensation of a prelude to orgasm but was unable to ejaculate after two trials. A neurologic evaluation was unremarkable. The patient tried vibratory stimulation several more times, along with psychotherapy, with no results and has been lost to follow-up. DISCUSSION
Lack of ejaculation, semen emission with retrograde ejaculation, or no semen emission, anejaculation, is due to a defect in any part of the normal ejaculation process. Treatment of retrograde ejaculation is either harvesting the retrograde ejaculate for insemination or administering sympathomimetic agents. 4 The management of anejaculation has not been as expeditious. Anejaculation is a rare problem, occurring in < 3% of infertile couples/ probably because it is a problem that only becomes urgent when the patient attempts to have children.3 Synonyms of anejaculation include retarded ejaculation, ejaculatory impotence, and ejaculatory failure or incompetence.3 Possible causes of anejaculation include significant impairment of the sympathetic nervous system ablating seminal emission (i.e., a complete retroperitoneal node dissection), sympatholytic drugs, antihypertensive and antipsychotic drugs, spinal cord injury (SCI), diabetes mellitus, drug and alcohol abuse, fatigue, and psychologic factors. 1·3-5 Patients who have no other obvious cause for their anejaculation are labeled as idiopathic. Most of these patients are also unable to masturbate but have nocturnal emissions, as in our two cases.1·2•3·5 The patient's history is similar to our two patients with an ejaculatory ability that ranges from the patient never ejaculating under any circumstances to the patient being able to ejaculate only outside the vagina. 2 Usually, the problem has been lifelong, as in our two patients, but if the problem is secondary, an organic etiology is more likely. 3 Even if no 378
Wheeler et al. Communications-in-brief
overt psychopathology is found, a subtle psychosocial etiology should be sought in idiopathic cases. Even though our two patients claim to be stable psychologically, both patients had a slow sexual adolescence that may have altered their current sexual ability. Psychosocial factors that may influence ejaculatory ability include fear of pregnancy,1·3 emotional immaturity,3•5 religious orthodoxy,1·3 lack of libido,3 poor body image, 3 performance anxiety, 1•3 fear for partner,3 and hostility to females. 3 The psychologic explanation is that the central ejaculation center in the brain has decreased reactivity to the usual ejaculation stimulus.3·5 Therefore, treatment must focus on increasing the local sexual stimulus and altering the brain's reactivity to it. 3·5 Because psychosocial factors may be prominent in the etiology of idiopathic anejaculation, the mainstay of therapy has been psychologic. Even though classic psychotherapy, sex therapy, and behavioral therapy have had some success, the duration of therapy is long. 1-3•5 Therefore, other treatment modalities have been developed, some in conjunction with psychotherapy, including human chorionic gonadotropin injection,4 alpha-adrenergic agents (similar to patients with retrograde ejaculation),4 dextroamphetamines, 5 electroejaculation,3 and electrovibration. 3·4•6·7 Electrovibration has been successful for organic anejaculation, especially in SCI patients, but only rarely tried in patients with idiopathic anejaculation.6•7 Electrovibration was successful in our first patient and may yet be effective in our second patient. A vibrating head (40 to 80 HZ) is placed at the penile frenulum, and ejaculation should occur in less than 1 hour. Vibratory time may diminish, and eventually normal vaginal ejaculatory ability may return. 3·6·7 In our first case, vibration time is now 5 minutes, but he has not had intravaginal orgasms. Several attempts of vibration therapy should be done to assure no response. Penile electrovibration increases the ejaculatory stimulus by stimulating dermal pacinian corpuscles to increase afferent input to the spinal cord, increasing the ejaculatory reflex. 3·4·6 In SCI patients with organic anejaculation, electrovibration stimulates the pelvic floor reflexes that should be intact, if the level of injury is above Ll. With increased pelvic floor activity, some SCI patients successfully ejaculate.4 Patients with idiopathic anejaculation also have preserved pelvic floor reflexes and should ejaculate with electrovibration. Furthermore, electrovibration is a more intense stimulus than masFertility and Sterility
turbation. However, even with improved ejaculation, the central nervous system ejaculatory center is still abnormal, and psychotherapy may be beneficial.3·5 SUMMARY
Idiopathic anejaculation is a rare cause of infertility usually treated by psychotherapy. However, electrovibration may be a simple, noninvasive adjunct to the treatment of this disorder. In our two cases, we obtained ejaculate adequate for insemination in one patient and noted some gain in orgasmic sensation in the other. The success in these two infertile patients who had already undergone lengthy psychotherapy is promising. Nevertheless, psychotherapy will continue to be the standard of
Vol. 50, No.2, August 1988
therapy until we have more experience with penile electrovibration. REFERENCES 1. Masters WH, Johnson VE: Human Sexual Inadequacy. Boston, Little, Brown, & Co., 1970, p 92
2. Kaplan HS: The New Sex Therapy. New York, Bruner/ Maze!, 1974, p 289 3. Shull GR, Sprenkle DH: Retarded ejaculation reconceptualization and implications for treatment. J Sex Marital Ther 6:234, 1980 4. Murphy JB, Lipshultz LI: Abnormalities of ejaculation. Urol Clin North Am 14:583, 1987 5. Rowan RL, Howley TF: Ejaculatory Sterility. Fertil Steril 16:768, 1965 6. Sobrero AJ, Stearns HE, Blair JH: Technic for the induction of ejaculation in humans. Fertil Steril 16:765, 1965 7. Schellen TM: Induction of ejaculation by electrovibration. Fertil Steril 19:566, 1968
Wheeler et al.
Communications-in-brief
379
Vol. 50, No. 2, August 1988 Printed in U.S.A.
Idiopathic anejaculation treated by vibratory stimulation
JohnS. Wheeler Jr., M.D.*t:j: James S. Walter, Ph.D.*§ Daniel J. Culkin, M.D. II John R. Canning, M.D.*t Loyola University Medical Center, Maywood, Hines Veterans Administration Hospital, Hines, Illinois, and Louisiana State University Medical Center, Shreveport, Louisiana
Anejaculation, the inability to ejaculate even with an adequate erection, is a rare cause of sexual dysfunction and infertility. 1 The cause of anejaculation is usually organic in nature; however, if there is no cause, then it is considered idiopathic. Vibratory stimulation to the penis has been successful for treating patients with organic anejaculation. For idiopathic anejaculation, the usual mode of treatment has been psychotherapy. 1- 3 Recently, two patients presented with idiopathic anejaculation who wand expeditious treatment of their infertility and underwent vibratory stimulation for ejaculation, in addition to psychotherapy. CASE REPORTS
Patient 1, a healthy 30-year-old white male, was referred for infertility. He has been married for 12 years, having regular sexual intercourse with normal erections, but has never had a coital orgasm. He admits to a diminished libido and has never successfully masturbated, although he has had periodic nocturnal emissions. His past medical hisReceived January 18, 1988; revised and accepted April 22, 1988. *Department of Urology, Loyola University Medical Center. t Department of Surgery, Hines Veterans Administration Hospital. :j: Reprint requests: JohnS. Wheeler Jr., M.D., Department of Urology, Loyola University Stritch School· of Medicine, 2160 South First Avenue, Maywood, Illinois 60153. § Rehabilitation Research and Development Center, Hines Veterans Administration Hospital. II Department of Urology, Louisiana State University Medical Center. Vol. 50, No. 2, August 1988
tory was normal. He is of East Indian descent and admits to a slow and naive adolescent sexual development. His wife is normal gynecologically. The physical examination is normal, except that he is uncircumcised with a sensitive glans penis. Our diagnosis was anejaculation, probably psychosocial or idiopathic in etiology. He was already undergoing psychotherapy. Because this was a slow process and the patient was anxious about fertility, he underwent penile vibratory stimulation. A vibrator (Ling, Dynamic Systems, Inc., Yalesville, CT) was adapted with a 2-cm domed plate on a 2-inch stem and a handle for self-stimulation. Vibration parameters were 80 HZ with a 2.5-mm wave length to the penile frenulum intermittently for 45 minutes. The resultant ejaculate was of adequate volume and quality for insemination. A random semenanalysis done early in his vibration therapy showed a sperm count of 300 million, motility 30%, and morphology 24%. He still uses the vibrator for insemination into his wife, requiring less stimulation time with each ejaculation, but is unable to have intravaginal orgasm. He continues with psychotherapy, and to date, there is no pregnancy. Patient 2, a healthy 32-year-old white male was referred for infertility and anejaculation. He has been married for 10 years, having intercourse weekly with a normal libido and normal erection, but he has never had a coital orgasm. He has never been able to masturbate, but he averages one nocturnal emission per month. He has recurrent low back pain but denies any other illnesses. He has been undergoing psychotherapy for 6 months but claims to be well adjusted psychologically. He is of Wheeler et al.
Communications-in-brief
377
British descent and was born into a strictly religious family that inhibited adolescent sexual awareness development. His wife is normal gynecologically. Physical examination shows normal genitalia, but he is uncircumcised with a sensitive glans penis. His prostate was normal, but the expressed fluid showed more than 10 white blood cells per high-powered field, indicative of prostatitis, for which he underwent a 1 month course of trimethoprim/sulfa. Because of the anxiety about fertility, he underwent vibratory stimulation similar to patient 1. He claims to have had a sensation of a prelude to orgasm but was unable to ejaculate after two trials. A neurologic evaluation was unremarkable. The patient tried vibratory stimulation several more times, along with psychotherapy, with no results and has been lost to follow-up. DISCUSSION
Lack of ejaculation, semen emission with retrograde ejaculation, or no semen emission, anejaculation, is due to a defect in any part of the normal ejaculation process. Treatment of retrograde ejaculation is either harvesting the retrograde ejaculate for insemination or administering sympathomimetic agents. 4 The management of anejaculation has not been as expeditious. Anejaculation is a rare problem, occurring in < 3% of infertile couples/ probably because it is a problem that only becomes urgent when the patient attempts to have children.3 Synonyms of anejaculation include retarded ejaculation, ejaculatory impotence, and ejaculatory failure or incompetence.3 Possible causes of anejaculation include significant impairment of the sympathetic nervous system ablating seminal emission (i.e., a complete retroperitoneal node dissection), sympatholytic drugs, antihypertensive and antipsychotic drugs, spinal cord injury (SCI), diabetes mellitus, drug and alcohol abuse, fatigue, and psychologic factors. 1·3-5 Patients who have no other obvious cause for their anejaculation are labeled as idiopathic. Most of these patients are also unable to masturbate but have nocturnal emissions, as in our two cases.1·2•3·5 The patient's history is similar to our two patients with an ejaculatory ability that ranges from the patient never ejaculating under any circumstances to the patient being able to ejaculate only outside the vagina. 2 Usually, the problem has been lifelong, as in our two patients, but if the problem is secondary, an organic etiology is more likely. 3 Even if no 378
Wheeler et al. Communications-in-brief
overt psychopathology is found, a subtle psychosocial etiology should be sought in idiopathic cases. Even though our two patients claim to be stable psychologically, both patients had a slow sexual adolescence that may have altered their current sexual ability. Psychosocial factors that may influence ejaculatory ability include fear of pregnancy,1·3 emotional immaturity,3•5 religious orthodoxy,1·3 lack of libido,3 poor body image, 3 performance anxiety, 1•3 fear for partner,3 and hostility to females. 3 The psychologic explanation is that the central ejaculation center in the brain has decreased reactivity to the usual ejaculation stimulus.3·5 Therefore, treatment must focus on increasing the local sexual stimulus and altering the brain's reactivity to it. 3·5 Because psychosocial factors may be prominent in the etiology of idiopathic anejaculation, the mainstay of therapy has been psychologic. Even though classic psychotherapy, sex therapy, and behavioral therapy have had some success, the duration of therapy is long. 1-3•5 Therefore, other treatment modalities have been developed, some in conjunction with psychotherapy, including human chorionic gonadotropin injection,4 alpha-adrenergic agents (similar to patients with retrograde ejaculation),4 dextroamphetamines, 5 electroejaculation,3 and electrovibration. 3·4•6·7 Electrovibration has been successful for organic anejaculation, especially in SCI patients, but only rarely tried in patients with idiopathic anejaculation.6•7 Electrovibration was successful in our first patient and may yet be effective in our second patient. A vibrating head (40 to 80 HZ) is placed at the penile frenulum, and ejaculation should occur in less than 1 hour. Vibratory time may diminish, and eventually normal vaginal ejaculatory ability may return. 3·6·7 In our first case, vibration time is now 5 minutes, but he has not had intravaginal orgasms. Several attempts of vibration therapy should be done to assure no response. Penile electrovibration increases the ejaculatory stimulus by stimulating dermal pacinian corpuscles to increase afferent input to the spinal cord, increasing the ejaculatory reflex. 3·4·6 In SCI patients with organic anejaculation, electrovibration stimulates the pelvic floor reflexes that should be intact, if the level of injury is above Ll. With increased pelvic floor activity, some SCI patients successfully ejaculate.4 Patients with idiopathic anejaculation also have preserved pelvic floor reflexes and should ejaculate with electrovibration. Furthermore, electrovibration is a more intense stimulus than masFertility and Sterility
turbation. However, even with improved ejaculation, the central nervous system ejaculatory center is still abnormal, and psychotherapy may be beneficial.3·5 SUMMARY
Idiopathic anejaculation is a rare cause of infertility usually treated by psychotherapy. However, electrovibration may be a simple, noninvasive adjunct to the treatment of this disorder. In our two cases, we obtained ejaculate adequate for insemination in one patient and noted some gain in orgasmic sensation in the other. The success in these two infertile patients who had already undergone lengthy psychotherapy is promising. Nevertheless, psychotherapy will continue to be the standard of
Vol. 50, No.2, August 1988
therapy until we have more experience with penile electrovibration. REFERENCES 1. Masters WH, Johnson VE: Human Sexual Inadequacy. Boston, Little, Brown, & Co., 1970, p 92
2. Kaplan HS: The New Sex Therapy. New York, Bruner/ Maze!, 1974, p 289 3. Shull GR, Sprenkle DH: Retarded ejaculation reconceptualization and implications for treatment. J Sex Marital Ther 6:234, 1980 4. Murphy JB, Lipshultz LI: Abnormalities of ejaculation. Urol Clin North Am 14:583, 1987 5. Rowan RL, Howley TF: Ejaculatory Sterility. Fertil Steril 16:768, 1965 6. Sobrero AJ, Stearns HE, Blair JH: Technic for the induction of ejaculation in humans. Fertil Steril 16:765, 1965 7. Schellen TM: Induction of ejaculation by electrovibration. Fertil Steril 19:566, 1968
Wheeler et al.
Communications-in-brief
379