What Causes Delayed Ejaculation? |
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What is the cause of delayed ejaculation?Difficulty in ejaculating during sex is called delayed ejaculation. Men who experience delayed ejaculation may be able to maintain prolonged thrusting for 30 minutes or more before they ejaculate (often even longer) during either sexual intercourse or masturbation. This leads to massive frustration for both the man and his partner. Physical causes of delayed ejaculation include the following:
But by far and away the most frequent cause of delayed ejaculation is any one or more of a panoply of psychological issues. For example, cultural or religious taboos about sex, or inhibitions about performance or sexual activity, can cause delayed ejaculation. And another very common cause is a kind of behavioral conditioning from certain masturbation patterns. This is called idiosyncratic masturbation and often involves hard and fast movements which leave a man unable to reach orgasm during the less gentle stimulation received from intercourse. A medical history and physical or neurological examination can determine if delayed ejaculation is due to a some significant underlying medical condition or if it is the result of a side effect of medication. Treatment of delayed ejaculation will therefore depend on the underlying cause but may include:
Psychological factors in delayed ejaculation are also mentioned elsewhere. There aren't many well designed studies on men who have had delayed ejaculation all their lives. This is because many men with the condition prefer to keep it secret rather than seek help, but the importance of the condition is also underestimated y doctors - it can certainly severely impact on the quality of life of a couple where the man has delayed ejaculation. You sometimes even find the opinion expressed that delayed ejaculation is useful in allowing a man to satisfy his partner (i.e. bring her to climax during intercourse - perhaps even more than once). The reality, of course, is that delayed ejaculation is beyond the control of the man concerned, and it can produce many emotional and physical reactions, not least because of the difficulty in conceiving and the attendant emotional reactions. Naturally enough, men can also become frustrated by not being able to ejaculate and reach orgasm. The partners of men who have delayed ejaculation also have difficulties: they may see themselves as victims, believing that the cause of the delayed ejaculation is their lack of attractiveness or that they may be unable to sexually arouse their man. In addition, the prolonged vaginal intercourse which follows the development of delayed ejaculation may be uncomfortable if not downright painful.Ejaculation and orgasm are two separate processes, though we tend to think of them as being simultaneous. They actually involve separate responses in the body: ejaculation is specific to the genitals, and orgasm is a whole body phenomenon. There is an experience colloquially known as "numb come" (which doctors term anesthetic ejaculation) which illustrates how the experience may be physiologically and psychologically separated. There is ejaculation, but no experience of orgasm - probably due to lack of sexual arousal. Delayed ejaculation is a similar phenomenon, although there may be neither ejaculation nor orgasm. The difference between orgasm and ejaculation is not made explicit in the DSM IV, where ejaculation disorders are grouped under Orgasmic Disorders. However, "male orgasmic disorder", something similar to "female orgasmic disorder", muddles the classification of premature ejaculation. Anesthetic ejaculation and partial ejaculatory incompetence do not even feature in the DSM IV. This means that DSM-IV makes the process of ejaculation and orgasm more or less synonymous, which is not in line with current medical and especially neurobiological views. We now know that the neurobiology and neuropharmacology of ejaculation and orgasm involve by different neural circuits and various neurotransmitter systems. While a psychological perspective is still extremely helpful for reviewing ejaculatory problems, there is no now doubt that some ejaculatory disorders are neurobiologically determined - which in turn means that they might be treated with medication. We know much more about ejaculation than orgasm, however. Ejaculatory and orgasm difficulties have been explained in the basis of psychological theories but there remains little evidence to support them. Many of the studies that have been conducted are poorly designed and subject to criticism DSM-IV defines delayed ejaculation as Male Orgasmic Disorder: that is, a persistent or recurrent delay in orgasm or even a complete absence of orgasm after normal sexual that should have raised a person's sexual arousal to a level adequate in focus, intensity, and duration. The difficulty of leaving such judgments to the clinical practitioner means that "normal" and "adequate in focus, intensity and duration" are not objectively defined. and these criteria are notoriously subject to variation between couples anyway. It's better to suggest that delayed ejaculation is a condition where a man cannot ejaculate, easily or indeed at all, even when he has plenty of sexual stimulation, has an erection and wishes to achieve orgasm. The effort of trying to get to orgasm and ejaculate may be fruitless and exhausting for both a man and his partner. This can apply to intercourse, masturbation and oral sex. Synonyms for delayed ejaculation are retarded ejaculation, late ejaculation, anejaculation, ejaculatory incompetence, lack or loss of ejaculation, and failure to ejaculate. There is lifelong delayed ejaculation and acquired delayed ejaculation where delayed ejaculation starts in life after a man has previously had normal ejaculatory functioning. Symptoms of delayed ejaculationIf a man has difficulty ejaculating in all situations, regardless of what sexual activity he is enjoying, and with all his sexual partners, the delayed ejaculation "generalized". If his delayed ejaculation is limited to certain situations or specific sexual partners, it is "situational" - for example, he may be unable to ejaculate within the vagina of his partner but can do so by masturbation, or he may be able to ejaculate during sex with a man but not with a female partner, and so on. This would include difficulty in ejaculating with one partner at some times and not others. PrevalenceLifelong delayed ejaculation occurs in about ten per cent of men. Acquired delayed ejaculation under 65 years of age is somewhat higher. (This reflects the natural tendency of men to last longer during sex as they get older.) However, the problem is that there is no agreement on what constitutes delayed ejaculation: nor is there any agreement on what makes up "reasonable" ejaculation time during intercourse. Psychological theories of delayed ejaculationClassical psychology suggests lifelong delayed ejaculation is caused by fear, anxiety, hostility, resentment and relationship difficulties. In psychodynamic terms, this fear could be about death, loss of self, loss of self in the feminine, fear of emasculation by the female genitals, fear of hurting the woman, fear of being hurt by the female, having sexual performance anxiety, being unwilling to give semen as an expression of love, fear of getting the woman pregnant, and sexual guilt or shame. These ideas are pretty much impossible to prove. But in working out where a man's delayed ejaculation originates, the first task is to establish if his delayed ejaculation is generalized or situational (in other words, is it specific to certain places or activities or partners), and whether it is acquired or life-long. Various treatments have been tried for men with delayed ejaculation, including vibratory electrical stimulation, sexual exercises, and psychotherapy. Ejaculation has been brought about in men with delayed ejaculation by persistent vibratory stimulation of the penis, but this does not reflect any improvement in real life. Equally, transrectal electrical stimulation can be used to cause ejaculation to get semen, but this is not an option in life for men with delayed ejaculation. Masturbation exercises have been used to treat delayed ejaculation, along with psychodynamic psychotherapy, marital therapy, CBT, sexual skills training and psychotherapy. Controlled clinical trials are few and far between. The significant shortcomings of most studies include the fact that the results are assessed with a single statement; there is a lack of specific information on the length of time to ejaculation; and standardized treatments do not feature in the protocols. No firm conclusions or recommendations on a particular treatment approach can be offered. Neurobiological approach to lifelong delayed ejaculationRats reared in isolation cannot achieve ejaculation or will remain sexually inactive even when they meet a receptive female. In contrast, rats raised with same-sex or other-sex cage mates do not have these problems. However, the rats' sexual performance will gradually improve as they get more experience. This could be interpreted to mean that experience and learning play a role in rat copulatory performance. Ejaculation distribution theory Waldinger and his colleagues formulated a neurobiological theory on premature ejaculation and delayed ejaculation. they concluded that lifelong delayed ejaculation, and also premature ejaculation, are simply part of a normal biological variability of latency time (time between penetrating and ejaculation). Any sample of men will include some who ejaculate too soon, and some who always or almost always, show delayed ejaculation or inability to ejaculate at all. Lifelong delayed ejaculation is therefore a neurobiological variant found in the population, which may or may not cause psychological or psychosocial distress. Studies on rats have tried to create hyposexual behavior by manipulating their level of sexual experience. 278 sexually inexperienced male rats were exposed to receptive females (in estrus) for 15 minutes: 23 showed no sexual activity at all; 211 displayed sexual activity, but failed to ejaculate; the average tie between penetration and ejaculation in the remaining rats was about ten minutes. Treatment with 5-HT1A receptor agonists - especially 8-OH-DPAT and flesinoxan - improved the sexual performance of these sexually inexperienced rats to levels almost similar to that of sexually experienced rats. In addition 2-adrenoceptor antagonists including yohimbine and idazoxan shortened the time to ejaculation time. Mos et al. also showed that male rats given 5-HT1A receptor agonists (flesinoxan, gepirone) were more sexually attractive to female rats in estrus than untreated males. Hyposexual behavior in sexually naive and inactive rats can be reversed by the opioid receptor antagonist naloxone. Other work has shown that certain pharmacological compounds neuropeptides also have the ability to act as stimulants to copulatory behavior in sexually naive rats. The 5-HT1A receptor agonist 8-OH-DPAT is one of these compounds and clearly increases levels of sexual activity in rats that were previously sexually inactive . Similarly, sildenafil (Viagra) and low doses of melatonin also have the capacity to reverse hyposexual behavior. All of this research suggests that specific neurobiological mechanisms are responsible for hyposexual behavior, at least in these sexually naive rats. One of the neurotransmitters which is involved in ejaculation is oxytocin; it's produced mainly in the paraventricular nucleus of the hypothalamus, parts of which extend into the lumbosacral part of the spinal cord. Arletti and colleagues demonstrated that expression of oxytocin mRNA is less in the paraventricular nucleus of the hypothalamus of sexually naive and inactive rats, which in turn suggests that oxytocin plays some role in copulatory behavior. It is unclear exactly what this may be. Opioids are other neuropeptides associated with the neurobiology of copulatory behavior; recent work suggests mRNA expression of pro-enkephalin and pro-dynorphin, and endogenous opioid octapeptide levels, are increased in the hypothalami of sexually inactive rats. It may be that hypothalamic endogenous opioid expression is responsible for differences in copulatory behavior, an idea which matches the suggestion that brain opioids inhibit sexual behavior. In summary, some neurobiological substrates may be responsible for hyposexual behavior. This may also be true for men with delayed ejaculation and complete failure of ejaculation. Oxytocin and brain peptides seem to play a small role in copulatory behavior, while serotonergic neurotransmission appears to be more significant. Treatment of male rats with 5-HT1A receptor agonists (8-OH-DPAT or flesinoxan) leads to shorter ejaculation latency times. So maybe lifelong delayed ejaculation is related to hypofunction of 5-HT1A receptors and/or hyperfunction of 5-HT2C receptors. However, the improving effects of 5-HT1A receptor agonists, contrast with treatment with 5-HT2C receptor antagonists in men (nefazodone and mirtazapine), did not have any effect on ejaculation time. It seems that hyperfunction of the 5-HT2C receptor as a cause of delayed ejaculation is not proven. But the researchers emphasize that nefazodone and mirtazapine are not considered as selective 5-HT2C antagonistic agents. Practically, experimental 5-HT1A receptor agonists like 8-OH-DPAT or flesinoxan accelerate ejaculation in male rats, but these agents are not available for human use. Based on rat research, the development of new and safe 5-HT1A receptor agonists can be advocated as a starting point for human clinical drug research in delayed ejaculation. Brain imaging Nothing is known about the brain regions involved in delayed ejaculation and absence of ejaculation. A recent PET-scan study on absence of ejaculation was performed by Georgiadis and Holstege. 11 healthy male volunteers with anejaculation tried to achieve ejaculation in the PET-scan, but only about half of them managed to do so. However, successful ejaculation caused marked increase in cerebral blood flow in the meso-diencephalic transition zone and the cerebellum. Those men who tried unsuccessfully to achieve ejaculation showed blood flow in the right orbitofrontal cortex, the left dorsal prefrontal cortex, and bilaterally in the anterior insula. By comparison, non-ejaculation blood flow involved more cortical activity than that associated with ejaculation, especially in the left temporal pole and most anterior amygdala, parts of the brain that have a role to play in vigilance and fear behavior. This may mean that higher levels of activity in the anterior temporal lobe are the cause of absence of ejaculation. Psychological causes of acquired delayed ejaculationAcquired delayed ejaculation may happen suddenly caused perhaps by psychological trauma (a partner's unfaithfulness, or poor sexual and psychological stimulation. A moderate delay in ejaculation occurs with ageing, the result of androgen deficiency; loss of ejaculatory capacity can be caused by traumatic or surgical injuries with damage to the lumbar sympathetic ganglia and associated nerves, various kinds of surgery, and neurodegenerative disorders, such as multiple sclerosis or diabetic neuropathy. And many drugs (including SSRIs and tricyclic antidepressants and alcohol) can cause a reduction in ejaculatory capacity. Treatment of acquired delayed ejaculationDoctors need to look out for drugs, vascular or neuropathic damage, and other causes which may be irreversible. In such cases the man concerned may have to find other methods of gaining sexual pleasure and satisfying his partner. If he has low testosterone, he may need testosterone replacement therapy. and of course attention to the relationship always helps couples establish better sexual activity.
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