Delayed Ejaculation

Content written by Irwin Goldstein MD

OVERVIEW:

An orgasm is a pleasurable feeling (a cerebral event) usually associated with emission and/or ejaculation. In delayed ejaculation, there is an undue delay in reaching ejaculation during sexual activity. Delayed ejaculation is a particularly troublesome sexual problem. The true prevalence of this ejaculatory disorder is not well studied.

CAUSES:

Delayed ejaculation is common in men who have decreased feelings in their genitals, history of excessive alcohol use, symptoms of testosterone deficiency such as muscle weakness or depression, diabetes or take medications that are inhibitory to sexual activity such as selective serotonin reuptake inhibitors (SSRI’s). Delayed ejaculation is also a common problem of the aging male. Like premature ejaculation, the problem is manifested with the partner as well as the patient, as fatigue before sexual release is common.

Since ejaculation requires sympathetic nerve activity, surgeries that interfere with sympathetic nerves, such as retroperitoneal lymph node dissection or surgeries involving aortic reconstruction can interfere with ejaculation. In younger men with this syndrome, the problem is expressed by difficulty with fertility.

DIAGNOSTIC TESTS:

The diagnosis of an ejaculatory problem is established by history. Physical examination in patients with complaints of delayed ejaculation may reveal diminished penile sensation. Blood testing is indicated in men with ejaculation disorders to measure the “calculated free testosterone” level. In addition, diminished sensation is associated with thyroid disorders, for which TSH should be measured. Neurologic testing such as biothesiometry is strongly recommended to objectively assess the integrity of the dorsal nerve. There are also validated questionnaires that may be completed for assessment of ejaculatory disorders.

TREATMENT:

There are several strategies available for men with delayed ejaculation. The first step is to identify the cause of the ejaculatory problem in order to treat it. The next step is to aid in maintaining the erection until orgasm can be achieved.

Should low androgens be identified as the problem, testosterone administration would be indicated, assuming there are no contraindications such as prostate cancer. If the quantitative sensory testing values are abnormal, indicated by a significant difference between the perception of vibration, hot or cold in the control site and versus the genitals, and there are no obvious neurologic explanations for the difference such as multiple sclerosis, androgen therapy should be considered. This is because the integrity of the dorsal nerve is androgen dependent. If the patient is on a selective serotonin reuptake inhibitor (SSRI) anti-depressant or another medication known to inhibit ejaculation such as a sympatholytic agent, discussion should ensue with the prescribing physician to seek an alternative class of drug. If the delayed ejaculation is a result of surgery in the sympathetic nerve chain, studies have shown that administration of adrenaline-like drugs can facilitate ejaculation.

Should the ejaculation/orgasm problem persist despite the above considerations, one theory is that there is insufficient central dopamine present, since dopamine is a well-recognized facilitator in the brain of the orgasmic response. Dopamine agonists such as buproprion or cabergaline have improved orgasmic response, as well as sexual interest, when compared to placebo (sugar pill).

A new report shows that yohimbine hydrochloride taken on an empty stomach at doses of 20 – 40 mg one to two hours prior to sexual activity has the ability to restore ejaculation capabilities in some men.

For men with these symptoms, aids to facilitate maintenance of the erection allow the man the time necessary, despite fatigue, to achieve orgasm and satisfaction.

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