Diagnostic Considerations

Debilitating medical conditions that have the potential to decrease sexual desire and performance can result in secondary inhibited male orgasm. The most common medical conditions associated with sexual difficulties are diabetes mellitus and hypertension, possibly because of the microvascular and neurovascular changes that are inherent in these conditions.^[3]

Pain syndromes, shortness of breath, angina pectoris, and muscle weakness should be included in the differential diagnosis. Cigarette smoking can cause vascular insufficiency, as well as a decrease in intrapenile nitrous oxide (NO) levels. Excessive consumption of alcohol or the use of other recreational drugs can have a direct inhibitory effect on the genital neurovascular system, an indirect effect via increased prolactin or decreased testosterone production, or both.

The following classes of prescribed medications should be considered in the differential diagnosis^[3]:

Alpha-adrenergic blockers – Prazosin and terazosin (retrograde ejaculation)
Combined alpha- and beta-adrenergic blockers - Labetalol (inhibited ejaculation)
Sympathetic nerve blockers - Guanethidine (erectile dysfunction and retrograde ejaculation)
Antiulcer medications - Cimetidine (decreased libido)
Tricyclic antidepressants (via increased serotonin) - Amitriptyline, desipramine, doxepin, imipramine, maprotiline, nortriptyline, protriptyline (inhibited ejaculation); clomipramine was reported to induce anorgasmia within days of starting treatment, which persisted with minimal tolerance over 5 months of clomipramine therapy^[23])
Monoamine oxidase inhibitors (via increased serotonin) - Isocarboxazid, phenelzine, and tranylcypromine (inhibited ejaculation and decreased libido)
Selective serotonin reuptake inhibitors (via increased serotonin) - Fluoxetine (anorgasmia in 8-30%) and paroxetine (anorgasmia)^[24]
Other antidepressants - Venlafaxine (anorgasmia)^[24]
Neuroleptics (mainly via increased prolactin) – First-generation or typical (haloperidol, thiothixene, perphenazine, and trifluoperazine) and second-generation (risperidone)^[25](inhibited ejaculation, decreased libido)
Mood stabilizers - Topiramate (anorgasmia)^[26]

Workup

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