Boston University Medical Campus

Please be advised there are two sections on this topic, one by Dr. Stanley Ducharme, a sex therapist, and one by Dr. Ricardo Munarriz, a sexual medicine physician.

Stanley Ducharme, Ph.D.

For men, erectile dysfunction and ejaculatory problems are the most common sexual difficulties. With the introduction of Viagra however, problems of erectile dysfunction are much less frequent and more easily treated. In contrast, ejaculatory problems continue to be commonplace among men and often create feelings of shame and embarrassment for those men who struggle with this difficulty.

When does an ejaculation problem become a disorder? This is a subjective question and is based on the level of distress that is experienced by the man or his partner. The time from initiating sexual activity to ejaculation varies from one individual to another. This time period is called the ejaculatory latency. What may be a problem for one man may be acceptable to another. Typically, ejaculatory disorders fall into two categories. These are: delayed ejaculation and early ejaculation. This column will explore some of the psychological factors and treatment options related to these two distinct male dysfunctions.

In the vast majority of cases, the most effective therapeutic approach for ejaculatory dysfunction is a combination of biologic and psychologic therapy. In this way, both the emotional and physical aspects of the problem can be addressed. From an emotional standpoint, it is important to understand the history and background of the individual. Issues such as depression, anxiety, past sexual experiences, psychological trauma and relationship history are important considerations that need to be discussed early in the evaluation.

Regardless of the psychological issues, a good medical or urologic work-up is always encouraged before embarking on a behavioral treatment program. In this manner, any medical considerations that contribute to the problem can to be understood from the onset. From a medical perspective, ejaculatory dysfunction is often considered to be a nerve related issue. In such cases, penile sensitivity may be evaluated using various instruments that produce vibration. In addition, a medical history is obtained paying particular attention to any previous neurologic injury or trauma to the penis. Other sexual dysfunctions such as low desire and erectile dysfunction may also accompany the ejaculatory problem and need to be addressed.

The psychological definition of delayed ejaculation refers to the inability to have an ejaculation during sexual intercourse. Interestingly enough, ejaculatory issues are rarely defined as a dysfunction if they occur only during masturbation. As a result, an important diagnostic question for sex therapists is the context in which the problem occurs. Does this difficulty occur with self-stimulation, with all partners or with specific partners? This question will ultimately be important as a treatment program is designed and implemented.

Problems of delayed ejaculation tend to be somewhat rare and not well understood by psychologists and sex therapists. In addition, they are not well understood by most medical doctors and urologists. It is not unusual for doctors to minimize the dysfunction and to dismiss it. For many men, finding the right professional, who has experience and realizes the seriousness of the problem may be one of the most difficult aspects in the treatment process.

In many cases, the man himself may tend to delay treatment or to minimize the distress of the situation. At other times, there is the hope that ejaculatory problems will disappear without proper treatment. Unfortunately however, problems such as delayed ejaculation seldom disappear without professional intervention. For many men, feelings of shame prevent them from seeking medical and professional help.

In spite of the lack of information regarding delayed ejaculation, the most successful approach, for sex therapists, is to engage both members of the couple into addressing the problem. Thus, ejaculatory dysfunction is always perceived as a couple’s issue. Resolving the problem is most successful when both partners can work together as a team toward a successful solution. If the man is in a relationship, he needs the support and understanding of his partner. This helps to insure a successful treatment. Otherwise, the partner’s frustration and distress may contribute to the continuation of the problem. Overcoming an ejaculation problem when under stress and pressure from a partner is extremely difficult for any man.

Ejaculatory problems can have a devastating affect on self-esteem. Men with ejaculation problems undoubtedly have feelings of inadequacy, feelings of failure and a negative view of themselves. They feel that they have little to offer in a relationship and to tend to avoid emotional and physical intimacy. Over time, partners become frustrated and communication becomes strained. Thus, resentments, anger and feelings of rejection often accompany an ejaculation problem. In couples where ejaculation is an issue, the partner often internalizes this dysfunction as their mistake; the partner feels responsible ultimately intensifying the man’s stress and performance anxiety.

Ejaculation problems may also contribute to a low libido and lack of interest in sexual activity. Without ejaculation, sex can become a source of frustration and devoid of satisfaction. As a result, sexual activity can be perceived as more work than pleasure. In some cases, the woman may not be interested in sexual intimacy because of her frustration and anger at the situation. Ultimately in such cases, couples agree to avoid sexual contact rather than face the emotional pain of another sexual failure.

For some men, there may be additional psychological issues that underlie an ejaculatory dysfunction. For example, there may be issues of performance anxiety related to infertility, fears of rejection or the desire to please a partner. Early psychological trauma can also be a significant factor. If sexual abuse of the man has occurred, these can have a direct correlation to the sexual dysfunction itself. Sex can serve as a trigger to bring back painful emotional feelings and memories from the past. Ignoring these important emotional issues can lead to difficulties resolving the problem or to a future re-occurrence of the sexual dysfunction.

Traditional behavioral sex therapy for delayed ejaculation is as follows: the man begins by masturbating, then starts intercourse when he is almost ready to ejaculate; the procedure continues with the man beginning intercourse earlier and earlier. The partner may assist the man to masturbate and maintains a supportive and encouraging attitude. Sensitivity may be improved with the use of androgens such as testosterone or by using a vibrator.

In July 2003, the World Health Organization recommended that the term “pre-mature ejaculation” be replaced by the more neutral phrase ” early ejaculation”. In contrast to delayed ejaculation, early ejaculation difficulties are much more common and frequently seen in sexual medicine clinics. The literature suggests that early ejaculation is the most common of any male sexual difficulties. It is certainly one of the most stressful.

By definition, early ejaculation is an ejaculation that occurs before it is desired. Typically, the ejaculation has become inevitable either during foreplay or in the first moments following penetration. In spite of his best efforts, the man experiences a sense of helplessness in controlling his ejaculation. A significant amount of distress from the man or his partner almost always accompanies an early ejaculation. The partner feels equally unsatisfied and frustrated.

Psychologists and sex therapists tend to view ejaculatory control as a skill that is mastered via masturbation during adolescence and early adulthood. As a result, most men ejaculate quickly in their early sexual years when they are young and inexperienced. With masturbation, the adolescent or young man learns various techniques that allow him to maintain a high level of arousal without ejaculating. As the young man becomes sexually active with a partner, these skills can then be transferred to his new sexual encounters. As the man becomes more sexually experienced, latency of ejaculation increases although not always to the satisfaction of the man and his partner.

In addition to early sexual experiences, family attitudes toward sexuality as well as cultural and religious beliefs all play a role in sexual development and ejaculatory control. For example, when a boy is young he may feel rushed or ashamed about masturbation; he may feel guilty because of religious or cultural values; he may feel conflicted regarding self-pleasuring. Such circumstances may provide the groundwork for future problems with sexual desire, erections or ejaculation. In other cases, these early messages may lead to areas of conflict regarding trust and intimate relationships.

Although less common, some men develop early ejaculatory problems later in life. After years of satisfying sexual experiences, these men suddenly find themselves struggling to maintain ejaculatory control. Sometimes, these problems develop with a new partner, after a divorce, during periods of stress or when dealing with infertility issues. At other times, there may be no clear precipitating events to the onset of a early ejaculation pattern. Essentially, treatment for these cases is similar to younger men but psychological issues are probably even more critical to address.

TREATMENT APPROACHES / CONCLUSIONS

As mentioned, the most effective approach is a combination of psychological assistance and medical intervention. In this way, the man can quickly achieve positive sexual experiences and gain a sense of confidence. Urologists and other medical doctors typically treat early ejaculation with a combination of medications and creams. Anti-depressant medications such as Paxil and Zoloft are often prescribed and are taken by the patient 2 hours prior to sexual activity. If this is not effective, the patient is further instructed to take the medication on a daily basis rather than before sexual activity. The dosages are usually adjusted as the patient progresses.

Viagra is also prescribed for many men with early ejaculation. Viagra helps to maintain the erection after ejaculation and reduces the refractory time before a second erection can be obtained. These medications may be combined with various creams aimed at reducing sensitivity. After successful intercourse and renewed confidence, men begin to learn the signs of pending ejaculation and ultimately learn to gain increased control.

Sex therapy for early ejaculation includes learning a behavioral program designed to improve self-control. In a therapeutic program, the first step is usually education. It is important that the couple have an understanding of the problem, it’s origins, the prognosis and the need to work together toward a satisfying solution. The partner must also understand that the man is not being selfish and that ejaculatory control is unsatisfying for him as well. The most common behavioral approach taught by sex therapists is either the squeeze technique or an approach described as “start and stop”. These techniques, originally developed by Masters and Johnson, require patience, practice and a commitment to solving the problem. Specific instructions are adapted to the individual and unique characteristics of each patient. With the instructions from the therapist, the patient begins a series of daily masturbatory exercises designed to help him understand his ejaculation pattern and gain control.

In summary, under the right circumstances and with ongoing motivation, ejaculation disorders can be overcome. The most important lesson to be learned by men and their partners is that there is hope and there are therapies that can help resolve the distress of ejaculatory difficulties. Often the first step, deciding to seek treatment and finding the proper professional is the most difficult.

Ejaculation Problems: Too Fast, Too Slow or Not at All

Ricardo Munarriz, M.D.

The most common sexual dysfunction for men is ejaculatory disorder. These include rapid or premature ejaculation (75%), delayed (8%) often nerve or drug induced, no ejaculation, and retrograde ejaculation from incompetence of bladder neck (ejaculate goes back into bladder instead of out) which occurs after a TURP.

The DSMIV describes premature ejaculation as persistent or recurrent ejaculation within minutes. Statistics list 4 to 39% of men have premature ejaculation. Treatment is usually with SSRI’s and Sildenafil (Viagra™). The disorder may be lifelong or acquired, global or situational, with different treatments. It can be biogenic, psychogenic or mixed. Discussion included the criteria for clinical trials. Objective assessment is made by number of thrusts and intra-vaginal latency time, but there is no information regarding a normal range of number of thrusts, and the average intercourse lasts 4-7 minutes according to current literature. The classic definition of rapid ejaculation is if the man ejaculates within 1 minute of penetration. It is theorized that the central regulation is by dopamine and penile hypersensitivity, so treatment may be with Sildenafil and local anesthetic. If you have premature ejaculation there is a 91 % chance that a first degree relative (father, brother, son) will also have it. SSRI’s which are used for depression are a first line treatment as well. They may be used before intercourse or taken every night. This treatment works better for people whose rapid ejaculation is acquired. Since Sildenafil is more effective than SSRI’s, a combination of an anti-depressant, local anesthetic and Sildenafil is effective in 97% of the time. The anti-depressant with sildenafil is signficantly better than the SSRI alone. Although this is currently the preferred therapy, medical insurance typically covers 30 pills for SSRI’s and only 4 sildenafil tablets per month. If that doesn’t work a local anesthetic like Emla cream (with a condom to protect the partner) should be added to the regimen. If that still is not effective the patient make you intracavernosal injection. Fast acting SSRI’s specifically for rapid ejaculation are currently in development.

Delayed ejaculation carries with it issues of inability to achieve orgasm and infertility. Anti-depressants or agents which act centrally such as Valium, anti-hypertensives and alchohol abuse all can affect this. First it is important to evaluate if this is a psychological problem, but a physical assessment must be made as well. A common cause is pudendal neuropathy, caused by a crush to the perineum such as from bike riding with a narrow saddle. If the delayed ejaculation is situational is is probably psychologic; if it is generalized the problem is probably biologic. Buproprion may be used but it is not all that effective. The patient must be checked to see if there are reversible causes before being given medication. There is research still needed in this area.