I. Definition and classification Non-ejaculation means that the penis can be strongly erected during sexual intercourse and inserted into the vagina, but the ejaculatory reflex and orgasm do not occur. It often leads to male infertility. The ejaculation process is a complex physiological and psychological phenomenon. After the erection and insertion of the penis into the vagina, it is necessary to enhance the sexual stimulation (expanding the imagination of sexual enjoyment in the mind, and the penis thrusting rapidly and substantially in the vagina to strengthen the stimulation of the sexual sensory area at the first level) in order to complete the entire ejaculation reflex. There are many causes of non-ejaculation, which can be divided into organic and functional non-ejaculation. Those who have never ejaculated in the waking state are considered to have primary ejaculation, while those who have had normal ejaculation in the vagina and then gradually developed ejaculation are considered to have secondary ejaculation. Functional ejaculation is mainly due to sexual ignorance in China, due to lack of sufficient sexual knowledge, lack of correct understanding of the process of sexual life, or the sexual education received from childhood distorts sex as dirty, filthy and obscene. In the sexual life is not active, resulting in the first level of sexual feeling area can not get enough stimulation, can not reach the stimulation required for ejaculation intensity, can not trigger the ejaculation reflex, at the same time, because in the long-term sexual life can not reach orgasm, resulting in a decline in libido, further aggravating the condition of non-ejaculation. Some of them are due to the spouse’s fear of pain during sexual intercourse, fear of damaging the vagina and limiting the male penis’s pumping, resulting in a long-term state of inhibition of the ejaculatory center. Malignant stimuli such as exertion, noisy family environment, cold treatment by the wife and psychosocial trauma may all lead to functional ejaculation. Organic ejaculation is caused by lesions in the nervous system that weaken the conduction of sexual stimulation or prevent the conduction of sexual stimulation impulses to the ejaculatory center, or by lesions in the ejaculatory center itself that cause the failure to issue ejaculatory impulses, or by weak contraction of the effector organ in the ejaculatory reflex that prevents the discharge of semen. The common causes are as follows: (a) Spinal cord injury and neurological lesions Spinal cord injury is the most common cause of organic non-ejaculation. In spinal cord injuries above T10, the innervation of the vas deferens, seminal vesicles, ejaculatory ducts, prostate, bladder neck, etc. is still intact due to its inferior spinal cord still having autonomic reflexes, and the ejaculatory center located in the sacral medulla is intact, and the sensory fibers of S2 to S4 and the motor nerves controlling The ejaculatory center in the sacral medulla is intact, the sensory fibers of S2 to S4 and the motor nerves controlling the contraction of the ejaculatory muscles are not damaged, and the fibers of the ejaculatory integration center are also intact; in this group of patients, the entire ejaculatory reflex exists, but only the regulation of the cerebral cortex and other higher centers is lost. In spinal cord injuries that occur below T10, the ejaculatory reflex no longer exists due to disruption of the circuitry of the ejaculatory reflex, disruption of the connection between the integrating center and sympathetic neurons (T10-L2), or damage to one of the sub-integrating centers that weakens the afferent impulses of sympathetic fibers and the efferent impulses of motor fibers. Neurological lesions are also often the cause of non-ejaculation, such as diabetic peripheral neuropathy and multiple sclerosis involving peripheral neuropathy. (B) Surgery and trauma Retroperitoneal lymph node dissection often occurs in malignant tumors of the testis. The traditional retroperitoneal lymph node dissection removes lymph connective tissue from the adrenal gland up to the inguinal ring, and the left and right ureteral borders as a whole, including the upper part of the affected spermatic cord. The thoracolumbar sympathetic nerve trunk (T12-L5) and the inferior abdominal nerve are often damaged during surgery. Statistics show that approximately 75% of patients who undergo retroperitoneal lymph node dissection will suffer from ejaculation due to injury to the thoracolumbar sympathetic trunk and the inferior ventral nerve. In place of the previous bulk removal, selective lymph node dissection with nerve preservation and reversal dissection, where the lymph nodes and lymphatics are removed with minimal damage to the inferior abdominal nerve plexus, the incidence of postoperative ejaculation decreases significantly to about 10%-15% without affecting the surgical outcome or increasing the recurrence rate of the tumor. Most of these patients can often have normal orgasmic experiences (afferent sensory impulses and increased cortical stimulation will activate the ejaculatory integration center), and some patients can even feel rhythmic muscle contractions around the urethra during ejaculation. Lumbar sympathetic ganglionectomy, aortic C-iliac artery surgery, prostatectomy, and radical abdominoperineal rectal cancer may damage the thoracolumbar sympathetic trunk as well as the inferior ventral nerve leading to the development of ejaculation. Impaired sensory impulse afferents to the sexual receptors due to pelvic fractures or blocked ejaculatory impulse efferents can also lead to the development of ejaculation. (c) Alcohol and drugs Excessive alcohol consumption, chronic alcoholism or excessive use of sedative drugs can also lead to ejaculation by inhibiting the sensitivity of the higher ejaculatory centers in the cerebral cortex. Taking α1C adrenergic receptor blockers can lead to weakened contraction of the epididymis, vas deferens, ejaculatory duct, bulbocavernosus muscle, and urethral cavernosus muscle, and failure to discharge semen, triggering the production of ejaculation. Certain toxic substances such as chronic cocaine intoxication, chronic nicotine intoxication, and morphine addiction can also lead to non-ejaculation. Common drugs that can affect ejaculatory function are shown in Table 6C4. III. Clinical manifestations Most patients with non-ejaculation can have erection and vaginal insertion, have sufficient sexual stimulation but lack the action of ejaculation and orgasm during intercourse, and some patients can have sexual dreams and seminal emission. Male patients will gradually experience a loss of libido and a significant reduction in the frequency of intercourse, but rarely will they seek medical attention for non-ejaculation, mostly due to infertility after marriage. Most of them end up with penile weakness after a period of sexual intercourse, while some of them fail to ejaculate even after their erections are exhausted. Diagnosis and Differential Diagnosis As people’s research on the etiology, physiology and pathophysiology of ejaculation continues to advance, many methods have been developed to detect and evaluate the ejaculatory function of patients, and these methods certainly have important auxiliary diagnostic value for the diagnosis of ejaculation, but detailed medical history and comprehensive physical examination are still the most important basic principles for the diagnosis of ejaculation. (In order to achieve this task, it is necessary to first clarify what the patient really means by “not ejaculating” and to understand the patient’s ejaculation through his or her sexual partner. 1. The main purpose of the sexual history is to clarify the following aspects: ① the time of onset and duration of ejaculation, and whether there is a history of normal ejaculation in the female vagina. ②Whether there is a time and place restriction for non-ejaculation. ③The development of erectile dysfunction, such as whether ejaculation function was normal before. ④Whether there are any obvious environmental and emotional factors for the non-ejaculation, such as obvious marital discord, increased stress in life and work, and whether the environment of sexual life is safe and warm. ⑤ Whether the occurrence of non-ejaculation is selective in terms of sexual partners. ⑥The patient’s family history and reproductive history. 2, disease or surgical history: mainly ask about diseases that have a more obvious relationship with ejaculation ability, neuropsychiatric system diseases (mainly including history of spinal cord injury, multiple sclerosis, depression, etc.), endocrine system diseases, especially diabetes, genitourinary system diseases (including prostatitis, urethral cleft, history of abnormal penile erection, etc.). The presence or absence of retroperitoneal lymph node dissection, radical rectal cancer resection, TURP, and major vascular surgery below the abdominal aorta should be understood in detail during medical history questioning. 3, drug history: mainly ask in detail whether there is a history of taking drugs affecting the ejaculatory function, the type of drugs taken, the time of taking drugs, the dose of drugs taken, etc. should be asked in detail, whether there is a history of alcohol addiction and psychoactive drug abuse, common drugs affecting sexual dysfunction such as anti-hypertensives, digitalis preparations, antipsychotics, hormonal drugs, etc. should be the focus of inquiry. (B) Physical examination A systematic and comprehensive physical examination can provide etiological evidence for the diagnosis of erectile dysfunction, thus making appropriate and targeted treatment possible. In order to detect possible pathologies, targeted and focused examinations should be performed for common signs of endocrine system diseases, neurological diseases and cardiovascular system diseases, and of course, the genitourinary system is indispensable. Most patients with ejaculation have damage to the nervous system, so it is more important for patients with ejaculation to undergo a neurophysiological examination, a measurement of the sensory threshold of penile vibration, or a measurement of the somatosensory evoked potential of the dorsal penile nerve to understand whether there are functional changes in the nervous system. Patients with a history of ejaculation, a neurological examination with objective criteria of neurological impairment, and neurological impairment that can explain the etiology of ejaculation, or patients with symptoms of chronic alcoholism and a clear history of drug use, can be initially diagnosed with organic ejaculation, and functional ejaculation can only be diagnosed after the factors of organic impairment in patients with ejaculation have been excluded. The patient should be distinguished from the following diseases: 1. Retrograde ejaculationPatients with retrograde ejaculation do not have semen ejected from the urethral orifice during sex, but the patients themselves can often feel the ejaculation-like rhythmic contraction of the perineal muscles and can have the experience of orgasm, and sperm and fructose can be found after urine centrifugation after sex. The patient without ejaculation does not have the feeling of ejaculation and the experience of orgasm, and the urine centrifugation after sex is negative for sperm. 2, azoospermia with low semen volume When patients with ejaculatory duct stenosis or vas deferens syndrome or congenital bilateral (unilateral) vas deficiency, although they can have the feeling of ejaculation, but the semen volume is often <1ml, and there is often no sperm in the semen, and no sperm cells can be found in the urine examination after sex, the diagnosis can be confirmed by ejaculation and vasography to clarify whether there are lesions of the vas deferens and ejaculatory ducts. The diagnosis can be confirmed by ejaculation and vasography. If necessary, penile vibration stimulation can also be used for diagnostic treatment.