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The Elephant in the Room: Delayed Ejaculation

 

Delayed ejaculation may be defined as inability to ejaculate when desired, despite with what the man considers to be appropriate sexual stimulation.1 Although it typically accompanies lack of orgasm (but not lack of erection), it should be noted that men may have orgasms without ejaculation. Retrograde ejaculation (semen is pushed into the bladder rather than out the penis) is also different, and may be confused with delayed ejaculation unless the urine is examined. Delayed ejaculation may be further classified as lifelong or acquired, and generalised or situational (e.g. with particular types of stimulation or partners).2

The DSM V criteria specify that for this condition to be a ‘disorder’, it must have been present for 75-100% of the time, for at least six months and must cause significant distress to the individual. It also should not be able to be better explained by a nonsexual mental disorder, a medical condition, the effects of a drug or medication, severe relationship distress or other significant stressors.

It is important to note that delayed ejaculation affects both partners in the relationship, especially if the unaffected partner develops concerns about how attractive they might be, or feels stressed by what more they could do to help. This typically feeds into performance anxiety on both sides, further complicating the sexual relationship.

Most causes of delayed ejaculation are due to psychological reasons and/or relationship issues. Contributory causes include fatigue, stress, performance anxiety, fear of pregnancy, insecurity concerning the relationship, feeling uncomfortable during sex (physically or mentally), anger and resentment towards the partner, major depression, having negative feelings or inhibitions about sex, and past sexual abuse.2 Persistent delayed ejaculation (especially if it is able to be achieved through masturbation) is uncommonly due only to relationship problems.1

Medications (especially the anti-depressant and anti-anxiety medications, tricyclics, neuroleptics, SSRIs and SNRIs) are associated with anorgasmia and delayed ejaculation, as are mood stabilisers, antiulcer treatment and alpha adrenergic blockers.2 Illicit drug use (notably chronic use of marijuana, cocaine, ecstasy, amphetamines and opioids) and alcohol excess are also possible causes.2

Physical causes 1,2,  are less common than psychological2 and include neurological disease or trauma, especially affecting the spinal cord, pelvic surgery and trauma affecting nerves from the L2 level, diabetes, hyperprolactinaemia and hypoanaesthesia from advanced age. It may also occur with repeated intracavernous injections.

It is normal for the man affected by delayed ejaculation to worry about pleasing his partner, to feel frustrated, embarrassed and vulnerable.  Both partners in the relationship need to understand and reinforce to each other that ejaculation is not the only source of enjoyment from sexual activity. In a good sexual relationship, satisfaction is achieved by many actions and a sensitive partner will be aware of this.

Delayed ejaculation is difficult to manage, but it should be noted that only 75% of men state that they always ejaculate during sex.2 In the absence of reversible physical causes, couples counselling may be indicated. The use of other techniques, such as vibrators or oral sex, may reduce performance anxiety for the affected partner. Medications are generally not prescribed for this condition, with the exception of psychotropic-induced male orgasmic disorder, in which case sildenafil and imipramine have shown some success.2

 

1. Andrology Australia: Delayed ejaculation.
https://www.andrologyaustralia.org/sexual-difficulties/ejaculation-problems/

2. Preda, Adrian. Delayed Ejaculation. Medscape. 12th Nov 2014
http://emedicine.medscape.com/article/2184956-overview