In our clinic we see patients suffering from neuropathy only. Inability to have an erection is a common finding, for instance in diabetes. Inability to experience an orgasm, while semen flows however, is rare.

Recently in my clinics I saw two male patients suffering from neuropathy, one due to diabetes and onther due to chemotherapy, both have the same issue: they ejaculate, but without any orgasmic feeling. They describe it like a candle going out instead of fireworks. This prompted me to write this entry on penile neuropathy.

Classification of ejaculatory disorders

Ejaculatory disorders are divided into 4 categories: 

1. premature ejaculation (PE),
2. delayed ejaculation (DE),
3. retrograde ejaculation, (RE) and
4. anejaculation/anorgasmia (A). 

The role of the nervous system in orgasm and ejaculation 

Case of anorgasmia in presence of ejaculation

In the internet only few cases can be found, and in medical databases reports are so rare that we could not find any. Here is a typical case description:

I'm a 29 yr old male, who hasn't been able to orgasm for the last 3yrs. Just before ejaculation I'm unable to sense any pressure or tension build up and the release of semen happens right away. I have been able to achieve orgasm before but then it just stopped and I've been miserable since then along with the broken marriage - our initimate life suffered alot due to this fact. I'm unable to achieve orgasm even through masturbation.My semen analysis is normal and so are my testosterone levels. My urologist mentioned that anatomically everything is fine with me, so did my endocrinologist and my sex therapist who confirmed it's not a psychological thing.

Neuropathy, ejaculation and orgasm 

A doctor commented on this case, and in our view gave a not totally correct answer:

Given that you are able to ejaculate, the nervous system connections necessary are present and functioning.

I am wondering if there may actually be some unrecognized psychological pressures that are changing your perceptions of the sensations of orgasm. It may also be that your body is now recognizing the sensations of orgasm differently such that you are not perceiving the sensation as an orgasm. Often, these changes find their root in some psychological issues as well.  

If afferent input is disturbed, as in neuropathy, it might be that nerve fibres bringing the sensible (afferent) input from the penis to the orgasm centre in the brain do not function as they should, and devoid of impulse input centrally the dopamine release in the nucleus accumbens will remain absent and thus the subjective feeling of orgasm is lacking. 

Penile neuropathy and anorgasmia

Thus, one of the symptoms less often mentioned of penile neuropatyy is this anorgasmia. It is the absence of orgasm, the pleasurable sensation that occurs in the brain generally simultaneously with ejaculation. And anorgasmia can be a physical phenomenon due to decreased penile sensation due to various forms of neuropathy. 

Treatment of anorgasmia due to penile neuropathy 

I have come across two suggestions: melaocorticoids and oxytocine spray during intercourse intranasally.

Refering to the latter we quote a citation from a website:

But not only does oxytocin love foreplay, it also triggers powerful orgasms. Research indicates that oxytocin causes the nerves in the genitals to fire spontaneously, and this leads to orgasm. During orgasm, male oxytocin levels quintuple, but this is nothing compared to female oxytocin levels. Women need more oxytocin if they are to reach an orgasm and during peak sexual arousal, oxytocin levels become stratospheric. If this point is reached and the woman’s brain is flooded with oxytocin, she may indeed be capable of achieving multiple orgasms. 

http://www.antiaging-systems.com/PRG-171/oxytocin-love-drug.htm 

A case of treatment-resistant male anorgasmia was described in literature, successfully treated with intracoital administration of intranasal oxytocin.^[1] In this article the authors described the following:

Because oxytocin has an ultra-short half-life of 2–3 minutes, the patient was instructed to use 20–24 IU during intercourse at the point when ejaculation was sought. Following its use, the patient ejaculated regularly (multiple times per week) after sexual intercourse; an effect that is persisting consistently for 8 months until the time of submission of this report. 

If anyone has suggestions of certain treatment modalities, I would be greatly interested.  

PS: I received a well appreciated suggestion form one of the authors of the paper discussed above I would like to share with you. He wrote:

I would recommend using oxytocin here. We used intranasal oxytocin at 20-25 IU that was obtained by writing a prescription to a compounding pharmacy that prepares the nasal spray solution. 

Literature on penile neuropathy 

Penile neuropathy. Study of 186 cases Authors: Amarenco G.; Le Cocquen A.; Bosc S .In: Annales de Readaptation et de Medecine Physique, Volume 42, Number 1, January 1999 , pp. 29-32(4)  

Jan M. Keppel Hesselink, MD, PhD, august 2010 

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