Delayed Orgasm and Delayed Ejaculation

Delayed orgasm and delayed ejaculation in cisgender men (also historically referred to as retarded ejaculation) refer to difficulty reaching orgasm (climax) and/or ejaculating even with a firm erection and sufficient sexual arousal and stimulation. This delay is often associated with personal distress. Delayed orgasm or ejaculation is estimated to occur in 1-4% of men.

Delayed orgasm and delayed ejaculation can be classified as either primary or secondary. Primary or "lifelong" delayed orgasm/ejaculation is when a man has never been able to orgasm/ejaculate with adequate sexual stimulation. Secondary or "acquired" delayed orgasm/ejaculation is when a man was able to orgasm/ejaculate with adequate sexual stimulation at one time in his life, but no longer is able to, or he does so infrequently.

Delayed orgasm/ejaculation may occur during any sexual activity but occurs less commonly during masturbation. In fact, 85% of men with either primary or secondary delayed ejaculation are usually able to reach climax through masturbation. In some circumstances, delayed orgasm/ejaculation occurs in both situations. This problem can be frustrating and may cause distress for both patients and their partners.

In some circumstances, a man can reach pleasurable orgasm without ejaculating semen. This is often referred to as ‘dry orgasm’ (but only if this occurs in the absence of retrograde ejaculation). This may occur following removal of the prostate. Sometimes a man can ejaculate without experiencing pleasure (orgasm). This rare condition is called ‘orgasmic anhedonia.’

Through a detailed history physical examination, a provider (typically a urologist) can often determine the cause of a man’s delayed orgasm/ejaculation.

Delayed orgasm/ejaculation may be caused by:

• Medication side-effects - Antidepressants, anti-anxiety drugs and blood pressure medications can slow the ejaculatory response. Delayed orgasm/ejaculation is a very common side effect of men taking SSRIs (selective serotonin reuptake inhibitors; a type of antidepressant).
• Alcohol or illicit drug use
• Diabetes
• Low testosterone or other hormonal imbalances
• Neurological damage – Nerve damage caused by strokes and spinal cord injury or conditions such as multiple sclerosis
• Psychological causes – Sexual performance anxiety, depression, relationship issues, etc.
• Conditioning by use of unique (“idiosyncratic”) masturbation practices may cause men to experience delayed orgasm. This man may not gain a sufficient amount of penile stimulation during intercourse to achieve orgasm. For example, a man who is used to masturbating with a very fast motion may find it difficult to climax with the slower pace of intercourse.

Many experts believe that the majority of delayed orgasm/ejaculation problems do not have an underlying physical abnormality present. This is based on the fact that 85% of men with either primary or secondary delayed orgasm/ejaculation are able to achieve orgasm through masturbation. Therefore, it is likely that these men have a behavioral or psychological issue which needs to be addressed.

Delayed orgasm/ejaculation is diagnosed during the history-taking process. The provider may ask for an estimate of the usual time between starting sexual stimulation and orgasm/ejaculation. There is no strict definition of delayed orgasm/ejaculation, but an approximate duration of 25-30 minutes has been suggested as one definition. Some patients may become exhausted prior to orgasm or ejaculation leading to cessation of sexual activity. A stopwatch can be used to determine the amount of time between starting sexual stimulation and orgasm/ejaculation (orgasmic or ejaculatory latency time).

There are several treatments for delayed orgasm/ejaculation. Treatment is mainly determined by the suspected cause of the problem.

If a prescribed medication is suspected to be the cause of the man’s delayed orgasm/ejaculation, finding an alternative prescription with a doctor’s guidance can usually solve the problem. For example, replacing an SSRI antidepressant with bupropion might reduce the risk of delayed orgasm/ejaculation. However, certain essential prescriptions can neither be removed nor replaced, so never discontinue a prescribed medication without consulting the prescribing physician.

Since delayed orgasm/ejaculation and erection problems are very common among excessive drinkers, the solution to this is simple: limit drinking. The same is true of individuals whose use of illicit drugs is the suspected cause of their delayed orgasm.

Since many experts think that the majority of delayed orgasm/ejaculation problems are due to behavioral or psychological causes, counseling and sex therapy with a licensed professional specializing in this area is a common treatment for restoring sexual function.

Generally, the objective of psychological therapy is to gradually diffuse the man's sexual anxieties and shed any “baggage” he may be bringing into his sexual encounters so that he can more readily reach climax and have a pleasurable experience.

Men with low testosterone may find improvement with testosterone replacement. Several other prescriptions medications have been used for delayed orgasm/ejaculation, but no single medication has been reliably effective or universally accepted. Some medications which have been proposed include cabergoline, oxytocin, bupropion and amphetamine/dextroamphetamine salts (Adderall).

Penile vibratory stimulation (using a vibrator) may also be useful for some men.

For heterosexual couples desiring pregnancy in which the man is unable to ejaculate inside the vagina, couples can achieve pregnancy through several measures. These men can produce an ejaculate by masturbation, or by the use of electrical stimulation of the prostate area, called electroejaculation. These samples can be used for intrauterine insemination (IUI) or in vitro fertilization (IVF) in order to conceive. If this is not successful and fertility is still a concern, it is also possible for a trained physician to extract sperm from the testicles and use artificial insemination in order to initiate pregnancy. If artificial insemination fails, IVF (egg-sperm fertilization in a test tube and then inserted into uterus of mother) or single sperm injection can be attempted.

Condition overview written by Petar Bajic, MD