An Overview of Delayed Ejaculation

Delayed ejaculation (DE) is a medical condition in which a man has difficulty reaching an orgasm. It should not be confused with erectile dysfunction (the inability to achieve an erection) or decreased libido (low sex drive), although both can sometimes contribute to DE.

The Diagnostic and Statistical Manual of Mental Disorders defines DE as a significant delay, infrequency, or absence of ejaculation at least 75% of the time during partnered sexual activity for six months. 

DE is not only frustrating to men but can complicate the sex lives of their partners as well. Whereas a male orgasm can normally be achieved within several minutes, DE prolongs ejaculation time by at least 5-7 minutes. During that time, the partner may lose vaginal or anal lubrication or simply lack the energy or will to sustain sex.

Fortunately, there are ways to diagnose and treat DE. Some of the techniques take time but can often improve sexual function and increase the speed by which you climax and ejaculate.

Symptoms

Delayed ejaculation is usually self-evident, especially to those affected. In some cases, the man may feel as if he on the verge of climax but is unable to reach the point of ejaculation. At other times, there may be an erection but no sense of an approaching orgasm.

The condition can range in severity, and symptoms can include:

• Able to ejaculate during intercourse but only under certain controlled conditions
• Cannot ejaculate during intercourse but can with oral sex or masturbation
• Can only ejaculate when alone
• Unable to ejaculate

Causes

Delayed ejaculation may have pathologic, neurological, hormonal, pharmaceutical, or psychological causes. In some cases, there may be overlapping causes that only add to the dysfunction.

Some of the causes your doctor may consider include:

• Pathologic causes, such as heart disease (which can lower blood pressure), diabetes, prostate problems, and urinary tract infection
• Neurological causes, like stroke, neuropathy, spinal cord injury, or multiple sclerosis
• Hormonal causes, including thyroid problems, hypogonadism (low testosterone), and Cushing's disease
• Medication side effects, including benzodiazepines like Valium (diazepam), selective serotonin reuptake inhibitors (SSRI) antidepressants, opioids like Oxycontin (oxycodone), antihypertensives (including diuretics), and certain antipsychotics
• Recent pelvic surgery, including prostate surgery
• Drug or alcohol abuse

Psychological problems can both cause and contribute to DE. Depression, anxiety, or emotional trauma can alone cause dysfunction. Religious or social taboo may interfere with your ability to enjoy sex and reach orgasm. Work stress, financial stress, or stress within the relationship are common narratives among couples experiencing DE.

Diagnosis

Diagnosing DE is not always straightforward and simple, and there are several different definitions in use. In some of the more severe cases, it may require multiple doctors or specialists to pinpoint the cause.

With that being said, a physical exam and review of your medical history may be all that is needed to render a diagnosis. If the cause is not readily apparent, the doctor may order tests to help narrow the causes. These may include:

• Blood tests to check for diabetes, low testosterone, thyroid disease, prostate problems or systemic inflammation suggestive of an infection
• Urinalysis to look for signs of diabetes or infection in urine

If the cause is believed to be psychological (and no other reasonable explanation can be found), the doctor may refer you to a psychologist or sex therapist trained in treating sexual dysfunction.

If a disease, medical condition, or surgical complication is believed to be the cause, various lab tests, imaging studies, and diagnostic procedures may be performed to support or rule out the suspicion.

Treatment

The treatment of delayed ejaculation depends on the underlying cause or causes of the dysfunction.

If DE is caused by medication side effects, it sometimes helps to lower the dose or substitute the drug with another agent. While there are no FDA-approved drugs used to treat DE, there are medications doctors will sometimes prescribe off-label if the problem is moderate to severe. These include:

• Cabergoline (Dostinex), a dopamine agonist
• Buspar (Buspirone), an anti-anxiety drug
• Periactin (Cyproheptadine), an allergy medication
• Symmetrel (Amantadine), a Parkinson's disease medication

Testosterone injections or patches may sometimes be used if hypogonadism is diagnosed. (The use of testosterone in men without hypogonadism is unlikely to help.)

Medical interventions may be explored if chronic conditions are not being managed, including high blood pressure, diabetes, and thyroid disease.

If there is anejaculation (the inability to ejaculate) with the sense of orgasm, your doctor may also consider ruling out retrograde ejaculation with post-ejaculatory urinalysis. He or she may also suggest trying medication to tighten the bladder neck, such as pseudoephedrine.

Additionally, a psychologist or psychiatrist may help you overcome any emotional barriers that are standing in the way of an orgasm. This may involve one-on-one counseling or counseling with your partner.

If the cause is functional (meaning caused by sexual practices or habits), a sex therapist may use talk therapy, toys, devices, or sexual and mental exercises to alter the way you approach sex and orgasm.

Coping

Delayed ejaculation is a frustrating condition for both you and your partner. Overcoming DE can take time and require commitment from both of you as a team. Central to this is open and honest communication, not only about what you are experiencing but also what is working or not working in bed.

Being honest doesn't mean criticizing or hurting your partner. It is about expressing how you feel clearly ("I find this position uncomfortable") rather than telling your partner what he or she is doing wrong. Focus on the positive and don't put stress on yourself by trying to "make things right."

By working together as a team, you are more likely to improve not only your sex life but your relationship as well.