Andrew Siegel MD 10/24/2020
Delayed ejaculation (DE) is a condition in which prolonged sexual stimulation is necessary in order to ejaculate. In its severest form, regardless of considerable efforts and protracted sexual activity, ejaculation does not occur. As tempting and enticing as it is to believe that in terms of pleasing one’s partner, DE is advantageous and endows one with the ability to bring their partner to multiple orgasms, in reality a marathon performance has major shortcomings and can be significantly disturbing for both delayed ejaculator and his partner.
A study of 500 couples across five nations measured time from vaginal penetration to ejaculation (ejaculatory latency time):
- Range: 33 seconds to 44 minutes
- Median: 5.4 minutes
It has been proposed that time from penetration to ejaculation exceeding 25 minutes and causing distress to the delayed ejaculator or partner meets the criteria for a DE diagnosis.
DE is poorly understood and is hampered by the absence of clearly effective treatments, unlike its counterpart—premature ejaculation. DE at one time was referred to as “retarded” ejaculation, but because of the politically incorrect nature of the “R word,” this label has gone by the wayside, similar to “impotence,” replaced by “ED,” and “frigid,” replaced by “anorgasmic.”
THE SCIENCE OF EJACULATION
Ejaculation occurs after sexual stimulation gets one beyond an “ejaculatory threshold” until the “point of no return” occurs and ejaculation becomes inevitable and imminent. Whereas men with premature ejaculation are thought to have increased sensitivity of the penis, men with delayed ejaculation are thought to have decreased penile sensitivity.
The ejaculatory center is located within the spinal cord and integrates nerve input from the brain and the penis and coordinates the two phases of ejaculation: emission and expulsion.
- Emission: secretions from the prostate, seminal vesicles and testes are released via the ejaculatory and prostate ducts into the urethra
- Expulsion: semen is propelled out the urethra via rhythmic contractions of the pelvic floor muscles
The spinal ejaculatory center is controlled mainly by the neurotransmitters serotonin and dopamine, although others are involved as well. Serotonin inhibits ejaculation whereas dopamine facilitates it. One’s balance of neurotransmitters is determined by genetics and other considerations including age, stress, illness, medications and other factors.
BAD FOR ALL PARTIES
DE can be problematic for both the delayed ejaculator and his partner, resulting in frustration, exhaustion, and penile and/or vaginal soreness, pain, friction burns and irritation. Prolonged arousal and erection without ejaculation can sometimes result in testicular congestion, a.k.a. “blue balls,” a condition in which the testes become swollen, painful, and bluish in tint because of venous engorgement.
The sexual partner often feels distress and responsibility because of the implication that the problem may be their fault and that they are inadequate in attractiveness or having the facility to enable a climax. The combination of not being able to achieve sexual “closure,” the inability to enjoy the mutual intimacy of ejaculation, and denying the partner the gratification of knowing that they are capable of bringing forth a climax is a formula for relationship stress.
Interestingly, some men with this condition can ejaculate in an appropriate amount of time with masturbation. As well, some men can ejaculate in a normal period of time with manual or oral stimulation from their partner although they cannot do so with intercourse. It is plausible that one’s masturbation technique can provide more sensory stimulation than that duplicated by sex with a partner. The amount of sensory stimulation derived from intercourse is predicated upon partner skill, anatomy, pelvic floor tone, the quality of the “fit,” the level of arousal, and many other elements, both physical and emotional.
PHYSICAL OR PSYCHOLOGICAL?
Underlying medical conditions may factor into problems of ejaculation, e.g., hypothyroidism is associated with delayed ejaculation whereas hyperthyroidism is associated with premature ejaculation. Since serotonin and dopamine as well as oxytocin, prolactin, and other chemicals are involved with the physiology of ejaculation, any drug that modifies the levels of these chemicals may affect ejaculation timing. Neurological conditions—diabetes, spinal cord injury, multiple sclerosis, etc.—that disrupt the communication between the spinal ejaculatory center and the brain/penis may contribute to ejaculatory dysfunction including DE. Psychological and relationship issues may also play into DE. In general, DE occurs more commonly with aging, thought to be on the basis of declining peripheral nerve function and genital skin changes.
The selective serotonin reuptake inhibitors (SSRIs) – the most widely prescribed medications for depression – are notorious for their effect on delaying ejaculation, and are, in fact, used for the treatment of premature ejaculation. These include, among others, Zoloft, Paxil, Prozac, Luvox, Celexa and Lexapro.
As with so many sexual issues, excessively focusing on the problem instead of allowing oneself to be “in the moment” in a sexual situation may exacerbate the problem. When a man suffering with DE is in a sexual situation, instead of being present and engaged, he often becomes a third-party spectator of his own performance because of fears of being unable to ejaculate, creating a self-fulfilling prophecy that perpetuates the problem.
MANAGEMENT OPTIONS
Although numerous medications have been tried to help improve DE, none are FDA approved and none have met with much success. This is as opposed to premature ejaculation that can be effectively managed with topical anesthetics, selective serotonin reuptake inhibitors, and pelvic floor training. DE is one of the most difficult and challenging sexual dysfunctions to treat.
- Avoid ejaculation for a number of days prior to intercourse, the same line of reasoning used for managing premature ejaculation by masturbating immediately before intercourse.
- Modify sexual positions, which may increase arousal and lead to more timely ejaculation.
- If on an SSRI, consider switching to an alternative non-SSRI such as bupropion.
- Consider psychotherapy or cognitive-behavioral therapy provided by a psychologist/psychiatrist.
- Consider sex therapy provided by a sexual therapist.
- Medication trial results have been generally underwhelming, including bupropion, cabergoline, and testosterone. A recent pilot study of amphetamine/dextroamphetamine (Adderall), a central nerve stimulant typically used for ADHD, has shown promise. On-demand use of a low dose of 7.5 mg resulted in more than half of the subjects in the study showing improvement in DE parameters, with average intercourse latency time decreasing from 41 minutes to 11 minutes and average masturbation latency time decreasing from 20 to 11 minutes. Side effects included insomnia and jitters.
- Penile vibratory stimulation. This stimulates sensory nerves involved in the ejaculatory reflex and has the potential to intensify arousal.
Wishing you the best of health,
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Dr. Andrew Siegel is a physician and urological surgeon who is board-certified in urology as well as in female pelvic medicine and reconstructive surgery. He is an Assistant Clinical Professor of Surgery at the Rutgers-New Jersey Medical School and is a Castle Connolly Top Doctor New York Metro Area,Inside Jersey Top Doctor and Inside Jersey Top Doctor for Women’s Health. His mission is to “bridge the gap” between the public and the medical community. He is a urologist at New Jersey Urology, the largest urology practice in the United States. His latest book is Prostate Cancer 20/20: A Practical Guide to Understanding Management Options for Patients and Their Families.
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Dr. Siegel’s other books:
PROMISCUOUS EATING— Understanding and Ending Our Self-Destructive Relationship with Food
MALE PELVIC FITNESS: Optimizing Sexual and Urinary Health
THE KEGEL FIX: Recharging Female Pelvic, Sexual, and Urinary Health
Tags: Andrew Siegel MD, Delayed ejaculation, dopamine, ejaculation, serotonin, solutions to delayed ejaculation
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