Ejaculatory dysfunctions occur when a man has problems ejaculating, even when he is completely aroused. Types of ejaculatory dysfunctions include:
- Premature ejaculation: man ejaculates before he and his partner wish it to happen.
- Delayed ejaculation: for men with delayed ejaculation, ejaculation takes longer than he would like, even if he has a full erection and he is well stimulated.
- Anejaculation: men suffering from delayed ejaculation cannot ejaculate at all.
- Retrograde ejaculation: when retrograde ejaculation happens, semen travels back into the bladder instead of out of the penis. It leaves the body when a man urinates.
What is delayed ejaculation?
Delayed ejaculation represents a medical condition that is also called “impaired ejaculation” or “ejaculatory insufficiency”. It is defined as the persistent or recurrent delay, difficulty or, absence of orgasm after sexual stimulation, which causes personal distress. Delayed ejaculation represents an inhibition of the ejaculatory reflex, with absent or reduced seminal emission and impaired ejaculatory contractions, possibly with an impaired or absent orgasm. This condition occurs when it takes a prolonged period of sexual stimulation for a man to ejaculate. If a man takes longer than 30 minutes of penetrative sex to ejaculate, despite a normal erection, it is considered delayed ejaculation.
Delayed ejaculation affects around 1-4% of men. This condition can result in distress for both partners. Delayed ejaculation is a trigger for anxiety, low libido and sexual dissatisfaction.
What are the risk factors of delayed ejaculation?
Delayed ejaculation is probably the least common, least studied, and least understood of male sexual dysfunctions. It appears that even young men, with ages of 18–59 years, reported an inability to achieve climax or ejaculation. It is believed that both the overall ageing of the population as well as the global increased use of biological treatments for erectile disorders are associated with increased ejaculatory latency secondary to both disease and the side effects of medications to treat them.
Men using pro-erectile medications may experience delayed ejaculation due to confusion over their erections produced through increased vasocongestion as a result of pharmacotherapy rather than sexual arousal.
Several classes of drugs are involved in the occurrence of delayed ejaculation. These drugs include antidepressants (like citalopram, escitalopram, fluoxetine, fluvoxamine, paroxetine, sertraline, amitriptyline, amoxapine, clomipramine, desipramine, duloxetine, mirtazapine, venlafaxine), anxiolytics (like alprazolam, chlordiazepoxide), neuroleptics, diuretics and certain anti-inflammatory drugs.
Alcohol also can induce delayed ejaculation.
When is important to see a doctor?
Go to the doctor if:
- Delayed ejaculation is an issue for you or your partner;
- You have other known health problem that might be linked to delayed ejaculation, or you take medications that could be causing the problem;
- You have other symptoms along with delayed ejaculation that might or might not seem related.
How is delayed ejaculation diagnosed?
Diagnosis of delayed ejaculation involves taking a medical history and performing a physical examination, neurological exam, and diagnostic tests to determine the underlying cause for the condition. The list of the necessary tests will be handed to you by your doctor. Please consult a sexologist or urologist if you have any suspicion that you are suffering from delayed ejaculation. A medical history includes information about the following:
- Existing diseases and conditions (diabetes, stroke);
- History of symptoms (circumstances surrounding the onset of symptoms);
- Injury or trauma (spinal cord injury, trauma to the back or pelvis);
- Medications (antidepressants).
- The diagnostic tests will look for infections and hormonal imbalances.
- Blood tests: your health care provider might take a blood sample and send it to a lab to check for signs of cardiovascular disease, diabetes, a low testosterone level and other health problems.
- Urine tests (urinalysis): urine tests are used to look for signs of diabetes, infection and other underlying health conditions.
According to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), delayed ejaculation belongs to a group of sexual dysfunctions disorders typically characterized by a clinically significant inability to respond sexually or to experience sexual pleasure.
The specific criteria of DSM-15 for delayed ejaculation include the following:
- In almost all or all (75-100%) sexual activity, the experience of either marked delay in ejaculation or marked infrequency or absence of ejaculation
- The symptoms above have persisted for approximately 6 months
- The symptoms above cause significant distress to the individual
- The dysfunction cannot be better explained by nonsexual mental disorder, a medical condition, the effects of a drug or medication, or severe relationship distress or other significant stressors.
Based on the level of distress, delayed ejaculation can be classified as mild, moderate or severe. The duration of the dysfunction is specified as follows:
- Lifelong (present since first sexual experience);
- Acquired (developing after a period of relative normal sexual functioning).
A new method for evaluating ejaculatory dysfunction is represented by perineal ultrasound, a less invasive procedure. During this procedure, the clinicians should be able to view the bulbospongiosus, bulbocavernosus, pelvic floor, and bladder neck muscles. The procedure also allows clinicians to measure muscle contractions, ejaculation latency time, number of semen expulsions, and the force of the ejaculate.
What questions could you expect from your doctor?
How long have you had trouble ejaculating? Does it happen only now and then, or is it an ongoing problem?
Are you able to ejaculate during sexual intercourse? Or are you able to ejaculate only when your partner directly touches your penis or when you masturbate?
If you’re able to ejaculate, how long does it take after sexual activity starts?
Have you had any changes in sexual desire or any other sexual problems?
Are there any problems in your relationship with your sexual partner?
Have you had any recent surgeries? Or have you had surgery to the pelvic area, such as surgery to treat an enlarged prostate?
What health problems or chronic conditions do you have? Are you taking any medications for these conditions?
Have you had any other sexual problems, such as trouble getting or maintaining an erection (erectile dysfunction)?
Do you drink alcohol or use illegal drugs? If so, how much?
What are the most frequent symptoms of delayed ejaculation?
Some men suffering from delayed ejaculation need usually 30 minutes or more to of sexual stimulation to have an orgasm and ejaculate, while other men might not be able to ejaculate at all. These men suffer from anejaculation.
Delayed ejaculation is divided into the following types based on symptoms:
Lifelong vs. acquired
With lifelong delayed ejaculation, the problem is present from the time of sexual maturity. Acquired delayed ejaculation occurs after a period of normal sexual functioning.
Generalized vs. situational
Generalized delayed ejaculation isn’t limited to certain sex partners or certain kinds of stimulation. Situational delayed ejaculation occurs only under certain circumstances.
What treatments are available?
The first step in the treatment of delayed ejaculation must be directed at the underlying cause of the problem. For example, sexual therapy is an effective modality for a psychological cause of delayed ejaculation. One study investigated targeted therapy for secondary delayed ejaculation and found 82% of men improved with stopping their SSRI (also called selective serotonin reuptake inhibitor, a class of drugs that are typically used as antidepressants in the treatment of major depressive disorder and anxiety disorders) and 60% of men with altered penile sensation had improvement with penile vibratory stimulation.
Psychological and sexual therapy
Psychosexual factors are suspected to be the main cause of delayed ejaculation when no organic cause has been identified. Psychotherapeutic treatments are patient-centred and include:
cognitive behavioural therapy and sex education;
- masturbatory retraining and adjustment of sexual fantasies;
- psychotherapy targeting the areas of conflict and sensate focus exercises;
- altering one’s orientation from oneself to one’s partner;
- sexual anxiety reduction by teaching individual mindfulness and breathing techniques, progressive relaxation, and increasing sensory tolerance;
- couples’ sex therapy and the use of interactional techniques;
- the sexual tipping point model, which emphasizes the utility of a biopsychosocial- cultural perspective combined with special attention to the patient’s narrative.
There is no medication approved for treating delayed ejaculation. Using off-label medications is based on the pharmacological and physiologic considerations. These medications facilitate ejaculation by different mechanisms of action.
Considering that pharmacological therapy for delayed ejaculation is under consideration, it is important to eliminate iatrogenic causes, including medications (e.g., alpha-adrenergic blockers, other antihypertensives, antidepressants, and antipsychotics. For example, if you are depressive and you are treated with SSRIs which are known to be responsible for causing delayed ejaculation some medication can help you. These include:
Cyproheptadine (Periactin), an allergy medication;
Cyproheptadine represents a first-generation antihistamine drug, its primary indication being an allergy. Also, cyproheptadine was shown to be an antidote in the treatment of serotonin syndrome induced by antidepressants. The mechanism of antidepressants-induced delayed ejaculation and delayed orgasm is thought to involve stimulation of postsynaptic 5-HT2A and 5-HT2C receptors by the increased synaptic levels of serotonin. Cyproheptadine acts as a 5-HT2A antagonist, being effective as an antiserotonergic agent.
Yohimbine is a central alpha-2 adrenergic receptor antagonist that has been used for the treatment of erectile dysfunction before the development of phosphodiesterase type 5 inhibitors. It was found to be effective in the improvement of the sexual function.
In a retrospective study including 21 patients complaining of antidepressant-induced sexual dysfunction, yohimbine was found to be superior to both cyproheptadine and amantadine in improving the sexual function. Seventeen patients (81.0%) were shown to respond to yohimbine. The average dose for yohimbine was 16.2±4.0 mg/day. The most encountered side effect reported with yohimbine was agitation, which contributed to drug discontinuation in three patients.
Another study performed on 29 men with orgasmic dysfunction of different aetiology that were provided yohimbine at 20 mg and were allowed to increase the dose at home up to 50 mg. Approximately 55% of these patients succeeded to reach orgasm and were able to ejaculate either during masturbation or sexual intercourse. A further three men ejaculated by using yohimbine and a vibrator together. Of the 19 men, 11 ejaculated with the first dose whereas the remaining eight men required dose escalation at home. Side effects included dartos contraction, a rise in the pulse and blood pressure, tremor, pleasurable tingling, palpitations, malaise, nausea and headache.
Amantadine is a drug which is originally used as an antiviral drug and for treating Parkinsonism, extrapyramidal symptoms and many other disorders.
Amantadine works by increasing dopamine neurotransmission and it is thought to enhance sexual function but there is insufficient evidence to recommend amantadine for treatment of delayed ejaculation.
Buspirone (Buspar), an anti-anxiety medication.
The mechanism of action of buspirone in treating delayed ejaculation may be through reduced serotonergic tone via stimulation of presynaptic 5-HT1A receptor. It appears that the effects of on sexual behaviour may be possible at different parts of the central nervous system. Its efficacy and safety were assessed in several clinical studies.
A retrospective study was undertaken of 16 patients treated with adjunctive buspirone in the context of sexual dysfunction associated with the use of SSRIs. Sexual functioning was rated as much or very much improved in 11 patients. Treatment was generally very well tolerated. However, several patients that had become less irritable after treatment with an SSRI, reported increased irritability.
In another prospective study placebo-controlled trial designed to explore the efficacy of buspirone as an add-on treatment for patients not responding to an SSRI alone, evaluated the possible influence of buspirone on sexual dysfunction in depressed patients treated with SSRIs. Among a total of 119 patients (82 women, 37 men), 12 men reported orgasmic dysfunction. Buspirone (flexible dosage, 20–60 mg/day) or placebo was administrated together with SSRI for 4 weeks. During treatment, approximately half of the subjects treated with buspirone reported an improved orgasmic function;
What are the complications?
Delayed ejaculation can cause:
- problems with self-esteem in addition to feelings of inadequacy;
- avoiding intimacy with others due to frustrations and fear of failure;
- decreased sexual pleasure;
- anxiety about sex;
- inability to conceive, or male infertility;
- low libido;
- stress and anxiety;
- conflicts in a relationship.
Alcohol and delayed ejaculation
You should know that alcohol makes it more difficult to reach orgasm and ejaculation. The way that alcohol works in your body is by depression, or slowly shutting down of the nervous system. The more you drink, however, the more your brain and nervous system are shut down. Eventually, you are not getting the same sensation from your nerve endings to your brain or the same messages from your brain back down to your body. This makes it more difficult, if not impossible, to reach orgasm and ejaculation during sex.
Person’s reaction time is slowed down when he/she consumes too much alcohol. Therefore, drunken persons are not able to drive or operate any heavy machinery or dangerous tools. Also, the alcohol your brain can’t build up sufficient stimulation to send the body over the edge into orgasm.
Alcohol does not only delay orgasm, but it can mess up sex in other ways. Increased levels of alcohol make the brain to turn off more and more. Therefore, the nerves are dulled and the physical experience of sex is lessened. This results in less intense feeling over the entire body, including the genitals. Alcohol also can severely impair one’s judgment so that it may lead a person to choose things they might not necessarily do, such as put themselves in danger by having riskier sexual behaviour, like not using a condom for example.
Not just the moment of sex is negatively affected by alcohol. Alcohol can also increase your blood sugar, your cortisol levels and also your oestrogen levels. This will cause you to gain weight over time, damage your blood vessels causing premature heart disease and erectile difficulties, and put you at a higher risk for cancer, especially breast and prostate cancer. So you see that alcohol has some very negative effects on sex as well as your overall health.
Rowland et al. observed that men with delayed ejaculation show high levels of relationship distress, sexual dissatisfaction, and anxiety about their sexual performance and that they have significantly more general health issues than sexually functional men.
In addition, along with men with other sexual dysfunctional conditions, men with delayed ejaculation typically report lower frequencies of coital activity. In another article, those authors reported that although men with delayed ejaculation usually have little or no difficulty attaining or keeping their erections and are often able to maintain erections for prolonged periods of time, they nevertheless report low levels of subjective sexual arousal, at least compared with sexually functional men.
- Di Sante S, Mollaioli D, Gravina GL, Ciocca G, Limoncin E, Carosa E, Lenzi A, Jannini EA. Epidemiology of delayed ejaculation. Transl Androl Urol. 2016 Aug;5(4):541-8. doi: 10.21037/tau.2016.05.10. Review. PubMed PMID: 27652226; PubMed Central PMCID: PMC5002002.
- Abdel-Hamid IA, Ali OI. Delayed Ejaculation: Pathophysiology, Diagnosis, and Treatment. World J Mens Health. 2018 Jan;36(1):22-40. doi: 10.5534/wjmh.17051. Review. PubMed PMID: 29299903; PubMed Central PMCID: PMC5756804
- Abdel-Hamid IA, Elsaied MA, Mostafa T. The drug treatment of delayed ejaculation. Transl Androl Urol. 2016 Aug;5(4):576-91. doi: 10.21037/tau.2016.05.05. Review. PubMed PMID: 27652229; PubMed Central PMCID: PMC5001980.
- Rowland D, van Diest S, Incrocci L, et al. Psychosexual factors that differentiate men with inhibited ejaculation from men with no dysfunction or another sexual dysfunction. J Sex Med 2005;2:383-9. 10.1111/j.1743-6109.2005.20352
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