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Vers une approche physiopathologique des troubles de l’éjaculation

Rationale for a pathophysiological approach of ejaculatory disturbances

Résumé

Les mécanismes locaux de l’éjaculation comprenant l’émission et l’expulsion du sperme sont commandés non seulement par la composante sympathique de l’innervation autonome mais également par l’innervation parasympathique auxquelles s’associe l’innervation somatique de la musculature striée périnéale empruntant le nerf pudendal. Les 2 phases de l’éjaculation sont médiées par des réflexes organisés aux étages spinaux thoraco-lombaires et sacrés dont l’organisation et la coordination demeurent mal connues. De nombreux neuromédiateurs périphériques participent à la survenue de l’éjaculation: les neuromédiateurs classiques: noradrénaline et acétylcholine mais également des neuromédiateurs non adrénergiques non cholinergiques c’est à dire peptidergiques, purinergiques et le monoxyde d’azote. Le rôle des afférences de l’ensemble tractus séminal dans le déclenchement de l’éjaculation n’a pas été exploré à l’exception de l’innervation de la verge représentée par le nerf dorsal de la verge. La participation de plusieurs centres supraspinaux à la modulation de l’activité des centres spinaux qui commandent l’éjaculation a été mise en évidence: des noyaux hypothalamiques, l’amygdale, et le noyau paragigantocellulaire. Sur la base de ces données anatomiques et neurophysiologiques, la physiopathologie des perturbations de l’éjaculation est ensuite discutée. L’éjaculation prématurée pourrait être liée à l’existence d’une hypersensibilité à la stimulation à la fois périphérique et centrale. Les autres troubles de l’éjaculation résultent d’altérations des mécanismes de commande centraux et/ou périphériques.

Abstract

Seminal emission and sperm expulsion are under the control of both the sympathetic and parasympathetic outflows and also of the somatic innervation conveyed by the pudendal nerve. The 2 phases of ejaculation are reflexive with the reflexes handled at the thoraco-lumbar and sacral levels of the spinal cord. Such a spinal organization remains widely unknown. The role of various peripheral neurotransmitters has been evidenced including norepinephrine and acetylcholine and also peptidergic, purinergic i.e. ATP and nitric oxide. Stimulation of the seminal tract afferents play a crucial in the onset of ejaculatory mechanisms. Except for the dorsal nerve of the penis, there is a lack of information concerning these afferents. Several supraspinal centers i.e. hypothalamus, medial amygdala, pons and nucleus paragigantocellularis exert descending and ascending inhibitory and excitatory influences on spinal nuclei controlling emission and expulsion of sperm. Central neurotransmission responsible for this supraspinal control could involve serotonin, oxytocin and norepinephrine. In the light of the available anatomical and neurophysiological data, pathophysiological aspects of ejaculatory disorders are futher discussed. Premature ejaculation could be related to a periheral and central hypersentivity. Most of the other ejaculation abnormalities are likely mainly related to an impairment of the central mechanisms.

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Giuliano, F., Mac Kenna, K., Droupy, S. et al. Vers une approche physiopathologique des troubles de l’éjaculation. Androl. 9, 226–246 (1999). https://doi.org/10.1007/BF03035235

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Mots clés

  • Ejaculation
  • neurophysiologie
  • éjaculation prématurée
  • anéjaculation

Key-words

  • Ejaculation
  • emission
  • neurophysiology
  • central nervous system
  • premature ejaculation