Orgasm MIA

Male Anorgasmia After Age 50

Retention of erection without orgasm (anorgasmia) is distinct from absent ejaculation. The two may coexist but are neurologically separate.

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Principal Causes

Cause	Mechanism	Reversible?
Low total or free testosterone	Reduced central orgasmic trigger	Usually
SSRIs, SNRIs, tricyclics	Serotonin-mediated inhibition of orgasm pathway	Often
Diabetic or post-surgical neuropathy	Impaired afferent signaling from penis/pelvis	Partially
Pelvic-floor hypertonicity or weakness	Disrupted expulsive reflex	Usually
Chronic masturbation with high-pressure grip	Desensitization of glans mechanoreceptors	Usually

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Diagnostic Steps

1. Morning serum testosterone (total + free) and SHBG.
2. Medication review—focus on psychotropics and alpha-blockers.
3. Neurological exam of perineum and bulbocavernosus reflex.
4. HbA1c and fasting glucose if not recent.

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Management Options

Intervention	Evidence Level	Notes
Testosterone replacement (if <350 ng/dL)	High	Improves latency in 60–70 % within 6 weeks
Switch SSRI → bupropion or add low-dose sildenafil	Moderate	Restores orgasm in ~50 % of cases
Pelvic-floor physical therapy	Moderate	Reverse Kegels + trigger-point release
High-frequency vibratory stimulation	Low–moderate	Bypasses peripheral neuropathy
Two-week sensory re-training	Low	No pornography, light touch only

Neurological red flags requiring prompt referral: absent perineal sensation, saddle anesthesia, or new urinary retention. Evaluate for cauda equina or pudendal neuralgia.

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Clinical Pearl

Orgasm is a central event; ejaculation is peripheral. Treat the brain and nerves first, the prostate second.