In the past, there has been a lot of confusion about how to categorize and define delayed ejaculation, with various terms used such as “retarded ejaculation,” “inhibited ejaculation,” “inadequate ejaculation,” “idiopathic ejaculation,” “anejaculation,” “anorgasmia,” “male orgasmic disorder,” and more.
What is Delayed Ejaculation?
Delayed ejaculation (DE) is a male sexual dysfunction where men find it difficult or impossible to ejaculate and/or experience orgasm. It is often misunderstood and misdiagnosed, and there are no FDA-approved treatments for it. DE rates are expected to rise due to demographics and age-related diseases. Men with DE often report sexual dissatisfaction and anxiety about their sexual performance and suffer from general sex health issues. Partners may also experience pain, injury, and distress and question their own desirability. However, men with DE can gain the necessary skills to overcome their suffering from this disorder through clinical research and practice. (1)
Physiology of Ejaculation and Orgasm
Ejaculation is a natural bodily process that occurs during sexual activity in males. It involves the release of semen through the penis. There are certain physical sensations that can signal when ejaculation is about to happen, such as increased heart rate and muscle tension. Ejaculation itself involves three stages – emission, bladder neck closure, and expulsion of fluid. The nervous system and various neurotransmitters in the body control this process. Factors such as genetics, medical history, and psychological and cultural factors can all affect the timing of ejaculation. It’s important to note that ejaculation and orgasm are two separate phenomena that often happen at the same time during sexual activity. Orgasm is a subjective experience characterized by feelings of pleasure and a release of tension. Sometimes men may experience orgasm without ejaculation. Some men may also experience delayed ejaculation, where ejaculation is difficult or impossible, which can
also lead to diminished orgasmic sensations. The diagnosis and treatment for delayed ejaculation and other male orgasmic disorders are similar. It involves a thorough medical history and assessment. While the causes of these conditions can be complex, treatment often consists in increasing awareness of sensations during sexual activity and addressing any underlying physical or psychological factors.
Diagnosis
The International Consultation on Sexual Medicine (ICSM) defines DE as an intravaginal ejaculatory latency time (IELT) threshold beyond 20-25 minutes of sexual activity accompanied by negative personal consequences such as bother or distress. However, there is an extensive range of ejaculatory latency data, and too restricted a focus on a temporal criterion may limit access to care.
Satisfactory sexual experiences and the distress related to DE are probably mediated more by perceived control over ejaculation than by its latency time. Therefore, the personal impact of the disorder on a man and his partner, in terms of control and distress rather than time, should be considered the more critical parameters when diagnosing DE.
The fifth edition of the American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders (DSM-5) and the World Health Organization International Classification of Diseases (ICD-11) do not have a quantitative latency metric to define DE. Instead, they define DE as an inability to achieve ejaculation or an excessive or increased latency of ejaculation, despite adequate sexual stimulation and desire to ejaculate.
Causes
Psychological Factors
Early psychoanalytic explanations saw DE as a result of psychic conflicts and unexpressed anger. At the same time, other theories suggested that men with DE are “unwilling” to receive pleasure. Other factors that historically contributed to DE include anxiety, depression, lack of confidence, and poor body image. Apfelbaum believed that DE was a desire disorder specific to partnered sex. The cognitive-behavioral perspective suggests that negative thoughts interfere with positive thoughts and genital stimulation.
Social/Cultural Factors
According to Masters and Johnson (1970), some men’s DE may be related to religious orthodoxy. Sociocultural and religious beliefs, such as prohibitions against masturbation, can limit sexual experience and hinder the learning of ejaculation, potentially leading to DE (Perelman, 2014).
Masturbation
Perelman identified insufficient stimulation and masturbation as important factors in the development of DE. He found that a disparity between a man’s sexual fantasies during masturbation and his sexual experiences with his partner can result in DE due to insufficient arousal. High-frequency masturbation is also correlated with DE, and an idiosyncratic masturbatory style is the most common behavioral factor causing DE. Such men engage in self-stimulation patterns that condition them to respond only to specific forms of stimulation, making it difficult to achieve ejaculation with a partner.
Despite the clinical manifestations of penile irritation and erythema, men’s masturbation patterns often remain unexplored by clinicians. They may not communicate their stimulation preferences to their partners due to shame or embarrassment. Therefore, sex therapists should inquire about their clients’ masturbation habits to better understand the underlying causes of DE.
Interpersonal Issues
Fertility concerns and anger/resentment with a partner can be specific issues that contribute to DE. Men with DE may have distress related to pregnancy concerns and may avoid sex or dating altogether due to fear. Anger can also act as a powerful anti-aphrodisiac, causing men to avoid sexual contact or attempt to perform inadequately. Misguided accusations and trust issues can lead to disconnection and avoidance of partnered sex. These issues should be explored during assessment and addressed in treatment.
Biomedical Factors
There are various somatic conditions other than infertility that can lead to DE. Any procedure or disease that disrupts sympathetic or somatic innervation to the genital region can interfere with ejaculation and orgasm. Neurological and endocrine disorders, aging, pelvic-region surgery, severe diabetes, alcoholic neuropathies, and hormonal abnormalities can all cause DE. Additionally, medication for benign prostatic hypertrophy, baldness, depression, and antihypertensive, anti-adrenergic, and antipsychotic drugs can cause ejaculatory delay.
Assessment
The evaluation of a man with delayed ejaculation (DE) should include both medical investigation and a focused psychosexual history to uncover potential physical, psychological, and learned causes of the disorder. A functional assessment, preferably through a focused sexual history or “sex status exam,” can differentiate DE from other sexual problems by reviewing the conditions under which the man can ejaculate. The problem’s developmental course should include variables that improve or worsen performance. In addition, relationship issues can cause or exacerbate DE and must be ruled out or explored. Referral for medical evaluation, usually by a urologist, is essential in cases where DE is generalized or primary. Dichotomizing etiology and diagnosis into classifications such as psychogenic and biological are too categorical, and a formulation that highlights the immediate cause(s) of the problem should be offered to the patient by the end of the evaluation.
Sex Therapy
Delayed ejaculation (DE) is a sexual disorder that can be treated with a combination of techniques, including sex education, psychoanalysis, couple therapy, cognitive-behavioral therapy, mindfulness, and sex therapy. Therapy for primary DE aims to identify sexual arousal preferences through self-exploration and stimulation, while therapy for secondary DE involves temporarily suspending masturbatory activity and limiting the orgasmic release to desired goal activity, usually coital orgasm.
Clinicians need to provide support to ensure compliance for a solo masturbation hiatus and to negotiate a compromise if necessary. Reducing the frequency of solo self-stimulation and altering style can also help approximate stimulation from a partner. It is required to use considerable reassurance for men and their partners who suffer from DE secondary to aging.
Medical Treatment
There are currently no drugs proven to treat DE and no pharmaceuticals approved by the FDA for this purpose. Physicians may prescribe certain medications despite limited evidence supporting their use. Testosterone has also been considered as a first-line treatment. Still, it is not helpful unless T levels are meaningfully below normal. Yohimbine has been explored as a potential antidote, but research has been limited to animal experiments. Some experts believe that Wellbutrin may hold promise for patients with antidepressant-induced DE. Still, research has not identified a drug that can decrease orgasmic latency for non-compliant patients.
Conclusion
The high-frequency idiosyncratic masturbation, sometimes combined with fantasy-partner disparity, can lead to problems with arousal and ejaculation in men. Sex therapists need to take a personalized approach to treating delayed ejaculation (DE) by identifying and prioritizing various factors, including masturbation-related ones, that may result in diminished arousal and an inability to ejaculate. Studies suggest that multidisciplinary cooperation within an integrated treatment is the optimal approach. Although success rates vary among sex therapists, sex therapy remains the best option for men suffering from DE. Well-designed multicenter clinical trials are needed to establish a more definitive answer on the effectiveness of sex therapy for DE.