Male orgasmic disorder

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Definition

Male orgasmic disorder may be defined as a persistent or recurrent inability to achieve orgasm despite lengthy sexual contact or while participating in sexual intercourse.

The mental health professional's handbook, the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) , includes this disorder among the sexual dysfunctions , along with premature ejaculation , dyspareunia , and others.

Description

The individual affected by male orgasmic disorder is unable to experience an orgasm following a normal sexual excitement phase. The affected man may regularly experience delays in orgasm, or may be unable to experience orgasm altogether.

Normal orgasm

First, it is important to this discussion to understand the characteristics of a "normal" orgasm. The sensation of orgasm in the male includes emission followed by ejaculation. The term emission refers to a sensation of impending ejaculation produced by contractions of the prostate gland, seminal vesicles, and urethra accompanied by generalized muscular tension, perineal contractions, and involuntary pelvic thrusting. Orgasm is followed by a period of resolution characterized by feelings of well-being and generalized muscular relaxation. During this phase, men may be unable to respond to further sexual stimulation, erection, and orgasm for a variable period of time.

It is also important to distinguish orgasm from ejaculation, although in most instances they occur almost simultaneously. Orgasm is a peak emotional and physical experience, whereas ejaculation is simply a reflex action occurring at the lower portion of the spinal cord and resulting in ejection of semen. Some men have been able to recognize the separation of the two processes, enabling them to experience multiple orgasms without the occurrence of ejaculation. Once ejaculation takes place, a period of recovery time is required prior to a subsequent orgasm.

The sensation of orgasm differs between individuals, and individual orgasms may differ in the same person. All orgasms share certain characteristics in common including rhythmic body and pelvic contractions, elevation of the heart rate, systemic hypertension, hyperventilation, and muscle tension, followed by the sudden release of tension.

The physiological mechanism of normal orgasm

The cycle of sexual response is under the control of a balanced interplay between the two major nervous systems, the sympathetic and the parasympathetic. In general, the sympathetic nervous system prompts action whereas the parasympathetic system's main action is recovery and calming. In order for a penis to become erect, its smooth muscles are relaxed and it becomes congested with blood vessels. This process is mediated by a complex cascade of humoral, neurological and circulatory events in which the parasympathetic nervous system plays a key role. Orgasm and ejaculation and subsequent relaxation of the penis are predominantly functions of the sympathetic nervous system.

Thus, whereas emission is a balanced interplay between the parasympathetic and sympathetic nervous systems, orgasm and ejaculation are predominantly under the control of the sympathetic nervous system. The mechanisms of this system may be blocked by impaired function of the brain or of the hormonal, circulatory, and neurological systems. Additionally, certain medications may block these actions.

Abnormalities affecting the process of orgasm

Abnormalities in these processes may be "primary" or "secondary." Primary abnormalities are of lifelong duration with effective sexual performance never having been experienced. Secondary abnormalities are acquired after a period of normal function. If an orgasmic problem only occurs under a particular set of circumstances, or only with certain sexual partners, the condition is considered to be "situational" rather than "generalized" (occurring regardless of the circumstances or partner). The defect in sexual function may be total or partial.

The evidence strongly suggests that orgasm has more to do with the brain than with the body. Electrode stimulation of certain parts of the brain will produce sexual pleasure similar to that produced by physical stimulation. The fact that orgasm occurs during sleep is supportive of this concept.

Causes and symptoms

Causes

The cause of male orgasmic disorders may be organic (related to a condition in the body), but, in most cases, is of psychological origin. It is important for the physician to make every effort to find an underlying cause because the therapy and prognosis depend upon it. A detailed history (including an interview with the sexual partner, if feasible), a general physical examination, the performance of certain laboratory and, in some cases, special tests, are important in the investigation of the underlying cause of the male orgasmic disorder.

Organic causes of male orgasmic disorder include the following:

• Hypogonadism, in which the testes do not produce enough testosterone.
• Thyroid disorders (both hyperthyroidism—too much thyroid hormone— and hypothyroidism, or abnormally low levels of thyroid hormone).
• Pituitary conditions (Cushing's syndrome, excessive production of the hormone that induces lactation called prolactin).
• Diseases that affect the nervous system, such as strokes, multiple sclerosis, diabetic neuropathy, spinal cord injuries.
• Surgery affecting the prostate and other pelvic organs.
• Diseases of the penis.
• Substance abuse, including alcohol.
• Certain medications. Some of these medications include: the phenothiazines [antipsychotics such as chlorpromazine (Thorazine) or trifluoperazine (Stelazine)]; certain medications used to treat high blood pressure, including the thiazides [such as triamterene (Dyazide) or spironolactone (Aldactone)] and beta blockers [such as propranolol (Inderal)]; and the tricyclic antidepressants such as doxepin (Sinequan) and protriptyline (Vivactil).

The most common causes of the male orgasmic syndrome are psychological in nature. The responsible psychological mechanisms may be "intrinsic" (due to basic internal factors), or "extrinsic" (due to external or environmental factors).

Intrinsic psychological factors that may cause male orgasmic disorder include:

• depression
• feelings of guilt, anger, fear, low self-esteem, and anxiety
• fear of getting the partner pregnant or of contracting a sexually transmitted disease or HIV
• Extrinsic psychological factors that may cause male orgasmic disorder include:
• living under conditions that cause undue stress
• unsatisfactory relationship with sexual partner
• past history of traumatic sexual encounters such as sexual abuse, rape or incest
• having been raised in an atmosphere of strict sexual taboos

Environmental factors may interfere with sexual functioning. There may be no safe, private place in which the patient can exercise sexual activity or he may be too fatigued from other activities to participate sexually. The difficulties in striving for "safe sex" and the psychological effects and stresses that may result from homosexuality may also interfere with sexual function.

Symptoms

In order to be diagnosed with male orgasmic disorder, the following symptoms must be present according to the DSM-IV-TR :

• Persistent or recurrent delay in, or absence of, orgasm following a normal sexual excitement phase during sexual activity that the clinician judges to be adequate. The affected man's age is considered, as well.
• As with all of the sexual dysfunctions, the manual states that the dysfunction must cause the affected man "distress or interpersonal difficulty." According to the DSM-IV-TR, the orgasmic dysfunction cannot be better accounted for by another disorder (except another sexual disorder), and cannot be due exclusively to the direct effects of substance abuse, a medication, or a general medical condition. This entry, however, discusses the full scope of male orgasmic difficulties, and so discusses general medical conditions and medications as well as psychological factors.

In addition to specific symptoms involving sexual function (inability or delay in reaching orgasm after sufficient stimulation), most patients complain of anxiety, guilt, shame and frustration, and many develop bodily complaints on a psychological basis. Although sexual dysfunction usually occurs during sexual activity with a partner, the clinician should inquire about sexual function during masturbation. If problems occur during masturbation, the problem probably has nothing to do with the sexual partner.

The physician should differentiate male orgasmic disorder from other sexual disorders such as retarded or delayed ejaculation and retrograde ejaculation. In both of these conditions, orgasm occurs but is delayed or, in the case of retrograde ejaculation, occurs in a retrograde direction (into the bladder).

Demographics

Male orgasmic disorder is found in all races and ethnic groups. In the case of the lifelong type of the disorder, manifestations will occur around the age of puberty. In certain genetic hypogonadism disorders, such as Klinefelter's syndrome, certain bodily signs and symptoms may alert the physician. Similarly, in associated thyroid, testicular and pituitary abnormalities, there may be other manifestations of the underlying disorder. In the acquired type of male orgasmic disorder, the patient will have had the previous experience of normal sexual function. In these cases, it is usually a situational factor that precipitates the disorder.

Diagnosis

The diagnosis is usually readily made on the basis of the patient's history and the presence of the DSM-IVTR diagnostic criteria. Male orgasmic disorder may be part of a complex of sexual malfunctioning that may include erectile dysfunction , abnormalities in ejaculation (such as premature ejaculation or retrograde ejaculation), and hypoactive sexual desire disorder .

In order to differentiate between the various potential disorders, the physician may request laboratory tests and/or may perform further diagnostic evaluations. Blood plasma levels of testosterone are of help in diagnosing hypogonadism. A number of tests of thyroid, pituitary and adrenal function are available to diagnose hormonal abnormalities of those glands. A test for nocturnal penile erections may be performed to diagnose erectile dysfunction.

Treatments

If an extrinsic mechanism is discovered as the cause of the orgasmic disorder, steps should be taken to eliminate or ameliorate the problem. An example would be substance or alcohol abuse or the use of certain provocative medications. In the case of antihypertensives, for example, a number of equally effective agents are available if the one in current use is suspect. Therapy should be directed toward improvement of concurrent conditions such as diabetes that may be having an adverse effect on sexual function. Environmental factors that interfere with sexual activity should be corrected.

In the majority of cases, psychotherapy will be suggested even in those cases where psychological factors are secondary rather than the primary mechanism for the disorder. Such treatment should be rendered by therapists with special training in the disorders of sexual function and who can tactfully evaluate the sexual compatibility of the patient and his partner. Treatment usually requires the support of the sexual partner in improving both the psychological as well as the physical aspects of the problem. A step-wise program of partner stimulation of the patient to initially ejaculate outside the vagina, then at the vaginal labia, and finally inside the vagina may be helpful.

Prognosis

The prognosis of the patient with male orgasmic syndrome is dependent on whether the condition is lifelong or acquired and the condition's causes. Prognosis is best when it can be demonstrated that the condition is related to some extrinsic or environmental factor that can be corrected or ameliorated. The prognosis is also favorable in those cases that are due to a remedial organic condition such as a thyroid disorder or hypogonadism. The prognosis is guarded when the disorder is found to be secondary to a deep-seated and chronic psychological or actual psychiatric problem that, in itself, carries an unfavorable prognosis.

Prevention

There are no definitive steps that can be taken to prevent the onset of the male orgasmic disorder. Prompt recognition of the syndrome is important so that appropriate therapy can be attempted as early as possible. As with many chronic conditions, the longer the condition exists, the more difficult therapy becomes.

Resources

BOOKS

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th edition, text revised. Washington, DC: American Psychiatric Association,2000.

Lue, Tom F., F. Goldstein. "Impotence and Infertility." In Atlas of Clinical Urology. Volume 1. New York: Current Medicine, 1999.

Masters, William and Virginia Johnson. Masters and Johnson on Sex and Human Loving. New York: Little, Brown,1986.

Steidle, Christopher P., MD. The Impotence Source Book. Los Angeles: Howell House, 1998.

Ralph Myerson, M.D.