Anorgasmia Treatments?

[vanfanal]

Looking for some input from the hive mind here.

33yo with schizophrenia. Had him on inpt for about 4 months before he was finally stabilised on Abilify Maintena 400mg and olanzapine 10mg. But he’s had Anorgasmia since being on the meds. Not sure which one did it as he came to me on both. No erectile difficulties, he just can’t finish. I tried bupropion and mirtazapine, no effect. Right now I’ve left him on trazodone 50mg qhs and amantadine 100mg BID (amantadine to counteract D2 blockade and also for some EPS). Two prolactin levels have been normal, and normal testosterone too.

The family and I are hesitant to taper meds given how Sick he was and how much better he is now.

Any suggestions would be appreciated.

---

Members don't see this ad.

 

[splik]

Is it delayed ejaculation or is it anorgasmia? The two are distinct physiologically even though orgasm and ejaculation typically go together in men. Both are very difficult to treat when continuing offending drugs.
If delayed ejaculation, I would suggest increasing amantadine to 200mg BID. How high did you go w/ bupropion? you want to do 300mg. could also try buspirone up to 30mg BID. cyproheptadine has also been used but it can be a bit sedating. Is the pt sexually active or just masturbating?

 

[vanfanal]

I didn’t specifically ask, but I don’t think he achieves orgasm regardless of ejaculation. Although tbh, I’m not sure how I would differentiate them clinically??

Just masturbation. I took bupropion to 200mg BID. I’ll try titration amantadine as you suggest. Yeah, I was thinking maybe cyproheptadine as next step; I just wonder because as my PD used to say he may get improved sexual function but he’ll be asleep for it 😅

 

[adiradirim]

Any consideration for low dose PRN immediate release stimulants?

 

[mistafab]

Delayed orgasm and anorgasmia - PubMed

Delayed orgasm/anorgasmia defined as the persistent or recurrent difficulty, delay in, or absence of attaining orgasm after sufficient sexual stimulation, which causes personal distress. Delayed orgasm and anorgasmia are associated with significant sexual dissatisfaction. A focused medical...

pubmed.ncbi.nlm.nih.gov

this article provided a good overview of the subject and treatment options. I know you dont want to trial off these SGAs right now. Yohimbine was surprising to me. I was also surprised there was no mention of penile pumps which may increase penile sensitivity.

 

[Stagg737]

Has he been on sildenafil? Yes, it's used for ED, but there's also solid data that it's more helpful for anorgasmia than pretty much any other option we'd use. Data is pretty poor for most other options, but I have had success with SSRI-induced sexual dysfunction with bupropion, buspirone, cyproheptadine, and mirtazapine on more than one occasion. Ironically, I've also used Abilify a couple of times but obviously not really helpful here.

Delayed orgasm and anorgasmia - PubMed

Delayed orgasm/anorgasmia defined as the persistent or recurrent difficulty, delay in, or absence of attaining orgasm after sufficient sexual stimulation, which causes personal distress. Delayed orgasm and anorgasmia are associated with significant sexual dissatisfaction. A focused medical...

pubmed.ncbi.nlm.nih.gov

this article provided a good overview of the subject and treatment options. I know you dont want to trial off these SGAs right now. Yohimbine was surprising to me. I was also surprised there was no mention of penile pumps which may increase penile sensitivity.

Yes, though the evidence is not great. There's also weak evidence for ginkgo biloba and ephedrine. I've never used any of those 3, but have had a couple of cases where I discussed them with patients.

 

[FlowRate]

I didn’t specifically ask, but I don’t think he achieves orgasm regardless of ejaculation. Although tbh, I’m not sure how I would differentiate them clinically??

Just masturbation. I took bupropion to 200mg BID. I’ll try titration amantadine as you suggest. Yeah, I was thinking maybe cyproheptadine as next step; I just wonder because as my PD used to say he may get improved sexual function but he’ll be asleep for it 😅

The link provided above gets into it but usually orgasm without ejaculation in a schizophrenic patient is retrograde ejaculation. Particularly described when using risperidone/paliperidone due to alpha 1 antagonism. I had a patient who, despite orgasming, found masturbation unfulfilling due to retrograde ejaculation. I believe we tried midodrine but no luck.

I agree with above that you need to try at least 300mg bupropion XL for patients (at least with SSRI related dysfunction). I haven't seen an increase to 450mg lead to much interval improvement. I've never seen buspirone work for this purpose; most pts quit before they get to 30mg BID but those that do usually did not see improvement.

 

[clozareal]

Agree with the above. Most of the evidence of treatment (mostly non-RCTs) is in SSRI induced sexual dysfunction but incidence is high for FGAs and SGAs even in the CATIE trials.

1. Increase amantadine to 150mg BID or 200mg BID
2. Trialing bupropion XL 300mg
3. Trialing buspirone 30mg BID or 20mg TID
4. Trialing cyproheptadine 4-12mg 1-2 hours before sexual activity
5. Increasing trazodone to 100mg/day
6. Trialing methylphenidate 20-40mg
7. Trialing mirtazapine 15-30mg/day
8. Bethanechol 10-50mg/day to counteract anticholinergic effect of olanzapine
9. Consider bromocriptine 5-7.5mg/day, ropinirole 0.25mg/day up to 2-4mg/day, pramipexole 0.25mg/day up to 2.5mg/day
10. Interesting supplemental options:
    • Yohimbine (6mg/day) ± L-arginine glutamate (6/gday)
    • Ginkgo biloba 60-120mg/day
    • Maca root 1.5-3.0mg/day

Other than medication options, consider more behavioral approaches such as referring to a sex therapist, decreasing/abstaining from sexual activity including masturbation for a few weeks if he's desensitized himself, decreasing/abstaining from pornography consumption if he's visually desensitized himself.

 

[vanfanal]

Lots of things to try then. Thanks all.
I'll share if any successes.

 

[Merovinge]

Agree with the above. Most of the evidence of treatment (mostly non-RCTs) is in SSRI induced sexual dysfunction but incidence is high for FGAs and SGAs even in the CATIE trials.

1. Increase amantadine to 150mg BID or 200mg BID
2. Trialing bupropion XL 300mg
3. Trialing buspirone 30mg BID or 20mg TID
4. Trialing cyproheptadine 4-12mg 1-2 hours before sexual activity
5. Increasing trazodone to 100mg/day
6. Trialing methylphenidate 20-40mg
7. Trialing mirtazapine 15-30mg/day
8. Bethanechol 10-50mg/day to counteract anticholinergic effect of olanzapine
9. Consider bromocriptine 5-7.5mg/day, ropinirole 0.25mg/day up to 2-4mg/day, pramipexole 0.25mg/day up to 2.5mg/day
10. Interesting supplemental options:
    • Yohimbine (6mg/day) ± L-arginine glutamate (6/gday)
    • Ginkgo biloba 60-120mg/day
    • Maca root 1.5-3.0mg/day

Other than medication options, consider more behavioral approaches such as referring to a sex therapist, decreasing/abstaining from sexual activity including masturbation for a few weeks if he's desensitized himself, decreasing/abstaining from pornography consumption if he's visually desensitized himself.

Any of this help if it is, in fact, retrograde ejaculation as hypothesized above?

 

[clozareal]

Any of this help if it is, in fact, retrograde ejaculation as hypothesized above?

retrograde ejaculation would be having an orgasm without seminal fluid emission followed by cloudy urination. i think that OP's patient isn't having an orgasm at all let alone having a dry orgasm.

 

[clozareal]

Lots of things to try then. Thanks all.
I'll share if any successes.

Yep and if any of them don't work, you can consider going down on one of the doses of his medication. I would probably start with olanzapine first and if that doesn't work, then try to lower the maintena dose to 300mg qmonth. You can also consider urology referral.

 

[Crayola227]

retrograde ejaculation would be having an orgasm without seminal fluid emission followed by cloudy urination. i think that OP's patient isn't having an orgasm at all let alone having a dry orgasm.

Yes but probably good to make sure to specify with patient. Males don’t always differentiate or even really know They need to. A patient may describe either no orgasm/no ejaculation, or ejaculation no orgasm, or orgasm no ejaculation, all as ”failure to orgasm,” and they’re not all the same regarding tx approach so important to differentiate.

 

[Merovinge]

retrograde ejaculation would be having an orgasm without seminal fluid emission followed by cloudy urination. i think that OP's patient isn't having an orgasm at all let alone having a dry orgasm.

That's possible, but given the patient in question I think retrograde ejaculation should be high on the differential.

I asked a Urology fertility doc I know, they agree with FlowRate that this is caused by the alpha antagonism. They give males pseudophedrine 1-2 hours prior to planned ejaculation to treat this (e.g. to collect sperm for ICSI). If this is the cause and will help this young man continue on his antipsychotics I would consider PRN alpha agonists.

 

[littlefred]

I wonder why none of you guys have mentioned PDE-5 inhibitors for the treatment of anorgasmia?

There's evidence for it and patients with SRI induced anorgasmia, in my experience, respond well to them.

RCT showing evidence of the above: Efficacy and tolerability of tadalafil for treatment of erectile dysfunction in men taking serotonin reuptake inhibitors - PubMed

 

[calvnandhobbs68]

I wonder why none of you guys have mentioned PDE-5 inhibitors for the treatment of anorgasmia?

There's evidence for it and patients with SRI induced anorgasmia, in my experience, respond well to them.

RCT showing evidence of the above: Efficacy and tolerability of tadalafil for treatment of erectile dysfunction in men taking serotonin reuptake inhibitors - PubMed

@Stagg737 did.

Has he been on sildenafil? Yes, it's used for ED, but there's also solid data that it's more helpful for anorgasmia than pretty much any other option we'd use.

I've also used PDE-5 inhibitors for SSRI induced sexual dysfunction as long as there's no contraindications as well.

 

[clozareal]

I wonder why none of you guys have mentioned PDE-5 inhibitors for the treatment of anorgasmia?

There's evidence for it and patients with SRI induced anorgasmia, in my experience, respond well to them.

RCT showing evidence of the above: Efficacy and tolerability of tadalafil for treatment of erectile dysfunction in men taking serotonin reuptake inhibitors - PubMed

Yep this would be one of the first steps for me. I forgot to mention it above in my list.

 

[deleted1100659]

I wonder why none of you guys have mentioned PDE-5 inhibitors for the treatment of anorgasmia?

There's evidence for it and patients with SRI induced anorgasmia, in my experience, respond well to them.

RCT showing evidence of the above: Efficacy and tolerability of tadalafil for treatment of erectile dysfunction in men taking serotonin reuptake inhibitors - PubMed

i was scrolling through and was surprised it wasnt more mentioned. Can give small supply of it as well. Ive had some luck with wellbutrin XL but the other stuff not really, tbh. PDEs really seem to work the best if no contraindication, seems like the most simple solution.

As a side note i don't typically treat ED (I defer to primary for medical workup) but given that the medications appear to be causing it from what youve said (this being a more straightforward case), and he needs the current regimen to remain well, treating it would make sense.

 

[FlowRate]

As a side note i don't typically treat ED

This just sparked a tangent that I've had a several pts say they have "ED" and when they're outside of the typical demographic for that I usually ask some f/u questions. Many of those ultimately actually have performance anxiety and have found it helpful to discuss how they could work on that.

 

[deleted1100659]

This just sparked a tangent that I've had a several pts say they have "ED" and when they're outside of the typical demographic for that I usually ask some f/u questions. Many of those ultimately actually have performance anxiety and have found it helpful to discuss how they could work on that.

yep, exactly, thats why I added that disclaimer at the end of my post, haha.

I go on a good number of cruises. at the port in cozumel, right outside it, is a huge pharmacy that sells all the viagra, opiods, benzos, antibiotics you could imagine. Its always interesting seeing all the old men walking out with huge bags full of viagra

 

[Merovinge]

yep, exactly, thats why I added that disclaimer at the end of my post, haha.

I go on a good number of cruises. at the port in cozumel, right outside it, is a huge pharmacy that sells all the viagra, opiods, benzos, antibiotics you could imagine. Its always interesting seeing all the old men walking out with huge bags full of viagra

That's not just Mexico (which is preposterously permissive with pharmaceuticals in general), Viagra is OTC in much of Asia. I can definitely see it helping to avoid the stigma around discussion with a doctor but the medication can be fairly dangerous for men with significant comorbidity. Really not sure what the science behind the right amount of regulation is, but I will say it does seem like we do this better in the US.

 

[ObsequiousAplomb]

That's not just Mexico (which is preposterously permissive with pharmaceuticals in general), Viagra is OTC in much of Asia. I can definitely see it helping to avoid the stigma around discussion with a doctor but the medication can be fairly dangerous for men with significant comorbidity. Really not sure what the science behind the right amount of regulation is, but I will say it does seem like we do this better in the US.

Fairly dangerous? The only two contraindications are patients taking nitrates and people with known hypersensitivity. Aside from the very rare type of blindness and hypotensive events, what are you alluding to? My understanding is that the risks are very frequently over-emphasized.

 

[Merovinge]

Fairly dangerous? The only two contraindications are patients taking nitrates and people with known hypersensitivity. Aside from the very rare type of blindness and hypotensive events, what are you alluding to? My understanding is that the risks are very frequently over-emphasized.

Very old men with cardiac conditions or general cachectic states with the hypotension mainly. Not as common for psychiatrists, but other specialties see patients like this more.

I agree the risks in younger to middle aged individuals are over-emphasized, I have even prescribed the medication myself as a CAP for SSRI induced dysfunction despite supremely limited experience prescribing it.