Ejaculation Problems–Too Fast, Too Slow or Not at All: What to Know

Woman and man in bed

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 the 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 significantly 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 alcohol 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 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.
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