madman
Super Moderator
Dr. Khera!
Abstract
Introduction
Anorgasmia is a poorly understood phenomenon defined as either a lifelong or acquired consistent inability to achieve ejaculation. Despite the prevalence of anorgasmia, there is currently no established treatment for the condition.
Aims
To report a unique case of a patient with lifelong anorgasmia who was able to achieve his first orgasm with off-label use of flibanserin.
Methods
The present case study relies on the patient’s self-report and a review of the relevant literature. The patient provided written informed consent.
Results
A 28-year-old male presented to our office with complaints of lifelong anorgasmia, without any signs of erectile dysfunction. He reported good libido and energy levels and denied any urinary symptoms or history of depression. The patient failed medical management with numerous off-label medications, including bupropion and bremelanotide. Despite having received 4 or 5 sex therapy sessions over 3 months, the patient reported that this treatment approach was not effective. Off-label use of flibanserin was then initiated, and after 28 to 32 doses over 4 weeks, he achieved his first orgasm. Notably, the patient experienced nocturia and insomnia. The follow-up International Index of Erectile Function score marginally improved by 2 points without any improvement in the overall satisfaction subdomain.
Conclusion
This case highlights the challenges of managing anorgasmia and anejaculation in a young male patient. A stepwise approach involving pharmacotherapy and sex therapy was not successful. However, the off-label use of flibanserin ultimately resulted in the patient achieving his first orgasm, albeit with some side effects. Further studies are needed to evaluate the efficacy and safety of flibanserin in men for this indication.
Introduction
An orgasm is a fundamental component of human sexual function, and its absence or impairment can lead to distress and affect the overall quality of life. Although the neurobiological processes underlying orgasm have been extensively studied, disorders of orgasm remain a challenging clinical problem. The orgasm is a complex neurobiological process that results from sexual activity and/or arousal. During ejaculation, the brain processes the sensation of pressure buildup within the posterior urethra, leading to seminal fluid emission and contraction of the periurethral musculature, which triggers an orgasm.1
Anorgasmia—a disorder characterized by a perceived absence of orgasm experience, regardless of whether physiologic concomitants of ejaculation occur—is a common form of orgasmic dysfunction.2 Primary anorgasmia, which persists throughout life, is a rare disorder arising from an individual’s first sexual experience.1 Despite being an uncommon complaint, primary orgasmic disorders in men have an estimated prevalence of 1.5 per 1000.3 However, owing to underreporting, the true prevalence is likely to be higher.
Flibanserin, a Food and Drug Administration (FDA)–approved medication, has been studied as a treatment for sexual dysfunction in pre-and postmenopausal women. It was first approved in 2015 with an indication to treat acquired, generalized hypoactive sexual desire disorder. 4 Further postmarketing studies have suggested that this medication may also improve orgasmic function in women. 5 However, research on the use of flibanserin in men is limited, and theoretically, it could be used as a treatment for the same condition. This case report describes a young male who experienced his first orgasm after flibanserin treatment and contributed to the limited data on the use of flibanserin in men. This case highlights the potential role of flibanserin in the treatment of male orgasmic dysfunction and underscores the need for further research in this area. This case report was deemed exempt, in accordance with institutional board review, although the patient provided full consent.
Discussion
Flibanserin, which is a serotonin 5-HT1A receptor agonist and 5-HT2A receptor antagonist, was prescribed for the patient.9 Although flibanserin is approved by the FDA for the treatment of hypoactive sexual desire disorder in premenopausal women, it is not approved for use in males.4 Nevertheless, the off-label use of flibanserin was considered in this case because of its potential to improve sexual function through its central effects on the serotonergic system and its proven improvement in orgasmic subdomain scores in the Female Sexual Function Index in women with hypoactive sexual desire disorder.5 After 28 to 32 doses of flibanserin, the patient achieved orgasm and ejaculation during masturbation for the first time. It has been shown that men and women share similar neural circuitry activation and deactivation during an orgasm. This process involves the activation of multiple brain zones, including the prefrontal cortex, as well as dopaminergic pathways from the ventral tegmentum to the nucleus accumbens.10 Owing to this shared circuitry, flibanserin may improve orgasmic function in men as well as women. Excitatory neurotransmitters such as dopamine and norepinephrine, which enhance orgasmic function, act in the prefrontal cortex. Conversely, inhibitory neurotransmitters that impair orgasmic function, such as serotonin, act in the same brain region. Evidence suggests that flibanserin increases the release of dopamine and norepinephrine while reducing the release of serotonin in prefrontal brain areas. This is consistent with the same sites of abnormal neuroimaging findings described in patients with reduced sexual interest and desire. As such, the mechanism of action of flibanserin can be described as the downstream release of dopamine and norepinephrine and the reduction of serotonin in these brain circuits, thereby regulating reward processing in premenopausal women with reduced sexual interest and desire.9
Conclusion
This case presents a challenging situation of lifelong anejaculation and anorgasmia in a young male with no apparent cause. The use of bupropion and sex therapy was not effective, and bremelanotide was ineffective in achieving an orgasm. The off-label use of flibanserin was eventually successful in achieving an orgasm and ejaculation in the patient, but further studies are required to validate its safety and efficacy in males. This case highlights the importance of considering less common causes of sexual dysfunction and exploring new treatment options when more common etiologies have been ruled out.
Abstract
Introduction
Anorgasmia is a poorly understood phenomenon defined as either a lifelong or acquired consistent inability to achieve ejaculation. Despite the prevalence of anorgasmia, there is currently no established treatment for the condition.
Aims
To report a unique case of a patient with lifelong anorgasmia who was able to achieve his first orgasm with off-label use of flibanserin.
Methods
The present case study relies on the patient’s self-report and a review of the relevant literature. The patient provided written informed consent.
Results
A 28-year-old male presented to our office with complaints of lifelong anorgasmia, without any signs of erectile dysfunction. He reported good libido and energy levels and denied any urinary symptoms or history of depression. The patient failed medical management with numerous off-label medications, including bupropion and bremelanotide. Despite having received 4 or 5 sex therapy sessions over 3 months, the patient reported that this treatment approach was not effective. Off-label use of flibanserin was then initiated, and after 28 to 32 doses over 4 weeks, he achieved his first orgasm. Notably, the patient experienced nocturia and insomnia. The follow-up International Index of Erectile Function score marginally improved by 2 points without any improvement in the overall satisfaction subdomain.
Conclusion
This case highlights the challenges of managing anorgasmia and anejaculation in a young male patient. A stepwise approach involving pharmacotherapy and sex therapy was not successful. However, the off-label use of flibanserin ultimately resulted in the patient achieving his first orgasm, albeit with some side effects. Further studies are needed to evaluate the efficacy and safety of flibanserin in men for this indication.
Introduction
An orgasm is a fundamental component of human sexual function, and its absence or impairment can lead to distress and affect the overall quality of life. Although the neurobiological processes underlying orgasm have been extensively studied, disorders of orgasm remain a challenging clinical problem. The orgasm is a complex neurobiological process that results from sexual activity and/or arousal. During ejaculation, the brain processes the sensation of pressure buildup within the posterior urethra, leading to seminal fluid emission and contraction of the periurethral musculature, which triggers an orgasm.1
Anorgasmia—a disorder characterized by a perceived absence of orgasm experience, regardless of whether physiologic concomitants of ejaculation occur—is a common form of orgasmic dysfunction.2 Primary anorgasmia, which persists throughout life, is a rare disorder arising from an individual’s first sexual experience.1 Despite being an uncommon complaint, primary orgasmic disorders in men have an estimated prevalence of 1.5 per 1000.3 However, owing to underreporting, the true prevalence is likely to be higher.
Flibanserin, a Food and Drug Administration (FDA)–approved medication, has been studied as a treatment for sexual dysfunction in pre-and postmenopausal women. It was first approved in 2015 with an indication to treat acquired, generalized hypoactive sexual desire disorder. 4 Further postmarketing studies have suggested that this medication may also improve orgasmic function in women. 5 However, research on the use of flibanserin in men is limited, and theoretically, it could be used as a treatment for the same condition. This case report describes a young male who experienced his first orgasm after flibanserin treatment and contributed to the limited data on the use of flibanserin in men. This case highlights the potential role of flibanserin in the treatment of male orgasmic dysfunction and underscores the need for further research in this area. This case report was deemed exempt, in accordance with institutional board review, although the patient provided full consent.
Discussion
Flibanserin, which is a serotonin 5-HT1A receptor agonist and 5-HT2A receptor antagonist, was prescribed for the patient.9 Although flibanserin is approved by the FDA for the treatment of hypoactive sexual desire disorder in premenopausal women, it is not approved for use in males.4 Nevertheless, the off-label use of flibanserin was considered in this case because of its potential to improve sexual function through its central effects on the serotonergic system and its proven improvement in orgasmic subdomain scores in the Female Sexual Function Index in women with hypoactive sexual desire disorder.5 After 28 to 32 doses of flibanserin, the patient achieved orgasm and ejaculation during masturbation for the first time. It has been shown that men and women share similar neural circuitry activation and deactivation during an orgasm. This process involves the activation of multiple brain zones, including the prefrontal cortex, as well as dopaminergic pathways from the ventral tegmentum to the nucleus accumbens.10 Owing to this shared circuitry, flibanserin may improve orgasmic function in men as well as women. Excitatory neurotransmitters such as dopamine and norepinephrine, which enhance orgasmic function, act in the prefrontal cortex. Conversely, inhibitory neurotransmitters that impair orgasmic function, such as serotonin, act in the same brain region. Evidence suggests that flibanserin increases the release of dopamine and norepinephrine while reducing the release of serotonin in prefrontal brain areas. This is consistent with the same sites of abnormal neuroimaging findings described in patients with reduced sexual interest and desire. As such, the mechanism of action of flibanserin can be described as the downstream release of dopamine and norepinephrine and the reduction of serotonin in these brain circuits, thereby regulating reward processing in premenopausal women with reduced sexual interest and desire.9
Conclusion
This case presents a challenging situation of lifelong anejaculation and anorgasmia in a young male with no apparent cause. The use of bupropion and sex therapy was not effective, and bremelanotide was ineffective in achieving an orgasm. The off-label use of flibanserin was eventually successful in achieving an orgasm and ejaculation in the patient, but further studies are required to validate its safety and efficacy in males. This case highlights the importance of considering less common causes of sexual dysfunction and exploring new treatment options when more common etiologies have been ruled out.
