Retarded Ejaculation - A Scientific Review |
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The Science Of Retarded EjaculationDr D Richardson and Dr D Goldmeier, produced a review on how retarded ejaculation should be defined, managed and treated. International Journal of STD and AIDS, 2006, 17, 7-13. To go straight to the treatment method for delayed ejaculation, follow this link. They were prompted to write the review paper because scientific evidence for the origin, treatment and management of this condition is lacking. (Numbers below in the text refer to the references given on the continuation page for this subject.) The authors start by making the observation that retarded ejaculation, which has been known by a variety of names including inhibited ejaculation and ejaculatory over-control, is defined in a way which may cause confusion. The American psychiatric Association has defined retarded ejaculation as "the persistent or recurrent difficulty, delay in, or absence of attaining orgasm following sufficient sexual stimulation, which causes personal distress." Although this definition has obtained wide recognition and acceptance, you will note that it refers to orgasm and orgasmic disorder. Technically speaking orgasm and ejaculation are separate and different events, orgasm being a cerebral event, and ejaculation and emission being physiological processes within the body. This distinction has been recognized implicitly by the European Association of Urology which has adopted two definitions: they define anorgasmia as the inability to reach orgasm and delayed ejaculation as a condition which requires abnormal stimulation of the erect penis before orgasm and ejaculation can be achieved. In some ways it's a matter of common sense: any man who cannot ejaculate during intercourse despite having received normal sexual stimulation when he has a normal erection is clearly experiencing some kind of ejaculatory dysfunction. It is possible to further define the condition into primary and secondary subcategories: primary retarded ejaculation is the term used to describe a man's ejaculatory capacity when he has actually never been able to ejaculate into his partner's vagina, and secondary retarded ejaculation (also known as secondary delayed ejaculation) is when he has lost the ability to do so, or is only able to ejaculate intravaginally from time to time. Although ejaculation by self-stimulation may be difficult, around 85% of men with either primary or secondary delayed ejaculation can reach orgasm and ejaculate through masturbation, while around 50% can achieve orgasm through non-coital stimulation by their partner. This is not to imply that we regard vaginal intercourse as a prerequisite for a definition of "normal" sexual behavior. There are many couples whose sexual repertoire is based on sexual activities other than intercourse. Masters and Johnson observed that ejaculatory incompetence, as they termed it, can be a source of pleasure because it allows prolonged periods of intercourse. This is a point which I have made myself from time to time: that if a woman is able to reach a vaginal orgasm through prolonged thrusting she may be delighted with her partner's stamina and ability to satisfy her without reaching orgasm himself. However, although this does not look like a dysfunctional state, I think it's fair to say that sooner or later problems almost always arise. This may be due to the fact that a man cannot ejaculate and a couple wish to start a family, or it may be down to the more prosaic reasoning that "if he can't ejaculate, then he doesn't find me attractive". You will note that in the definitions given above, the sexual satisfaction of the partner is not taken into account. Again, this seems logical, because although there may be some dysfunctional elements in the relationship, whether or not a man can reach orgasm and climax are more reflection of his level of sexual dysfunction than dysfunction within the relationship. And even if there are relationship problems which give rise to his ejaculatory difficulties, this is accounted for in the subcategories of primary and secondary delayed ejaculation. At the time of writing of the current article, guidelines for assessing men with ejaculatory disorders indicated that the only objective and acceptable measure dysfunction was the intra-vaginal ejaculatory latency time (IVELT or IELT), as measured with a stopwatch. Unfortunately, there has been no research into IELT that I'm aware of for men with ejaculatory dysfunction of this nature. So once again we are forced to ask the question: what is the normal time between penetration and ejaculation? The answer this question depends on the parameters that one puts on the definition of normal, but there is a kind of consensus that between four and seven minutes seems to represent both a reasonable and an average IELT. Needless to say the time varies according to the group that one is studying, and it's no surprise to find that the average ejaculation time is reported as just over two minutes in groups of younger men which have been studied. Equally, another study indicated that men with adequate or good control of their ejaculation could last for an average of nine minutes. The data around the time that it takes women to orgasm through vaginal intercourse is even more inadequate: but one study by Fisher suggested that a small proportion of women can reach orgasm within one minute, and two thirds will reach orgasm in eleven minutes. Apart from the fact that this time will clearly vary depending on how aroused a woman is before intercourse starts, this data may support the view that we have always taken that many more women would reach orgasm through vaginal intercourse if only stimulation lasted longer -- it's usually stopped because the man ejaculates and intercourse comes to an abrupt halt. Obviously, studies on sexual behavior are very difficult to design and equally difficult to interpret, none of which makes the study of delayed ejaculation any easier. It's a commonly held view that delayed ejaculation is a comparatively uncommon condition. However, the true percentage of men who experience it appears to be between 10 and 12%, which is an astoundingly high number for a condition which is comparatively unknown. This raises the question of why so few men who do have ejaculatory problems of this nature ever seek treatment or assistance. In a research project entitled Sexual Dysfunction In The US: Prevalence and Predictors, the data revealed that in a representative sample of American men aged 18 and 59 years 7.8% of 1246 men were prepared to admit to having experienced retarded ejaculation for at least one month over the previous year. In the United Kingdom, a detailed study of 5000 men aged between 16 and 44 years of age revealed that 5.3% had suffered from inability to reach orgasm for a period of at least one month in the past year, but by contrast only 2.9% of men had experienced the problem persisting for at least six months in the past year. 22 One of the interesting things about aging in men is that there are a number of very obvious physiological, behavioral, and sexual changes: the sexual organs atrophy, there is a delay in obtaining full erection, erection quality is lower, and a man has diminished testosterone levels which presumably impact on his sexual arousal. In addition there is a very obvious reduction in the intensity of orgasm and ejaculation. One of the reasons that this happens is that there is a lot of potential within the male reproductive system for degeneration of the neurological reflex arc responsible for climax. The fast conducting peripheral sensory axons are lost progressively, a change which begins in the third decade of life. In addition other factors include myelin collagen infiltration, cutaneous sensory units degenerating, and dermal atrophy. These age-related degenerative changes combined to produce difficulty in reaching the ejaculatory threshold. Other factors which would be expected to impact on a man's ejaculatory ability include peripheral vascular disease, some types of psychiatric problem, diabetic neuropathy, and psychosocial issues. One of the explanations which has been put forward for delayed ejaculation relates to physiological issues such as less penile sensitivity, reduced spinal stimulation, and a higher penile sensory threshold. These are basically the reverse of the biological and physiological explanations which have been put forward to explain rapid ejaculation. Remarkably there is indeed some evidence that the bulbo cavernosus or glandipudendal reflex is actually non-functional in two out of every nine men who suffer from complete primary ejaculatory failure. Another factor that has an impact on a man's ability to climax normally during sexual intercourse is the adoption of an idiosyncratic style of stimulation during masturbation as a teenager or young man: this is known as traumatic masturbatory syndrome, which you can read about here. Equally, congenital abnormalities of the Mullerian and Wolfferian ducts may induce cyst formation which eventually blocks the ejaculatory ducts; other abnormalities and anomalies of the development of the genital system, and even the surgical procedures used to correct them, can result in ejaculatory failure. Pelvic surgery in adult life can obviously affect a man's ability to ejaculate: radical prostatectomy is high on the list of culprits here, as is transurethral resection of the prostate and bladder neck surgery. Both of those can cause retarded ejaculation, as can other forms of pelvic surgery and spinal column trauma. Two researchers, Munjack and Kanno, identified over 20 prescribed drugs which may be responsible for retarded ejaculation. These include psychoactive, anticholinergic, anti-adrenergic, and antihypertensive drugs, tricyclic and selective serotonin reuptake inhibitor (SSRI) antidepressants, and antipsychotics. It transpires that almost all of the drugs licensed for the treatment of obsessive-compulsive or depressive disorders, with the exception of nefazodone and Bupropion, are associated with ejaculatory or orgasmic difficulty. Psychological causes of Retarded EjaculationMasters and Johnson classified the non-physical causes of retarded ejaculation into: psychosocial factors (behavioral patterns and relationships, life events, personality traits), developmental factors (traumatic childhood experiences around sex and conflicts of gender identity, troubled relationships between parents and children or between parents, negative family attitudes towards issues of sex) and personal factors (including anxiety, depression, guilt, low self-esteem, lack of sexual information, influence of cultural myths, and a very poor body image). 4 More psychodynamic theories include fear (of castration, pregnancy or relationship commitment), sexual performance anxiety, disassociation and spectatoring, rigid religious attitudes and pressures which cause sexual guilt, avoidance of sex and hostility (towards one’s partner or oneself). 77 Relationship issues almost certainly have a role. Winzce and Carey observed that a man who holds ambivalent feelings about his role as a man or partner in a sexual relationship may possibly withhold his ejaculation as an attempt to keep or increase power in that relationship. Certainly a man who is over-controlled and fears "letting go" psychologically may symbolically hold onto his ejaculate as a metaphor for maintaining power in the couple dynamic. But Shull and Spenkle suggest the explanation may be simpler: they think there may simply not be enough stimulation for the man to reach orgasm. This could be because the couple are using the wrong technique or because they have simply become bored with their sexual repertoire. However, given the speed with which many men ejaculate, and the anecdotal accounts from men with delayed ejaculation - such as the fact that this issue has been with them all their lives - this seems too simplistic an explanation. Bernard Apfelbaum has suggested that men who have difficulty reaching climax actually have an "autosexual orientation": they prefer masturbatory stimulation by their own hand rather than any kind of sex with a partner. He has also contested the view that such men are selfish: rather, he suggests, there is a case to be made that men in this position are actually over-concerned with pleasing their partners, they focus too much on their partner's pleasure at the expense of their own, and they are unaware of their own sexual pleasure, arousal and the stimulation they are experiencing. Of course, other possibilities exist, too: that a couple may not have an ideal environment for sex, or that one or other may have some physical issue which precludes satisfactory intercourse and demotivates them from sexual interaction - painful intercourse or a foreskin stretched over the glans (phimosis), for example. In all cases of ejaculatory dysfunction, it's clear that the wide variety of etiology which has been suggested means that comprehensive medical examination of all men with the condition is probably useful: their physiology, their psycho-social structure, and their relationship may all need examining to see where the roots of the problem might lie. But at the end of the day, the question is: "How to treat the delayed ejaculation?"If SSRI's can be used to control rapid or early ejaculation, then any drugs which have the opposite effect might be expected to decrease a man's IELT. Unfortunately, there is little evidence to show that drugs are an effective therapy for delayed ejaculation. Admittedly, some evidence exists that that amantadine, yohimbine and cyproheptadine have a limited impact on retarded ejaculation. Amantadine promotes dopamine release centrally, while yohimbine is an alpha-2 adrenergic antagonist. Cyproheptadine is a serotonin and histamine agonist. It has been shown that when men have delayed ejaculation as a result of taking SSRI's, Amantadine can reverse this effect; there is also evidence that yohimbine and cyproheptadine can do the same. Some reports suggest men with antidepressant-induced retarded ejaculation can be cured with Bupropion (81), but the evidence is very patchy. For example, a randomized controlled double blind study of SSRI-induced sexual dysfunction of 32 men who were given a low dose of Bupropion (150mg daily) showed no benefit over placebo over three weeks. 84 Cyproheptadine has been successful in reversing retarded ejaculation caused by clomipramine, nortryptiline, fluoxetine, imipramine, nortryptiline and fluvoxamine. 88–92 Even though much of the work which has been done has been lacking in rigorous controls, the use of Cyproheptadine, Yohimbine and amantadine are the methods favored for the treatment of the condition in the international guidelines. 25 [ Delayed ejaculation - retarded ejaculation - how to ejaculate during sex ]
Treatment of retarded ejaculation |
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