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General - Physiology of ejaculation (ejaculation)

The ejaculation is divided into three sections:

Emission
During this phase, there is a contraction (contraction) of the smooth muscle fibers of the male genital tract. That Testicular tubules, epididymis and vas deferens transport the sperm cells into the prostatic tubule (i.e., between the internal and external sphincters) and the seminal vesicles (vesicula seminalis) and the prostate gland empty their respective secretions into this section of the urethra. Simultaneous occlusion of the internal bladder sphincter prevents retrograde (backward) ejaculation into the urinary bladder. Due to the accumulation of the ejaculate in the area of ​​the prostatic urethra, this pressure causes a steady pressure increase in this area, whereby the second phase of ejaculation is reflexively initiated.

This phase is mediated by the so-called andrenergic system by the release of the messenger noradrenaline. In addition, local messengers, such as e.g. Oxytocin, endothelin and adenosine triphosphate (ATP) are involved. Glans penis feelers trigger the entire process by relaying tactile stimuli to the brain. In this area, after triggering with the stimuli in the prostatic urethra, the ejaculation reflex is triggered.

Ejaculation
This is the "point of no return", i. that feeling when ejaculation is unavoidable. It is a reflex-controlled process, which leads to an explosive ejection of the ejaculate due to the pulsatile contraction of the pelvic floor.

The brain transmits the signals of the ejaculation reflex via the sympathetic ganglia in the spinal cord (T12-L3) to both somatic and sympathetic and parasympathetic pathways. The so-called serotonergic system in the brain can influence or inhibit the triggering of this ejaculation reflex. Here, the starting point of the drug therapy of premature ejaculation - serotonin reuptake inhibitors and serotonin agonists - can be seen. In contrast, so-called. The D2 receptors in the brain act as an enhancer of the ejaculation reflex. The pathways that mediate the rhythmic contractions of the male genitalia and pelvic floor are parasympathetic and enter the pudendal nerve via the spinal cord (S2-4). Recent studies have shown that locally the messengers NO (nitrite oxide) and CO (carbon monoxides) play a role.

Orgasm
This is the sexual climax or the feeling of sexual satisfaction. Along with the og. rhythmic contractions of the pelvic floor, but also of the genital area and the rest of the body. In addition, there is an increase in the pulse rate in this phase. of blood pressure and respiratory rate u. -depth. The orgasmic life is also associated with different degrees of altered consciousness.


Ejaculation praecox, syn: premature ejaculation

Inability to control the timing of ejaculation. It usually comes shortly after penetration of the penis despite minimal stimulation for ejaculation. In particularly severe cases, the ejaculation occurs before the penetration (ejaculatio praecox ante portas) in contact with the penis. Timing is not possible because of the different sexual sensations.

In principle, two forms of ejaculatio praecox are distinguished:

Primary ejaculation praecox
Begins with the inclusion of sexual relationships and is mostly life-long.

Secondary ejaculatio praecox
Appears after a primarily undisturbed sex life at a later date.
Often there is a temporal relationship to a change of partner or to the manifestation of an erectile dysfunction.

Frequency
# Man's most common sexual dysfunction
# The exact frequencies are very high and range from 30 to 75% of all men
# sexually inexperienced and young men are more likely to be affected, i. also with age this disorder decreases
# often at the beginning of a new relationship

Causes
# Mental factors undoubtedly dominate, but also an organic predisposition has to be considered
# Psychological factors

# Sexual inexperience; dominant sexual partner
# Achievement pressure, "success force"
# Generalized timidity
# Fear of failure, especially the first time or new relationship
# so-called castration anxiety
# Ambivalent attitude or ambivalent attitude towards women
# negative sexual conditioning (e.g., time-pressed sex for fear of being discovered by parents)
# Child development in a sexually taboo environment

# Organic causes

# Hypersensitivity of the glans penis (glans), decreased vibration threshold in the glans and penile shaft skin
# Violation of the sympathetic nervous system (accidents, operations)
# Pelvis (ring) fractures
# Enlargement of the prostate (BPH), Z.n. Prostatitis (prostatectomy)
# Urethritis (urethritis)
# Diabetes mellitus
# Arteriosclerosis

Therapy

Conservative therapy, sex therapy

Squeeze handle
If the man feels that the ejaculation is imminent, the sexual partner or himself, until the onset of pain, exerts pressure on the glans with his fingers. This should lead to an interruption of the reflex arc.

intermittent intrusion

Medical therapy

Sympatholytics (alpha and / or beta-blockers)
are due to a disturbance of the sympathetic fibers regulated ejaculation
e.g. Phenoxybenzamine (sometimes associated with retrograde ejaculation)
e.g. Tamsulosin (sometimes accompanied by a lack of ejaculation)

Tricyclic antidepressants
By increasing the serotonin concentration in the brain they are supposed to inhibit ejaculation
e.g. Clompipramine, amitriptyline, imipramine

Dopamine receptor antagonists
By blocking the D1 / 2 receptors, inhibitory effect on ejaculation is achieved
e.g. haloperidol

Serotonin reuptake inhibitors
e.g. fluoxetine
Axiolytika

Locally effective drug therapy

locally anesthetic or sensibility-reducing ointment / cream
e.g. Prilocaine lidocaine cream, SS cream
e.g. SS cream (success rate was stated as 82%); this herbal medicine is not available in Germany
In order to achieve no sensory-reducing effect in the vagina (vagina), the cream residues on the penis should be removed before coitus

Operative therapy

# possible in principle, but not recommended
# selective transection or destruction of nerve fibers of the glans penis (glans)

Psychological therapy

# Sexual counseling
# Group therapy
# Couple counseling


Ejculatio deficines (Delayed ejaculation)

Depending on the degree of severity, a delayed or delayed ejaculation (anejaculation) can be differentiated. The latter may be due to backward ejaculation (s.u.) or may occur in the case of emission loss (i.e., lack of emission of semen into the posterior urethra). Detailed information on the ejaculation process can be found [here].

In anejaculation, the first step of seed ejection - the emission phase - is disrupted, i. the semen is not expelled into the posterior (prostatic urethra).

Ejaculatio retrograda (backward ejaculation)
Definition

Absence or decreased ejaculation due to an intact internal bladder sphincter muscle for anatomical and / or neurological reasons.

Frequency

A lack of ejaculation is usually based on a retrograde ejaculation. This is the cause in 0.3 to 2% of men unable to produce.

Causes

Undesirable side effect of drug therapy with
# Psychotropic drugs (neuroleptics, antidepressants, serotonin reuptake inhibitors, MAO inhibitors)
# centrally effective antihypertensive agents (antihypertensive drugs), e.g. Reserpine, alpha-methyldopa

Congenital "structural" diseases
# Seekgangverschluss, Samengangszyste
# missing seminal vesicles (agenesis)
# Urethral valves
# Utriculus cysts

Disorders of nerve transmission
# autonomic neuropathy, e.g. in diabetes mellitus
# Diseases of the central nervous system (spinal cord, brain). Spinal cord injury is the most common cause in men around the age of 30 years.
# Disruption of the pathways due to small pelvic or retroperitoneum masses, see iatrogenic causes

Traumatic damage
# Pelvic fracture
# Urethral tears
# Puncture injuries (traumatic, but also due to unusual sexual practices)

Iatrogenic
# Z.n. transurethral prostate resection (TUR-P) and / or bladder neck surgery (slitting)
# Z.n. Operations on the large vessels (aorta, vena cava) and lymph node stations through concomitant injury to the sympathetic nerves of the hypogastric plexus. The most frequent cause here is the so-called retroperitoneal lymphadenectomy (syn lymph node dissection, RLA), which is performed in some men with testicular tumors.
# Z.n. Surgery on the rectum (rectum resection / amputation)

Idiopathic (i.e., cause is unknown)

Diagnosis

Anejaculation lacks seed ejection from the urethral orifice. In addition, no sperm can be detected in post-orgasmic urine.

In retrograde ejaculation, however, the seed output may be completely absent or only diminished. The feeling of orgasm is usually preserved. In the urine obtained in the following, sperm cells can be detected.

Therapy

Causal therapy, e.g. Avoidance of potential causes
# Consistent treatment of diabetes mellitus to prevent the manifestation of autonomic neuropathy
# Conversion of the medication in a proven relationship to the ejaculation disorder
# Use of modified, nerve sparing, retroperitoneal lymph node dissection
# Use of intraopeartic electrostimulation methods to identify the nerve tracts

# Neurally induced anejaculation can be used with sympathomimetics
# Attempt of electrostimulation, especially in paraplegic patients with good success
# if necessary surgical treatment (for example, removal of a cyst in the area of ​​the seed gland)
# In case of retrograde ejaculation and existing fertility, sperm from postmastubic urine can be used for assisted fertilization (fertilization)