Ejaculatory and Orgasmic Disorders
Ejaculation is the expulsion of semen from the penis. Orgasm is a feeling of intense pleasure, relaxation, and connection that is associated with sexual climax. In most men, orgasm and ejaculation happen simultaneously but they are in fact different physiological events that can occur independently of one another. One can think of ejaculation as the events that happen in the pelvis at sexual climax and orgasm as what happens in the mind.
Many men experience disruption or disturbance of their ejaculatory function at some point in their life. This may occur in the setting of erectile dysfunction (trouble getting or keeping an erection) or low libido (decreased sexual interest) but can also occur in men with normal erection responses. These problems can be lifelong or acquired. The cause and management of ejaculation/orgasmic issues depends in large part on where the problem lies.
Early or Premature Ejaculation (PE) is ejaculation that occurs before the man wishes it to occur and over which he has little to no sense of control. Precise definitions for this condition have varied but the current bulk of evidence suggests that clinically relevant PE is typically associated with ejaculation before or within one minute of penile penetration in the case of lifelong PE and within 2-3 minutes of penetration in acquired PE.
It is important to note that many men may think that they have an abnormally short ejaculation latency. In some cases this may be related to what they have seen or heard through popular culture and/or sexually explicit media. There is a wide range of what is normal; however, existing population studies have suggested that the average latency time (i.e. time between penile penetration to ejaculation) is about 5 minutes and most men have latency times that are within 2-3 minutes of that. Hence, some men may think that they have rapid ejaculation when in fact they are well within the range of what is normal. Occasional very rapid ejaculation is also common, particularly in men who have not ejaculated recently.
The cause of PE is not completely understood. Over the years experts have theorized that anxiety about sexual performance, conditioning, relationship stress, conditions such as thyroid disorders or prostate infection, penile hypersensitivity, and/or differences in metabolism of the neurotransmitters serotonin and dopamine may cause PE. There is some support for each of these different theories and it is likely that in many cases the issue is not related to one single cause.
A number of psychotherapeutic and behavioral approaches have been promoted for managing PE. These are typically geared towards helping a man to recognize the signs of impending climax, thus enabling him to take steps to diminish or slow his arousal state. Support and involvement of the partner is essential.
There is no FDA approved medical therapy for PE in the United States although a drug has been approved for PE in other countries. Although no drug has been formally approved, off label use of oral Selective Serotonin Reuptake Inhibitors (SSRI) has been associated with improvement in ejaculation latency for men with PE. Brief application of of a topical anesthetic to the penis may also be of benefit in select cases. A careful consultation and review of the risks and benefits of medical therapy for PE should be considered before starting any therapy.
Delayed Ejaculation (DE) can be thought of as the opposite of PE. It is defined as difficulty or inability to reach sexual climax after a period of desired sexual stimulation. This condition is poorly understood; it is more common in older men but can occur in men of any age. It may be related to changes in serum testosterone levels, declines in penile sensitivity, secondary to issues of decreased erection responses and/or libido, or other relationship causes. Anti-depressants, particularly those of the SSRI class, are commonly associated with delayed or absent orgasmic responses.
Some experts have theorized that delayed ejaculation may be the result of conditioning of their sexual responses; this theory is based on the observation that some men (typically young) may be able to reach climax during masturbation but have trouble when engaging in sex with a partner. While interesting, it may also be hypothesized that these younger men simply need more intense sexual stimulation. The true cause of delayed ejaculation in such cases is difficult to determine.
There is no specific treatment for DE. The patient’s general medical and sexual history should be assessed. Time of onset is important to know…potential precipitating factors (e.g. surgery, new medications) should be assessed. Basic lab tests, including assessment of sex hormones, should be obtained. Medications that are known to impair orgasmic response should be stopped or changed if possible. The quality and nature of the patient’s intimate relationship(s) should also be assessed.
Although there is no FDA approved therapy for DE, some medical therapies have been studied and may have some efficacy in helping alleviate symptoms. Men with DE and their partners may also consider modifying their sexual routines; use of sex enhancement devices and/or novel sexual practices may increase arousal and help men with DE reach climax. Open and honest communication and agreement on what is and is not acceptable is essential to treatment success.
The force and volume of ejaculation tends to decline as men age. Absent or diminished ejaculation is also common in men who are taking certain medications or who have had surgery for an enlarged prostate or prostate cancer. Many of these men will experience no ejaculation during sexual climax; depending on their prior treatment this can be due to lack of semen production or “retrograde ejaculation”, when semen is released but goes backwards into the bladder rather than out through the penis. Decline or absence in ejaculation force/volume is not dangerous but can be disturbing to some men; it may also change the man’s feeling or orgasm through mechanisms that are not entirely understood.