What is delayed ejaculation

Delayed ejaculation also sometimes called impaired or retarded ejaculation, is a medical condition in which a male cannot ejaculate in spite of sufficient sexual stimulation and erection. It takes an abnormally long time for him to climax and ejaculate (release semen from the penis). Sometimes, ejaculation does not happen at all. It may occur either during intercourse or by manual stimulation with or without a partner (solo sexual activity).

Delayed ejaculation can be a temporary or a lifelong problem. It is normal for some men to experience it from time to time. Also, sexual response often changes with age. The older a man gets, often, the more stimulation he may need to get an erection and ejaculate (‘come’), and the more time he needs between erections before he can have sex again.

Delayed ejaculation is only a problem if it is worrying you or your partner and it affects you all the time. Some men who are not able to ejaculate are still able to have an orgasm.

For some men, delayed ejaculation is situational (for example, it may only occur during sex with a partner and is not a problem when masturbating). For other men, delayed ejaculation occurs in all situations.

Delayed ejaculation is thought to be less prevalent then erectile dysfunction or premature ejaculation as a presenting problem. Estimates are difficult to obtain due inconsistent definitions and research approaches but it is generally agreed to occur in <1%-3% of the male population.

Delayed ejaculation (male orgasmic disorder) is classed as either:

• Experiencing a significant delay before ejaculation
• Being unable to ejaculate at all, even though the man wants to and his erection is normal

You may have delayed ejaculation if:

• You experience a repeated and unwanted delay before ejaculation lasting for 30 to 60 minutes
• You’re unable to ejaculate at least half the times you have sex.

Some men with delayed ejaculation need 30 minutes or more of sexual stimulation to have an orgasm and ejaculate. Or, they may not be able to ejaculate at all (anejaculation).

Delayed orgasm is divided into the following types based on symptoms:

• Lifelong vs. acquired. With lifelong delayed ejaculation, the problem is present from the time a male reaches 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.

These categories help in diagnosing an underlying cause, and determining what might be the most effective treatment.

Figure 1. Male reproductive system

What is ejaculation?

Ejaculation is the release of semen from the penis at orgasm (sexual climax). When a man is sexually stimulated, the brain sends signals to the genital area through nerves in the spinal cord to make the pelvic muscles contract.

At orgasm, waves of muscle contractions transport the sperm, with a small amount of fluid, from the testes through to the vas deferens. The seminal vesicles and prostate contribute extra fluid to protect the sperm.

This mixture of sperm and fluid (semen) travels along the urethra to the tip of the penis where it is ejaculated (released).

Whereas females may experience two or more orgasms in rapid succession, males enter a refractory period, a recovery time during which a second ejaculation and orgasm is physiologically impossible. In some males, the refractory period lasts only a few minutes; in others it lasts for several hours.

Delayed ejaculation possible complications

If the problem is not treated, the following may occur:

• Avoidance of sexual contact
• Inhibited sexual desire
• Stress within the relationship
• Sexual dissatisfaction
• Difficulty with conception and getting pregnant

Fertility can be a problem for men who have anejacuation (inability to ejaculate). If you would like to father a child you may need treatment to achieve this.

Remember that there are treatments available for delayed ejaculation. Understanding the problem and communicating with your partner are important in reducing stress and resolving any relationship problems.

If you and your partner are trying to get pregnant, sperm can be collected using other methods.

Delayed ejaculation causes

Most men ejaculate within a few minutes of starting to thrust during intercourse. Men with delayed ejaculation may be unable to ejaculate or may only be able to ejaculate with great effort after having intercourse for a long time (for example, 30 to 45 minutes).

Many physical (e.g. certain pharmacologic agents and diseases) and psychological factors (e.g. performance anxiety, idiosyncratic masturbatory styles) have been identified as potential contributors to delayed ejaculation.

Common psychological causes include:

• Anxiety, depression or other mental health conditions
• Anxiety about performance
• Religious background that makes the person view sex as sinful
• Poor body image
• Lack of attraction for a partner
• Relationship issues due to stress, poor communication or other concerns
• Conditioning caused by a habit of excessive masturbation
• Traumatic events (such as being discovered masturbating or having illicit sex, or learning one’s partner is having an affair)
• Differences between the reality of sex with a partner and sexual fantasies

Some factors, such as anger toward the partner, may be involved.

Physical causes may include:

• Blockage of the ducts that semen passes through
• Certain birth defects affecting the male reproductive system
• Retrograde ejaculation, a condition in which the semen goes backward into the bladder rather than out of the penis
• Use of certain drugs
• Certain infections, such as a urinary tract infection
• Nervous system diseases, such as stroke or nerve damage to the spinal cord or back
• Hormone-related conditions, such as low thyroid hormone (hypothyroidism) or low testosterone (hypogonadism)
• Chronic illnesses like diabetes (diabetic neuropathy) or multiple sclerosis (MS)
• Increasing age.
• Prostate surgery, such as transurethral resection of the prostate (TURP) or prostate removal
• Nerve damage during surgery in the pelvis.

The use of some recreational drugs, particularly alcohol — drinking too much (alcohol abuse or alcoholism), can result in delayed ejaculation.

Medication side effects

Delayed ejaculation can be a side effect of certain medicines.

Medicines that have been found to cause delayed ejaculation in some men include:

• some types of antidepressants, such as selective serotonin reuptake inhibitors (SSRIs);
• some medicines used to treat high blood pressure (for example, beta-blockers);
• certain muscle relaxants; and
• some antipsychotic medicines, such as those used to help treat schizophrenia.

Risk factors for delayed ejaculation

A number of things can increase your risk of having delayed ejaculation, including:

• Older age — as men age, it’s normal for ejaculation to take longer
• Psychological conditions, such as depression or anxiety
• Medical conditions, such as diabetes or multiple sclerosis
• Certain medical treatments, such as prostate surgery
• Medications, particularly certain antidepressants, high blood pressure medications or diuretics
• Relationship problems, such as poor communication with your partner
• Alcohol abuse, especially if you’re a long-term heavy drinker

Delayed ejaculation prevention

Having a healthy attitude about your sexuality and genitals helps prevent delayed ejaculation. Realize that you cannot force yourself to have a sexual response, just as you cannot force yourself to go to sleep or to perspire. The harder you try to have a certain sexual response, the harder it becomes to respond.

To reduce the pressure, focus on the pleasure of the moment. Do not worry about whether or when you will ejaculate. Your partner should create a relaxed atmosphere, and should not pressure you about whether or not you have ejaculated. Openly discuss any fears or anxieties, such as fear of pregnancy or disease, with your partner.

Delayed ejaculation diagnosis

A physical exam and medical history may be all that’s needed to recommend treatment for delayed ejaculation. However, if delayed ejaculation appears to be caused by an underlying problem that might need treatment, you may need further tests or you may need to see a specialist.

Tests for underlying problems can include:

• Physical exam. This may include careful examination of your penis and testicles. The doctor will use light touch to make sure you have normal sensation in your genitals.
• Blood tests. A sample of your blood may be sent to a lab to check for signs of heart disease, diabetes, low testosterone levels and other health problems.
• Urine tests (urinalysis). Urine tests are used to look for signs of diabetes, infection and other underlying health conditions.
• Stimulating the penis with a vibrator or other device may determine whether you have a physical problem. This is often a nervous system problem. A nervous system (neurological) exam may reveal other nerve problems that are connected with delayed ejaculation.

Delayed ejaculation treatment

Treatment for delayed ejaculation will depend on the cause.

If medicines are causing delayed ejaculation, you should discuss with your doctor whether or not there are alternatives, and whether or not the delay matters to you and your partner. Your doctor may be able to recommend a different treatment that avoids this unwanted side effect. Alternatively, a change in dose or adding another medicine may help.

The management of delayed ejaculation is similar to that of erectile dysfunction and premature ejaculation: providing accurate information and removing blame, and the use of sensate focus to reduce performance anxiety. If idiosyncratic masturbatory practices are contributing to delayed ejaculation, masturbation retraining to a style more resembling the sensations of penis-vaginal intercourse may be useful.

If you have never ejaculated through any form of stimulation, see a urologist to determine if the problem has a physical cause. (Examples of stimulation may include wet dreams, masturbation, or intercourse.)

Psychotherapy

If there are psychological causes, then the best approach is to talk to your partner and to seek counseling and therapy.

See a therapist who specializes in ejaculation problems if you are unable to ejaculate in an acceptable amount of time. Sex therapy most often includes both partners. During sex therapy, you’ll have the opportunity to discuss any emotional or psychological issues related to your sexuality and relationship, in a non-judgemental way.

Activities may also be recommended for you to try at home while you’re having sex with your partner (you should never be asked to take part in any sexual activities during a session with the therapist).

These may include:

• viewing erotic videos and magazines before having sex to increase the feeling of stimulation
• erotic fantasies and “sex games” to make your lovemaking more exciting
• using lubricating creams, or jellies, to make the physical act of sex more comfortable and relaxing
• using sexual aids, such as vibrators, to increase pleasure

In most cases, the therapist will teach you about the sexual response. You also will learn how to communicate and guide your partner to provide the right stimulation.

Therapy often involves a series of “homework” assignments. In the privacy of your home, you and your partner engage in sexual activities that reduce performance pressure and focus on pleasure.

Typically, you will not have sexual intercourse for a certain period of time. In this time, you will gradually learn to enjoy ejaculation through other types of stimulation.

In cases where there is a problem with the relationship or a lack of sexual desire, you may need therapy to improve your relationship and emotional intimacy.

Sometimes, hypnosis may be a helpful addition to therapy. This may be useful if 1 partner is not willing to participate in therapy. Trying to self-treat this problem is often not successful.

What happens in a sex therapy session?

A sex therapist will listen to you describe your problems and assess whether the cause is likely to be psychological, physical or a combination of the two.

Talking about and exploring your experiences will help you get a better understanding of what is happening and the reasons. The therapist may also give you exercises and tasks to do with your partner in your own time.

Each therapy session is completely confidential. You can see a sex therapist by yourself, but if your problem affects your partner as well, it may be better for you both to attend.

Sessions usually last for 30-50 minutes. The therapist may advise you to have weekly sessions or to see them less frequently, such as once a month.

Treatment commonly requires about 12 to 18 sessions. The average success rate is 70% to 80%.

You will have a better outcome if:

• You have a past history of satisfying sexual experiences.
• The problem has not been occurring for a long time.
• You have feelings of sexual desire.
• You feel love or attraction toward your sexual partner.
• You are motivated to get treated.
• You do not have serious psychological problems.

If medicines are causing the problem, your provider may recommend switching or stopping the medicine, if possible. A full recovery is possible if this can be done. Never stop taking any medicine without first talking to your health care provider.

Couples need accurate and normative information about delayed ejaculation, and should be encouraged to adopt a flexible behavioral approach to sexual relations. Sex needs to be positioned as a pleasurable activity no matter how late the man ejaculates and that the female’s orgasm can precede or follow penis-vaginal intercourse.

Individual, partner/relationship and environmental factors need to be considered. Where delayed ejaculation is strongly associated with pressure to conceive, treatment of performance anxiety is the most likely option to manage delayed ejaculation. Sensate focus is a procedure designed to help men focus on the sensations and process of sex rather than on penis activity and the outcome of sex. Couples are educated to remove blame, increase sexual communication, and to explore sexual activity other than penis-vaginal intercourse until performance anxiety has decreased.

Fertility treatment

If you are experiencing anejaculation (inability to ejaculate) and you and your partner would like to have a baby, there are treatments available. Vibrator stimulation and electrical stimulation of the penis are treatments that can be used to achieve reflex ejaculation. Talk to your doctor, who may refer you to a specialist for treatment if you want to father a child.

If you’re concerned about your sexual response, ask your doctor for further advice.

Delayed ejaculation pills

There aren’t any pills that have been specifically approved for the treatment of delayed ejaculation. Medications used to treat delayed ejaculation are used primarily to treat other conditions.

Medications sometimes used to treat delayed ejaculation include:

• Amantadine (Parkinson’s)
• Buspirone (antianxiety)
• Cyproheptadine (allergy)
• Pseudoephedrine tablets may be tried, but these will need to be prescribed “off-label”. This means the medicine shows promise in treating delayed ejaculation but it hasn’t been licensed for this particular use (pseudoephedrine is normally used as a decongestant).

Coping and support

If it’s an ongoing concern, delayed ejaculation can cause mental and emotional stress for a man and his partner. If you have delayed ejaculation only on occasion, try not to assume that you have a permanent problem or to expect it to happen again during your next sexual encounter. Remember, occasional delayed ejaculation due to stress or other temporary factors may improve when the underlying cause gets better.

In addition, if you experience occasional or persistent delayed ejaculation, it’s important to reassure your sexual partner. Your partner may think your inability to reach climax is a sign of diminished sexual interest.

Communicate openly and honestly with your partner about your condition. Treatment is often more successful if couples work together as a team. You may even want to see a counselor with your partner. This can help you address concerns you both may have about delayed ejaculation.