Delayed Ejaculation

Delayed ejaculation is marked delay in ejaculation, infrequent ejaculation, or inability to ejaculate despite adequate sexual stimulation and desire, for at least 6 months, causing personal distress. Anejaculation is the complete absence of antegrade or retrograde ejaculation. Anorgasmia is absent orgasm.

• Prevalence about 1 to 4 percent of men, rises with age.
• Causes:
  • Psychological: performance anxiety, relationship conflict, trauma, religious or cultural restriction, idiosyncratic masturbation (excessive pressure or speed not reproducible during partnered sex).
  • Medications: SSRIs and SNRIs (paroxetine, sertraline), tricyclic antidepressants, antipsychotics, alpha blockers (tamsulosin, silodosin), 5-alpha reductase inhibitors, opioids, benzodiazepines, antihypertensives (methyldopa, guanethidine, thiazides), alcohol.
  • Endocrine: hypogonadism, hypothyroidism, hyperprolactinaemia, diabetes mellitus.
  • Neurological: diabetic autonomic neuropathy, multiple sclerosis, spinal cord injury, pelvic or retroperitoneal surgery (lymph node dissection, prostatectomy, colorectal surgery) injuring sympathetic nerves, pudendal nerve injury, Parkinson disease.
  • Anatomical: prior genital surgery, circumcision with reduced sensitivity, congenital absence of seminal vesicles or vas, ejaculatory duct obstruction, bladder neck surgery (retrograde ejaculation).
  • Age related decline in penile sensitivity.
• Delayed ejaculation can cause infertility, sexual avoidance and relationship strain.

• Prolonged stimulation (often over 20 to 30 minutes) required to reach orgasm or inability to do so, often with fatigue, penile discomfort and partner discomfort. Distinguish lifelong from acquired and situational (only partnered sex) from generalised.
• Ask about nocturnal emissions, masturbation technique, libido, erections, post-ejaculation urine appearance (cloudy suggests retrograde ejaculation), urinary symptoms, diabetic complications, medications, surgery, injury, mental health, relationship and sexual history.
• Examination: blood pressure, BMI, secondary sexual characteristics, testicular volume and consistency, penile sensation (vibration sense, bulbocavernosus reflex), prostate, thyroid, peripheral neuropathy signs, genital anatomy.
• Red flags: new onset after pelvic surgery or trauma, back pain or lower limb neurology (cord compression), visible haematuria, loss of libido with visual field loss or headache (pituitary adenoma), testicular mass, marked weight loss.

• Clinical from history and examination.
• Bloods: morning total testosterone (repeat if low) with SHBG, LH, FSH; prolactin; TSH; HbA1c or fasting glucose; consider PSA after counselling.
• Post-ejaculation urinalysis: sperm in urine confirms retrograde ejaculation.
• Semen analysis if fertility is a concern.
• Neurological assessment (biothesiometry, bulbocavernosus reflex latency) and MRI pituitary or spine only if indicated.
• Differential: retrograde ejaculation, hypogonadism, drug effect, anorgasmia.

• Counselling and psychosexual therapy (sensate focus; graded stimulation; stopping reliance on high intensity masturbation; vibratory stimulation at home). Involve the partner.
• Review and adjust medications: reduce the dose or switch SSRI (for example to bupropion 150 mg daily or mirtazapine 15 to 30 mg at night, under the prescriber's advice); alpha blocker alternatives; avoid abrupt stopping of antidepressants and antipsychotics.
• Treat the cause: testosterone replacement if confirmed hypogonadism (testosterone undecanoate 1000 mg intramuscularly at weeks 0, 6 and then every 10 to 14 weeks, or testosterone gel 50 mg daily; monitor haematocrit, PSA, lipids; avoid if fertility desired because it suppresses spermatogenesis); levothyroxine for hypothyroidism; cabergoline for hyperprolactinaemia (0.25 mg twice weekly increased to 0.5 mg twice weekly according to prolactin; monitor for nausea, postural hypotension, impulse control and valvulopathy at high doses); optimise glycaemic control.
• Off label pharmacotherapy (limited evidence, specialist initiation): cabergoline 0.5 mg orally twice weekly for several weeks; buspirone 10 to 20 mg twice daily; amantadine 100 mg daily; bupropion 150 mg daily; yohimbine is not recommended.
• Retrograde ejaculation: pseudoephedrine 60 mg orally 1 to 2 hours before intercourse (alternatively imipramine 25 mg daily or midodrine 5 mg 1 hour before; monitor blood pressure); sperm retrieval from post-ejaculate urine for fertility.
• Anejaculation with infertility: penile vibratory stimulation, electroejaculation, or surgical sperm retrieval with assisted reproduction.
• Follow up at 6 to 8 weeks; refer for failure of psychosexual and drug measures or when fertility is desired.