delayed ejaculation , according to the Diagnostic and Statistical Manual of Mental Disorders (DSM 5; APA, 2013) is within the male orgasm disorders . It is characterized by a marked delay or inability to achieve ejaculation.
These symptoms last for at least about 6 months and cause clinically significant distress in the individual. The man reports difficulty or inability to ejaculate despite adequate sexual stimulation and a desire to ejaculate.
The man and the partner may report prolonged attempts to reach orgasm up to pain in the genitals and thus suspend all attempts. Some men may tend to avoid sexual activity due to a constant difficulty in ejaculating.
Spread of the orgasmic problem
The prevalence of delayed ejaculation is extremely variable among the studies in the literature, with data ranging between 0.15% and 11%.
This variability is certainly due to the fact that there is still no quantitative data with respect to what we clinically define as “ejaculatory delay”.
Furthermore, the prevalence of delayed ejaculation is age-dependent, with an increase directly proportional with advancing age.
Factors affecting this correlation are changes in penile sensitivity, increased prevalence of testosterone deficiency and the increase in the use of drugs impacting ejaculatory times and orgasmic capacity.
Organic classification and etiology of delayed ejaculation
Based on the onset and manifestation of the disorder, we distinguish a delayed ejaculation:
- permanentwhich refers to a sexual problem that has been present since the first sexual experiences;
- acquiredapplies to sexual disorders that develop after a period characterized by the absence of sexual problems;
- generalizedrefers to sexual difficulties that are not limited to certain types of stimulation, situations or partners;
- situationalwhen delayed ejaculation occurs based on the environment, partner and a specific situation.
The severity of this disorder varies. They range from an involuntary inhibition of completely occasional ejaculation, which can be overcome with the simple use of fantasy and / or additional stimulation. But it goes as far as severe inhibition, in which the patient has never experienced an orgasm in the course of his entire life.
In the mildest form of this disorder, the symptom appears only in anxious situations while the subject is able to ejaculate when he feels calm.
In more serious situations, the man reports that he is unable to ejaculate during coitus; in these cases, however, the man may be able to ejaculate through manual or oral stimulation by the partner.
Other times the ejaculatory reflex is inhibited even by the contact by the partner. The situation in which the man has to go away is always serious because he cannot ejaculate in the presence of the woman but can only do it in solitude.
The most serious, but also the rarest, picture is characterized by the case in which the patient has never experienced an orgasm in his entire life, not even alone.
Organic causes
Many organic conditions can cause ejaculatory delay. The severe form of delayed ejaculation is generally related to neurological diseases (e.g. multiple sclerosis) or endocrine diseases (e.g. diabetes mellitus and hypothyroidism), Or to the administration of neuroleptic , opiate, antihypertensive, serotonergic antidepressants .
All actors responsible for the increase in the threshold beyond which ejaculatory mechanisms are triggered, thus prolonging the duration of sexual intercourse. Furthermore, any damage to the sympathetic or somatic innervation of the genital area can potentially cause problems with ejaculatory and orgasmic function.
Differential diagnosis
L ‘ delayed ejaculation should be distinguished from two organic terms. The first is retrograde ejaculation (or ejaculation in the bladder). A particular condition that occurs when the bladder sphincter does not close properly during orgasm. This results in an erection and orgasm but no visible external ejaculation.
This condition is generally attributed to organic causes such as spinal cord injury, diabetes mellitus, prostatectomy or abdominal aortic surgery outcomes, or the use of antihypertensives.
The second condition is called anejaculatory orgasm. In this case the ejaculatory expulsive phase occurs in the absence of a previous emission phase and therefore of accumulation of seminal fluid. This condition is usually associated with surgical, endocrine or pharmacological causes.
Psychological delayed ejaculation
Once organic causes have been excluded, psychological etiopathogenetic hypotheses can be considered.
L ‘ performance anxiety can negatively impact during the sexual act and be responsible for the ejaculatory delay. In these cases, the man prepares for sexual intercourse with the fear of not being up to par and not being able to satisfy his partner.
The individual suffering from performance anxiety worries about ejaculation and this affects arousal. If the arousal subsides progressively the orgasm is delayed.
For some men, ejaculation corresponds to an anxious moment not so much for the act itself, rather for the impossibility of controlling the body and one’s sensations. For still others, ejaculatory delay reflects a selfish act in which ejaculation is unknowingly postponed in order to maintain iron control of one’s actions.
It may happen that the orgasm disorder appears, in some cases, when the partners decide to have sexual intercourse aimed at conception. The explanation for these difficulties can be found both in performance anxiety (having to ejaculate in the vagina) and in the fear of the responsibilities derived from becoming parents.
Among the conflictual problems of the couple as causes of the disorder various authors indicate repressed aggression, ambivalence towards a possible pregnancy, fear of addiction and therefore the fear of intimacy, the anxious need to succeed and sexual fantasies felt as unacceptable, perhaps linked to a rigid religious education that generates a sense of guilt about sexuality.
Delayed ejaculation and psychological implications
Males with delayed ejaculation report experiencing high levels of personal and relationship distress, poor sexual satisfaction, high levels of anxiety before sexual intercourse, and a higher frequency of general health problems than the healthy target population.
Furthermore, they report a lower frequency of penetrative sexual intercourse than their counterparts of males without delayed ejaculation.
When delayed ejaculation becomes a frequent and ordinary phenomenon, the condition could cause serious obstacles in the couple relationship, especially within the sexual sphere. The partner of the delayed ejaculator often experiences frustration and dissatisfaction within the relationship. This is because they may interpret the mate problem as personal rejection and therefore feel less attractive and unable to sexually satisfy their partner.
In delayed ejaculation, male orgasm is not always so obvious and prolonging intercourse excessively can cause genital pain or irritation. This repeated, exhausting and painful search with no happy ending often results in the avoidance of sexual intercourse and the decrease of sexual desire in partners.
Furthermore, secondary or reactive erectile dysfunction is sometimes a consequence of delayed ejaculation. In fact, the patient can foresee failure even before having intercourse and be so blocked by these thoughts as to completely mortify his erect reaction.
Evaluation of the patient with delayed ejaculation
There are several factors that must be taken into consideration to identify the exact cause of the disorder and, consequently, to choose the appropriate treatment. Evaluation of the patient who reports difficulty in reaching orgasm and ejaculating should start with a good medical history, physical examination, and sex history.
Medical history
It should elaborate on the following points:
- evaluation of etiological factors;
- ascertaining the use of drugs inducing delayed ejaculation;
- evaluation of penile sensitivity (especially in diabetic patients);
- assessment of hormonal levels (attention to low testosterone levels, hyperprolactinemia, hypothyroidism);
Sexological history
It should include the evaluation:
- the history of the symptom (mode of appearance, duration, severity, impact on the person / couple);
- masturbatory habits (frequency, intensity of the act, modality);
- desire, arousal and orgasm, sexual fantasies, contraceptive use;
- thoughts (intrusive dysfunctional thoughts, anxious thoughts, etc.), religious and cultural beliefs;
- the ability to ejaculate in the presence of the partner;
- psychopathological aspects inherent in the patient (anxiety and depression, sexual orientation);
- relational problems (with respect to the current partner but also with previous companions);
- the presence of environmental stressors (work, financial problems, illness or bereavement in family members, etc.).
Delayed ejaculation treatments
Therapies aimed at dealing with delayed ejaculation are mainly:
- Pharmacological therapy: it is based on the administration of sympathetic-mimetic drugs, capable of stimulating the excitatory nerve centers, responsible for orgasm. Unfortunately, however, there is little evidence in the literature that demonstrates the efficacy of medical therapy in the management of delayed ejaculation. Some advantages seem to derive from the use of Cabergoline and Buprioprione.
- Psychoeducation: knowledge of sexual anatomy and sexual response cycle, improvement of body awareness, understanding of physiological and psychological factors involved in sexual intercourse, examination of common beliefs and myths concerning sex, etc .;
- Behavioral sex therapy(integrated job psychotherapy): psychotherapy should involve both partners and treatments aimed at reducing performance anxiety and increasing the sources of physical stimulation with gradual approximation to ejaculation in the vagina are implemented. In practice, through behavioral techniques, such as sensory focus and desensitization, the therapist teaches the couple to approach sexuality gradually. Initially shifting attention from coitus, starting with general bodily stimulation, which does not include genital stimulation. At a later stage the couple will learn genital stimulation up to orgasm and ejaculation near the vaginal intake. To then get to the final phase in which the partner stimulates the male to reach the plateau,
Sometimes it is also necessary to work on managing the resistance of the partner who comes to feel “used” for the resolution of the sexual symptom.
In these cases, a good couple therapy , which brings out negative experiences such as the partner ‘s angry emotions , sometimes also associated with procreative impossibility, allows the partner to overcome the resistance to therapy and finally the couple to be able to work in balance to achieve full sexual satisfaction .
Conclusions
Although delayed ejaculation is a disabling sexual symptom, for both the individual and the couple, to date it is probably the least diagnosed and least studied male orgasm disorder in the field of sexology.
Since delayed ejaculation is usually under-diagnosed, the specialist should pay particular attention to the orgasmic / ejaculatory capacity when faced with a patient with hormonal imbalances, neurological damage, psychiatric problems.
Similarly, if an infertility problem due to delayed ejaculation is suspected, the patient should be sent to a physician / psychologist expert in sexology so as to be able to restore the fundamental sexual function for conception, but also for good couple satisfaction.
