The previous blog discussed my response to a urology colleague who asked about the cause of greater numbers of men complaining about delayed ejaculation (DE) in his practice. This blog describes my suggestions to him for diagnosing the problem, how most of his colleagues currently treat DE, and an alternative approach he could provide to improve that condition for his own patients.
Men with DE find it difficult or impossible to ejaculate and/or experience orgasm. DE is a failure to ejaculate during masturbation and/or partner manual, oral, coital, or anal stimulation. Diagnosis of DE requires distress about the symptom(s), adequate sexual stimulation, and a conscious desire to achieve orgasm. Almost all these men have no difficulty attaining or maintaining erections, and most of these men are able to ejaculate with masturbation. The most common pattern reported to doctors is a man who is unable and/or finds it very difficult to ejaculate in the presence of a partner (especially during intercourse). Yet, he is able to orgasm and ejaculate during solo masturbation. Because of that anomaly (atypical situation), most men who seek assistance with DE, do so with a partner related complaint.
How do most doctors assess DE?
It is frequently useful for a physician (usually a urologist) to conduct a physical examination and medical history to help identify any “Physical” factors contributing to DE. Many men who suffer from DE will want such a consultation by a urologist to ensure nothing is “physically wrong” with them. While the answer to that question is typically “no, you are fine,’ that does not mean it is “all in your head” as some folks might erroneously think… or a doctor might even mistakenly state! What can an exam by a physician tell you that is very important though is the following.
A physician will know that any procedure or disease that disrupts the nervous systems path to the genitals (spinal cord injury, multiple sclerosis, pelvic-region surgery, severe diabetes, alcoholism, etc. -- all have the potential to interfere with ejaculation and orgasm. Decreased sensation of the penis (often associated with aging) may also be a factor, and such changes in sensitivity to touch, vibration and temperature can now be accurately measured. In particular, a urologist will look for reversible urethral, prostatic, epididymal, and testicular infections, as well as hormonal (testosterone, etc.) contributory factors. A number of drugs may cause DE. Common culprits include drugs for high blood pressure, antidepressants, antipsychotic drugs, and some drugs that are used to treat prostate growth or baldness. It is also important to know that many medications used to treat prostate symptoms may produce DE-like symptoms. That situation, as well as men who experience difficulty ejaculating when using a condom during sex, are not necessarily diagnosed with DE, but the symptoms and bother may be similar.
Additionally, DE is one of many ejaculation problems that can be confused with each other, and/or can occur together. The doctor will differentiate anejaculation (no cum), painful ejaculation, and retrograde ejaculation (during the climax, the semen goes in the wrong direction back into the bladder), decreased volume/force/sensation of ejaculation, and the very rare post orgasmic illness syndrome. DE is distinct from erectile dysfunction (ED), the condition where a man is unable to attain or maintain an erection rigid enough for sexual activity). DE is also different from the normal refractory period, the length of time after an ejaculation during which men are physically incapable of having a repeat ejaculation. DE is also different from anorgasmia (inability to experience orgasm or sexual climax).
What might your doctor suggest?
Many physicians, for better and sometimes for worse, will begin treatment by ﬁrst prescribing pharmaceuticals, lubricants, and devices (e.g. vibrators). Unfortunately, there are no FDA approved treatment for DE and the drugs that doctors typically use have only anecdotal (here and there reports) of success. The most commonly used medications that doctors use that have only slight benefits are Cabergoline, Bupropion, Oxytocin, and Cyproheptadine. Additionally, testosterone (T) is often considered the first-line treatment, but unless T levels are meaningfully below normal levels this has not proved to be helpful. Other “antidotes” such as yohimbine, have been explored but that research was typically confined to animal experiments. There is some evidence that the antidepressant Wellbutrin will decrease orgasmic latency for patients experiencing antidepressant-induced DE, but that works best when the current antidepressant is reduced, and Wellbutrin is used as a supplement. Despite such poor results, most physicians continue prescribing medication as the most common treatment approach, and only refer to mental health professionals for sex therapy when the drugs fail to help.
How do some sex therapists currently assess DE?
The most important tool available to any healthcare professional for diagnosing any sexual disorder is a “sex status” exam. A sex status exam is not a lab test or a questionnaire. It is a detailed focused diagnostic interview that examines all aspects of current sexual functioning in combination with potentially relevant historical experiences. A description of current sexual attitudes and experiences will help rule out physical causes and help identify antecedents (early causes) and/or maintainers of any sexual problem including DE. Often a sexual history can help rule out the probability of anatomical, hormonal, neurological abnormalities as well as pharmaceutical causes, by juxtaposing circumstances where ejaculation was/is successful with those where it is not. History taking will identify the effects of a substance (e.g. drugs of abuse) or by relationship distress, partner violence, or other significant stressors.” An important question your therapist might ask you is to describe your most recent experience. If your doctor does not ask you to do so in detail, ask yourself about it in advance about your session. That is a great question to consider in order to expedite the diagnostic process. Many people often fail to communicate their preferences to either their partners or their doctors because of embarrassment. Yet, answering detailed questions about sexual behavior and attitudes unveils the causes of dysfunction and offers guidance to solutions. Some of the most important and often neglected sources of information about the cause of an inability to ejaculate with one’s partner is obtained from a very detailed masturbation history or status.
The difference between what a man experiences in coupled sex, versus self-stimulation, must be explored. Idiosyncratic masturbatory patterns are a frequent hidden cause of DE as noted in the previous blog. Questions such as the following among others should be asked and answered: 1) “What is the frequency of your masturbation?” 2) “How do you masturbate?” 3) “In what way does the stimulation you provide yourself, differ from your partner’s stimulation style, in terms of speed, pressure, etc.?” 4) “Have you communicated your preference to your partner and if so, what was their response?” 5) “How do your thoughts/feelings during sex with a partner differ from those during solo masturbation?:
Attention must be paid to the degree of immersion and focus on arousing thoughts and sensations during masturbation, compared with partnered sexual activity. This often requires exploration of sexual fantasies, as well as examining the use of erotica and pornography. Examine the proportion of sexy versus anti-erotic intrusive thoughts e.g. “It’s taking too long.” The difference between the reality of sex with a partner and his preferred sexual fantasy (whether or not unconventional) used during masturbation is potentially an important cause of DE. That difference takes many forms, such as partner attractiveness, body type, sexual orientation, and the specific sex activity performed. If orgasm was possible previously, life circumstances that relate to orgasmic cessation should be explored, including “street” and prescription drugs, illness, and life stressors. Research has that shown all the above information is critical to a successful resolution of DE.
In summary, the therapist is likely to ask questions about desire, the frequency of sex, as well as the effects of drugs and alcohol. The goal is to identify all the relevant immediately acting factors that are associated with sexual experience and how those factors impact desire, arousal, and orgasm. “Think 4Fs” is a good mnemonic tool for remembering what must be assessed: friction, frequency, fantasy, and feelings. Fantasy refers to all erotic thoughts and feelings that are associated with a given sexual experience. High-frequency negative thoughts and associated negative emotions (feelings) can neutralize or override erotic cognitions (fantasy) and subsequently delay, ameliorate, or completely inhibit sexual response; inadequate partner stimulation (friction) may result in an unsatisfying experience. Most importantly, are any of those “F’s” different when a man is with his partner as opposed to flying solo? The answer(s) are important clues as to what needs to change in order for him to ejaculate with his partner.
How does this sex therapist treat DE?
Sex therapists have reported good success rates using cognitive-behavioral techniques. Often the single most important suggestion that a sex therapist can make is essentially common sense: the man must temporarily suspend masturbatory activity and limit orgasmic release to his/their desired goal activity, e.g. such as orgasm during penetrative sexual encounters with their partner. Research has definitely shown that temporarily refraining from ejaculating alone usually causes a man’s need/desire for a “release” to increase, as his stimulation requirements to reach orgasm or threshold for ejaculation decreases, thus making it easier to ejaculate during partnered sex. While this is usually not sufficient to solve the problem on its own, the probability for success during partnered sex is increased greatly. The therapist begins with what the man can currently experience easily and suggests a slight alteration. That is called “shaping” a response. For instance, if a man can ejaculate with masturbation in the presence of the partner, then the man must coach his partner so that the partner learns how to duplicate the speed, rhythm, and type of touch that the man himself uses. This continues until he can ejaculate with partnered manual and/or oral sex with greater ease. For men who already can accomplish that but cannot ejaculate during intercourse; then ejaculating during intercourse must be the only outlet allowed until it begins to happen more easily. Reducing or discontinuing both self and partnered manual (or partner oral) stimulation to ejaculation is often difficult, especially if it was the only sexual activity that “worked.” Men often need support from both their therapist and partner to adhere to this restriction. In my experience, this can take anywhere from a few attempts to a number of months. Sometimes, the man will re-experience the “wet dreams” of youth as a release seems needed by his body. It is often necessary to remind repeatedly that the need for such restraint is only temporary and not a permanent injunction against masturbation.
Nonetheless, sometimes, this masturbation hiatus must be negotiated, and a compromise reached. When a patient refuses to stop solo self-stimulation, I typically negotiate a reduction in masturbation frequency with a minimum commitment of no ejaculation within 72 hours (based on experience) of their next partnered sexual encounter. Men who refuse to cease masturbating are guided to at least alter the style in which they masturbate (“switch hands”). Instead of his familiar pattern, he is instructed to try and approximate the stimulation likely to be experienced from his partner. In addition to suspending non-partnered ejaculations, men should use fantasy and bodily movements during intercourse, which approximate the thoughts and sensations experienced in masturbation. Men who report difficulty reaching a climax when using a condom may consider using condoms during masturbation as a “dress rehearsal” for “safe sex.” For men whose sexual fantasies do not align with their reality, guided modification/change of fantasy may be useful to align sexual preference with experience. These efforts must, of course, take into account that for many men sexual preferences are relatively fixed. While the use of vibrators or other sexual enhancement devices is usually not necessary, it can be particularly important in cases of DE related to radical pelvic surgery such as prostatectomy.
What the partners of men with DE can do to help?
Partners should ask their men about sexual preferences and desires. Partners may consider adapting their sexual practices accordingly, however, that should only be done within the bounds of what is comfortable and morally acceptable to the partner. A common complaint from partners about sex therapy as described above is that the man is essentially masturbating with his partner’s body as opposed to engaging in connected lovemaking. That is a legitimate concern that must be addressed. Indeed, some men are more comfortable being emotionally disconnected from their partners. The sex therapist must help the partner become comfortable with the idea of temporarily postponing their desired intimacy level. Once the man is functional, the sex therapist can encourage a man/couple towards greater intimacy if that is what is desired. Having open and honest discussions about this is an important part of any sexual relationship. Sometimes both partners are disconnected from each other, but otherwise in a valued and stable relationship. For these folks, it is important for the therapist to support the couple’s preference and not try to manipulate them into a more intimate relationship that they themselves prefer.
How successful is this type of DE treatment?
Most urologists find treating DE to be difficult and challenging. However, for many men and couples, it is often possible to successfully overcome DE especially with the guidance of a well-trained sex therapist. For a few, however, the best that can be accomplished is to help them modify their sexual practices to accommodate the man’s difficulty with achieving ejaculation during sexual activity. For men with very severe DE, (especially when caused by medical problems or medication side effects), this may even mean engaging in partnered sex and “finishing off” with masturbation or other non-penetrative sexual activity.
Failure can occur in any therapeutic endeavor. A meaningful disparity in partner’s sexual scripts (which are not integrated into either fantasy or reality within partnered sex) often reﬂects more severe problems (relational or otherwise). Such situations tend to result in “treatment rebellion”, and a much longer treatment is required where sex therapy is supplemented with more traditional individual and couples’ therapy. For one couple in my practice, numerous marital problems needed to be resolved before he was willing to stop masturbating and be truly motivated to experience ejaculation during intercourse with his wife.
In a few cases penile/vaginal orgasms are obtained, but no longer remain the preferred choice. For most men and their partners, his orgasm experienced during intercourse is presumed to be the most satisfying for them both for a variety of psychosocial-cultural reasons. Despite being the patient/partner’s initial preference, ejaculation during intercourse may, in reality, be less pleasurable and less intense than masturbatory orgasms for some men. Be reminded that this is similar to what is now societally presumed to be normal for many women. In such situations, the choice of post-treatment orgasmic preference should remain the decision of the man/couple. Sometimes these men will need a therapist’s support to express their preference for non-intercourse orgasms, especially when their coital orgasms were less satisfactory and only obtained by painstaking effort. But that is the exception and not the rule!
In summary, high-frequency idiosyncratic masturbation, combined with fantasy–partner disparity, often predispose men to experience problems with arousal and ejaculation. The MAP Education & Research Foundation’s Sexual Tipping Point Model provides a useful framework for helping men (and their partners) understand the cause(s) of DE and how treatment will proceed. A sex therapist should be able to explain how the mental and physical erotic stimulation a man is receiving is insufficient for him to ejaculate in the manner he prefers, and how this can be changed to achieve the desired result. Of course, successful treatment will depend on a man’s willingness to follow therapeutic recommendations, which will be influenced by the extent of organic/medical complications, relational issues, and potentially deeper patient/partner psychodynamic problems. When a safe and effective drug becomes available, a shift toward combining drug treatment and sex therapy when treating DE will occur, which has already happened for the treatment of ED. But as of right now, sex therapy is the preferred treatment for DE.