Practice Essentials
There is a spectrum of delayed ejaculation (DE) disorders ranging from increased latency to ejaculation to absent ejaculation and including DE, retrograde ejaculation, painful ejaculation and anorgasmia.
DE is typically self-reported. While there is no firm consensus on what constitutes a reasonable time frame for reaching orgasm, men with latencies beyond 25–30 minutes are assumed to suffer from DE.
Signs and symptoms
The history should address the following:
Sexual history (eg, repetitive pattern of difficulty in ejaculating)
Medical history (eg, lower urinary tract symptoms in elderly men)
Current medications (eg, certain antidepressants and alpha blockers can affect ejaculation)
History of injury or surgery (eg, bilateral sympathectomy at L2, high bilateral retroperitoneal lymphadenectomy)
History of alcohol and illicit drug use (including marijuana, cocaine, opioids, amphetamines, and 3,4-methylenedioxy-N-methylmphetamine (ecstasy)
Psychological factors (eg, a history of trauma, severe guilt, a fear of impregnation, hostility toward a woman, severe depression)
See Presentation for more detail.
Diagnosis
Conditions that should be included in the differential diagnosis include the following:
Diabetes mellitus
Hypertension
Pain syndromes
Shortness of breath
Angina pectoris
Muscle weakness
Cigarette smoking
Excessive consumption of alcohol or the use of other recreational drugs
The following classes of prescribed medications should be considered in the differential diagnosis
:
Alpha-adrenergic blockers
Combined alpha- and beta-adrenergic blockers
Sympathetic nerve blockers
Antiulcer medications
Tricyclic antidepressants
Monoamine oxidase inhibitors
Selective serotonin reuptake inhibitors
Other antidepressants
Neuroleptics
Mood stabilizers
Microscopic examination of the bladder urine after a dry ejaculation is informative in differentiating between retrograde ejaculation and emission failure.
See Workup for more detail.
Management
When pharmacotherapy for delayed ejaculation is under consideration, it is important to eliminate iatrogenic causes, including medications. Adjunctive therapies should be considered. Agents that have been used include the following:
Alpha sympathomimetics (eg, ephedrine or a combination of chlorpheniramine maleate and phenylpropanolamine hydrochloride [withdrawn from the US market])
Sildenafil
Imipramine
Any psychological intervention must address both historical factors and current factors that might contribute to the present dysfunction. Historical factors that can contribute to anorgasmia include the following:
Traumatic or unpleasant past sexual experiences
Negative cognitions about sex
Current factors that can contribute to anorgasmia include the following:
Performance anxiety
Relationship problems
Stress (due to causes other than relationship difficulties or sexual problems)
Environmental factors (eg, lack of privacy or uncomfortable room temperature)
Anecdotal reports suggest that an electrovibrator applied at the lower surface of the glans penis can be an effective intervention in cases of primary male anorgasmia.
See Treatment and Medication for more detail.