Scientific reviews of delayed ejaculation |
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GO NOW to the treatment for delayed ejaculation by following this link.Recommendations for the management of retarded ejaculation: BASHH Special Interest Group for Sexual DysfunctionDaniel Richardson and David Goldmeier summarized the recommendations of the British Association of sexual health and HIV special interest group for the treatment and management of delayed ejaculation. They covered the physiology, etiology, frequency, and matters of patient assessment for the condition. They also outlined various possible treatment options, made some recommendations for management of delayed ejaculation, and suggested how the outcome of treatment might be audited. Their work was reported in the International Journal of STD & AIDS 2006; 17: 7-13. As the authors observe, orgasm in men is regarded as the sum of two events which take place at the same time: the intensely pleasurable feelings of orgasm, and the ejaculation of semen. One of the possible mechanisms by which semen is ejaculated at the moment of climax is through a trigger reflex prompted by the creation of pressure within the proximal end of the urethra when semen is released into the urethra. The pressure created, it is suggested, triggers closure of the opening of the bladder and a series of reflex contractions of the pelvic muscles. The actual process of ejaculation is controlled by the autonomic nervous system through the hypogastric and pudendal nerves. The former is a part of the sympathetic nervous system, the latter is a part of the parasympathetic. It isn't known, even now, where the pleasure of orgasm is felt within the brain. However, in considering the possible courses of action in men who display difficulties with ejaculation, this is not especially relevant or problematic. Over the years there have been many names given to delayed ejaculation, including retarded ejaculation, male orgasmic disorder, ejaculatory incompetence, anejaculation, inhibited male orgasm, and ejaculatory over control. It is nowadays defined as '...the persistent or recurrent difficulty, delay in, or absence of attaining orgasm following sufficient sexual stimulation, which causes personal distress', a definition which is you will observe includes an element of subjective judgment as to what is in fact sufficient sexual stimulation to achieve orgasm. How common is delayed ejaculation?It's not entirely clear because research in this field is lacking. Masters and Johnson observed 17 cases out of 448 couples they assessed, a rate of 3.8%, while estimates from the late 1970s suggested the frequency of delayed ejaculation is between 4 and 10%. The most reliable data appears to be that from a 2003 cross sectional sample of men visiting their general practitioners in London, where the rate reported was 11%. This figure fits with the experience of the authors of this website who believe that the correct figure for the occurrence of ejaculatory difficulties in the male population is around 12%. The reason that estimates appear so much lower is the extraordinarily high rate of under-reporting by men experiencing these problems. The reluctance to report appears to come from low awareness that such a condition is not uncommon combined with very high levels of embarrassment, shame, and feelings of sexual failure and inadequacy. Another study based on 5000 men aged between 16 and 44 years old in the United Kingdom reported that 5.3% of these men indicated some kind of difficulty in reaching orgasm for a least one month in the previous 12 months, although only 2.9% reported that the condition had continued for six months or more. This is rather suggests that delayed ejaculation has much in common with other sexual dysfunctions, in that it may occur for brief periods in many men for reasons which are unclear, and that it spontaneously resolves in the majority of these men. What causes delayed ejaculation?The primary causes would be classically listed as shown below in Table 1. Table 1 Causes of retarded ejaculation Physiological: Reduced penile sensitivity / Slower bulbocavernosal reflexes / Idiosyncratic genital stimulation Age Congenital: Mullerian duct cyst / Wolfian duct abnormality / Prune Belly Syndrome Anatomical: Transurethral resection of prostate / Bladder neck incision Neurological: Diabetic neuropathy / Spinal cord injury / Radical prostatectomy / Proctocolectomy / Bilateral sympathectomy / Abdominal aortic aneuysmectomy / Para-aortic lymphadenectomy Endocrine: Diabetes / Hypogonadism / Hypothyroidism Various drugs known to be associated with retarded ejaculation (listed below): Alpha blockers
Psychological and Psycho-social causesLet us examine these in turn. Physiological etiology of delayed ejaculationAfter several years working on this website, it's become clear to the author that reduced penile sensitivity and slower bulbo-cavernous reflexes can be regarded as the sort of explanation for sexual difficulties that explain everything and nothing at the same time. It's very questionable if there is any kind of physiological basis for "reduced penile sensitivity" other than that caused by diabetic neuropathy. Nonetheless, many of the men who have e-mailed the author have been told by doctors that because of their sexual difficulties is reduced penile sensitivity with no explanation of how or why this might developed. In the opinion of the current author, it is most likely that what appears to be reduced physiological sensation in the penis is in fact the product of an emotional complex, where a man is essentially cut off from his feelings in both an emotional and a physical sense. However, if we are to accept that there may be a physiological basis to delayed ejaculation, the best explanation that has been offered appears to be that of Brindley and Gillan, who found that bulbo-cavernosus or glandipudendal reflex was, quite simply, missing in about 20% of a very small sample of men who displayed an absence of ejaculation. It's been suggested by Shull and Spenkle delayed ejaculation may be caused by a limited amount of sexual stimulation, that is to say, the sexual stimulation received by a man may be inadequate to provoke his ejaculation reflex. In other cases, it's been suggested that some kind of 'autosexual orientation' lies behind the phenomenon of retarded ejaculation: this is interpreted as meaning that a man prefers the stimulation of his own hand during masturbation to that of a partner during sexual activity, because he knows how to best stimulate himself to achieve pleasure. This leads to a form of habituation which prevents him receiving stimulation in adequate intensity from his partner. And it is certainly true that men who indulge in what is euphemistically termed an idiosyncratic style of masturbation -- by which is usually meant an extremely intense form of masturbation against an object, usually the bed mattress -- may find it very difficult to receive adequate stimulation during sexual activity with a partner, although they usually have no problem achieving ejaculation when they stimulate themselves. This is a condition that has come to be called Traumatic Masturbatory Syndrome. Age and delayed ejaculationEvidence has accumulated that the ageing process in men, associated as it is with a decline in the fitness of the pelvic musculature and the level of free testosterone circulating in the blood stream, is one of the factors in the etiology of ejaculatory difficulties. The table below illustrates the percentage of men in each age group with symptoms of retarded ejaculation, and you will see that there is indeed a slight increase with age, although the evidence is hardly conclusive. Table 2 Age as a predictor for retarded ejaculation Number of men with retarded ejaculation (% in brackets) Total=1246
The explanation offered for this change in ejaculatory capacity with age is that there is a degeneration of the fast-conduction peripheral sensory axons from the age of 30 onwards, which results in problems achieving the required level of stimulation and neuronal activity to trigger ejaculation. Whether or not this really represents an explanation for the postulated decreased sensitivity of the penis is still an open question. Certainly however, diabetic neuropathy, peripheral vascular disease, obesity, lack of physical fitness and consumption of recreational drugs are factors which do affect the nervous system and may therefore have an impact on a man's capacity to function sexually. Congenital malformations of the genitalia such as Mullerian and Wolffian duct malformation are certainly plausible candidates for disruption of the ejaculatory system in the human male. The consequences of such malformations can include obstruction of the ejaculatory ducts, and the lack of emission of semen into the urethra prior to ejaculation. Obviously, serious congenital malformations such as an imperforate anus may require surgery, during which pelvic nerve damage is likely to occur, thus rendering the normal mechanism of ejaculation non-functional. Pelvic surgery There are other kinds of pelvic surgery that can affect a man's ability to ejaculate. Prime amongst these is radical prostatectomy, which frequently results in loss of ejaculation (and indeed erectile function and orgasm). More modern nerve-sparing surgical procedures have been developed to avoid the previously expected postoperative loss of sexual function. Unfortunately, more common procedures such as trans-urethral resection of the benignly enlarged prostate can also cause retarded ejaculation. Neurological It's highly likely that any spinal cord injury will prejudice a man's ability to maintain normal ejaculatory function. Indeed, a man's ability to ejaculate is severely impaired by spinal cord injuries: the likelihood of loss of this function is dependent upon the level and degree of the injury. Only about one man in 20 with complete upper motor neuron lesions is able to ejaculate normally. Equally, multiple sclerosis and Parkinson's disease severely prejudice male sexual function including the ability to reach orgasm and ejaculate. Diabetes mellitus Studies have revealed that there is a close relationship between diabetes mellitus and the loss of ejaculatory function in men, presumably due to diabetic neuropathy. Prescription and nonprescription drugs Many drugs cause retarded ejaculation. Indeed, there are only three drugs prescribed for depression and obsessive-compulsive disorder which are not associated with delayed ejaculation. These are nefazodone, and bupropion and escitralopram. Many of the more common anticholinergic, antiadrenergic, antihypertensive and psychoactive drugs are also clearly associated with retarded ejaculation. Other drugs where a clear association has been reported between the pharmacological agent and slowing of ejaculation include monoamine oxidase inhibitors, selective serotonin re-uptake inhibitors (SSRIs), tricyclic antidepressants, and alpha blockers. Psychological causes of male orgasmic disorderIt is the firm contention of the current author that a huge proportion of men suffering from delayed ejaculation can find the root of their difficulty in the psychological issues that they face either in life in general, or their relationship in particular. And while hostile attacks on this position had been mooted from scientists stating that "If the literature is searched long enough, almost any and every psychological problem can be associated with male orgasmic disorder", the simple reality of the situation is that when one works with men who have no obvious causative factors for their ejaculatory difficulties, it becomes clear very quickly that many of them are in relationships about which they are, to say the least, ambivalent. While it may be trite to make the observation that a man's lack of ejaculation is a way of holding back, of keeping to himself, "the reward" of his sexual investment in his partner, it is a commonplace finding that men with delayed ejaculation frequently do not know how to give themselves sexual pleasure, in that they are always putting their sexual partners pleasure before their own, may have deeply held hostile feelings to the partner, of which they are sometimes unaware, and often demonstrate high levels of "over-control" during sex, often seeing sex more as a performance than as an opportunity to let go, and gain pleasure from the interaction with their partner. Other possibilities as causative factors in delayed ejaculation include pain from a tight frenulum, a torn frenulum, or a phimotic foreskin. All these may be an inhibitor of the ejaculatory mechanism, as indeed may social factors such as the presence of family members in the adjacent rooms during sexual activity. Patient assessment The authors of the paper make the observation that any man who presents with ejaculatory difficulties should be fully assessed to establish whether his difficulties are ejaculatory or orgasmic or both. Clearly his social and cultural environment, and his use of drugs, both prescription and nonprescription, should be monitored to establish if this may be the cause of his problems. The same applies to any physical condition including peripheral neuropathy, autonomic dysfunction (by means of lying and standing blood pressure) and spinal cord pathology. A detailed medical and sexual history, as well as a physical examination and necessary physical investigations, possibly including imaging investigations, are needed to exclude organic causes such as drugs, pelvic surgery, diabetes or congenital abnormality. No doubt the most common cause retarded ejaculation is the use of drugs prescribed for other medical conditions such as depression. Options do exist for alternatives to the drugs known to cause ejaculatory difficulty; or a partial or perhaps permanent cessation of drug use, are things to be considered by the physicians treating the man in question. Amantadine induces the release of dopamine centrally. A couple of reports of the use of amantadine to treat fluoxetine-induced retarded ejaculation have been recorded. A small retrospective study of SSRIs-associated sexual dysfunction in men used amantadine, cyproheptadine and yohimbine to reverse the men's ejaculatory problems. (Level of evidence III.) Bupropion is a serotonin/norepinephrine/dopamine re-uptake inhibitor and has been studied in men with SSRI induced ejaculatory dysfunction, but the results are unclear. Even so, bupropion has been used in the reversal of SSRI-induced retarded ejaculation. (Level of evidence III.) Buspirone, a 5HT1A agonist, is another drug that has been reported as capable of reversing the sexual dysfunction side-effects of SSRIs including retarded ejaculation. (Level of evidence Ib.) Cyproheptadine is a serotonin and histamine agonist again appranelty capable of reversing the retarded ejaculation caused by fluoxetine, fluvoxamine and clomipramine, imipramine and nortryptiline (Level of evidence III). Cyproheptadine has also been reported to reverse citralopram-induced retarded ejaculation (level of evidence III). Yohimbine, which is an alpha-2 adrenergic antagonist, appears to be capable of reversing delayed ejaculation caused by clomipramine, fluvoxamine, ertraline, paroxetine and fluoxetine (level of evidence III). Table 4 Adjunctive pharmacotherapy for SSRI-induced retarded ejaculation
Psychological approaches to retarded ejaculationI think anyone who has worked in this field would accept that psychotherapy alone is not likely to produce an improvement in ejaculatory disorders of men. The therapy needs to be combined with relationship therapy, couples work and possibly meditative relaxation or sensate focus training. Indeed, an eclectic approach which centers on the individual man, his partner and their relationship, is most likely to be successful, for it addresses the specific issues presented by the couple concerned. Thus fantasy, masturbatory exercises, sexual play, and even the use of porn to stimulate sexual arousal, may all be necessary as part of treatment. Munjack and Kanno record sex therapy is having a success rate between 42% and 82% in a meta-analysis (level of evidence IV). At a superficially simpler level, Bancroft took the view that inadequate stimulation is the 'block' to ejaculation, and suggested that the use of vigorous stimulation with a lubricant could induce ejaculation extra-vaginally, then to be followed by the introduction of a man's penis closer and closer to his partner's vagina until he was finally able to penetrate her and ejaculate internally, usually in the man on top position which he regarded as facilitating ejaculation. Certainly it appears that one of the crucial elements of this treatment is that the man should focus on his own sexual arousal and excitement rather than his partner's, although this loss of control may be very threatening to a man with delayed ejaculation and can interfere with the effectiveness of the treatment. It follows that any therapist dealing with this condition should certainly take account of any associated issues such as fear of pregnancy or sexual shame and disgust. These may be conditions for which it is appropriate to use some kind of hypnotic induction technique, although this would certainly only be useful as an adjunct to classical sexual therapy , and not a substitute for it. Conclusion The authors of the paper concluded that retarded ejaculation is an uncommon problem, a suggestion which does not seem to be borne out by the statistics they themselves present about the frequency of occurrence. In any event, it is true that well constructed research studies have not been conducted on this condition, which seems to reflect the reluctance of men to report their difficulty in this area. The precedent for treatment is therefore lacking, but a combination of medical assessment along the lines suggested above, together with therapy on an eclectic and individualistic basis should be sufficient to bring about an improvement in most in men is delayed ejaculation. It is undoubtedly extremely important to treat each man and his partner as an individual case while seeking the key to successful treatment. Their recommendations were rather vague but were as follows:
Levels of evidence Ia Evidence obtained from meta-analysis of randomized controlled trials Ib Evidence obtained from at least one randomized controlled trial IIa Evidence obtained from at least one well-designed controlled study without randomization IIb Evidence obtained from at least one well-designed quasi-experimental study III Evidence from well designed non-experimental studies such as comparative studies, correlation studies and case studies IV Evidence obtained from expert committee reports or opinions and/or clinical experiences of respected authorities References Levin RJ. The mechanism of human ejaculation - a critical analysis. J Sex Relat Ther 2005;20:123-31 American Psychiatric Association. Diagnostic and Statistics Manual of Mental Disorders. 4th edn. Washington, DC: American Psychiatric Association, 1994 Masters W, Johnson V. Human Sexual Inadequacy. Boston: Little, Brown, 1966 Kaplan HS. The New Sex Therapy. New York: Brunner Mazel, 1974 Frank E, Anderson C, Rubenstein D. Profiles of couples seeking sex therapy and marital therapy. Am J Psychiat 1978J33:559-62 Nettelbladt C Uddenberg N. Sexual dysfunction and satisfaction in 58 married Swedish men. J Psychosom Med 1979;23:141-7 Fugl-Meyer AR, Sjogren Fugl-Meyer K. Sexual disabilities, problems and satisfaction in 18-74 year olds Swedes. Scand J Sexol 1999;3:79 -105 Lindal E, Stephansson JG. The lifetime prevalence of psychosexual dysfunction among 55-57 year olds in Iceland. Social Psychiat Psychiat Epidemiol 1993;28:91-5 Solstad K, Hertoft P. Frequency of sexual problems and sexual dysfunction in middle aged Danish men. Arch Sexual Behav 1993;22:51-8 Catalan J, Gimes I, Bond A, Day A, Carrod A, Rizza C. The psychosocial impact of HIV infection in men with haemophilia: controlled investigation and factors associated with psychiatric morbidity. J Psychosom Res 1992;36: 409-16 Catalan J, Klimes I, Day A, Carrod A, Bond A, Gallwey J. The psychosocial impact of HIV infection in gay men. A controlled investigation and factors associated with psychiatric morbidity Br J Psychiat 1992,161:774-8 Rosser BR, Metz ME, Bockting WO, Buroker T. Sexual difficulties, concerns and satisfaction in homosexual men: an empirical study with implications for HIV prevention. J Sex Marital Ther 1997;23:61-73 Nazareth I, Boynton P, King M. Problems with sexual function in people attending London general practitioners: cross sectional study. BMI 2003;327:423-6 Laumann EO, Paik A, Rosen RC. Sexual dysfunction in the United States: prevalence and predictors. JAMA 199901: 537-644 Mercer CH, Fenton KA, Johnson AM, et al. Sexual function problems and health seeking behavior in Britain: probability sample survey. BMJ 2003;327:426-7 Kamischke A, Nieschlag E. Update on medical treatment of ejaculatory disorders. Int J Androl 2002;25:333-44 Bindley CS, Cillan P. Men and women who do not have orgasms. Br J Psychiatry 1982;140:351-6 [
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