Delayed ejaculation (DE) is an inhibition of the ejaculatory reflex, with absent or reduced seminal emission and impaired ejaculatory contractions, possibly with impaired or absent orgasm. It affects between 1% to 10% of the adult male population. Some men with DE can ejaculate after prolonged intercourse and with great effort, while other men with DE are unable to ejaculate at all. No drugs are currently approved to address such problem; however behavioural therapy can be initiated and has a high rate of success. ED (Erectile dysfunction) and DE are often mistaken, even though these conditions vary significantly.
Definition of DE
The Fourth International Consultation on Sexual Medicine recommends the following definitions for DE:
- Primary DE—a lifelong experience of an inability to ejaculate at all or almost all (75-100%) occasions of coital activity, which causes distress.
- Acquired DE—distressing lengthening of ejaculatory latency that occurs at most (>50%) coital experiences after a period of normal ejaculatory function and/or a clinically meaningful change that results in distress.
What is the Difference between DE and ED?
Men suffering from DE find it difficult or impossible to ejaculate and experience orgasm during sexual encounters. While some men may have difficulty achieving ejaculation during masturbation, for the majority (90%) of men with DE, lack of ejaculation during intercourse is the primary problem.
On the other hand, men suffering from ED cannot achieve or maintain an erection that is enough for satisfactory sexual performance.
It is likely that many men with DE are misdiagnosed with ED even if DE prevalence is as low as 3%.
Men with DE typically encounter more relationship distress and report less sex. Some partners may enjoy the extended intercourse but couples trying to conceive face real problems as deposition of semen in the female reproductive tract is essential to conception.
Men with DE usually have no difficulty attaining or maintaining erections.
What is the Difference between DE and Anorgasmia?
Ejaculation and orgasm occur almost simultaneously in men even if physiologically, these phenomena are separate. Ejaculation is the process during which semen is deposited in the urethra (urine tube) and then released by contractions of the pelvic muscles.
During an erection, a high amount of arterial blood enters in corpus cavernosum and corpus spongiosum (spongy erectile tissues located close to the urethra) and is trapped there, allowing the penis to be firm.
The urethra responsible for the transport of the semen from the testes is exerting high pressure on the sphincter located at the end of the bladder, closing it. Contraction of the pelvic muscles determine the sperm cells to advance from the epididymis (where the sperm are stored prior to ejaculation) to ductus deferens (vas deferens). The seminal vesicles and prostate gland produce a whitish fluid called seminal fluid, which mixes with sperm to form semen when a male is sexually stimulated. Semen is pushed out of the male’s body through his urethra — this process is called ejaculation.
Most of the time, ejaculation happens during orgasm but it’s possible to have an orgasm without ejaculating. And it’s also possible to ejaculate without having an orgasm.
Orgasm is a mental/emotional process that primarily occurs in the brain and has significant personal variation.
DE: a challenging disorder
But is delayed ejaculation a problem? DE is a challenging disorder since it is the least understood sexual dysfunction. Some men cannot reach orgasm at all, at least not with a partner.
The symptoms of DE can occur both during intercourse and with manual stimulation in the presence or absence of a partner.
It is often quite concerning for patients and it can cause a lot of stress.
DE is a self-reported condition. That means that a diagnosed is obtained when a man reports a marked delay or infrequency of achieving ejaculation during most sexual encounters over a period of 6 months or more, and when other problems have been ruled out.
To reach a diagnosis, a doctor will speak with you about your symptoms and how often they occur. He or she will then rule out other potential medical problems, such as infections, hormonal imbalance, and so on. This may involve using blood and urine tests.
The most common factors which can increase the risk of having DE include:
- Older age: as men age, it is 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;
- Alcohol abuse, especially if you’re a long-term heavy drinker;
- Drug abuse.
Men using pro-erectile medications may experience DE 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 DE. 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.
Heavy alcohol use also can induce DE, by depressing the nervous system. Even if alcohol is known as a social lubricant and is used in inducing a relaxing atmosphere, the key is to drink responsibly.
The more you drink, however, the more your brain and nervous system are inhibited or slowly shut down. In the final stage, 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.
Diagnosis of DE involves several procedures such as taking a medical history and performing a physical examination, neurological exam, and diagnostic tests to determine the underlying cause for the condition. In some cases, a device is used to manually stimulate the penis to detect erectile problems.
It is frequently useful for a urologist to conduct a genitourinary examination and medical history that may identify physical anomalies, as well as contributory neurological and endocrinological (especially androgen levels) factors.
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, selective serotonin reuptake inhibitor (SSRIs)).
The diagnostic tests will look for infections and hormonal imbalances. They include:
- Blood tests: these tests are done to check the signs of cardiovascular disease, diabetes, low testosterone levels and other health problems.
- Urine tests (urinalysis): these 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), DE 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 DE 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.
Treatment of DE
Currently, there is no approved treatment for DE. Treating DE is challenging due to its reduced prevalence and patients are sometimes not so in a hurry to speak about their problem.
Men sometimes even try to cover the problem, faking orgasm to avoid an anticipated negative reaction from the partner.
Sex therapists have found that practising behavioural techniques have led to good success rates in DE management. The rate of success of behavioural techniques depends on man to man. Generally, patients are recommended to suspend masturbatory activity temporarily and limit the orgasmic release to their desired goal activity, e.g., orgasm during penetrative sexual encounters with their partner. Reducing or discontinuing both self and partnered masturbation (typically for 14–60 days) is often difficult, and patients may need support to adhere to this restriction.
Partners should adhere to these techniques and support the partner in changing his habits.
That usually involves changes in sexual preferences and desires.
However, this should only be done within the bounds of what is comfortable and morally acceptable to the partner. Having open and honest discussions about this is an important part of any sexual relationship.
The Good-Enough sex method for sexual satisfaction
The ‘‘Good-Enough Sex’’ model for couple sexual satisfaction proposed by Michael Metz was defined to help couples facing sexual issues to balance their sex life and overcome their sex problems.
There are many types of sexual dysfunction and it is reported that approximately 45% of couples at a given time suffer a male, female or couple sex problem.
This model is based on pleasure and mutual emotional acceptance and encourages couples to pursue positive, realistic meaning in their intimate lives.
Sex is integrated into the couple’s daily life and daily life is integrated into their sex life to create the couple’s unique sexual style.
The model challenges couples to set realistic expectations based on intimacy as the ultimate focus, pleasure as important as function, mutual emotional acceptance as the environment, and sex at times experienced as mature playfulness, spiritual connection, and special bonding, as well as pleasure.
In the Good-Enough model, sex is not an isolated fragment of one’s life; rather, it is integrated into the couple’s daily life and their daily life is integrated into their sex life to create the couple’s unique sexual style. Living daily life provides the opportunity to experience sexual interactions in a subtly yet distinctively personalized and enriched way.
The principles of this model promote a positive attitude towards sex and a deep commitment to mutual sexual health, taking personal responsibility for pursuing developmental (‘‘lifelong’’) sexual growth and preparing oneself with physiologic relaxation.
The 12 principles of the Good-Enough model are:
- Sex is a good element in life, an invaluable part of an individual’s and a couple’s long-term comfort, intimacy, pleasure and confidence;
- Relationship and sexual satisfaction are the ultimate developmental focus and are essentially intertwined;
- Realistic, age-appropriate sexual expectations are essential for sexual satisfaction;
- Good physical health and healthy behavioural habits are vital for sexual health. Individuals value their and their partner’s sexual body;
- Relaxation is the foundation for pleasure and function;
- Pleasure is as important as a function;
- Valuing variable, flexible sexual experiences (the ‘‘85%’’ approach) and abandoning the ‘‘need’’ for perfect performance inoculates the couple against sexual dysfunction (SD) by overcoming performance pressure, fears of failure, and rejection;
- The five purposes for sex are integrated into the couple’s sexual relationship;
- Integrate and flexibly use the three sexual arousal styles: partner interaction, self-entrancement and role enactment;
- Gender differences are respectfully valued, and similarities mutually accepted;
- Sex is integrated into real life and real life is integrated into sex. Sexuality is developing, growing and evolving throughout life;
- Sexuality is personalized: Sex can be playful, spiritual, special.
How can I prevent DE?
DE can be prevented by having a healthy attitude about your sexuality and genitals. It is very important to realize that you cannot control a sexual response, as well as you cannot force yourself to go to sleep or to perspire. The harder you try to have a certain sexual response, the more it becomes inhibited.
To reduce the pressure, you should absorb yourself in the pleasure of the moment, without worrying about whether or when you will ejaculate. Your partner should also create a relaxed atmosphere without any pressure.
Finally, any fears or anxieties, such as fear of pregnancy or disease, should be openly discussed with your partner.
The problem’s developmental course should be noted, including variables that improve or worsen performance (particularly those related to psychosexual arousal).
Male reproduction and DE
Men with no known medical reasons for infertility may have trouble with conception due to DE. The psychosocial basis for these disorders may be overlooked or may be incompletely assessed during a fertility workup due to a physician’s lack of expertise in understanding the psychological and social nuances that are often present in DE.
Fertility experts can manage such cases of sexual dysfunction by identifying the psychosocial factors as well as the biomedical factors that may be contributing to the problem. By providing accurate and reassuring information, addressing issues of performance anxiety, and making suggestions to a couple about the importance of an erotic environment, a fertility expert can effectively address a significant number of DE cases.
Take home messages:
A multitude of biological as well as psychosocial factors has been identified as possible contributors to DE.
Successful treatment of DE depends on the cause of DE and the type of treatment.
As it was mentioned above, there is no drug specially approved to treat DE. However, there are still numerous techniques, which can be combined to treat DE including:
- sex education,
- cognitive-behavioural therapy,
- exploration of underlying conflicts, and/ or
- couples’ therapy.
Principles of the “Good-Enough Sex” model are useful in creating realistic premises in having a satisfactory sex experience. DE can be prevented by having a healthy attitude about your sexuality, adapting your desires, your fantasies to your partner and to real life.
Prescription drugs known to cause secondary DE, like most commonly serotonin-based prescriptions—should be excluded from the patients’ treatment plan.
Treating DE involves a sex therapist. By using highly detailed and specific sexual language and exploration towards perceived partner attractiveness, the use of fantasy during sex, anxiety surrounding coitus, and masturbatory patterns, the sex therapist can review all the conditions under which the man is able to ejaculate and to find the best methods that stimulate him.
The therapist must support the patient’s goals but not push the man (or couple) unnecessarily toward a preordained concept of success.
In preparation for an appointment to your primary care doctor, make a list in which you should include:
- any upsetting symptoms you had including that may seem unrelated to DE;
- key personal information including any major stress or recent life changes, illnesses, or changes in medications you take;
- all medications, vitamins, herbal remedies and supplements you take.
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