What is delayed ejaculation? Is it a medical problem?

Delayed ejaculation can cause psychological distress for the man who has the problem, and create stress between sex partners. The problem - a relatively rare sexual dysfunction of both medical and psychological causes - is often misdiagnosed, and it is relatively poorly addressed by research.¹

Use this page to find out what constitutes a true diagnosis of delayed ejaculation. Certain criteria need to be met, and these do not include an infrequent or non-troubling case of taking longer to reach orgasm, which many men may experience at some point.

Contents of this article:

1.  What is delayed ejaculation?
2.  What causes delayed ejaculation?
3.  Diagnosis of delayed ejaculation and How long is too long for a man to reach orgasm?
4.  What difficulties are created by delayed ejaculation?
5.  reatment of delayed ejaculation

Also on this page:

• What is anejaculation? What is retrograde ejaculation? What is painful ejaculation?

Fast facts on delayed ejaculation

Here are some key points about delayed ejaculation. More detail and supporting information is in the body of this article.

• Delayed ejaculation is a form of sexual dysfunction affecting a man's ability to reach an orgasm.
• The disorder is a form of ejaculatory dysfunction (others include premature ejaculation and anejaculation).
• Delayed ejaculation is not a diagnosis until certain factors have been met, including how persistent and troublesome the problem is.
• There is no strict figure on the "normal" time taken for men to ejaculate after penetration, and averages vary.
• Nor is a strict amount of time for penetrative sex diagnostic of delayed ejaculation - but researchers have identified around 20 mins after penetration to be an average length of time taken by men diagnosed with the problem.
• Delayed ejaculation can be present from the beginning of a man's sexual activity, or can be acquired, often in certain situations.
• Most causes are psychological, but organic reasons are also possible and are ruled out first during diagnosis.
• Psychological causes are often complex, but can sometimes be obvious - such as to do with a couple's mixed desire for pregnancy.
• Styles of masturbation can strongly influence the way a man goes on to experience sexual intercourse - certain behaviors are linked to delayed ejaculation.
• Medical cases may be more straightforward for doctors to treat than psychological ones - by addressing the underlying condition.
• Psychological issues are not treated in the same way for every man or couple - psychological therapists instead address individual concerns.
• Sex therapy, which can be arranged via doctors, may include the offer of practical tips to try at home during sexual activity.
• No pharmacological therapies are available for psychological causes of delayed ejaculation.

What is delayed ejaculation?

Delayed ejaculation is one of the ejaculatory dysfunctions (abbreviated to EjD in research papers) and probably the least understood.¹ It is also the least common form of male sexual dysfunction, affecting an estimated 1-4% of men.²

Men with a persistent problem of delayed ejaculation are likely to be distressed by it.

Compare this with how many men get premature ejaculation: based on estimates of how many at least think they have a problem with rapid ejaculation, the range for that condition is between 15-30%.^3,4

Delayed ejaculation falls in the middle of the spectrum of ejaculatory dysfunction:^1,5,6

• Premature ejaculation (ejaculation always, or nearly always happening before sexual penetration has been achieved, or within about a minute of penetration)
• Delayed ejaculation
• Anejaculation (inability to ejaculate, including "retrograde ejaculation" and "painful ejaculation").

The term "delayed ejaculation" recently became the officially preferred name for what had once been labeled "male orgasmic disorder."⁷ What was considered a derogatory meaning has also been conferred on the disorder: "retarded ejaculation."¹ And another term that is used for the condition is "ejaculatory insufficiency."⁵

In summary, delayed ejaculation is the difficulty or inability of a man to reach an orgasm and ejaculate semen.¹

The problem is diagnosed when a man is concerned about a problem during most sexual intercourse encounters over at least six months, with a marked delay or marked infrequency of achieving ejaculation - when other problems have been ruled out and in spite of a normal erection and sexual stimulation.^1,3

What causes delayed ejaculation?

Delayed ejaculation can have a psychological or biological cause - and there can be overlap between the two. It can be a lifelong condition in which the man has always had difficulty reaching an orgasm, or, more commonly, acquired, in which there has been a time when the man's ejaculatory function was normal.⁸

Biological causes of delayed ejaculation will be ruled out first, leaving the more common psychological causes to be addressed. Organic reasons for a case could be disease or a factor such as medication, and this underlying cause can be addressed.⁸

Physical causes of delayed ejaculation include:^1,2,5,8-10

• Medication side effects - from antidepressants, anti-anxiety drugs, blood pressure drugs (antihypertensives), painkillers, among others. A proportion of men taking SSRI (selective serotonin reuptake inhibitor) antidepressants acquire delayed ejaculation
• Alcohol or illicit drug-taking
• Nerve damage (neurological causes) - stroke, spinal cord injury, surgery, multiple sclerosis, and severe diabetes can all lead to this
• Increasing age can decrease the sensitivity of the penis to sexual stimulation
• Delay in ejaculation can mask other conditions such as pain during intercourse, which the doctor or therapist would rule out or give as the differential diagnosis in place of delayed ejaculation.

An acquired case can usually be identified as having a psychological cause if it happens only in relation to certain situations. An example may be a man being able to ejaculate normally when masturbating, but finding there is a delay during sex with a partner.⁸

Some psychological factors - disharmony in a relationship, for example - can help to maintain or exacerbate the factors that predispose a man to delayed ejaculation.³

Psychological causes of both lifelong and acquired cases of delayed ejaculation can be complex, and differ from one individual to the next. Also, psychological causes in general are debated by psychologists.¹

One correlation seems to be fairly consistent, however - the behavior developed when learning to reach ejaculation through masturbation may differ from the sexual behavior with a partner.¹

Among some of the psychological factors thought to be behind cases of delayed ejaculation are:^1,3

Average penis size

Psychological concerns about sex are not confined to problems with ejaculation. Men can become unnecessarily concerned about the size of their penis.

• Early life history, including abuse, difficulties bonding, neglect by parents, negative sexual upbringing
• Unexpressed anger
• Unwillingness to enjoy pleasure
• Religious belief, perhaps that sexual activity is a sin
• Fears, such as of semen, of the female genitalia, or of somehow hurting or defiling a partner through ejaculation
• Fear of pregnancy
• Issues of lost confidence or performance anxiety - for example, anxiety about body image that interrupts the process of sexual stimulation
• Issues of perceived readiness for ejaculation because there is a good erection, but when there has been inadequate arousal - including higher expectations when erections are gained through erectile dysfunction medication.

A factor strongly related to the abnormal sexual experience of ejaculation is previous masturbation.¹

Certain types of masturbatory behavior may develop a particular way of reaching ejaculation that cannot be achieved when sex is with a partner, and one specialist in the condition who has done research into correlations has found a relationship between delayed ejaculation and the following masturbatory patterns:¹

• Masturbating more often, typically more than three times a week
• Having a style of masturbation that cannot be matched by sexual intercourse - particularly a high speed, high pressure, high-intensity form
• The partner's hand, mouth or vagina being unable to duplicate the learned style easily
• The sex partner differing from the fantasy used during masturbation to reach an orgasm.

Dr Michael Perelman - clinical professor of psychiatry, reproductive medicine and urology at the Weill Medical College of Cornell University in New York - also found that most men he had seen with delayed ejaculation reported no problems reaching an orgasm and ejaculating via masturbation.¹

This finding is similar to the experience of a study of 24 men with delayed ejaculation - only two did not or could not masturbate to ejaculate.¹¹ Some others with the condition needed to employ an "idiosyncratic" form of self-manipulation to reach orgasm: rubbing their penis against the bed sheets, masturbating with pressure on a particular spot when reading erotic books, or one patient masturbated by "urethral instrumentation" - inserting a foreign body down into the opening of his penis.

Diagnosis of delayed ejaculation

The latest edition of the manual used by psychiatrists and psychologists, the Diagnostic and Statistical Manual of Mental Disorders - known as DSM-V and published in May of 2013 - has confirmed "delayed ejaculation" as the preferred term for a diagnosis that used to be called "male orgasmic disorder."⁷

The diagnosis is made only when a man's orgasm response and ejaculation of semen is delayed or absent, and this problem has persisted:^1,3

Ejaculation problems

Delayed ejaculation is one of a number of problems men can have with orgasm - another is reaching a climax before entering the partner, or very soon after.

1. During at least three-quarters of sexual intercourse activity over at least six months
2. With a marked delay or marked infrequency of achieving ejaculation in spite of a normal erection and sexual stimulation
3. With marked distress or interpersonal difficulty
4. When other problems have been ruled out.

For all sexual disorders - except when caused by a general medical condition, or by medication or substance use - DSM-V requires that diagnosis is made only if all three criteria of 1, 3 and 4 are met.⁷

How long is too long for a man to reach an orgasm?

Men's average times to reach an orgasm are as unique and varied as men are, and the latency between penetration and ejaculation relates to numerous biological and psychological factors that are specific to each individual.¹

Similarly, there is no strict amount of time having penetrative sex that clinicians would consider to be diagnostic of delayed ejaculation.¹

However, for guidance, an idea of what constitutes a typical amount of delay is given by a recent small study of men with the disorder.

Men with the diagnosis showed an average of 20 minutes of "intravaginal ejaculation latency time" (IELT) - which is simply the time between penetrating the vagina and ejaculating inside it.¹¹

This figure is about four times longer than a "normal" time to ejaculation in healthy men, an average IELT of just over 5 minutes (around 6.5 minutes in men aged 18 to 30 years; just over 5 minutes in 31-50-year-olds; and just over 4 minutes for older men).¹²

The study that found an average of 20 minutes in men who had delayed ejaculation also cited normal latency times of between 4 minutes and 10 minutes.¹¹

Other authors of research and information on delayed ejaculation also give intravaginal times for a diagnosis of over 20 mins, with some giving a window of 20 to 30 mins, and others saying between 30 and 60 minutes.^5,8

What difficulties are created by delayed ejaculation?

Being unable to ejaculate within a desired amount of time is often misunderstood as being no problem. It can be misperceived, even by clinicians and therapists, as offering some benefit, by offering sufficient time for a man's partner to enjoy multiple orgasms, say.¹¹

"Does he really desire me?" Partners of men having difficulty reaching orgasm may be troubled by such questions.

The truth, however, is that while some partners do enjoy the extended intercourse, many become distressed by questions such as, "does he really desire me?"¹

Partners may feel rejected, blame themselves, and become angry. Extended intercourse can also cause pain or even injury, and sex may be stopped as a result of exhaustion and discomfort.^1,11

A case of delayed ejaculation meeting all the criteria for the diagnosis can cause quality-of-life issues and the risk of ill effects on mental health:^1,6,11

• Significant sexual dissatisfaction
• Relationship distress
• Anxiety over male sexual performance and about general health.

Men with delayed ejaculation are more likely to suffer anxiety and depression.¹¹

It is obvious to expect that psychosocial distress and relationship difficulties as a result of delayed ejaculation are amplified for couples aiming to start a family.^1,6,11

Treatment of delayed ejaculation

Treatment depends on the cause of the delayed ejaculation, so may be simple in the case of it being due to medication such as SSRI antidepressant, in which case doctors can help with a switch to an alternative.^2,8

Similarly, if excessive alcohol or illicit drug use are to blame, simply limiting or stopping intake should help.² So, too, if other medical conditions underlie the problem: managing the, for example, neurological cause may resolve a secondary problem of delayed ejaculation.

Primary cases of delayed ejaculation, however, may not be as straightforward to treat, and will need the help of counselors such as psychologists, psychotherapists, psychosexual counselors, sex therapists, or couples' therapists.¹¹

Psychologists know that no single intervention works for all patients, and that the key to successful treatment is to identify the source of the problem and to select therapy that helps to deal with those psychological factors that are precipitating (triggering) the problem or maintaining it.¹³

Numerous psychotherapeutic treatments have been described in the literature. Some appear to be effective, but none has been properly tested by large-scale scientific evaluation.^5,6

Examples include:⁵

• Sex education
• Reducing goal-oriented anxiety
• Recommending increased and more genitally-focused stimulation during sex with a partner
• Role playing to exaggerate the ejaculatory moment, both when the man is on his own, or in front of his partner.

Further, whereas drug treatments are available for some cases of premature ejaculation, no medications in 2014 have been approved by the US Food and Drug Administration for delayed ejaculation. Those that have been investigated have shown only limited promise.¹

It is not all bad news, however, because individual psychological therapy may work, and its general aim is to reduce a man's sexual anxieties gradually, until he is comfortable reaching orgasm inside his partner.²

During sex therapy sessions, in addition to help with exploring any emotional or psychological issues to do with relationships and sexuality, home-based activities may be offered (but would not be suggested for practise during the actual counseling session), including:⁸

• Increasing sexual stimulation by viewing erotic videos or magazines before having sex
• Trying to make sex more exciting through erotic fantasies or sex games
• Trialing lubricating creams or gels to increase comfort, and sex toys to increase pleasure.

The most common issue underlying delayed ejaculation is previous masturbatory behavior, and practical tips have also been recommended by authors of a study that investigated penis stimulation in men who have the condition.¹¹ The authors cite this method:

"Patients should temporarily suspend masturbatory activity - at least reducing the frequency - and limit orgasmic release to their desired goal activity, for example, orgasm during penetrative sexual encounters with their partner."

Also recommended are ways to bring the experience of having penetrative sex closer to that of successful ejaculation during masturbation:¹¹

"Patients should use fantasy and bodily movements during intercourse, which make the thoughts and sensation intensity comparable to the experienced conditions in masturbation."

The use of a vibrator to increase stimulation may help¹⁴, and the use of a special device to provoke ejaculation - penile vibratory therapy - can be an appropriate option for some cases in which there is a desire to harvest sperm for conception, especially for some cases of anejaculation, which is the subject of this last section.¹⁵

What is anejaculation?

Anejaculation is the inability to ejaculate, as opposed to a delayed ability.

Retrograde ejaculation is an example of this, and a common side-effect of a type of urological surgery, transurethral resection of the prostate.⁵

Retrograde ejaculation means the semen does not escape in an external ejaculate and instead goes in the wrong direction, into the urinary bladder.^14,16

Three types of cause could apply in retrograde ejaculation, although in some cases no cause can be identified (idiopathic):^14,16

• Anatomical - either a malformation present at birth (congenital), or created following surgery of the neck of the urinary bladder or a certain type of prostate surgery
• Neurological, including nerve damage caused by diabetes, multiple sclerosis or spinal cord injury - nerve disorders, which can be surgical as well as medical, that interrupt the closure of the bladder neck during an ejaculatory emission
• Pharmacological - drugs that cause paralysis of the bladder neck. All antidepressants can cause this, as well as some classes of antihypertensive, antipsychotic and prostate medications.

Diagnosis of the problem is confirmed by finding ejaculate contents in a urine sample taken immediately after an orgasm, and treatment is possible in cases caused by medication - by stopping the drug - but is more difficult in other cases. Neurological causes may respond to drug treatment, and anatomical causes may, sometimes, be corrected with surgery.^14,16

Painful ejaculation¹⁴

Pain during ejaculation may obviously cause a man to delay his orgasm, and can lead to him avoiding sex altogether. Such a problem can cause frustration, relationship difficulties, and anxiety and depression.

A number of possible causes might be suspected for a man with painful ejaculation, including genitourinary inflammation, sexually transmitted infection, nerve damage, chronic pelvic pain, blockage of the ejaculatory system, radiation therapy to the pelvis, prostate cancer, or psychological issues. Antidepressants, spermicides, and contraceptive creams have also been implicated.

Treatment will match the cause, so could involve drugs against an infection, withdrawal of the suspect medication, or psychological counseling.

References:

1.        Delayed ejaculation (chapter six). Perelman MA. In: Principles and practice of sex therapy (fifth edition). Binik YM, Hall KSK (editors). New York, New York, US: Guilford Press, 2014.

2.        Delayed ejaculation. Holly Ridge, North Carolina, US: Sexual Medicine Society of North America. Information published online, accessed 25 November 2014.

3.        Premature ejaculation (chapter 3), Rowland DL, McMahon CG. Handbook of sexual and gender identity disorders,Rowland DL, Incrocci L. Hoboken, New Jersey, US: John Wiley & Sons, 2008.

4.        Premature ejaculation. Linthicum, Maryland, US: Urology Care Foundation, the American Urological Association. Information published online, accessed 25 November 2014.

5.        Ejaculatory disorders: pathophysiology and management. Bettocchi C, Verze P, Palumbo F, and others. Nature Clinical Practice Urology, 2008, volume 5, pages 93-103 (DOI:10.1038/ncpuro1016).

6.        Management of ejaculatory dysfunction. McMahon CG. Internal Medicine Journal, 2014, volume 44, issue 2, pages 124-131 (DOI: 10.1111/imj.12344).

7.        DSM-5 changes in diagnostic criteria of sexual dysfunctions. IsHak WW, Tobia G. Reproductive System & Sexual Disorders, 2013, volume 2, page 122 (DOI: 10.4172/2161-038X.1000122).

8.        Delayed ejaculation. London, UK: National Health Service, NHS Choices. Information published online, accessed 25 November 2014.

9.        Delayed ejaculation. A.D.A.M. Medical Encyclopedia. Bethesda, Maryland, US: US National Library of Medicine. Information published online, accessed 25 November 2014.

10.     Ejaculation and orgasm. In: The Merck Manual, edited by Robert S. Porter and others. Published online by Merck & Co., accessed 25 November 2014.

11.     Clinical characteristics and penile afferent neuronal function in patients with primary delayed ejaculation. Xia JD, Han YF, Pan F, and others. Andrology, 2013, volume 1, issue 5, pages 787-792 (DOI: 10.1111/j.2047-2927.2013.00119.x).

12.     Original research - ejaculation disorders: a multinational population survey of intravaginal ejaculation latency time. Waldinger MD, Quinn P, Dilleen M, and others. Abstract.

13.     Psychological interventions for delayed ejaculation/orgasm. Althof SE. Int J Impot Res, 2012, volume 24, issue 4, pages 131-136 (DOI: 10.1038/ijir.2012.2).

14.     Ejaculation disorders. New York City, New York, US: Weill Cornell Medical College, James Buchanan Brady Foundation Department of Urology. Information published online, accessed 25 November 2014.

15.     Anejaculation. Holly Ridge, North Carolina, US: Sexual Medicine Society of North America. Information published online, accessed 25 November 2014.

16.     Ejaculatory disorders (chapter 16). McMahon CG, Waldinger M, Rowland D, and others. In: Standard Practice in Sexual Medicine. Porst H and Buvat J (editors). Oxford, UK: Blackwell Publishing, 2006.

17.     What is painful ejaculation? Wormerveer, The Netherlands: International Society for Sexual Medicine. Information published online, accessed 25 November 2014.