Michael A. Perelman, Ph.D.
N. Y. Weill Cornell Medical Center
New York, N.Y. USA
Retarded ejaculation (RE) is probably the least common, and least understood, of all the male sexual dysfunctions. RE is one of the diminished ejaculatory disorders (DED), which is a subset of male orgasmic disorders (MOD). DED is a collective term for an alteration of ejaculation and /or orgasm that ranges from varying delays in ejaculatory latency to a complete inability to ejaculate, anejaculation, and retrograde ejaculation, as well as reductions in volume, force, and the sensation of ejaculation. The American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) defines RE as the persistent or recurrent delay in, or absence of, orgasm after a normal sexual excitement phase during sexual activity that the clinician, taking into account the person’s age, judges to be adequate in focus, intensity, and duration. The disturbance causes marked distress or interpersonal difficulty. Similar to the term “premature ejaculation,” the most commonly used term—“retarded ejaculation”—is sometimes avoided because of its pejorative associations.
In general, RE is reported at low rates in the literature, rarely exceeding 3%. However, based on clinical experiences, some urologists and sex therapists are reporting an increasing incidence of RE. The prevalence of RE appears to be moderately and positively related to age, which is not surprising in view of the fact that ejaculatory function as a whole tends to diminish as men age.
Failure of ejaculation can be a lifelong (primary) or an acquired (secondary) problem. Many men with secondary RE can masturbate to orgasm, whereas others, for multiple reasons, will or cannot. A distinguishing characteristic of men with RE—and one that has implications for treatment—is that they usually have little or no difficulty attaining or keeping their erections—in fact they are often able to maintain erections for prolonged periods of time. Yet, despite their good erections, they report low levels of subjective sexual arousal, at least compared with sexually functional men.
In some instances, a somatic condition may account for RE, and indeed, any procedure or disease that disrupts sympathetic or somatic innervation to the genital region has the potential to affect ejaculatory function and orgasm. Thus, spinal cord injury, multiple sclerosis, pelvic-region surgery, severe diabetes, and medications that inhibit a-adrenergic innervation of the ejaculatory system have been associated with RE. Of course, radical prostatectomies (RP) can have a significant negative impact on the sexual function of the patient’s (and partner’s) quality of life. An adequate discussion of the impact of RP on orgasmic capacity is beyond the scope and focus of this article, but suffice it to say a major part of sexual experience and satisfaction has been missing from discussions of sexual rehabilitation following RP. Regrettably, to date, minimal data are available on the post prostatectomy orgasmic experience. While there are anecdotal reports of diminished sensation and pain, Barnas et al. described the only study providing statistics on the prevalence and nature of orgasmic dysfunction after RP. While admirable, this not-yet-replicated study’s sample size (N = 239) was exceedingly modest, given the enormous number of RP procedures performed annually worldwide. Nevertheless, sizable portions of men with RE exhibit no clear somatic factors that account for the disorder.
Pathophysiological causes of RE are far more readily identifiable; they generally surface during a medical history and examination, and they typically stem from predictable sources: anomalous anatomic, neuropathic, endocrine, and medication (iatrogenic). All types of RE show age-related increases in prevalence, independent of increased severity with lower urinary tract symptoms. Commonly used medications, particularly antidepressants, may delay ejaculation as well.
Multiple psychosocial explanations have been offered for RE, with unconscious aggression, unexpressed anger, and malingering recurring as themes. In addition, pregnancy fears have been emphasized, as professional referral has often been tied to the female partner’s wish to conceive. Masters and Johnson were the first to suggest an association between RE and religious orthodoxy, positing that certain beliefs limit sexual knowledge and familiarity, causing individuals to “not learn” to ejaculate, or experience an inhibition of normal function.
Recent clinical samples of RE men have noted a disproportionately large number of religiously orthodox/fundamentalist men. Some of these men had very limited sexual knowledge and
masturbated minimally, or not at all. Others, similar to their more secular counterparts,
masturbated for years, but with guilt and anxiety about “spilling seed” subsequently
resulting in RE. The role that religious orthodoxy/fundamentalism plays in the etiology of RE for some menvaries considerably around the world as a function of cultural differences.
Alternatively, men with RE sometimes indicate greater arousal and enjoyment from masturbation than from intercourse. Such an “autosexual” orientation may involve an idiosyncratic and vigorous masturbation style—carried out with high frequency. An “idiosyncratic” masturbation style is one that is not easily duplicated by their partner’s hand, mouth, or vagina. Specifically, many men with RE engage in self-stimulation that is striking in the speed, pressure, duration, and intensity necessary to produce an orgasm, and dissimilar to what they experience with a partner. Disparity between the reality of sex with the partner and the sexual fantasy (whether or not unconventional) used during masturbation is another potential cause of RE.
In short, high-frequency idiosyncratic masturbation, combined with fantasy/partner disparity, may well predispose men to experiencing problems with arousal and ejaculation. This pattern suggests that RE men may lack sufficient levels of physical and/or psychosexual arousal during coitus to achieve orgasm. Inadequate arousal may be responsible for increased anecdotal clinical reports of RE for men using oral medications for the treatment for ED. While most men using phosphodiesterase inhibitors type 5 (PDE-5s) experienced restored erections and coitus with ejaculation, others experienced erection without adequate psycho-emotional arousal. That is, they did not experience sufficient erotic stimulation before and during coitus to reach orgasm, confusing their erect state as an indication of sexual arousal when it primarily indicated vasocongestive success.
Finally, the evaluative/performance aspect of sex with a partner often creates “sexual performance anxiety” for the man, a factor that may contribute to RE. Such anxiety typically stems from the man’s lack of confidence to perform adequately, to appear and feel attractive (body image), to satisfy his partner sexually, to experience an overall sense of self-efficacy, and to measure up against the competition. Anxiety surrounding the inability to ejaculate may draw the man’s attention away from erotic cues that normally serve to enhance arousal. This “ejaculatory performance” anxiety interferes with the erotic sensations of genital stimulation, resulting in levels of sexual excitement and arousal that are insufficient for climax (although more than adequate to maintain an erection).
Retarded ejaculation, then, is best understood as an endpoint or response that represents the interaction of biological, psychological, relationship and cultural factors.
A genitourinary examination and medical history may identify physical anomalies associated with ejaculatory dysfunction as well as contributory neurologic, endocrinologic, or erectile factors. Attention should be given to identifying reversible determinants including: urethral, prostatic, epididymal, testicular infections, and especially insuring the presence of adequate androgen levels. Particularly with secondary RE, adverse pharmaceutical side effects—most commonly from serotonin-based prescriptions—should be ruled out.
A focused psychosexual evaluation is critical and typically begins by differentiating this sexual dysfunction from other sexual problems and reviewing the conditions under which the man is able to ejaculate. The developmental course of the problem—including predisposing issues of religiosity—and variables that improve or worsen performance, particularly those related to psychosexual arousal, should be noted. Perceived partner attractiveness, the use of fantasy during sex, anxiety surrounding performance, and coital and masturbatory patterns all require exploration.
Current sex therapy approaches to RE continue to emphasize the importance of masturbation in the treatment of RE. Men who are unaware or unable to become aroused are taught through masturbation and/or partner stimulation to experience increasing levels of arousal through a combination of improved/increased “friction and fantasy.” For others, the focus is on masturbatory retraining, integrated into sex therapy. Masturbation can serve as a type of “dress rehearsal” for sex with a partner. By informing the patient that his difficulty is merely a reflection of “not rehearsing the part he intended to play,” the stigma associated with this problem can be minimized and cooperation of both the patient and partner can be evoked. A man may be encouraged to alter the style of masturbation (“switch hands”) and to approximate (in terms of speed, pressure, and technique) the stimulation likely to be experienced through manual, oral, or vaginal stimulation by his partner.
Of course, masturbation retraining is typically merely a means to an end, and the goal of most current therapeutic techniques for RE (either primary or secondary) is not merely to provide more intense stimulation, but rather to stimulate higher levels of psychosexual arousal and, eventually, orgasm within the framework of a satisfying experience.
Therapy for secondary RE follows a strategy similar to that of primary anorgasmia. Men are counseled to use fantasy and bodily movements during coitus, which help approximate the thoughts and sensations perhaps previously experienced only in masturbation. For those individuals the clinician or urologist will often need to counsel these patients to temporarily suspend masturbatory activity and limit orgasmic release to only the desired activity, which is typically coitus.
To increase satisfactory outcomes from treatment, the partner needs to cooperate with the therapeutic process, finding ways to pleasure the man that enhance arousal and that can be incorporated into the couple’s lovemaking. Sexual fantasies may have to be realigned so that thoughts experienced during masturbation better match those occurring during coitus. Efforts to increase the attractiveness and seductive/arousing capacity of the partner and to reduce the disparity between the man’s fantasy and the actuality of sex with his partner may be useful.
While a number of other partner-related issues may affect a male’s ejaculatory interest and capacity, two require special attention: fertility/conception and anger/resentment.
Regarding conception, the pressure of the woman’s “biological clock” is often the initial treatment driver. The woman—and often the man as well—usually meet any potential intrusion on their plan to conceive with strong resistance. If the urologist or other HCP suspects the patient’s RE is related to fear of conception, he may inquire about the patient’s ability to experience a coital ejaculation with contraception (including condoms) but not during “unprotected” sex. Such a “test” can serve as a powerful diagnostic indicator: if the RE occurs with high probability only during unprotected sex, the HCP can assume that conception is a primary factor causing/maintaining RE.
Whether related to fertility or not, the man’s anger (expressed/unexpressed) toward his partner may be an important intermediate causational factor and must be ameliorated through individual and/or conjoint consultation. Anger is typically a powerful anti-aphrodisiac, and while some men avoid sexual contact entirely when angry at a partner, others attempt to perform, only to find themselves only modestly aroused and unable to maintain an erection/and or reach orgasm. While the man’s assertiveness should be encouraged, the HCP should also remain sensitive and responsive to the impact of this change on the partner—the object of the newly expressed anger—and the resulting alteration in the couple’s equilibrium.
Alternative Treatment Approaches
While anecdotally viewed by urologists as a difficult-to-treat sexual dysfunction, some sex therapists have reported good success rates, in the neighborhood of 70-80%. Furthermore, although this review has concentrated on the use of counseling methods, there are some medical treatments available.
A number of pharmacological agents have been used off-label to facilitate orgasm in patients taking SSRI antidepressants and other drugs known to delay or inhibit ejaculatory response. Although not approved by regulatory agencies for the treatment of RE, the anti-serotonergic agent cyproheptadine and the dopamine agonist amantadine have been used with moderate success in this population of patients. However, the lack of large, controlled studies with these and other ejaculatory-facilitating agents suggests a high ratio of adverse effects to potential efficacy. Appropriate assessment and consideration of androgen levels is a critical component of treatment. Penile Vibratory Stimulation (PVS) is a potential inexpensive and convenient first-line urological treatment to increase sexual friction and provide the stimulation necessary to restore orgasmic capacity for some who suffered from either a primary or a secondary RE. PVS has been used adjunctively, with discretion, by sex therapists for over thirty years to treat delays/inhibitions of both male and female orgasmic disorders. However, the urological evidence for using PVS, is almost exclusively fertility related; typically for spinal-cord injured men suffering primary RE.
Future Directions: Combination Treatments
Any technique that improves orgasmic response can be usefully incorporated into a combination treatment. Once proof of orgasmic capacity has been reestablished (PVS, for instance), follow-up sessions provide opportunity to increase the probability that orgasm may be evoked by a variety of stimulation techniques, depending on patient and partner preference. As research continues to uncover greater understanding of the ejaculatory process, the likelihood of finding pro-ejaculatory agents increases. As with PE and ED, should safe and effective pharmacological options become available for RE, treatment for this dysfunction will undergo a major paradigm shift, with combination drug and sex therapy protocols likely producing the greatest efficacy and best outcomes in terms of patient satisfaction.
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I gratefully thank Dr David L. Rowland who was my co-author on an earlier article upon which this current manuscript was adapted and updated. The original version of this article was published in World Journal of Urology 2006; 24(6): 645-652, Perelman MA, Rowland DL: Retarded Ejaculation. Copyright was kindly granted by Springer Science and Business Media.’ In addition, I also thank Dr Ian Kerner, who graciously provided both editorial guidance and writing assistance for this current version.