Treatment For Delayed Ejaculation: When You Can't Orgasm Or Ejaculate During Lovemaking(And For Women Who Have A Man In Their Life Who Can't Come During Sex) |
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What follows is my interpretation of paper published electronically by Marcel D. Waldinger, Department of Psychiatry and Neurosexology, Leyenburg Haga Hospital, Leyweg and Dave H. Schweitzer, Department of Internal Medicine and Endocrinology, Reinier de Graaf Groep Hospital, Delft-Voorburg, The Netherlands. Retarded ejaculation in men: psychological and neurobiological aspectsThe DSM IV confuses the issue of ejaculatory dysfunction with orgasmic problems. These two events - although spoken of as if they were simultaneous and inseparable - are in fact different neurobiological phenomena. This means that the term male orgasmic disorder is not necessarily appropriate to the condition in which a man cannot ejaculate during sex. However, in practice, most men who cannot ejaculate are experiencing delayed ejaculation and will not achieve orgasm either. Approaches to treatment have centered on sexual psychotherapy and, more recently, a neurobiological approach. This latter approach started with animal studies, and has shown that there are various neurotransmitters with the power to inhibit ejaculation. One of the problems with research in this field is that there are few well conducted studies on men with long term delayed ejaculation. That is surprising considering that there are so many men with the condition - estimates range from around 6% to over 10% of men. (The latter figure matches our experience as online therapists and group psychotherapists for men. However, the exact figure may be even higher since few men with this problem seek treatment or help.) Long term delayed ejaculation is not a consciously determined condition - in fact it is completely involuntary, and produces many emotional and practical difficulties for both the man and his partner. One of the most challenging consequences is the failure to conceive because of the lack of male ejaculation, but frustration and low self-esteem are no less significant. Delayed ejaculation is also extremely challenging for a man's partner, as she may consider herself to be unattractive, undesirable, and possibly even a sexual failure. She may believe that another woman would be better at satisfying her man sexually, and even if she engages in intercourse with her partner, she may be very upset about the extended period of thrusting that may be necessary for him to achieve ejaculation (if he is able to reach orgasm at all). I mentioned above that ejaculation and orgasm are two separate events in the male body: ejaculation is clearly an event that occurs in the genitals, mediated by nervous pathways through the spinal column. Orgasm is a much more widespread event, with sensations of pleasure originating in the brain, and possibly spreading throughout the body. The so-called "numb come", more scientifically termed "anesthetic ejaculation", is an illustration of how orgasm and ejaculation can occur independently. The idea of anesthetic ejaculation is rather strange; if you've never experienced it, you may find it hard to believe that one can ejaculate without any sensation of orgasm, but it's not uncommon. This lack of understanding is reflected in DSM-IV, which categorizes inability to ejaculate as male orgasmic disorder, while listening premature ejaculation as an ejaculation disorder. Having said that, DSM-IV does offer a reasonable definition of delayed ejaculation: A persistent or recurrent delay in, or absence of, orgasm in a man who has experienced sexual excitement and arousal during sexual activity at a level which would normally produce an orgasm in a man of that age and circumstances. Unfortunately the DSM-IV definition also includes the statement that the clinician is the judge of what would be "enough" sexual activity to normally produce an orgasm! Taking this rather dubious proposition out of the definition allows us to define delayed ejaculation in a different way: it is a condition where a man finds it difficult or impossible to ejaculate despite receiving adequate sexual stimulation, becoming erect, and desiring to achieve orgasm and ejaculation. It is a condition that can occur in sexual intercourse, masturbation or oral sex. There have been many terms used to refer to this particular problem with ejaculation: retarded ejaculation, inhibited ejaculation, and anejaculation being some of the less derogatory-sounding terms. it's also necessary to distinguish between lifelong or primary delayed ejaculation, and acquired or secondary delayed ejaculation. These terms are probably self-explanatory. Neurobiology and neuropharmacology In recent years, it has become clear that orgasm and ejaculation are mediated by different nerve pathways and involve different neurotransmitters. Clearly, the research into neurotransmitters raises the possibility of pharmacological intervention as an approach to curing retarded ejaculation. Recent work has served to explain the neural pathways and cellular biochemistry of ejaculation. We now know that orgasm and ejaculation are the product of the activity of different nerve circuits and different neurotransmitters. Obviously, the possibility of pharmacological intervention to cure delayed ejaculation arises from ongoing research into neurotransmitters: however, rather more is known about the neurobiology of ejaculation than is known about the neurobiology of orgasm. Symptoms of retarded ejaculationIf a man is unable to ejaculate in all sexual situations with all sexual partners his condition is described as generalized DE (delayed ejaculation). If, on the other hand, his inability to reach orgasm and ejaculate is limited to certain situations or certain partners, he is said to have situational delayed ejaculation. For example a man may be unable to ejaculate during sex with one particular partner, or he may be unable to ejaculate unless he is stimulated in a particular way. Attempts to study and work out the frequency with which DE occurs in the male population are frustrated by the lack of data, and the lack of data relating to what is an abnormally long time between vaginal penetration and ejaculation in the normal male population. Psychological aspects of lifelong delayed ejaculationTraditionally, DE has been seen as the product of fear, hostility, anger or other relationship issues between the man and his partner. In classical Freudian terms, the primal fears that cause DE have variously been described as including fear of castration, fear of death, an unwillingness to ejaculate because the semen represents a giving away a part of the self, sexual guilt, and fear of making the woman pregnant. There is unfortunately no evidence to support or deny these hypotheses. There is probably no need to go into the level of Freudian psychodynamic analysis implied by the previous sentence when working with men who are experiencing a retarded ejaculation. This is because improvements have been recorded with treatments as varied as masturbation exercises, cognitive behavioral therapy, rational emotive therapy, psychodynamic psychotherapy, marital therapy, and even social skills training! This implies that DE may be the product of a combination of psychological deficiencies, including but not limited to, a lack of appropriate sexual experience in young adulthood, repressive sexual experiences during childhood, and possibly more general issues of low self-esteem or lack of knowledge about relationships and sexual involvement with women. There is also a characteristic which has not received sufficient attention - that is, the driven personality of men with delayed ejaculation, a personality type which seems to encourage the men concerned to put the achievement of their partner's sexual pleasure before their own, and to use the female orgasm as a symbol of their own sexual success! Neurobiological approach to lifelong delayed ejaculationCertainly there must be a developmental aspect to this condition because rats reared in isolation do not know how to copulate and achieve orgasm through mating when they reach adulthood. If subsequently exposed to other rats, some of these rats will learn how to achieve orgasm and ejaculate; others will not. It's also possible that delayed ejaculation is simply an extreme variant which is quite normal in an average population distribution of men, arguably in the same way that premature ejaculation is also a normal condition in an average population of men. Animal studies of delayed ejaculationWaldinger's initial research used rats in which hyposexual behavior was created by raising the rats with different levels of sexual experience. Of 278 sexually naive rats, 23 showed no sexual activity, 211 displayed sexual activity but failed to ejaculate, and 44 were able to copulate and ejaculate. The rat's sexual performance improved when they were treated with 5-HT1A receptor agonists. In particular, 8-OH-DPAT and flesinoxan increased sexual behavior almost to the level of the sexually experienced rats. Sexual performance was also improved after administration of partial 5-HT1A receptor agonists buspirone and ipsapirone. Furthermore, 2-adrenoceptor antagonists such as yohimbine and idazoxan also have a degree of efficacy in reducing the ejaculation time of these sexually naive rats [20, 21]. Mos et al. [20] also demonstrated that male rats which received 5-HT1A receptor agonists (flesinoxan, gepirone) were in fact more attractive to sexually receptive females than a control groups of rats. These results contrast with the finding that 2-adrenoceptor antagonist treated male rats showed no increase in sexual attractiveness to estrus females. Hyposexual behavior can be reversed by the opioid receptor antagonist naloxone [22]. And other research studies have demonstrated that certain pharmacological compounds and various neuropeptides may also increase and improve copulatory behavior in sexually inactive rats. For example, the 5-HT1A receptor agonist 8-OH-DPAT clearly increased sexual activity in rats that demonstrated hyposexual behavior. [23]. Similarly, the erection promoting drug Viagra (sildenafil) [25] when administered with low doses of the hormone melatonin [26] also demonstrated the capacity to reverse hyposexual behavior in these sexually inactive rats. All in all, such pharmacological studies indicate with a fair degree of certainty that specific neurobiological mechanisms are responsible for hyposexual behavior. And it is a fact that neurobiological differences have actually been demonstrated in rats that are not sexually active when compared to those which show normal sexual behavior. A compound implicated in facilitating ejaculation is the neurotransmitter oxytocin [27]. The neurons which produce oxytocin are mostly located in the paraventricular nucleus situated in the hypothalamus; it may be no coincidence that projections from these areas of the hypothalamus reach into the lumbosacral area of the spinal cord [28]. Arletti and colleagues [29] demonstrated that the expression of oxytocin mRNA is reduced in the paraventricular nucleus of sexually inactive rats; one conclusion which may be drawn from this is that oxytocin is intimately involved in the copulatory behavior of male rats. However, the exact role of oxytocin is as yet uncertain. As implied above, more brain neuropeptides, the opioids, may well be associated with the neurobiology of copulatory behavior [27, 30]. Thus, for example, mRNA expression of pro-enkephalin and pro-dynorphin, in addition to endogenous opioid octapeptide levels, actually increase in the hypothalami of rats showing sexually inactive behavior. [29, 31]. It is not clear yet if hypothalamic endogenous opioid expression lies behind changes in copulatory behavior, though it is worth remarking that this seems to support the idea that brain opioids inhibit sexual behavior. Clearly, transferring this research to
the human male is rather problematic, for all kinds of ethical and
practical reasons. In contrast, treatment with 5-HT2C receptor antagonists in men (more specifically, nefazodone and mirtazapine), did not have any noticeable effect on ejaculation time [32, 33]. The evidence for hyperfunction of the 5-HT2C receptor as a cause for delayed ejaculation is therefore not sustainable. But, in practice, Waldinger suggests that safe 5-HT1A receptor agonists should be researched on the basis that they may form a class of drugs which acts to alleviate this particular ejaculatory disorder in men. Brain imaging When you ask men to ejaculate whilst they are located inside a PET scan, you can get some interesting information about changes in the activity of the male brain during the process of ejaculation. Perhaps not surprisingly, only half of the volunteers who tried this managed to ejaculate under these conditions. What emerged quite clearly was that non-ejaculation involved much more activity in the brain cortex than did ejaculation. This activity was centered on the amygdala and left temporal areas of the brain, and it is known that these areas are responsible for both fear behavior and vigilance. Obviously the implication is that higher than normal activity in these areas of the brain may be the cause of a man's inability to ejaculate, both fear and vigilance would inhibit sexual arousal and ejaculation in almost all men. Acquired delayed ejaculationPsychological causesAny experience of acquired retarded ejaculation suggests there may have been the precipitating event for the man concerned. Clearly any sexual situation that involves an adverse emotional experience may fulfill this condition. It's also possible that there are more obvious causes of anejaculation - hi among these is the simple fact that a man's ejaculation takes longer to achieve as he ages. This can be due to androgen deficiency, i.e. low testosterone levels, or damage to the nerves through neurodegenerative disorders such as diabetic neuropathy, spinal injuries, nerve damage during surgery, and a large number of prescription drugs including SSRIs, antipsychotics, and antidepressants. Treatment of acquired delayed ejaculationIn cases of acquired delayed ejaculation, appropriate treatment can be administered according to the perceived cause: testosterone supplementation, a change of medication, or even a change in sexual behavior. Research on lifelong delayed ejaculation is scarce. Much of the work that exists was not conducted in a scientifically valid way, and serves no useful purpose. It seems that a good way to treat men with lifelong DE is to provide adequate information and to provide counseling and support. The effects of psychotherapy depend on a man's individual receptivity to the process and his willingness to change his behavior. The greatest success is probably achieved when a man seeks combined treatment from both therapist and doctor with a treatment progam that involves changing both sexual and psychological behavior. Effective drug treatment is not yet available. References 2. Riley AJ, Riley EJ (1982) Partial ejaculatory incompetence: the therapeutic effect of Midodrine, an orally active selective alpha-adrenoceptor agonist. Eur Urol 8: 155 3. Waldinger MD (2004) Lifelong premature ejaculation: from authority based to evidence based medicine. Brit J Urol Int 93: 201 4. Dekker J (1993) Inhibited male orgasm. In: ODonohue W, Geer JH (eds) Handbook of sexual dysfunctions. Simon and Schuster, p 279 5 . Nathan SG (1986) The epidemiology of the DSM-III psychosexual dysfunctions. J Sex Marital Therapy 12: 267 6. Kaplan HS (1974) Retarded ejaculation. In: Kaplan HS (ed) The new sex therapy. Brunner/Mazel, New York, p 316 7. Munjack DJ, Kanno PH (1979) Retarded ejaculation: a review. Arch Sex Behav 8: 139 8. Shull GR, Sprenkle DH (1980) Retarded ejaculation reconceptualization and implications for treatment. J Sex Marital Therapy 60: 234 9. Delmonte MM (1984) Case reports on the use of meditative relaxation as an intervention strategy with retarded ejaculation. Biofeedback Self-regulat 9: 209 10. Delmonte M, Braidwood M (1980) Treatment of retarded ejaculation with psychotherapy and meditative relaxation: a case report. Psychol Rep 47: 8 11. Gagliardi FA (1976) Ejaculatio retardata; conventional psychotherapy and sex therapy in a severe obsessive-compulsive disorder. Am J Psychother 30: 85 12. Apfelbaum B (1990) Retarded ejaculation: a much-misunderstood syndrome. In: Leiblum SR, Rosen RC (eds) Principles and practice of sex therapy. Update for the 1990s, 2nd edn. Guilford Press, New York p 168 13. Beckerman H, Becher J, Lankhorst GJ (1993) The effectiveness of vibratory stimulation in an ejaculatory man with spinal cord injury. Paraplegia 31: 689 14. Brindley GS (1981) Reflex ejaculation: its technique, neurological implications and uses. J Neurol Neurosurg Psychiatry 44: 9 15. Beach FA (1942) Comparison of
copulatory behaviour of male rats raised in isolation, cohabition, and
segregation. J Genet Psych 60: 3 17. Waldinger MD (1999) Klaar is Kees: Een nieuwe visie op vroegtijdige zaadlozing. De Arbeiderspers, Amsterdam 18. Waldinger MD (2002) The neurobiological approach to premature ejaculation. J Urol 168: 2359 19. Waldinger MD (2005) Lifelong premature ejaculation: current debate on epidemiology and SSRI treatment. World J Urol (this issue) 20. Mos J, Olivier B, Bloetjes K, Poth M (1990) In: Slob AK, Baum MJ (eds) Psychoneuroendocrinology of growth and development. Medicom Publishers, Rotterdam, p 221 21. Mos J, Van Logten J, Bloetjes K, Olivier B (1991) The effects of idazoxan and 8-OH-DPAT on sexual behaviour and associated ultrasonic vocalizations in the rat. Neurosci Biobehav Rev 15: 505 22. Gessa GL, Paglietti E, Pellegrini-Quarantotti B (1979) Induction of copulatory behaviour in sexual inactive rats by naloxone. Science 204: 203 23. Haensel SM, Mos J, Olivier B, Slob AK (1991) Sex behavior of male and female wistar rats affected by the serotonin agonist 8-OH-DPAT. Pharmacol Biochem Behav 40: 221 24. Giuliani D, Ottani A, Ferrari F (2002) Influence of sildanefil on copulatory behaviour in sluggish or normal ejaculator rats: a central dopamine mediated effect? Neuropharmacology 42: 562 25. Ottani A, Giuliani D, Ferrari F (2002) Modulatory activity of sildenafil on copulatory behaviour of both intact and castrated male rats. Pharmacol Biochem Behav 72: 717 26. Drago F, Busa L (2000) Acute low doses of melatonin restore full sexual activity in impotent male rats. Brain Res 878: 98 27. Argiolas A (1999) Neuropeptides and sexual behaviour. Neurosci Biobehav Rev 23: 1127 28. Swanson LW, Kuypers HG (1980) The paraventricular nucleus of the hypothalamus: cytoarchitectonic subdivisions and organization of projections to the pituitary, dorsal vagal complex, and spinal cord as demonstrated by retrograde fluorescence double-labeling methods. J Comp Neurol 194: 555 29. Arletti R, Calza L, Giardino L, Benelli A, Cavazzuti E, Bertolini A (1997) Sexual impotence is associated with a reduced production of oxytocin and with an increased production of opioid peptides in the paraventricular nucleus of male rats. Neurosci Lett 233: 65 30. Pfaus JG, Gorzalka BB (1987) Opioids and sexual behaviour. Neurosci Biobehav Rev 11: 1 31. Rodriguez-Manzo G, Asai M, Fernandez-Guasti A (2002) Evidence for changes in brain enkephalin contents associated to male rat sexual activity. Behav Brain Res 131: 47 32. Waldinger MD, Zwinderman AH, Olivier B (2001) Antidepressants and ejaculation: a double-blind, randomized, placebo-controlled, fixed-dose study with paroxetine, sertraline, and nefazodone. J Clin Psychopharmacol 21: 293 33. Waldinger MD, Zwinderman AH, Olivier B (2003) Antidepressants and ejaculation: a double-blind, randomised, fixed-dose study with mirtazapine and paroxetine. J Clin Psychopharmacol 23: 448 34. Georgiadis JR, Holstege G (2004)
Ejaculation or no ejaculation: the left anterior temporal lobe decides?
Program no. 214.18.2004 Abstract. Society for Neuroscience, Washington 36. Holstege G, Georgiadis JR, Paans AM, Meiners LC, Van der Graaf FH, Reinders AA (2003) Brain activation during human male ejaculation. J Neurosci 23: 9185 37. Waldinger MD (1996) Use of psychoactive agents in the treatment of sexual dysfunction. CNS Drugs 6: 204 38. Waldinger MD, Pattij T, Olivier B (2005) Animal models of premature and delayed ejaculation. World J Urol (this issue) More information [ Delayed ejaculation - retarded ejaculation - how to ejaculate during sex ]
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