An Overview of Male Anorgasmia

Anorgasmia—sometimes referred to as Coughlan's Syndrome—is a type of sexual dysfunction characterized by the persistent inability to reach orgasm, even after sufficient sexual stimulation. It is less common in men than women, and is especially rare in younger men. Male anorgasmia is closely associated with delayed ejaculation, a condition that tends to be more prevalent in older men.

Though statistics vary, one study found that roughly 9% of men surveyed did not achieve orgasm during their last sexual encounter. That said, anorgasmia should not be confused with erectile dysfunction (the inability to achieve an erection) or low libido (the lack of sexual desire), although these conditions may co-exist.

The male orgasm is a complex neurobiological process that results from sexual activity (physical sensation) and arousal (cognitive awareness). It involves multiple hormones, organs, and nerve pathways.

The hormone testosterone, produced in the testicles, plays a central role in this process by enhancing the sexual desire (libido) that leads to arousal, erection, and ultimately orgasm. 

Generally speaking, there are four phases to male ejaculation, arousal, plateau, orgasm, and resolution/refraction. The orgasm phase is composed of emission and ejaculation, in which contractions of the penile muscle, anus, and perineal muscles help propel the semen from the body.

The main function of the male orgasm is to ejaculate sperm, although not all men will ejaculate during an orgasm. The male ejaculate, semen, is comprised of sperm cells and seminal fluid, which contains phosphorylcholine (an enzyme that aids in fertility) and fructose (which provides fuel for sperm).

During orgasm, the reward center of the brain (the cerebellum, amygdala, nucleus accumbens, and ventral tegmental area) is flooded with neurochemicals, inciting the intense emotional response associated with an orgasm.

At the same time, the lateral orbitofrontal cortex located behind the left eye shuts down entirely. This is the part of the brain that plays a role in judgment and self-control, which may explain why people often describe an orgasm as a state of utter bliss where nothing else seems to matter.

The most common, and obvious, symptom of male anorgasmia is the inability to achieve orgasm. However, there are actually four kinds of anorgasmia:

• Primary anorgasmia, in which climax has never been experienced
• Secondary anorgasmia, loss of the ability to reach orgasm due to an external factor
• Situational anorgasmia, an orgasm can only be achieved in specific situations, such as during oral sex or masturbation
• General anorgasmia, the inability to have an orgasm even though you have sufficient sexual stimulation and are sexually aroused

Besides issues related to advanced age, there are a number of possible psychological and physiological causes of male anorgasmia.

Psychological. Anxiety, stress, depression, fear, relationship difficulties, hostility —these can all contribute to anorgasmia. Other causes include:

• Sexual performance anxiety can affect men of any age and is cited as the most likely psychological cause of anorgasmia. It can be exacerbated by erectile dysfunction, which is more common in older men. Conversely, performance anxiety can also lead to erectile dysfunction by triggering extreme stress prior to and during sex.
• Negative attitudes towards sex typically start in early childhood, and are sometimes tied to a repressive religious upbringing or family/parental issues.
• Early sexual abuse and trauma
• Deeply rooted phobias, for example, haphephobia, which is the fear of being touched, and genophobia, which is a generalized fear of sexual intercourse, may lead to anorgasmia.
• Grief, such as the loss of a partner

In secondary anorgasmia, psychological causes are sometimes described as situational. You may be able to achieve orgasm with one partner but not another, or you can only have an orgasm under certain conditions. For example, if you and your partner are trying to conceive, the stress may result in anorgasmia.

Physiological. Medical conditions such as diabetes, hypertension, and low testosterone (hypogonadism) may inhibit orgasm. Other physiological causes include:

• Congenital absence of the bulbocavernosus reflex (in which the anal sphincter is meant to contract during ejaculation)
• Multiple sclerosis
• Prostate surgery (prostectomy)
• Diabetes, specifically diabetic neuropathy
• Medications, including antidepressants (especially SSRIs), antipsychotics, and opioids, may hamper sexual function and orgasm in men. In one study of approximately 2000 male patients evaluated for the sexual effects of anti-depressants, the inability to achieve orgasm was seven times higher in men who took SSRIs .

Secondary causes of male anorgasmia may include:

• Alcoholism
• Cauda equina syndrome, a rare condition in which exposed nerve fibers at the bottom of the spinal cord become irritated 
• Complications from genital surgery
• Endocrine disorders that affect hormonal balance
• Opiate abuse, especially heroin
• Prostate radiation therapy
• Spinal cord injury
• Untreated high blood pressure

The first step in dealing with male anorgasmia is to get an accurate diagnosis.This typically entails:

• A thorough physical exam
• A discussion of your social/religious history
• A review of the medications you take (and have taken in the past), including an evaluation of the timing of the anorgasmia as it pertains to when you started taking various medications

Your doctor, or a specialist you may be referred to, may prescribe a battery of laboratory tests to evaluate:

• Testosterone and TSH levels
• Hypothyroidism and hyperprolactinemia (which can occur when the pituitary gland overproduces prolactin)
• Endocrine function
• Thyroid hormone levels
• Penile sensitivity, which is especially relevant in men who lose penile sensation if they have conditions such as diabetes
• Biothesiometry, which examines the sensory threshold of vibratory tactile stimulation in men who experience loss of penile sensation
• Sympathetic skin testing to evaluate the sympathetic efferent flow to the skin of the genitals
• Sacral reflex arc testing to examine the motor and sensory branches of the pudendal nerve (which carries sensation from the external genitalia and the skin around the anus and perineum) and nerve roots .

Masturbatory style is another useful area of discussion since frequent masturbation may lead to anorgasmia. It may also be helpful to discuss your relationship status and how satisfied you are in your primary relationship (if you have one), and the role external stressors may be playing.

Treating anorgasmia may lead you to a number of specialists. Your primary physician may refer you to a urologist, psychologist, or other specialist.

Treatment depends on the underlying cause of your anorgasmia and will be guided by diagnostic findings and thorough evaluation. Some possible treatments:

• A change of medications may be recommended if your anorgasmia turns out to be drug-related.
• Testosterone replacement therapy, or the use of Dostinex (cabergoline), a dopamine promoter, can alter the hormonal response in some men with anorgasmia.
• Mood disorders, such as depression and anxiety, may require therapy and drug treatment (although care needs to be taken to minimize treatment-related sexual side effects).
• Psychotherapy may help overcome sexual performance anxiety or address past or recent traumas, both sexual and non-sexual.
• Couples counseling may help resolve relationship issues.
• A consultation with a sex therapist can directly address specific sexual issues that are interfering with your ability to achieve orgasm.

While popular erectile dysfunction drugs such as Viagra (sildenafil) and Cialis (tadalafil) don't help anorgasmia since their function is to increase blood flow to the penis, not to enhance libido, some men are able to enhance both an erection and orgasm with digital prostate massage. In this technque, a finger is inserted into the rectum prior to or during sex to manually stimulate the prostate gland, a walnut-sized gland that is considered by some to be the male G-spot.

Male anorgasmia, like any type of sexual dysfunction, can take a significant toll on your physical, psychological, and emotional life. The most important first step in addressing this condition is to seek diagnosis, rather than allowing shame or feelings of discomfort to eclipse or obscure your determination to deal with anorgasmia.

If you have had a radical prostatectomy, severe pelvic trauma, or have advanced multiple sclerosis, there may not be an effective treatment. In these cases, the best solution may be to focus on enhancing sexual pleasure and sexual intimacy, even if you can't reach orgasm. A psychologist or sex therapist can help you accept your condition and embrace a healthy sexual lifestyle despite anorgasmia.

We are all complex human beings, and in very few areas of our lives are we as vulnerable as around sexual health and functioning. Having a condition related to sexual dysfunction can tap into our early fears and experiences. Thankfully, we live in a time of access to excellent medical treatments, pharmaceutical approaches, and psychological awareness, any or all of which can guide you in your journey to resolve anorgasmia.