Fast Five Quiz: Sexual Disorders

Steve Soreff, MD; Bradley Schwartz, DO; Michel E. Rivlin, MD


August 11, 2020

Male orgasm is defined as a subjective, perceptual-cognitive event of peak sexual pleasure that in normal conditions coincides with the moment of ejaculation. Delayed ejaculation is typically a self-reported diagnosis; no firm consensus defines what constitutes a reasonable time frame for reaching orgasm.

Hyperprolactinemia has been associated with both decreased sexual desire and a decreased ability to reach orgasm in men. Hyperprolactinemia can be physiologic, pathologic, or drug induced. Patients with hyperprolactinemia may remain asymptomatic or can have signs and symptoms of hypogonadism and galactorrhea.

Reportedly, the intensity of orgasm correlates with the ejaculatory volume; thus, declines in ejaculatory volume can result in reduced sexual pleasure. Ejaculate volume is androgen-dependent, so it tends to decrease with age, and this decrease may result in a blunted orgasm experience in older adults.

The presence of a normal sexual excitement phase is a prerequisite for male orgasmic disorder. In other words, if the absence of orgasm follows a decreased desire for sexual activity, an aversion to genital sexual contact, or a decreased lubrication-swelling response, diagnoses such as hypoactive sexual desire disorder, sexual aversion disorder, or male erectile disorder might be more appropriate, even if they all have a final common outcome (ie, anorgasmia, defined as failure to experience an orgasm).

Patients with male orgasmic disorder can achieve firm erections and have normal sexual intercourse with penetration. Some patients reporting male orgasmic disorder with intercourse can achieve orgasm through manual or oral stimulation or at least report orgasm through nocturnal emissions ("wet dreams").

When pharmacotherapy for delayed ejaculation is under consideration, it is important to eliminate iatrogenic causes, including medications (eg, alpha-adrenergic blockers or other antihypertensive, antidepressant, and antipsychotic agents). In the case of antidepressant-induced inhibited male orgasm, consideration may be given to switching to bupropion (also used as adjunctive therapy), mirtazapine, nefazodone, or vilazodone, which have fewer sexual side effects than selective serotonin reuptake inhibitors.

Adjunctive therapies should be considered. Alpha sympathomimetic agents (eg, ephedrine) have been used successfully in patients with retrograde ejaculation. Sildenafil and imipramine appear to be effective in psychotropic-induced male orgasmic disorder.

A psychodynamic-oriented treatment aims to explore and understand such factors, decrease secondary feelings such as anxiety and guilt, and correct negative cognitions that can result in psychologic inhibition and orgasmic dysfunction. A psychodynamic approach is recommended for persistent, treatment-resistant anorgasmia. Psychodynamic treatment can also be classified as a short-term approach as opposed to an open-ended approach. In some cases of orgasmic dysfunction, couples therapy may be indicated.

Read more about delayed ejaculation and male orgasmic disorder.