Cindy M. Meston & Amelia M. Stanton
Definition, Diagnosis, and Prevalence
Delayed ejaculation (DE) is defined in DSM-5 as a persistent difficulty or inability to achieve orgasm despite the presence of adequate desire, arousal, and stimulation. In order to be diagnosed with the disorder, patients must present with one of two symptoms: either a delay in or an infrequency of ejaculation on 75-100% of occasions for at least six months. The disorder can be specified as lifelong or acquired as well as generalized or situational. Most commonly, the term refers to a condition in which a man is unable to orgasm with his partner, even though he is able to achieve and maintain an erection. Typically, men who present with DE are able to ejaculate during masturbation or sleep.
Researchers and clinicians alike agree that DE is not only the least common of the male sexual dysfunctions but also the least understood. A key concern that is often associated with DE but missed by clinicians is that partnered sexual activity may not be as exciting as masturbation. Techniques used during masturbation, such as rubbing the penis against different objects or rolling the penis between one’s hands, may create an intense sense of friction, which is otherwise elusive during sexual activity with a partner. In addition, masturbation may have a strong fantasy component, which again may be challenging to maintain when engaging in sexual intercourse with a partner.
It is important to note that men who are experiencing retrograde ejaculation do not meet the diagnostic criteria for DE. Retrograde ejaculation occurs when the ejaculatory fluid travels backward into the bladder rather than forward through the urethra. This may result from complications after prostate surgery or as a side effect of certain medications, particularly anticholinergic drugs.
A “delay” in ejaculation suggests that there are normative amounts of time in which ejaculation typically occurs. Only one study has addressed this question. Waldinger and Schweitzer (2005) measured intravaginal latency time in 500 heterosexual couples across five different countries. They found that the median time was 5.4 minutes, the mean was 8 minutes, and the standard deviation was 7.1 minutes. Though these values are illuminating from a research perspective, it is noteworthy that the DSM-5 does not include any objective measures of latency in the diagnostic criteria of the disorder, which makes it challenging to determine prevalence rates.
Prevalence rates of DE in the literature are low, usually 3% or lower (e.g., Christensen et al., 2011; Fugl-Meyer & Sjogren, 1999; Líndal & Stefànsson, 1993; Perelman & Rowland, 2006; Rowland, Keeney, & Slob, 2004). Researchers have suggested that the rate of DE will rise due to age-related ejaculatory decline (Perelman, 2003a) as well as widespread use of SSRIs (Georgiadis, Reinders, Van der Graaf, Paans, & Kortekaas, 2007), which have been implicated in increased ejaculation latency.
Factors Associated With Delayed Ejaculation
A number of biological and psychological factors have been shown to play an important role in delayed ejaculation. Biological factors include damage to the nerve pathways that facilitate ejaculation, chronic medical conditions, and potentially age. The various psychological etiologies of the disorder span from insufficient stimulation to assorted manifestations of “psychic conflict.”
Biological Factors
During ejaculation, the efferent nerves that cause the release of semen and the closure of the bladder neck are sympathetic fibers which travel through the sympathetic ganglia and the peripheral pelvic nerves (Segraves, 2010). Damage to any of these pathways may compromise ejaculation. Spinal cord injury is most likely to cause the nerve damage that results in DE.
Chronic medical conditions, such as multiple sclerosis and diabetes, are correlated with DE (Perelman & Rowland, 2006; Waldinger & Schweitzer, 2005). Short-term, reversible medical conditions, including prostate infection, urinary tract infection, and substance abuse may also lead to symptoms of DE. Many psychopharmacological agents, including antipsychotics and antidepressants, may also lead to ejaculatory delay (Segraves, 2010).
According to Segraves (2010), there is conflicting evidence regarding the effect of age on ejaculatory function. As DE is more common in older males (Perelman & Rowland, 2006) the disorder may be related to low penile sensitivity, which is associated with aging (Paick, Jeong, & Park, 1998; D. L. Rowland, 1998). However, low penile sensitivity usually is not the primary cause of DE (Perelman, 2014). Rather, individual variability in the sensitivity of the ejaculatory reflex, which is exacerbated with age, may be driving the relationship between age and DE.
Psychological Factors
Recently, Althof (2012) reviewed the four leading psychological theories of DE. The first theory focuses on insufficient mental or physical stimulation (Masters & Johnson, 1970). Men with DE may have a diminished ability to experience penile sensations, as they have been shown to experience less sexual arousal than men without the disorder (D. L. Rowland et al., 2004). A lack of proper ambiance for sexual activity may also contribute to insufficient mental stimulation (Shull & Sprenkle, 1980).
The second theory that Althof mentions (2012) posits that DE is caused by a high frequency of masturbation or by a unique, idiosyncratic masturbatory style that differs greatly from the physical stimulation that occurs during vaginal penetration (Perelman & Rowland, 2006; Perelman, 2005). Men with DE may experience a large disparity between the sensations that they experience when masturbating to a specific fantasy and the sensations that they experience during partnered sexual activity.
The third theory reviewed by Althof (2012) centers on “psychic conflict” as the root cause of DE. This theory was more common in the early stages of psychological treatment for DE, but some psychodynamically-oriented therapists still conceptualize the disorder in terms of psychic conflict. Examples of psychic conflict include fear of loss of self due to loss of semen, fear that ejaculation may hurt the partner, fear of impregnating the partner, and guilt from strict religious upbringing (Friedman, 1973; Ovesey & Meyers, 1968).
The final theory suggests that delayed ejaculation may be masking the presence of a desire disorder. In this case, the male may be overly concerned with pleasing his partner, and, even when he is not aroused, may seek to ejaculate (Apfelbaum, 1989).
Assessment and Treatment of Delayed Ejaculation
A medical doctor or clinical psychologist assesses for delayed ejaculation with an interview to determine ejaculation latency and to discuss reactions to this problem. The most common treatments incorporate behavioral techniques.
Assessment
Both physical and psychological assessment are necessary in order to gain a thorough understanding of the factors contributing to DE. To provide a thorough assessment, clinicians should conduct a genitourinary examination, check androgen levels, identify any physical anomalies, and assess any contributing neurological factors. Specific attention should be paid to the identification of urethral, prostatic, epididymal, and testicular infections (Corona, Jannini, Vignozzi, Rastrelli, & Maggi, 2012). Assessment of variables that improve or worsen performance in a given context may be informative, especially psychosocial factors like the use of fantasy during sex, anxiety during sexual activity, masturbatory patterns, and perceived partner attractiveness (Perelman, 2014).
Treatment
There has been limited success in the development and testing of pharmacological agents aimed at treating DE. Drugs that have been shown to be somewhat effective may only indirectly affect ejaculatory latency by altering other components of the sexual response cycle or by countering the effects of the drugs that led to the ejaculatory problem in the first place (Rowland et al., 2010). In the future, alpha-1 adrenergic receptor agonists, such as imipramine, ephedrine, and midocrine, may play a role in the pharmacological treatment of DE. One study indicated that midocrine facilitated ejaculation in men who were previously unable to ejaculate (Safarinejad, 2009), but further research is necessary. According to Rowland (2010) other pharmacological agents, including yohimbine, buspirone, and oxytocin have been anecdotally associated with decreased ejaculation latency in men with DE. However, well-controlled studies with large sample sizes are needed to conclusively determine the effects of these drugs on ejaculation.
If the disorder is determined to be primarily psychological in origin, there are a number of psychosocial interventions that have been shown to effectively reduce ejaculation latency. Most sex therapists who treat DE rely on masturbatory retraining (Masters & Johnson, 1970) as a way to induce higher levels of arousal and help men rehearse for partnered sexual activity (Apfelbaum, 2000; Perelman, 2003; Perelman & Rowland, 2006). This intervention may be particularly helpful for men who have grown accustomed to masturbating in idiosyncratic ways, such as with specific objects or under certain conditions. Masturbatory retraining typically entails introducing the patient to an alternative style of masturbation that mimics the sensations of partnered sexual activity. According to Apfelbaum (2000), masturbation exercises that progress from neutral to pleasurable sensations remove the “demand aspects” of performance. If the disorder is derives from insufficient stimulation, therapists typically recommend vibrator stimulation, enhanced mental stimulation, and vigorous pelvic thrusting (Althof, 2012). For those who are experiencing DE due to heightened concern for the sexual pleasure of their partners, therapists encourage less focus on pleasing the partner and more attention to the self and the sensations experienced during sexual activity.
