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354 Challenging Concepts in Urological Surgery
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A large study of men with sexual dysfunction identified that patients reporting PE had higher
testosterone levels compared to those with DE. Patients with DE had a higher prevalence of
hypogonadism compared to those with PE suggesting testosterone influenced the ejaculatory
pathway.9 It is therefore important to consider endocrine disorders as an underlying cause, as
correction of these conditions may reverse the ejaculatory or orgasmic dysfunction.
Expert comment Psychosexual elements
At this stage, further questions should be directed at investigating a psychosexual cause that would benefit
from counselling. If the DE/ DO is situational as opposed to consistent, occurring only during sexual
intercourse with a certain partner and not during masturbation or with other partners, this is more likely
to suggest a psychosexual element. A patient’s masturbatory techniques or practices or psychosexual
triggers can be embarrassing to openly discuss but must be explored. Hyperstimulation from excessive
masturbation has been linked to DO and increased frequency of masturbation linked to decline in penile
sensitivity.10 Asking these questions can identify patients who would benefit from psychosexual counselling.
To investigate his concerns further, a transrectal ultrasound (TRUS) scan was organized to look for an obstructive cause of his anejaculation/ reduced ejaculatory volume.
A post- void orgasmic urine was requested looking for the presence of sperm to suggest
RE as the underlying pathology. For his concerns of suboptimal erectile function, sildenafil, an oral phosphodiesterase type 5 inhibitor was prescribed to help improve
his erectile function. Psychosexual counselling was offered, but the patient declined.
At his follow- up appointment, the TRUS scan showed a closed bladder neck, and
no evidence of ejaculatory duct obstruction. A post- orgasmic urine analysis of 28 mL
of urine showed sperm at a concentration of 0.4 × 106 million/ mL suggesting RE.
Learning point Causes and diagnosis of RE
Out of the ejaculatory disorders, RE is typically organic and results from failure of the bladder neck
to close, causing retrograde passage of seminal fluid into the bladder. The diagnosis can be made
in patients with absent or low ejaculatory semen volume (defined as <1.5 mL by the World Health
Organization) with a post- orgasmic urine sample indicating the presence of sperm. No clear sperm
concentration has been defined. It can be partial or complete, where sperm is seen in both the
antegrade ejaculate and post- ejaculatory urine sample in partial retrograde ejaculation and only in the
post- ejaculatory urine sample with absent antegrade ejaculation when complete (Table 36.1).
Table 36.1 Causes of RE
Neurological Spinal cord injury/ shock
Retroperitoneal lymph node dissection
Pelvic surgery— radical prostatectomy, cystectomy, abdominoperineal resection
Diabetes mellitus
Multiple sclerosis
Cerebrovascular accident
Anatomical Bladder outflow obstruction
Medication Alpha- adrenergic blockers
Typical antipsychotics
Clozapine (atypical antipsychotic)
Congenital Incompetent bladder neck (lifelong RE)
Idiopathic
Data from: Hendry. Disorders of ejaculation: congenital, acquired and functional. Br J Urol. 82, 331– 341 (1998). Segraves,
R. T. Effects of psychotropic drugs on human erection and ejaculation. Arch Gen Psychiatry. 46, 275– 284 (1989).
4,11
The trial of sildenafil made an improvement to his erectile function only. He still re-
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mained bothered by delayed orgasm with predominantly dry ejaculates. He was given
a trial of yohimbine to be titrated from 5 mg up to a maximum of 40 mg once daily. He
was also given pseudoephedrine 60 mg titrated from once a day to three times a day,
to start the day before anticipated sexual activity. This was prescribed to manage his
delayed orgasm and ejaculatory dysfunction.
Learning point Management of RE
In this case, the focus was on treating a bothersome symptom rather than achieving sperm for
conception. Around 2% of patients presenting to fertility clinics are as a result of RE. Alpha- adrenergic
agonists, such as pseudoephedrine, can be used to increase bladder neck tone and promote
antegrade ejaculation; however, there is no established treatment protocol.12 It is the author’s practice
to start on 60 mg pseudoephedrine the day before intended sexual activity. This can be increased
up to 60 mg three times a day. Imipramine, a serotonin and noradrenaline reuptake inhibitor with
anticholinergic activity, can also be used at 25– 75 mg taken approximately 3 hours before sexual
intercourse. Urinary sperm retrieval can also be attempted from a post ejaculatory urine specimen,
usually after alkalization or dilution or urine with fluids, and the retrieved sperm is then used for
assisted reproductive technology (ART).13 Penile vibratory stimulation or electroejaculation can
achieve an antegrade ejaculate in patients with a neurogenic cause such as diabetes or spinal injury.
Samples obtained through these methods can then be used for ART in the form of intravaginal
insemination, intrauterine insemination, in vitro fertilisation (IVF) or intracytoplasmic sperm injection
(ICSI). Surgical techniques to bring about bladder neck closure are rarely performed but have been
reported with successful outcomes of achieving antegrade ejaculation14 (Table 36.2).
355Case 36 Ejaculatory orgasmic disorders
Table 36.2 Medical and surgical options for treatment of RE
Alpha- adrenergic agonist Pseudoephedrine hydrochloride
Midodrine
Anticholinergics Imipramine (tricyclic antidepressant)
Surgical Bladder neck collagen injection
V- Y plasty bladder neck reconstruction
Young– Dees bladder reconstruction
Data from: Jefferys, A., Siassakos, D. & Wardle, P. The management of retrograde
ejaculation: a systematic review and update. Fertil Steril. 97, 306– 312.e6 (2012). Mehta,
A. & Sigman, M. Management of the dry ejaculate: a systematic review of aspermia and
retrograde ejaculation. Fertil Steril. 104, 1074– 1081 (2015).
Learning point Causes and treatment of orgasmic disorders
Orgasm occurs as a consequence of physical and mental sexual stimulation and arousal. The onset
is usually triggered by ejaculation and stimulated by the increase in pressure within the prostatic
urethra that occurs with closure of the bladder neck and expulsion of the seminal fluid.10 A man’s
ability to orgasm after every sexual encounter has been reported to decrease with age. This can
be as a result of comorbidities such as diabetes or hypothyroidism, decreased stamina of both the
patient and partner to reach completion, and age- related changes in penile sensitivity.
reporting loss of penile sensation, neurophysiological investigations such as biothesiometry or
pudendal somatosensory evoked potentials can be done to assess the sensory vibratory perception
threshold and afferent signals from the dorsal nerve of penis respectively10 (Table 36.3).
Often a definite cause cannot be found, and empirical treatment with oral medication can be
trailed. There are no large randomized controlled studies in the empirical treatment of AO/ DO.
At the author’s institution, yohimbine is used. Yohimbine is titrated up from 5 mg to a maximum
of 40 mg daily dosing. Obtained from the Pausinystalia johimbe tree, it is an alpha- 2- adrenergic
receptor blocker and 5HT1a receptor agonist. It can be used to achieve orgasm and can be used
in patients on SSRIs experiencing symptoms of sexual dysfunction. A small study of 29 patients
10,15
In patients
356 Challenging Concepts in Urological Surgery
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demonstrated 19 out of 29 were able to achieve orgasm with or without the assistance of penile
vibratory stimulation.
Other drugs that have been trialled in small studies include bupropion, amantadine, cyproheptadine,
and oxytocin.
Table 36.3 Causes and treatment of delayed orgasm/ anorgasmia
Endocrine Hypogonadism
Pharmacological Antipsychotics
Decreased penile sensation Age related
Penile hyperstimulation Excessive masturbation
Psychosexual Psychosexual counselling
Data from: Jenkins, L. C. & Mulhall, J. P. Delayed orgasm and anorgasmia. Fertil Steril. 104, 1082– 1088 (2015).
16
17
Cause Treatment
Treat underlying disorder; aim to
Hyperprolactinaemia
Hypothyroidism
Antidepressants, SSRIs
Opioids
Diabetes
Lifelong
Personalized masturbatory
techniques
normalize hormone levels
Liaise with lead physician to assess if
change to alternative is appropriate
Optimize HbA1c
Neurology referral in cases of abnormal
neurophysiological investigations
Psychosexual counselling for
masturbation retraining
At his next follow- up visit, the patient had not noticed an improvement in the
ability to orgasm with daily yohimbine and had therefore stopped it after 1 month. He
felt the pseudoephedrine had made some improvement when taken at a dose of 60
mg twice daily started the day before intended sexual activity. He had come to terms
with his ejaculatory dysfunction as he was not aiming to ejaculate to conceive, but
rather to ‘feel like a man’. He wanted to continue with the pseudoephedrine on an asrequired basis. He admitted that he was under a lot of pressure recently and therefore
these issues were currently not at the forefront. Finding time to test the effect of the
medications was difficult. A further follow- up appointment was organized in 6 months
and the option of psychosexual counselling re- visited again, which the patient said he
would consider for the next appointment.
Discussion
In both ejaculatory and orgasmic disorders there can be an overlap in the neurotransmitters and hormones identified in association with these disorders at each end of the
spectrum.
DE or AO has been associated with hypothyroidism and hypogonadism, whereas
PE has been associated with hyperthyroidism and high levels of testosterone.
Treatment of the hormonal imbalances have also demonstrated an element of reversibility. Assessment of the patient should be systemic, focusing not only not only on
the genital examination but also looking for signs of endocrine disorders during the
examination. Laboratory tests should be performed for prolactin, testosterone and thyroid hormones. This should be performed in the morning between 8- 11am and fasted
to capture peak levels of testosterone which has a circadian variation.
A review of a patient’s medication history is important as antipsychotics and anti-
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depressants, mainly SSRIs, that increase serotonin levels have been found to inhibit
or delay the ejaculatory pathway. If this is identified, we suggest liaising with the
patient’s lead physician or psychiatrist to discuss an alternative that may not elevate
serotonin levels in the brain.
Similarly, in patients with PE, the same principle can be applied in an attempt to
delay ejaculation. Dapoxetine is the only licensed SSRI for use in PE and should be
used with caution in young patients and avoided in patients with a significant psychiatric history. For Pharmacological management should not be a first- line management
in PE, however, and treatment should start with psychosexual therapy with a focus on
behavioural strategies to delay ejaculation. The stop– start technique and the squeeze
technique are often taught in an attempt to maintain a level of sexual excitement
below the threshold for ejaculation.18 Topical anaesthetics such as eutectic mixture of
local anaesthetics (EMLA) cream or lidocaine/ prilocaine cream or spray or lidocaine
only spray have been found to be effective in increasing intravaginal ejaculatory latency time.19 Tramadol, a serotonin and norepinephrine reuptake inhibitor and opioid
receptor agonist, has also been used as off- label treatment for PE. There is, however,
limited long- term data and further information is needed regarding its potential for
addiction and side effects.20 In patients reporting lifelong PE, behavioural management
and psychosexual counselling should be offered in combination with pharmacological
treatment.
In patients who experience organic ejaculatory dysfunction secondary to pelvic
surgery or retroperitoneal lymph node dissection, spinal cord injury, or diabetes, explore the patient’s wishes regarding fertility. This will help guide management towards sperm retrieval should the use of sympathomimetics fail to achieve antegrade
ejaculation. Various techniques such as electroejaculation or surgical sperm retrieval
can be employed to retrieve sperm subsequently used in ART such as IVF or ICSI.
Anejaculation should be differentiated from RE with a post- orgasmic urine test looking
for the presence of sperm. If sperm is identified in the urine, the sperm can be extracted
and used in ART. A TRUS or multiparametric magnetic resonance imaging (MRI) of
the prostate will also be useful to for look for an obstructive cause with consequent
ejaculatory duct obstruction causing reduced ejaculatory volume or anejaculation.
Explore an underlying psychological cause and offer psychosexual counselling for
those presenting with orgasmic or ejaculatory disorders or both. Patients can adopt
techniques to focus on improving their current problem either to delay or hasten ejaculation and orgasm. Where appropriate, it is often helpful to offer treatment to the
couple to focus on issues together.
357Case 36 Ejaculatory orgasmic disorders
A final word from the expert
Managing patients with orgasmic and ejaculatory disorders can be challenging and it is important
to manage patient expectations from the start. Often, they can be multiple and cause the patient
embarrassment and distress when trying to vocalize their concerns. I find it useful to tease out their
most problematic symptom and focus on the time of onset, triggers such as life events or new
medications that may have been started simultaneously, and if it is situational or consistent. This
line of questioning prioritizes symptom management and helps to identify a psychosexual issue.
358 Challenging Concepts in Urological Surgery
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My next focus is to identify the reason the patient has sought help. This is to assess if the
symptoms are causing personal distress only or if fertility is also an issue. This will help focus the
line of treatment options if fertility is the priority.
Asking personal questions about masturbation techniques or excessive masturbation can
be challenging but this may indicate hyperstimulation as a cause and unless these questions
are asked, patients may not be aware or accept this as an issue. Therefore, if psychosexual
counselling is simply offered without a cause, patients may decline in the belief that there
is purely a pathological cause for their symptoms. Access to a psychosexual counsellor
is important to offer to patients with an ejaculatory or orgasmic disorder. For example,
masturbation retraining, cognitive therapy, and psychosexual counselling are not within the
armamentarium of the general urologist and such patients should have access to specialists who
are able to offer this.
During follow- up visits when assessing the efficacy of medications, revisit the timing and dose
of administration. On occasion, patients may not have done this correctly and is worth revisiting
prior to marking them as unresponsive to the medication.
References
1. Wein AJ, Kavoussi LR, Campbell MF, eds. Campbell- Walsh Urology. 10th ed. Philadelphia,
PA: Elsevier Saunders; 2012.
2. Collazos J. Sexual dysfunction in the highly active antiretroviral therapy era. AIDS Rev.
2007;9(4):237– 245.
3. Di Sante S, Mollaioli D, Gravina GL, et al. Epidemiology of delayed ejaculation. Transl
Androl Urol. 2016;5(4):541– 548.
4. Hendry WF. Disorders of ejaculation: congenital, acquired and functional. Br J Urol.
1998;82(3):331– 341.
5. Giuliano F. Impact of medical treatments for benign prostatic hyperplasia on sexual function. BJU Int. 2006;97(Suppl 2):34– 38.
6. Waldinger MD, Olivier B. Utility of selective serotonin reuptake inhibitors in premature
ejaculation. Curr Opin Investig Drugs. 2004;5(7):743– 747.
7. Alwaal A, Breyer BN, Lue TF. Normal male sexual function: emphasis on orgasm and ejaculation. Fertil Steril. 2015;104(5):1051– 1060.
8. Carani C, Isidori AM, Granata A, et al. Multicenter study on the prevalence of
sexual symptoms in male hypo- and hyperthyroid patients. J Clin Endocrinol Metab.
2005;90(12):6472– 6479.
9. Corona G, Jannini EA, Mannucci E, et al. Different testosterone levels are associated with
ejaculatory dysfunction. J Sex Med. 2008;5(8):1991– 1998.
10. Jenkins LC, Mulhall JP. Delayed orgasm and anorgasmia. Fertil Steril.
2015;104(5):1082– 1088.
11. Segraves RT. Effects of psychotropic drugs on human erection and ejaculation. Arch Gen
Psychiatry. 1989;46(3):275– 284.
12. Shoshany O, Abhyankar N, Elyaguov J, Niederberger C. Efficacy of treatment with pseudoephedrine in men with retrograde ejaculation. Andrology. 2017;5(4):744– 748.
13. Jefferys A, Siassakos D, Wardle P. The management of retrograde ejaculation: a systematic
review and update. Fertil Steril. 2012;97(2):306– 312.
14. Mehta A, Sigman M. Management of the dry ejaculate: a systematic review of aspermia and
retrograde ejaculation. Fertil Steril. 2015;104(5):1074– 1081.
15. Rowland DL. Penile sensitivity in men: a composite of recent findings. Urology.
1998;52(6):1101– 1105.
16. Adeniyi AA, Brindley GS, Pryor JP, Ralph DJ. Yohimbine in the treatment of orgasmic dys-
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function. Asian J Androl. 2007;9(3):403– 407.
17. Abdel- Hamid IA, Elsaied MA, Mostafa T. The drug treatment of delayed ejaculation. Transl
Androl Urol. 2016;5(4):576– 591.
18. Jannini EA, Ciocca G, Limoncin E, et al. Premature ejaculation: old story, new insights.
Fertil Steril. 2015;104(5):1061– 1073.
19. Martyn- St James M, Cooper K, Ren K, et al. Topical anaesthetics for premature ejaculation: a systematic review and meta- analysis. Sex Health. 2016;13(2):114– 123.
20. Martyn- St James M, Cooper K, Kaltenthaler E, et al. Tramadol for premature ejaculation: a
systematic review and meta- analysis. BMC Urol. 2015;15:6.
359Case 36 Ejaculatory orgasmic disorders
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SECTION 12
Emergency urology
and trauma
Case 37 Testicular torsion controversies
Case 38 Priapism
Case 39 Renal trauma
Case 40 Bladder and ureteric trauma
Case 41 Penile fracture
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CASE
37
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Testicular torsion
controversies
Lona Vyas and Mohamed Noureldin
Expert commentary Suks Minhas
Case history
A 19- year- old male presented to the accident and emergency department at 4 pm with
right- sided scrotal pain. He was a student and was taking regular antidepressants. He
previously had a left inguinal hernia repair and left orchiopexy, for undescended testis
during childhood. He had developed sudden onset of pain, 11 hours previously at 5
am, which was severe enough to wake him up from his sleep. He took paracetamol
tablets but this did not improve his pain. He denied having any history of trauma
related to his testis. He had noticed some frequency in passing urine on the day of
presentation.
Learning point Incidence
The two main peaks of age of torsion are perinatally and prepubertally. The annual incidence of
testicular torsion (TT) is 4.5 in 100,000 males between 1 and 25 years of age. It is more common in the
age group between 16 and 24 years, with an incidence of 2.8 per 100,000 males per year. According
to Mansbach and his colleagues’ database registry, approximately 86% of torsions occur above the age
of 10 years. Moreover, about one- third of all the cases will result in orchidectomy.
cannot be reliably excluded in adults of any age.
1,2
However, torsion
Learning point Aetiology
The mechanism of TT remains an enigma. There are a number of theories to explain this.
Extravaginal torsion
This occurs in perinatal life as the testes are descending into the scrotum, the tunica vaginalis (TV) has
not fully developed and therefore is not fixed to the inner layer of the scrotum. This congenital defect
may allow the spermatic cord to twist proximal to the TV leading to torsion. A reported association
with extravaginal torsion is a long mesorchium together with cryptorchidism, which can present as an
incarcerated inguinal hernia.
Intravaginal torsion and the bell clapper deformity
In the bell clapper deformity (BCD), the epididymis and testis lie intravaginally leaving them hanging
freely within the vaginal sac and risks subsequent twisting of the cord. The evidence, however, is
contentious. Reports suggest that 12% of the male population have the defect, though far fewer boys
have TT related to this.5 However, Scorer and Farrington reported about 80% of patients who had
torsion also had a BCD.5 Another interesting association is that 78% of boys with a BCD have the same
deformity on the contralateral side. Therefore, this places the other testis at an increased risk of torsion
in the future.
3,4
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