Delayed Ejaculation

Male orgasm is defined as a subjective, perceptual-cognitive event of peak sexual pleasure that in normal conditions coincides with the moment of ejaculation. ^[4]  Delayed ejaculation is typically a self-reported diagnosis; there is no firm consensus on what constitutes a reasonable time frame for reaching orgasm.

The presence of a normal sexual excitement phase is a prerequisite for male orgasmic disorder (MOD). In other words, if the absence of orgasm follows a decreased desire for sexual activity, an aversion to genital sexual contact, or a decreased lubrication-swelling response, diagnoses such as hypoactive sexual desire disorder, sexual aversion disorder, or male erectile disorder might be more appropriate, even if they all have a final common outcome (ie, anorgasmia, defined as failure to experience an orgasm).

Patients with MOD can achieve firm erections and have normal sexual intercourse with penetration. Some patients reporting MOD with intercourse can achieve orgasm through manual or oral stimulation or at least report orgasm through nocturnal emissions (“wet dreams”). A report of generalized, lifelong MOD with no orgasm at all (across an array of stimulative techniques) suggests an organic etiology.

Urologic classifications are usually explicit in differentiating between failure to ejaculate and absence of orgasm.

Diagnostic criteria (DSM-5-TR)

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Reviision (DSM-5-TR) classifies delayed ejaculation as belonging to a group of sexual dysfunction disorders typically characterized by a clinically significant inability to respond sexually or to experience sexual pleasure. ^[5]

Sexual functioning involves a complex interaction among biologic, sociocultural, and psychological factors, and the complexity of this interaction makes it difficult to ascertain the clinical etiology of sexual dysfunction. Before any diagnosis of sexual dysfunction is made, problems that are explained by a nonsexual mental disorder or other stressors must first be addressed. Thus, in addition to the criteria for delayed ejaculation, the following must be considered:

• Partner factors (eg, partner sexual problems or health issues)

• Relationship factors (eg, communication problems, differing levels of desire for sexual activity, or partner violence)

• Individual vulnerability factors (eg, history of sexual or emotional abuse, existing psychiatric conditions such as depression, or stressors such as job loss)

• Cultural or religious factors (eg, inhibitions or conflicted attitudes regarding sexuality)

• Medical factors (eg, an existing medical condition or the effects of drugs or medications)

The specific DSM-5 criteria for delayed ejaculation are as follows:

• In almost all or all (75-100%) sexual activity, the experience of either marked delay in ejaculation or marked infrequency or absence of ejaculation

• The symptoms above have persisted for approximately 6 months

• The symptoms above cause significant distress to the individual

• The dysfunction cannot be better explained by nonsexual mental disorder, a medical condition, the effects of a drug or medication, or severe relationship distress or other significant stressors

Delayed ejaculation is qualified as mild, moderate or severe on the basis of the level of distress the patient exhibits over the symptoms. The duration of the dysfunction is specified as follows:

• Lifelong (present since first sexual experience)

• Acquired (developing after a period of relative normal sexual functioning)

In addition, the context in which the dysfunction occurs is specified as follows:

• Generalized (not limited to certain types of stimulation, situations, or partners)

• Situational (limited to specific types of stimulation, situations, or partners)

The succession of erection, emission, ejaculation, and orgasm creates the impression that these events might have a common physiologic substrate. In reality, they are separate events. This separateness is clearly illustrated by the typical patient with male orgasmic disorder (MOD), who complains of sustaining hard erections without being able to ejaculate, or by the typical patient with erectile dysfunction, who complains of ejaculating through a flaccid penis.

Emission and ejaculation usually require external genital stimulation (nocturnal emission being the notable exception). Afferent impulses travel through the dorsal nerve of the penis, which is the deepest division of the pudendal nerves, to the S2-S4 dorsal root ganglia. Parasympathetic innervation to the penis originates from the intermediolateral columns of the S2-S4 sacral spinal segments. Sympathetic fibers from the T-11 to L-2 spinal segments travel through via the hypogastric plexus. The efferent impulses activate secretions and transport sperm from the distal epididymis, vasa deferentia, seminal vesicles, and prostate to the prostatic urethra. Closure of the internal urethral sphincter and concomitant relaxation of the external sphincter direct semen into the bulbous urethra, resulting in emission.

The somatomotor efferent of the pudendal nerve then produces subsequent rhythmic contractions of the bulbocavernous muscle, forcing the semen through a pressurized passage (the narrowed urethral lumen compressed by the engorged corpora cavernosa) and yielding 2–5 mL of ejaculate. Because this action is involuntary, integrated autonomic and somatic actions are required for completion.

The cerebral network modulating and controlling the final common output from all ejaculatory stimuli includes the posteromedial bed nucleus of the stria terminalis, the posterodorsal medial amygdaloid nucleus, the posterodorsal preoptic nucleus, and the parvicellular part of the subparafascicular thalamus. ^[6]

It has been suggested that the ejaculatory reflex is primarily regulated by the central serotonergic and dopaminergic systems, ^[7] with other neurotransmitters (eg, acetylcholine, adrenaline, neuropeptides, oxytocin, gamma-aminobutyric acid [GABA], and nitric oxide) playing important roles. ^[8]

Experimental evidence indicates that serotonin (5-HT), throughout brain descending pathways, exerts an inhibitory role on ejaculation. To date, 3 serotonin receptor subtypes (5-HT1A, 5-HT1B, and 5-HT2C) have been postulated to mediate the modulating activity of serotonin on ejaculation. Pharmacologic manipulation of the serotonergic system has been performed in rats, with the selective serotonin reuptake inhibitors (SSRIs) exhibiting the greatest efficacy in delaying ejaculation. ^[9]

It has been suggested that the presynaptic 5-HT1A somatodendritic autoreceptors, located in the mesencephalic and medullary raphe nuclei and responsible for decreasing 5-HT release into the synapse, decrease ejaculatory latency. In contrast, the postsynaptic 5-HT1B and 5-HT2C receptors have been shown to prolong ejaculatory latency. ^[9]

In view of the relation between the serotonergic receptors and their inhibitory and excitatory effects, it is likely that altered levels of 5-HT or altered 5-HT receptor sensitivity in the ejaculatory modulating centers of the central nervous system (CNS) contribute to the pathophysiologic mechanism behind ejaculatory disorders. Thus, 5-HT might suppress ejaculation by interrupting the action of oxytocin, which normally accompanies sexual behavior. ^[10]

Dopamine plays an important role in the male sexual response. ^[11] In animal models, dopamine levels in the medial preoptic area of the hypothalamus were shown to increase progressively during excitation and intercourse, ^[7] GABA-receptor antagonists were found to inhibit sexual behavior, and muscular contractions during ejaculation appeared to be mediated by oxytocin. ^[8]

Despite significant advances, the specific role and importance of each individual neurotransmitter in the multifactorial and complex ejaculatory reflex remain to be clarified. ^[12] Research into these subjects is ongoing.

The mechanism of orgasm is still the least well understood part of the sexual process. It probably involves central (cerebral) integration and response to sexual stimulation. Emission, ejaculation, and orgasm are typically associated with several other concomitant nongenital responses, which may include involuntary rhythmic contractions of the anal sphincter, hyperventilation, tachycardia, and elevation of blood pressure.

Transient sympathoadrenal activation during sexual activity, reflected by increases in epinephrine and norepinephrine plasma levels, together with increased cardiovascular activity, has been reported to be associated with orgasm in males.

The association of vasopressin, cortisol, luteinizing hormone (LH), follicle-stimulating hormone (FSH), growth hormone (GH), beta-endorphin, and testosterone with male orgasm remains unclear. Whereas both oxytocin and prolactin levels have been reported to peak immediately after orgasm, plasma prolactin levels seem to represent a more sustained and reliable endocrine marker of orgasm in males. ^{[13, 14]}

Hyperprolactinemia has been associated with both decreased sexual desire and a decreased ability to reach orgasm in males.

Reportedly, the intensity of orgasm correlates with the ejaculatory volume; thus, declines in ejaculatory volume can result in reduced sexual pleasure. Because ejaculate volume is androgen-dependent, it tends to decrease with age, and this decrease may result in a blunted orgasm experience in the elderly.

In rare subjects, orgasm may alter central neurotransmission, provoking a postejaculatory pain syndrome ^[15] or the postorgasmic illness syndrome (POIS) characterized by severe fatigue, intense warmth, and a flulike state with generalized myalgia. ^[16]

The increased frequency of delayed ejaculation in men older than 50 years may be associated with age-related loss of fast-conducting peripheral sensory nerves, as well as with age-related reduction in the secretion of sex steroids.

United States statistics

Epidemiologic research into orgasmic disorders must contend with the challenge of poor collateral confirmatory evidence based on subjective patient reports, the value of which is further limited by the fact that such disorders are highly sensitive topics in most cultures. Accordingly, it is not surprising that despite their apparent prevalence, sexual disorders in general and orgasmic disorders in particular typically have not been included in large-scale epidemiologic studies such as the Epidemiologic Catchment Area (ECA) study.

Because of the lack of a precise definition of the condition, the true prevalence of delayed ejaculation is not well defined. ^[1] This syndrome is considered to be the least common male sexual complaint, with prevalence raning from 1% (lifelong DE) to 4% (acquired DE). ^[1] However, more recent studies reported higher rates of DE, raising the question of old reports probably underestimating the rates of DE. ^[17]

Epidemiologic research in this field continues to be hindered by issues such as the following:

• Lack of well-controlled studies

• Wide variability of diagnostic criteria and definitions

• Lack of objective markers for the diagnostic criteria used for male orgasmic disorder (MOD)

• Lack of incidence data

Consequently, the available epidemiologic evidence is, at best, informative. Further epidemiologic research is needed to derive an accurate estimate of the incidence of orgasmic disorder in men across age periods, races, cultures, relationship status, and countries.

International statistics

The Global Study of Sexual Attitudes and Behaviors (GSSAB), which investigated attitudes, behaviors, beliefs, and satisfaction among 27,500 men and women aged 40–80 years, reported 13.2% of men as “not reaching orgasm.” It should be noted that this definition includes MOD as well as delayed ejaculation and anejaculation. ^[18]

Age-, sex-, and race-related demographics

The incidence of delayed ejaculation begins to increase after the age of 50 years. Compared with men younger than 59 years, men in their 80s report twice as much difficulty in ejaculating.

In a review of 52 studies, the estimated rate of MOD among gay men was 38% (notably higher than from other samples), leading the authors to speculate that this difference might reflect a greater recognition of the threat of infection with HIV. ^[19]

Reports of delayed ejaculation vary across countries and cultures. In general, this complaint is more commonly reported by men in Asian populations than by men living in the United States, Australia, or Europe. Such variation may be due to cultural or genetic differences.