Delayed ejaculation

• retarded orgasm (ejaculation) is characterized by prolonged ejaculatory latency
  • one of the most poorly understood and pharmacologically recalcitrant of the male sexual dysfunctions. In general, a scarcity of original research has focused on this dysfunction (1,2)
    
    
    • there is no set definition to describe 'how long is too long', but a persistent (and unwanted) delay of ejaculation that lasts for 30 to 60 minutes may suggest retarded ejaculation. Alternatively, if you are unable to achieve ejaculation at least half the times you have sex, you may have retarded ejaculation (3)
      
      
    • retarded ejaculation can also be classified as:
    • global - where it occurs in all sexual situations
    • situational - where it only occurs in certain situations
    • for example, a patient may be able to ejaculate normally when masturbating, but not during sex. Situational retarded ejaculation usually suggests the condition is the result of psychological causes
      
      
    • retarded ejaculation can be classified as (4):
      • mild (men who still experience vaginal orgasm, but only under certain conditions),
      • moderate (cannot ejaculate during intercourse, but can during fellatio or manual stimulation),
      • severe (can ejaculate only when alone),
      • or most severe (cannot ejaculate at all)
        
        
  • incidence rates of retarded orgasm have been estimated as relatively low, with rates in the general population between 1% and 4%
  • however, clinicians have increasingly identified retarded orgasm as a side effect of selective serotonin reuptake inhibitors (SSRIs)
    • SSRIs increase serotonin (5-HT) neurotransmission and ejaculatory delay has been related to activation in the 5-HT2C receptors in animal and human studies
    • anumber of studies have identified delayed orgasm as a side effect of SSRI medications, with rates generally ranging from 16% to 37% and some studies have reported rates of this side effect as great as 60% to 70%
    • other medications associated with this condition include beta blockers, methadone, antipsychotics and muscle relaxants such as baclofen
  • other proposed aetiologies for retarded ejaculation include neurologic disorders (such as spinal cord injuries, multiple sclerosis), diabetes; as well as psychological and relationship issues
    • this condition is more common with increasing age
    • also can occur secondary to prostate or bladder surgery
    • most of the research that has examined the association between neurologic disorders and ejaculatory problems has investigated patients with spinal cord injuries
    • in a large group of men, no overt etiology will be found (ie, idiopathic retarded orgasm). These men display no explicit physical or psychological difficulties (ie, relationship difficulties, attempting pregnancy) that would account for the extended ejaculation latency
      
      
  • management
    • recommended treatments for retarded ejaculation depend on the underlying cause. If it is thought to be a side effect of medication, switching to an alternative medication will help. However, if the cause is thought to be psychological, counselling may be recommended
      
      
      • cognitive-behavioral sex therapy and is the primary treatment for restoring orgasm during sexual relations
        • available evidence on the effectiveness of these treatments is rather limited
        • the relationship counselling service Relate also offers sex therapy at a number of its centres
          • during sex therapy, the patient will have the opportunity to discuss any emotional or psychological issues related to your sexuality and relationship, in a non-judgemental way. Activities may also be recommended for the patient to try at home while you are having sex with his partner
            • may include:
              • viewing erotic material prior to having sex, such as videos and magazines, to increase the feeling of sexual stimulation
              • erotic fantasies and 'sex games' to make lovemaking more exciting
              • using lubricating creams, or jellies, to make the physical act of sex more comfortable and relaxing
              • using sexual aids, such as vibrators, to increase pleasure
                
                
      • no pharmacologic therapy has demonstrated consistent efficacy in managing retarded ejaculation
        • medications that have been used in this condition include yohimbine, buproprion and amantadine
          
          
      • penile vibratory stimulation has been studied in the management of retarded ejaculation (2)
        • in a small study a total of 36 men met the inclusion criteria, and 72% reported the restoration of orgasm. These responders reported that orgasm during sexual relations occurred 62% of the time
        • in this study participants were instructed to use a commercially available vibrator (Pin Point Massager, Brookstone, Merrimack, NH) which provides a nonvariable vibratory amplitude and frequency)
          • the exact vibratory amplitude and frequency is unknown
          • patients were instructed to apply the vibrator to the frenular area of the penis for three 1-minute periods separated by 1-minute rest periods
          • at least three attempts using the vibrator were required for inclusion in the study
        • study authors concluded "...Penile vibratory stimulation is an effective treatment for retarded orgasm. Penile vibratory stimulation should be integrated into current cognitive-behavioral sex therapy techniques to achieve maximal effectiveness and satisfaction..."

Notes:

• retarded ejaculation is sometimes known as delayed ejaculation or male orgasmic disorder

Reference:

• 1) Waldinger MD, Schweitzer DH.Retarded ejaculation in men: an overview of psychological and neurobiological insights. World J Urol 2005; 23: 76-81.
• 2) Nelson CJ et al. Assessment of penile vibratory stimulation as a management strategy in men with secondary retarded orgasm.Urology. 2007 Mar;69(3):552-5; discussion 555-6.
• 3) NHS Direct Wales - Erectile Problems (accessed 6/7/2013).
• 4) Strassberg, D. S., & Perelman, M. A. (2009). Sexual dysfunctions. In P. H. Blaney & T. Millon (Eds.), Oxford textbook of psychopathology (2nd ed.), (pp. 399-430). NY: Oxford University Press