Classification, diagnosis and home treatment of ejaculatory dysfunction

**Inability to ejaculate** **Symptoms**

A normal male ejaculates upon reaching orgasm, with semen being ejected from the urethra. However, if a man can maintain an erection for a certain period during intercourse but does not experience orgasm, ejaculation, or semen discharge, and a urine test after intercourse shows no sperm or fructose, this abnormal phenomenon is medically termed "anejaculation" or "ejaculatory dysfunction."

**I. Classification of Anejaculation**

Anejaculation can be classified into two categories based on its nature: functional and organic.

1. Functional anejaculation accounts for approximately 90% of all cases of anejaculation. Due to dysfunction of the higher centers in the cerebral cortex and hypothalamus, the spinal ejaculation center is inhibited, and sexual stimulation in the waking state cannot reach the level of excitation required by the ejaculation center. During sleep, the activity of the subcortical centers increases, and sexual dreams can induce ejaculation, manifesting as nocturnal emission during sleep. Sometimes masturbation may also lead to ejaculation. Most cases end with penile flaccidity after a certain period of intercourse, while some remain erect until exhaustion without being able to ejaculate.

The unique Eastern cultural belief in the preciousness of semen is a significant factor contributing to the high number of men with ejaculatory dysfunction in my country. Men in my country and other Southeast Asian countries often regard semen as the "essence of life" and "vital energy," with the saying "one drop of semen is worth ten drops of blood," leading many to subconsciously suppress ejaculation. Approximately 75% of patients seek medical help for infertility, and 15% for nocturnal emission. In fact, nocturnal emission is a common compensatory response among men with ejaculatory dysfunction; "when semen is full, it overflows." However, patients attempt to "store" their semen by further reducing ejaculation, consciously or unconsciously controlling ejaculation or reducing sexual activity in hopes of longevity, which only exacerbates the problem.

Functional anejaculation is characterized by the inability to ejaculate during intercourse, although nocturnal emission may occur. Common causes include lack of sexual knowledge, emotional and psychological factors, female factors, family environment factors, and phimosis. In addition, homosexuality, fear of pregnancy, psychosocial trauma, and newlywed stress can all lead to anejaculation.

2. Organic anejaculation accounts for approximately 10% of all cases of anejaculation. This refers to the inability to ejaculate under any circumstances, whether awake or asleep, and is often caused by various diseases. These factors include:

(1) Neurological factors: diseases and surgery of the lateral lobe of the brain, damage to the output nerves of the thoracolumbar region, trauma or surgical damage to the sympathetic nerves, pelvic surgery, spinal cord injury, retroperitoneal lymph node dissection, etc.

(2) Metabolic factors: diabetes.

(3) Endocrine disorders: hypopituitarism, hypogonadism, hypothyroidism.

(4) Drug factors: Various drugs used to treat hypertension and mental illnesses can impair ejaculation ability, such as guanethidine, phenothiazines, reserpine, nitrazepam, etc.

(5) Congenital factors are rare, such as absence of unilateral or bilateral vas deferens and seminal vesicles, congenital ejaculatory duct obstruction, etc.

It should be noted that the following two situations do not fall under the category of "anejaculation": First, frequent sexual activity can slow down, prolong, or even prevent ejaculation. For example, newlyweds may have multiple sexual encounters in one night, eventually leading to anejaculation, which is normal. This is because the seminal vesicles have a limited capacity, and semen has a limited quantity. The secretion of the seminal vesicles and prostate gland requires a certain amount of time. If sexual intercourse is too frequent, not only will the stored semen be depleted, but the ejaculation center will also shift from over-excitation to inhibition, resulting in anejaculation. Second, people over 50 years of age do not always achieve ejaculation during intercourse. Reduced ejaculatory ability can prolong the duration of intercourse, and this ejaculation is often not a spurt but a slow, gradual flow, hence the term "weak ejaculation" or "ejaculatory dysfunction."

**II. Diagnosis of Anejaculation**

Diagnosing anejaculation is not difficult; the key diagnostic points are absence of sexual orgasm, absence of ejaculatory reflexes, and absence of semen ejaculation. Clinically, the following points should be noted:

(1) Diagnosis is mainly based on medical history. It is necessary to understand the entire process of sexual intercourse, especially the sexual intercourse method, the frequency and amplitude of penile thrusting in the vagina, etc.; and to understand whether sexual arousal is satisfactory during sexual intercourse.

(2) The "three haves" and "three no's" during sexual activity. That is, there is sexual arousal, penile erection, and sufficient time for intercourse, but no orgasm, no ejaculation, and no semen discharge.

(3) There are often subconscious ejaculation movements and orgasms (such as nocturnal emission), often accompanied by seminal emission or penile erection that does not retract, which is easily confused with priapism. The difference is that this condition is caused by sexual arousal, while priapism is generally not caused by sexual stimulation; there is no semen ejaculation during intercourse in this condition, while priapism continues to be erect after ejaculation.

**III. Treatment of Ejaculatory Dysfunction**

For patients with anejaculation, especially the functional anejaculation that accounts for about 90%, prevention is more important than treatment. Strictly speaking, as long as premarital sex education is vigorously promoted, sex knowledge is popularized, and the mystery is eliminated, various undesirable psychogenic sexual dysfunctions can be prevented among young people. Anejaculation can be cured without any injections or medications, with reported effectiveness rates of up to 60%. Secondly, electric massage, under the guidance of a doctor, can be used to stimulate sexually sensitive areas such as the glans and frenulum, or move up and down along the shaft of the penis to induce ejaculation, often with good results. It has been reported that about 50% of patients can recover to normal in the first treatment, while the rest can be cured after more than ten treatments.

Initially, continuous stimulation for 10-15 minutes is required, but ejaculation can be achieved in just 5 minutes thereafter. Various commercially available massage devices can be used. Other treatments include procaine-based presacral block, or levodopa and ephedrine as adjunctive medications, which can improve efficacy in some stubborn cases, but have more side effects. In addition, circumcision, quitting smoking and alcohol, and improving the living environment can help with treatment. Traditional fitness therapies such as Qigong and Tai Chi can also be used. Thiazide tranquilizers and certain antihypertensive drugs should be avoided during treatment.

For patients with excessive central nervous system inhibition, in addition to learning about sex in detail, it is advisable to temporarily separate from their wives for a period of time to allow the cerebral cortex to rest and adjust fully. The novelty of reunion can help break through the existing inhibitory state. For patients who are temporarily incurable but eager to conceive, masturbation or collecting semen during nocturnal emission and injecting it into the vagina can sometimes lead to the gradual disappearance of mental depression as the woman becomes pregnant, resulting in an unexpected cure.

**IV. Home Remedies for Ejaculatory Dysfunction**

Generally speaking, functional ejaculatory dysfunction can be cured by adopting effective methods of sexual intercourse. When the husband experiences ejaculation difficulties, the wife's cooperation, care, and understanding are crucial. This helps the husband relax and eliminates psychological pressure during intercourse. Avoid expressing resentment or aversion, and do not demand that the husband ejaculate during intercourse, as aversion often evolves into hostility or distrust between the couple, worsening the condition.

Generally speaking, once a patient with functional ejaculatory dysfunction has ejaculated inside his wife's vagina, this sexual dysfunction can be permanently eliminated; after several successful sexual encounters, both partners will have a strong sense of confidence, and the ejaculatory dysfunction can be cured.