Ejaculation dysfunction

　　First, excessive ejaculation and premature ejaculation:Premature ejaculation is the most common type of ejaculation disorder, mostly functional, caused by psychological factors. For example, those who are accustomed to masturbation in their youth, aiming for rapid climax; when the female partner dislikes sexual intercourse and wants to end the sexual act quickly; worrying about the health risks of sexual activity; having a low frequency of sexual intercourse or long-term sexual repression; or fear of sexual failure leading to anxiety, which can form a conditioned reflexive rapid response. As for the possible organic factors that may cause premature ejaculation, such as neurological diseases (multiple sclerosis, spinal cord tumors, seizures, or organic lesions of the cerebral cortex), inflammation of the lower urinary tract and genitals, there is no definitive conclusion.

　　Second, ejaculation deficiency

　　1. Disorders of seminal fluid production

　　(1) Local factors, such as congenital absence of seminal vesicles, congenital absence of bilateral vasa deferentia, and severe bilateral seminal vesiculitis, etc.

　　(2) Endocrine factors, such as Kallmann syndrome (with anosmia and hypogonadism), congenital anorchia, Klinefelter syndrome, postoperative bilateral orchiectomy, and bilateral testicular torsion, etc.

　　(3) Medication-related factors: such as in patients with prostate cancer undergoing estrogen therapy.

　　2. Ejaculation failure

　　(1) Central nervous system ejaculation disorder, involving lesions in the lateral lobes of the brain, injury to the spinal cord from T12 to L3 and the sacrum, leading to ejaculation disorder due to the inability of the ejaculation center to be excited and activated.

　　(2) Postoperative complications such as postoperative neurapraxia, sympathectomy, diabetes, pelvic surgery, retroperitoneal lymph node dissection, and main-iliac artery vascular surgery, where nerve impulses cannot be transmitted or the affected nerves cannot produce effects due to damage.

　　(3) Drug-induced ejaculation dysfunction, including some central nervous system depressants, antihypertensive drugs, etc., such as guanethidine, methyldopa, clomipramine, haloperidol, phentolamine, chlorphenamine hydrochloride, chlordiazepoxide, phenothiazine, and thioridazine (methylthioridazine).

　　(4) Obstructive ejaculation dysfunction, congenital ejaculation duct obstruction, traumatic ejaculation duct obstruction, and tuberculous ejaculation duct obstruction, leading to seminal fluid not being able to be expelled.

　　3. Retrograde Ejaculation

　　(1) Dynamic factors, congenital or acquired lesions causing dysfunction of the bladder neck contraction, leading to retrograde ejaculation of seminal fluid, such as congenital wide bladder neck and postoperative endoscopic or open bladder neck incision or Y-V plasty. It is reported that retrograde ejaculation occurs in about 64.5% of blood perineal prostatectomy, 59.5% of transurethral cases, and 71.8% of suprapubic bladder cases. Diabetes can cause autonomic neuropathy, sympathectomy, and low-dose sympathectomy blockers, which can often cause retrograde ejaculation, such as the use of reserpine, guanethidine, which causes smooth muscle contraction to be weak and seminal fluid retrograde.

　　(2) Obstructive etiology, stricture of the membrane urethra caused by urethral trauma and various inflammatory urethral strictures. Long-term difficulty in urination causes the proximal urethra to dilate, the neck of the bladder to decrease tension, and the distal resistance to increase, leading to retrograde ejaculation.

　　1. Ejaculation dysfunction can lead to male infertility.The combination of sperm and egg is a necessary condition for normal reproduction. If a man has ejaculation dysfunction, he cannot inject seminal fluid into the female vagina, which means there is no combination of sperm and egg, thereby causing the woman to be unable to conceive, leading to infertility and sterility.

　　2. Ejaculation dysfunction can induce abnormal ejaculation.Strongly inhibiting anejaculation by interrupting sexual intercourse, if this is done frequently, it may lead to ejaculation dysfunction. Mild cases may experience delayed ejaculation and unsatisfactory ejaculation, while severe cases may not ejaculate at all.

　　3. Ejaculation dysfunction can induce frequent seminal emission.During the sexual intercourse process, with the occurrence of sexual冲动, the secretion of accessory glands increases, and the seminal fluid volume increases sharply. If sexual intercourse is interrupted, these seminal fluids will have no place to go and will necessarily be excreted through seminal emission, which is easy to produce seminal fluid and induce frequent seminal emission, which is not good for physical health.

　　4. Ejaculation dysfunction can induce blood in seminal fluid.General and persistent congestion of the seminal vesicle, the capillaries on the seminal vesicle wall will dilate and rupture, leading to blood in seminal fluid.

　　1. Premature Ejaculation

　　During sexual intercourse, if a man ejaculates without inserting the penis into the vagina, it is definitely premature ejaculation. Generally speaking, healthy young adults usually ejaculate within 2 to 6 minutes of sexual intercourse, but ejaculation in a shorter time is still considered normal. The exact time for normal ejaculation from the beginning of intercourse, after the penis is inserted into the vagina, is not yet determined. Generally speaking, this period varies with age and physical condition and other factors, so there is no objective standard for premature ejaculation at present. In addition to typical premature ejaculation, many so-called premature ejaculation patients in clinical practice actually have no abnormalities, but just think that the sexual intercourse time is not long enough. It should be distinguished between functional and organic etiology. Functional anejaculation often has seminal emission and can ejaculate manually, with psychological trauma or lack of sexual knowledge without neurological disease, diabetes, and trauma, surgery history.

　　二、不射精症

　　患者在性生活时，阴茎可毫无困难地勃起，也高度渴望性高潮的释放并受到足够的性刺激，但即使性交很长时间，仍不能达到性高潮而不能射精，不射精的诊断关键在于：

　　1、阴茎在阴道中无法射精。

　　2、患者在性交过程中没有性高潮出现，原发性不射精需注意区别原发性绝对不射精和原发性选择性不射精，原发性绝对不射精在清醒状态下从未有过射精，多由性无知或性压抑引起，但平时可有遗精现象，原发性选择性不射精则在手淫时或由女方用手或口进行非性交刺激时能射精，这是一种无意识的性抵触，对阴道内射精有不正确的看法造成的。

　　三、逆行射精

　　指有性高潮和射精，但精液流入膀胱，尿道口无精液流出，性高潮后尿液检查可发现精子和果糖。

　　1、性生活过度是导致射精障碍的原因之一，虽说性生活是人类正常的生理需求，但也有一个度的问题。有些男性朋友一天几天性生活。这样特别容易造成阴茎充血过度，引起慢性炎症导致射精疼痛的发生。另外，由于阴茎持续受高强度的刺激，使阴茎长期处在一个高敏感的状况之下。这样会破坏男性正常的射精感觉。长此下去，就会因疼痛引起射精障碍生。

　　2、保持良好心态：有的人情绪波动比较大，愤怒也好，忧郁也好，造成人的气血、筋络不通畅，尤其是肝经瘀阻，中医认为睾丸是肝经的循经部位，如果情绪波动大，造成的肝经瘀阻，也会造成射精疼痛。所谓心顺而气顺，气顺就是和谐性生活的境界。

　　3、戒除烟酒：长期抽烟，酗酒等都是造成男性射精疼痛的因素之一，如果适当的饮酒和吸烟，没有什么问题，但是大量的酗酒、吸烟，长期之后，造成前列腺、精囊、尿道充血，在性生活的时候，也可以出现射精疼痛。还有少食辛辣、肥腻的食品。

　　4、日常饮食要清淡：男性朋友们要防治射精障碍首先必须要均衡饮食，少食辛辣刺激性食物。对于患有射精障碍的男性朋友，饮食上不妨多吃一些桃仁粥、橘皮饮、桃仁墨鱼汤、赤小豆粥等以补肾、柔肝、通窍、利湿、活血和调补气血为主食物的食物。

　　5、参加适当的锻炼：Men who want to prevent ejaculation dysfunction can take advantage of the weekend rest time to participate in outdoor physical exercises that are beneficial to the body and mind. Appropriate exercise can not only accelerate the speed of new metabolism and enhance physical fitness, but also help improve the quality of sexual life and prevent infertility caused by ejaculation dysfunction.

　　6. Sex education and sex psychological treatment:Most patients with ejaculation dysfunction can achieve immediate effects through explanations of sexual knowledge, elimination of adverse psychological influences and incorrect concepts, and guidance on sexual behavior.

　　7. Electrovibration and electric stimulation therapy:About 50% of patients with ejaculation dysfunction can be cured once. Most patients can recover normally after repeated treatment.

　　First, general examination

　　1. Determine the concentration of hormones such as FSH, prolactin, LH, and testosterone in the blood to clarify whether there are endocrine diseases such as hypogonadism and hyperprolactinemia.

　　2. For those who do not ejaculate during sexual intercourse, a condom test can be performed, observing the presence of seminal fluid in the condom after sexual intercourse and conducting relevant examinations. A vaginal smear test after sexual intercourse shows no seminal fluid or sperm.

　　3. For retrograde ejaculation, check for the presence of sperm and fructose in the urine after sexual intercourse.

　　Second, special examination

　　Patients with premature ejaculation can undergo a nerve excitability test, including the determination of the somatosensory evoked potential of the dorsal penile nerve, the determination of the penile vibration threshold, and the method of determining the latency period of the bulbocavernosus reflex. For those who do not ejaculate during sexual intercourse, a seminal duct造影 can be performed to determine whether there is obstruction.

　　Therapeutic diet for ejaculation dysfunction:

　　1. 250 grams of freshwater prawns, 150 grams of chives, stir-fried according to usual methods.

　　2. Six sparrow eggs, 60 grams of sweet rice wine lees, cooked and eaten after boiling.

　　3. 500 grams of mutton, 100 grams of goji berries, cooked into soup for eating.

　　4. Eight sparrows, 100 grams of green garlic, cooked or stir-fried according to usual methods.

　　5. Three dogs' penises, dried and ground into powder, take 3 grams each time, taken with yellow wine; for those who do not drink, it can also be taken with warm water.

　　6. One pair of pork kidneys, 30 grams of walnuts, cooked and eaten.

　　First, treatment

　　1. Treatment of premature ejaculation

　　(1) Knowledge guidance on sexual life: Newlyweds should understand the common knowledge about sex. Women tend to experience sexual climax later than men, and only through long-term sexual intercourse and appropriate movement can they reach the climax of desire. Usually, men reach climax before women, and the end of sexual intercourse is a physiological difference. This should not be misunderstood as premature ejaculation. If both partners understand this physiological difference and choose the right time for sexual intercourse with each other's cooperation, it can also extend the duration of sexual intercourse, making both parties satisfied with sex. Developing a regular lifestyle with normal living and moderate sexual behavior can help prevent premature ejaculation.

　　(2)性感集中疗法: It includes two aspects, one is to focus on the sexual sensation during intercourse; the other is psychological therapy, which aims to help the male partner achieve complete relaxation during contact with his spouse, establish an intimate environment between couples, and share sexual pleasure together, rather than mere sexual intercourse. Only in this way can the patient be completely relaxed through training, and most premature ejaculation patients can achieve significant improvement.

　　（3）阴茎挤压法：又叫耐受性训练，是通过女方对男子的阴茎加以刺激，提高男子射精的阈值，从而达到延长性交时间，控制射精的目的。捏挤疗法由女方操作比由男方自己操作效果好。本法的重要性在于调节男女双方的性和谐，在加强男方射精抑制力的同时，也能提高女方自己的性快感。

　　①方法：女方用拇指、示指、中指捏挤阴茎头，拇指放在包皮系带的部位，示指、中指放在阴茎冠状沟缘上方。轻捏挤4s，然后突然放松，即为1次捏挤。

　　②注意事项：

　　A、捏挤压力适当，一般以男方对捏挤的力量以不感到疼痛为宜。同时依据勃起的程度来调节捏挤力的大小。勃起坚、性感明显者，可稍用力捏挤；勃起不坚或松软者，可轻轻用力捏挤。

　　B、方向正确，捏挤时施加压力的方向是从前向后的，而不是从一侧向另一侧。否则，不能收到良好效果。

　　C、用指腹的稳压力作用于阴茎头，而不是用指甲捏掐或搔划。

　　③步骤：开始单纯捏挤，不进行性交。当男方阴茎勃起后，女方按上述方法捏挤4～5次；如男方勃起后进入性高潮，近于射精时，女方应在1～2min内捏挤阴茎头4～5次。这样可以使勃起的阴茎暂时变软，避免射精，可以提高射精的刺激阈。

　　采用上述方法，经过1周左右，男方性欲增强时，可在性交时施行捏挤术。即在性交时阴茎勃起后，女方捏挤4～5次，将阴茎插入阴道内，男方暂时不要用阴茎摩擦阴道，男女双方都把注意力引到其他部位的情感上。待阴茎在阴道内稍搁置后，将阴茎拔出，再次施行捏挤4～5次，再把阴茎插入阴道内。此时阴茎可以在阴道内摩擦，待近于快射精时，再次拔出阴茎，进行捏挤，如能在阴道内搁置4～5min时，可以摩擦阴道，并增加速度，让其射精。经过2周捏挤训练后，可延长射精的时间，心理状态也可得到改善。也可改变捏挤部位，如捏挤阴茎根部，效果也很明显，这样可以减少阴茎拔出的麻烦。使之完全进入正常的性生活阶段。本法只适用于单纯早泄者，对伴有原发病的早泄或勃起功能障碍症者效果不能巩固，而应及时治疗原发病，才能巩固疗效。

　　（4）药物治疗：

　　①内服药：酚苄明（酚苄胺）10mg，2～3次/d，可消除输精管、射精管的蠕动，延长射精及性交时间。其他还有氯米帕明、帕罗西汀等。

　　②外用药：性交前阴茎头部外涂药物，降低此处神经末梢感受器的敏感性，如1％丁卡因，1％达克罗宁油膏，或20％可卡因，性交前5～10min涂于阴茎龟头表面。或用3％氨基苯甲酸乙酯冷霜外涂。

　　2、不射精症的治疗

　　（1）性治疗：治疗目的在于消除高级中枢对射精反射的抑制，消除过去形成的与不良意外事件相联系的消极条件反射。治疗的基本原理是应用心理学的“系统脱敏”的基本策略。不射精治疗中采用的情境脱敏方法是由夫妻双方在家中进行的。让患者获得放松的方法是性幻想。性治疗的一般原则是患者在治疗最初2～3天仅局限于性激发，只激发性欲不进行性交。第二阶段尝试射精，在性激发的前提下进行手淫射精，由自我手淫逐渐过渡到妻子用手刺激射精，此后阴茎的刺激可在阴道的入口处进行，用阴道分泌物作润滑，由妻子刺激激发，待性高潮即将来临时立即插入阴道使之射精，如此反复，逐渐达到性高潮而在阴道内射精。

　　（2）药物治疗：采用左旋多巴0.25g/次，3次/d，能抑制催乳素水平并增加血中生长素和肾上腺素水平，从而达到兴奋大脑皮质作用。

　　（3）其他治疗：

　　①电动按摩器诱发射精，无论心理性或器质性不射精均可在医生的指导下进行治疗。

　　②对症治疗：包括包皮环切、戒烟酒、改善居室环境、增强体质等。

　　③针灸治疗：对某些患者可收到明显效果。

　　3、逆行射精的治疗

　　（1）药物治疗：药物治疗的前提是患者的膀胱颈组织完整和具有括约能力，最适合的治疗对象是糖尿病引起的外周神经损害造成的逆行射精，也用于腹膜后淋巴结清扫术后逆行射精的患者。

　　应用拟交感神经药物如咖啡君（去甲麻黄碱），也可用马来酸溴苯吡胺8mg，2次/d，对糖尿病患者的逆行射精有效。性交前1～2h服用去甲苯咪嗪70～150mg，可暂时恢复患者前向射精功能。

　　（2）姑息治疗：逆行射精就诊的最根本的诉求是解决生育问题，设法满足其生育要求就是姑息治疗的主要内容。

　　由于尿液过酸或过碱或低张均可杀死逆行排入膀胱的精子，保护并收集精子做夫精人工授精即可解决生育问题。具体方法如下：

　　①减少摄入液体量，性交前4h服用碳酸氢钠3g，排空膀胱，手淫或性交达到性高潮，把尿液排入容器，可直接进行人工授精。

　　②采集精液前1天开始服用碳酸氢钠以碱化尿液，前1天2g，当天3g，分3～4次服用，性生活前充分饮水，在性生活前1h饮水500ml，手淫或性交达高潮，10min内排尿，将尿液与精液混合物以2000～3000转/min，离心10min，然后将精子沉淀物用2～3ml精子孵育液悬浮，行夫精人工授精（AIH）。

　　③ If it is difficult for the patient to collect, it is necessary to collect through intubation if necessary.

　　Second, Prognosis

　　Premature ejaculation is a common male sexual dysfunction and also one of the most difficult diseases to define. The essence of premature ejaculation is the lack of reasonable voluntary control over ejaculation in men. The vast majority of the causes of premature ejaculation are psychological or psychological. Although it was previously believed that reproductive system inflammation or other injuries could cause premature ejaculation by affecting the ejaculation center due to local stimulation, recent research has shown that this conjecture is difficult to be proven. The treatment of premature ejaculation mainly lies in training, the purpose of which is to make men concentrate their attention on the feeling of an impending climax during sexual activity. The main component of this training treatment is the sexual experience of the sexual partner, therefore, both partners must take responsibility for successful treatment, must have an honest attitude towards sex, and eliminate the mystery of sexual behavior, so that sexual life can be completely relaxed and share the pleasure of sex together, avoid the sole pursuit of sexual intercourse, and make both partners work together to explore and share spiritual and physical pleasure. The treatment effect of premature ejaculation is the most satisfactory among all male sexual dysfunction treatments.

　　The incidence of patients with anejaculation seems to be higher in Chinese people than in Westerners. 70% of these patients are caused by lack of sexual knowledge and incorrect sexual behavior. Due to the lack of sexual knowledge, there is a general deficiency in sexual stimulation techniques, and in addition, the excessive emphasis on the preciousness of seminal fluid tends to suppress ejaculation in men subconsciously. From the perspective of treatment, sex therapy is the main treatment method, and it is necessary to understand the patient's medical history in detail, such as any specific reasons that affect their ejaculation or interfere with sexual expression; the patient's preferred sexual love style and sexual fantasy content; whether there were successful experiences in the past and the environment in which they were located, etc., and must be individualized. Those who are eager to have children can collect sperm through masturbation for artificial insemination.

　　The diagnosis of retrograde ejaculation is relatively easy. From the perspective of treatment, palliative treatment should be paid more attention to, because the vast majority of patients' main complaints when seeking medical treatment are infertility. Artificial insemination with husband's sperm, or insemination into the cervical canal or uterus after sperm washing can be performed until in vitro fertilization technology solves the fertility problem. Patients without fertility requirements can be untreated.