Causes and Treatment Of Delayed Ejaculation

Under normal circumstances a man's orgasm coincides with the time of his ejaculation. However, they are in fact different events. An orgasm is a subjective experience defined by perception of peak sexual pleasure.

Anorgasmia is defined as the absence of orgasm during sexual activity. In men, the absence of orgasm has become known as male orgasmic disorder.

The diagnostic conditions for male orgasmic disorder are as follows:

• a persistent delay in achieving orgasm, or the complete absence of orgasm, following the achievement of sexual excitement that would in normal circumstances be sufficient to trigger an orgasm
• that the condition causes personal distress
• and that's the orgasmic dysfunction is not better accounted for by some other sexual dysfunction

• whether the condition is lifelong or acquired
• whether the condition is generalized or situational [i.e. whether it occurs with all sexual partners or just one]
• whether it is due to psychological or physical factors

It's important to emphasize that the definition requires there to be in a normal phase of sexual excitement, because the absence of orgasm may well be expected in other situations: for example, where there is no desire for sexual activity, or where there is aversion to any kind of sexual contact with a partner, or where there is a sexual aversion disorder, or even an erectile disorder.

It's unfortunate that men who have male orgasmic disorder or delayed ejaculation can usually achieve firm erections and engage in normal sexual activity with adequate penetration. It's often been observed, as reported elsewhere on this site, that men with issue delayed ejaculation can often [although not always] reach orgasm through masturbation or perhaps even oral sex. It follows therefore that any man who reports having never experienced an orgasm despite having engaged in normal sexual activity probably has a physical or organic etiology behind the condition.

DSM IV, the diagnostic and statistical manual, makes no distinction between orgasmic disorders and ejaculation disorders in men, although it does make reference to premature ejaculation as an ejaculation disorder. This lack classification leads us to suppose that orgasm and ejaculation are at least overlapping if not simultaneous events. Yet many sex researchers acknowledge that disorders of orgasm and disorder of ejaculation are quite different: for example, disorders in the latter category would include delayed ejaculation, and retrograde ejaculation, ejaculatory insufficiency, and primary or complete anejaculation with the presence of an orgasm.

We certainly know that orgasm can occur without ejaculation -- this is seen in prepubescent children and adult males practicing certain Tantric sexual techniques.

A typical case of delayed ejaculation would be a 30-year-old man presenting with the bald statement that "he cannot come" or some similar complaint. Most men in this category will have no prior psychiatric history, nor will they show any medical signs that might account for the lack of an ejaculation. A typical client presenting to a sexual psychotherapist with this condition -- although few men do in fact seek treatment for it -- would report little anxiety, good relationship with friends and family, a normal level of social adjustment and a lack of any other obvious psychological issues.

But when one begins to investigate what's going on for these men one soon realizes that there is more in the relationship than might first meet the eye. A typical client presenting with this condition might refer to a new relationship that has only been in existence for a few months. It's possible that from the first time when the couple tried to engage in sexual activity, the man experienced this kind of orgasmic problem, and when questioned about the sex in which he and his partner were engaging he will often makes some telling observation such as: it was unusually vigorous or involved practices which he finds questionable or challenging or unacceptable in some way. An alternative scenario is that he may reveal issues about his relationship which suggest that there are fundamental aspects of the relationship that do not satisfy either the partners' emotional or psychological needs.

Usually men with this condition will report no difficulty in achieving the firm erection, and maintaining it. Indeed they are likely to report long-lasting erections: often they will report that they pretend to reach orgasm so that their partner does not feel guilty or disappointed. Classically none of these issues would be discussed with anyone else, not even the sexual partners.

So what's going on here? If we examine the events that lead up to the normal climax of male sexual activity there are distinct stages that can be defined as erection, emission [the release of semen into the base of the penis], ejaculation, and orgasm. This highly refined and familiar sequence of events might lead a man to believe that there is a common physiological mechanism underlying them. The truth is they are separate events. You need look no further than the fact that a typical client with male orgasmic disorder or delayed ejaculation can sustain a rigid erection for prolonged periods of time [or, indeed, you need look no further than the fact that a man with complete erectile dysfunction may find it easy to ejaculate provided his penis is stimulated in the correct way for sufficient length of time].

Stimulation of the penis is required in most circumstances to achieve both emission and ejaculation. Efferent nerve impulses travel from the pudendal nerves until they reach the region of the upper lumbar spinal sympathetic nuclei. At this point the hypogastric nerve acts as a conduit for impulses which activate both secretions and the movement of sperm from the epididymis through the vas deferens, seminal vesicles and prostate to the base of the urethra. When the internal urethral sphincter closes and the external urethral sphincter relaxes, the semen is directed into the bulb at the base of the penis - this is the moment of emission.

The somatomotor efferent branch of the pudendal nerve stimulates the bulbocavernous muscle into a series of rhythmic contractions, the effect of which is to force the semen through a narrowing of the urethra, producing a more or less powerful ejaculation of between two and 5 mL of semen. This is an involuntary action, but it involves an integration of both autonomic and somatic systems.

The network in the brain which controls the final output of all stimulation relating to ejaculation includes the posteromedial bed nucleus of the stria terminalis, along with the posterodorsal medial amygdaloid nucleus, and the parvicellular part of the subparafasicular thalamus.

It appears that the ejaculation reflex in man is mostly regulated by central serotonergic and dopaminergic systems while other neurotransmitters including acetylcholine, oxytocin, adrenaline and nitric oxide appear to have a secondary role.

There's evidence that serotonin 5HT exerts some kind of inhibitory role in the process of ejaculation through the brain's descending pathways. 5HT receptor subtypes A B and C have been associated with the modulating effect of serotonin on ejaculation.

Pharmacological manipulation of the serotonergic system has been undertaken in experimental rats, where SSRIs [selective serotonin re-uptake inhibitors] were the most effective compounds in the delaying of the ejaculation. Presynaptic 5HT1A  receptors appear to be responsible for decreasing ejaculatory latency; postsynaptic 5H1B and 5H2C receptors appear to prolong ejaculatory latency.

In various animal models, dopamine levels measured in the medial preoptic area of the hypothalamus apparently progressively increased during sexual excitation and intercourse, while GABA receptor antagonists inhibited sexual behavior. Muscular contractions during the moment of ejaculation are, according to some research, affected by oxytocin.

All in all, therefore, with this relationship between serotonergic receptors and the effects that inhibit the sexual mechanism, and the effects that excite the sexual mechanism, the altered levels of 5HT, or varying receptor sensitivity in the central nervous system centers that modulate ejaculation, it's most likely that these altered levels of 5HT lie behind ejaculatory disorders. It's been suggested for example the serotonin has the capacity to suppress ejaculation by interrupting the effect of oxytocin.

However, despite all this research, the exact role and importance of various neurotransmitters is far from clear due to the multifactorial and extraordinarily complex nature of the male ejaculation reflex.

Indeed, the mechanism of orgasm is one of the parts of the sexual process which is still far from understood. It involves central nervous system integration in response to various sexual stimuli, but emission, ejaculation, and orgasm are all associated with various other non-genital stimuli and responses in the body. For example, think of involuntary contractions of the anal sphincter, rapid breathing, tachycardia, or the elevation of blood pressure during sexual activity.

Transient sympathoadrenal activation during sexual activity which is associated with various increases in adrenaline and noradrenaline plasma levels have been reported as associated with male orgasm. And yet the association of vasopressin, luteinizing hormone, follicle stimulating hormone, growth hormone, cortisol and various other hormones to male orgasm all remain unclear.

Even though both oxytocin and prolactin levels are clearly observable as peaking immediately after the moment of orgasm, prolactin is a more reliable indicator of male orgasm.

So in the face of poor confirmation from various experiments of any hypothesis related to the mechanism of orgasmic disorder, it follows that investigation has been limited, and results of those studies which have been conducted is unclear.

However a review by Simons and Carey of over 10 years' work suggested that male orgasmic disorder occurred in around 8% of the community, a figure which has been backed up by many other studies, although there seems to be evidence that the rate may actually be higher than this, at around 10%.

The international survey of sexual attitudes and behaviors, the GSSAB, which investigated all aspects of sexual behavior and attitudes, beliefs and outcomes among more than 27,000 men and women between 40 and 80 years of age suggested that the real level of male orgasmic disorder in the population was 13%, however the definition of delayed ejaculation was imprecise and the figure may therefore include other conditions than delayed ejaculation.

A lack of well controlled studies in this area is undoubtedly one of the reasons why there is an apparent wide variation in the reported level of delayed ejaculation in the population. It's probably best to take any epidemiological evidence as suggestive or informative rather than definitive at this time: certainly further research is needed to determine an accurate estimate of the de facto incidence of delayed ejaculation in men of various ages, race, country of residence and to determine how it varies with other social variables.

Psychological factors in delayed ejaculation

Psychological factors may include a history of sexual trauma, guilt around sex, a fear of getting the partner pregnant, or hostility towards one woman or all women. These variables have all been associated with delayed ejaculation.

Yet there are many other causes of ejaculatory disorders, especially surgery. Ejaculatory dysfunction has been reported in about 40% of men with bilateral sympathectomy at the L2 level. There is an even higher rate of emmission failure in men who have surgery with high bilateral retroperineal lymphadenectomy.

Dysfunction of the sphincter of the bladder neck may occur after prostatectomy, which may lead to retrograde ejaculation into the bladder. Other conditions which can give rise to ejaculatory disorders include a history of disease and pelvic surgery (although of course one must be careful not to mistake the phenomena of orgasm without ejaculation for delayed ejaculation: this phenomenon may that be nothing more than retrograde ejaculation, where no ejaculation is observed because of the retrograde ejaculation, while orgasm occurs naturally and is succeeded by loss of erection).

Also, there are chronic medical conditions that can affect male sexual performance and orgasm. Angina, for example, is a strong suspect in this regard, while cigarette smoking can cause vascular insufficiency and decreasing levels of penile nitrous oxide.

As many men will know heavy consumption of alcohol or other recreational drugs may well inhibit the genital nervous and vascular system so that they do not operate correctly.

The most common medical conditions causing various forms of sexual difficulties are diabetes and high blood pressure. It's also well-known that various drugs which are available on prescription can induce male orgasmic disorder: these include Alpha and Beta adrenergic blockers, sympathetic nerve blockers, monoamine oxidase inhibitors, antidepressants, tricyclic antidepressants and  SSRIs.

As far as the treatment of delayed ejaculation is concerned, the first approach might be to investigate the possibility of changes in the man's drug regimen.

This might mean eliminating iatrogenic causes such as Alpha adrenergic blockers or antihypertensives, antidepressants, and antipsychotics. When antidepressants are implicated, switching to bupropion and mirtazapine may be helpful, as they have fewer side effects on the sexual system than SSRIs. Adjunctive therapies such as alpha sympathomimetrics may be helpful. Sildenafil and Imipramine may be effective in psychotropic-induced male orgasmic disorder.

Anorgasmia in men -  treatment by psychological interventions

Obviously any intervention aimed at curing male orgasmic disorder has to address not only the historical aspects of the condition but also the current factors that may be responsible for a man's inability to come during sex.

Among the current factors we can include the following:

Sexual performance anxiety. This would be addressed by cognitive behavioral interventions aimed at reducing a man's overall level of anxiety; in addition there would also be merit in providing sexual education and information to overcome any inhibitions due to a lack of knowledge or misinformation; it's also helpful to use guided imagery in conjunction with some kind of sensate focusing technique to increase a man's confidence about his ability to complete the sexual act satisfactorily.

Relationship issues. Very often male orgasmic disorder or delayed ejaculation is the product of relationship issues; in such cases, some kind of sexual psychotherapy is indicated.

Stress. When stress is the result of factors other than those mentioned above, some kind of therapeutic intervention appropriate to the situation can both reduce anxiety and increase self-confidence.

Environmental factors. These are the things that are much more under the control of the patient than the therapist: they include, for example, a lack of privacy in which to enjoy intimate relations, lack of warmth, the presence of children, and so on.

Historical factors include these:

Past sexual experiences which have led to negative beliefs or attitudes about sex (such as childhood sexual trauma, adult sexual trauma, or any other event which has led an individual to conclude that sex is a sin, or that his/her genitals are disgusting or dirty.

Psychodynamic psychotherapy aimed at uncovering the original trauma can reduce current anxiety and guilt and provide a balance to misinformation which may be inhibiting adult sexual performance.

It has been suggested that psychodynamic therapy is more appropriate when the trauma lies in the distant past, and relationship counseling is more appropriate where delayed ejaculation appears to be the product of the interaction between two individuals within a relationship.

Some researchers have suggested that a vibrator applied underneath the glans of a man's penis can provide enough stimulation to make him ejaculate: the view of the current author is that using extremely hard stimulation of this nature may be counterproductive in that it reinforces something resonant of traumatic masturbatory syndrome, a condition where vigorous and repetitive masturbation during adolescence renders a man incapable of achieving sufficient stimulation to his penis to trigger the ejaculatory reflex.

Unfortunately, little is known about the natural progression of delayed ejaculation when it is not treated, although one can speculate that situational and acquired forms of the condition may resolve more easily than generalized and lifelong types.

Finally it's worth mentioning that since the intensity of a man's ejaculation is directly related to the volume of semen that he produces, a reduction in the volume of ejaculate will result in a reduction in sexual pleasure. The significance of this observation is that ejaculation volume decreases with age, since it is testosterone dependent and plasma testosterone levels also fall as a man ages. Older men are therefore likely to experience less sexual pleasure than younger men at the moment of orgasm.

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