Ejaculatory Dysfunction
Male ejaculation is a highly complex process. It requires the central and peripheral nervous systems to work together for ejaculation to take place. The first stage is called emission, in which sperm from the vas deferens and fluid from the seminal vesicles and prostate gland that make up semen is pushed through the ejaculatory ducts and into the prostatic urethra. The second stage is called expulsion when the neck of the bladder closes and muscles at the base of the penis and urethra contract to propel the semen through the tip of the penis.
What are the Causes of Ejaculation Disorders?
- Prostate or pelvic surgery (including colorectal, bladder, and retroperitoneal surgery)
- Congenital anomalies, such as spina bifida
- Spinal cord injury
- Psychological disorders
- Underlying medical problems, such as diabetes
- Medications (side effects of medications can cause retrograde, delayed, or absent ejaculation)
Types of Ejaculation Disorders
Premature Ejaculation
Premature ejaculation is defined as an inability to delay ejaculation until it is mutually desirable for both partners, becoming a cause of stress and dissatisfaction. The classification ‘premature’ is subjective – it is not based on time, for instance, but rather on the impact the timing has on the sexual experience.
For some men who experience premature ejaculation, it is a lifelong condition that has affected them ever since they started to have orgasms, while for others it is acquired over a period of time. For some men, premature ejaculation is situational; it may occur only on some occasions. The causes and potential treatment options vary for individual patients.
The causes of premature ejaculation include both psychological factors, such as anxiety, and physical etiologies, such as increased penile sensitivity. Even the concentration of different hormones can have an impact on ejaculation. The exact cause has not been precisely identified, but there are several influences affecting how quickly a man reaches orgasm. One common factor is one’s sexual behavior, specifically how long it has been since the last ejaculation.
Early sexual conditioning
It is not uncommon for early sexual experiences to be associated with the need for the act to be completed as quickly as possible. Examples could be masturbation and the fear of being caught by parents, or having sex in risky locations such as a car. The impulse for speed may persist into situations where it is no longer needed or appropriate. For the majority of men, however, control over orgasms can be learned gradually.
Anxiety about performance
The natural and understandable anxiety felt by many men can develop into a long-term anxiety related to sex. This can have the counter-productive effect of persistent premature ejaculation and performance pressures. This is a particularly frequent occurrence in new relationships.
Absent internal clues
When researchers interviewed men who had good control over their orgasm, they made an interesting discovery. These men, unlike those who ejaculate prematurely, were able to identify the point at which ejaculation is unstoppable. They could also initiate corrective action prior to reaching that point.
Low level of desire or sexual arousal
It may seem counter-intuitive, but the underlying problem can sometimes come from a low level of desire or lack of sexual arousal. On some occasions, it is quite possible for a man to have a strong erection without strong sexual arousal. In such instances, the man actually needs to be more aroused, which would allow more control over the ejaculation.
There are two main approaches to tackling the problem of premature ejaculation: behavioral training and direct physical therapy. Which of these, or which combination of these, is most appropriate for any given man depends on the situation.
Psychotherapy and Behavioral Training
The ‘Masters and Johnson’ approach
This is a psychological and behavioral therapy that offers a way of learning to identify and control the sensations which trigger an orgasm. It requires a lot of patience and practice but is very effective and can be done at home, ideally with a caring partner.
Start by engaging with your partner in sexual stimulation that does not involve penetration, such as oral sex or masturbation, gradually approaching the point just before ejaculation. Stop at this point and let yourself relax and partially lose your erection before starting again. Repeat this a few times, each time approaching orgasm closer and closer until it cannot be held back any longer. Repetition will help you to identify your point of climax and enable you to control it. When you feel ready to try intercourse, follow the same pattern. Stop right before you are about to climax, relax, and then start again.
Try not to put too much pressure on yourself. If you don’t get it right at first, it’s OK – it may take time but it’s worth it in the end.
The ‘squeeze technique’
This is a variant of the ‘Masters and Johnson method’ with the difference being that the helping partner squeezes either the base or the tip of the penis just prior to the point of orgasm, essentially canceling it. The action forces blood away from the penis, thus reducing the erection. This technique could be used on its own or in combination with the ‘Masters and Johnson’ method.
Other psychological and behavioral methods
Men can also learn increased levels of control through masturbation training or pausing for a change of position during sex. Some men even find that ejaculation before engaging in sex is an effective way to increase the time before they climax. Another helpful trick can be to learn how to focus more away from the genital aspects of the experience and concentrate on feeling pleasure in other parts of the body. A variant of this method is to reduce sensation by focusing thoughts on something completely unrelated to sex.
Direct Physical Therapy
Topical anesthetic sprays, gels and creams
Creams, gels, and sprays designed to decrease sensation in order to delay ejaculation are available. Many of these can be bought over the counter and do not need a prescription. The downside of these treatments is that by decreasing penile sensation, sex may be less pleasurable. They can also have an effect on the partner’s sensation and pleasure as well.
Condoms
Similar to topical anesthetics, condoms can reduce sensation during sex, which can help delay ejaculation. If necessary, the effect can be increased by combining a condom with a topical desensitizing treatment.
Medications
Medications used for depression, such as tricyclic antidepressants and selective serotonin reuptake inhibitors (SSRIs), can be used off-label to delay ejaculation. Men who experience erectile dysfunction, as well as premature ejaculation, could also benefit from phosphodiesterase-5 inhibitors (PDE5i) such as Viagra or Cialis.
Retrograde Ejaculation
Retrograde ejaculation is when the ejaculate goes backwards into the bladder instead of moving forward through the tip of the penis. Ejaculate that enters the bladder is not harmful and will eventually come out in the urine. Men with retrograde ejaculation may notice that they have cloudy urine after orgasm. This condition can often be diagnosed with a simple test known as a post-ejaculatory urinalysis. The patient is asked to provide a semen sample through masturbation followed by a urine sample to check for the presence of sperm in the urine. If sperm is found, it can be frozen and stored for future use in assisted reproduction.
The condition is caused by a dysfunction of the neck of the bladder.
- Surgery (e.g. transurethral resection of prostate, pelvic surgery)
- Medications to help with urination (e.g. Flomax)
- Neurological disease
- Spinal cord injury
- Diabetes
Particularly in cases where the condition is a result of surgery, retrograde ejaculation can be difficult to treat. However, there are some medications, such as Sudafed, that can help propel the ejaculate forward. If the cause of retrograde ejaculation is a medication, the condition normally stops after the medication is discontinued.
Delayed Ejaculation and Anejaculation
Delayed ejaculation is when it takes an abnormally long time for ejaculation to occur. Anejaculation is when ejaculation does not occur at all. Some men have anorgasmia—the inability to have an orgasm—in addition to anejaculation, while others are able to have an orgasm but cannot ejaculate. Some men have delayed ejaculation or anejaculation only in certain situations, such as with masturbation or with intercourse.
- Aging
- Hormonal abnormalities
- Psychological causes
- Medications (e.g. antidepressants)
- Neurologic diseases (e.g. multiple sclerosis)
- Spinal cord injury
- Diabetes
- Surgery (e.g. prostatectomy, retroperitoneal lymph node dissection)
Treatment depends on the cause of the condition and the patient’s individual circumstances. The problem is sometimes resolved by discontinuing medications with sexual side effects. Other treatments can include certain medications, high-speed vibrators, or sex/couples therapy. If the cause is surgery or a neurological disease/injury, the problem is often permanent.