Ejaculation problems

What is ejaculation?

Ejaculation is the release of semen from the penis at orgasm (sexual climax). When a man is sexually stimulated, the brain sends signals to the genital area through nerves in the spinal cord to make the pelvic muscles contract.

At orgasm, waves of muscle contractions transport the sperm, with a small amount of fluid, from the testes through to the vas deferens. The seminal vesicles and prostate contribute extra fluid to protect the sperm.

This mixture of sperm and fluid (semen) travels along the urethra to the tip of the penis where it is ejaculated (released).

What are ejaculation problems?

Men can experience different kinds of ejaculation problems, including:

  • premature ejaculation
  • retrograde ejaculation
  • delayed ejaculation (or no ejaculation)
  • painful ejaculation.

How common are ejaculation problems?

Premature ejaculation is the most common male sexual problem and affects men of all ages. Premature ejaculation happens when a man is unable to control the timing of ejaculation, and ejaculates before he and/or his partner feels ready for this to happen, and this causes distress.

More details about premature ejaculation can be found in a separate Andrology Australia fact sheet.

The other ejaculation problems are less common than premature ejaculation but can also cause distress for the man and his partner.

What causes ejaculation problems?

Ejaculation problems can have a variety of causes, both physical and psychological. Physical causes include some illnesses such as diabetes, some types of surgery or trauma, some types of inflammation or infection, and certain medicines. Psychological causes include stress, anxiety (such as anxiety about ‘sexual performance’), relationship difficulties and depression.

For each type of ejaculation problem and for each individual man there may be one or more causes of an ejaculation problem.

What is premature ejaculation?

Premature ejaculation happens when a man is unable to control the timing of ejaculation, and ejaculates before he and/or his partner feels ready for this to happen, and this causes distress.

How soon is too soon when a man prematurely ejaculates?

For a heterosexual man, a commonly used definition of premature ejaculation is ejaculating within about one minute of his penis entering the woman’s vagina. However, there is no fixed time for ‘too soon.’ Premature ejaculation is a loss of control over ejaculation, and the distress it can cause to one or both partners, not just the time it takes a man to ejaculate.

How common is premature ejaculation?

Premature ejaculation is the most common male sexual problem and affects men of all ages.

Premature ejaculation is more common in younger men. This is because ejaculation generally takes longer as men get older and younger men may be less sexually experienced or feel less secure with the situation in which they are having sex.

Are there different types of premature ejaculation?

There are two types of premature ejaculation:

  • lifelong, sometimes referred to as primary
  • acquired, sometimes referred to as secondary

Lifelong premature ejaculation is when a man has not had control of ejaculation from the time of his first sexual experience. If left untreated, the premature ejaculation will continue for the rest of his life.

Acquired premature ejaculation is usually when there has been a period of normal functioning before the premature ejaculation began.

Acquired premature ejaculation is often linked to psychological (especially relationship) issues or other erectile problems such as erectile dysfunction.

What causes premature ejaculation?

The cause of premature ejaculation depends on whether the premature ejaculation is lifelong or acquired.

Lifelong premature ejaculation can be caused by a chemical imbalance in important brain centres that lowers the threshold for ejaculation. As these men need less stimulation, ejaculation can happen sooner than desired. Psychological problems, including performance anxiety, may be secondary to lifelong premature ejaculation rather than being the primary cause.

Acquired premature ejaculation is often caused by performance anxiety. The anxiety can be about sexual performance, fear of being caught in a sexual act or anxiety related to a specific situation, such as a new relationship. Some religious beliefs may also make a man feel anxious about having sex.

Acquired premature ejaculation can also be caused by problems such as erectile dysfunction. This may be because of the need for intense stimulation to get and maintain an erection or from anxiety about the erection problem.

How is premature ejaculation treated?

Treatment for premature ejaculation is usually based on the man’s relationship status and the cause of the condition (whether it is lifelong or acquired).

There are several treatments available for premature ejaculation including sex therapy, behavioural techniques, gels to reduce penile sensation, oral medicines and erectile dysfunction treatments (if erectile dysfunction is also a problem).

Your doctor may refer you to a specialist, such as a sex therapist, a urologist or an endocrinologist.

What is sex therapy?

Counselling with an experienced sex therapist may be very helpful in treating anxiety in men with either lifelong or acquired premature ejaculation. Counselling can help to identify any underlying sexual or relationship issues with the opportunity for open discussion.

What are behavioural techniques?

Semans’ “stop-start” technique involves the man telling his partner to stop stimulation when he feels he is close to ejaculation. When the feeling has passed, stimulation can be started again. These steps of stopping and starting can be repeated as needed.

Masters and Johnson’s “squeeze” technique involves squeezing the end of the penis for several seconds just before ejaculation, to lessen the urge to ejaculate. This is repeated until the man and his partner are ready for ejaculation to happen. This technique can help teach a man to control ejaculation.

How can a man reduce penile sensation?

Local anaesthetic gels and creams can reduce penile sensation and should be applied up to 30 minutes before sexual intercourse; using a condom will prevent absorption of the gel or cream by the partner.

Using two condoms may also reduce sensation and help a man take longer to ejaculate.

What are the oral medicines?

Some antidepressants—tricyclic antidepressants and selective serotonin reuptake inhibitors (SSRIs)—have the side-effect of delayed ejaculation and are now commonly prescribed by doctors for premature ejaculation.

Dapoxetine  is the only SSRI that has been approved as a specific treatment for premature ejaculation (in men 18-64 years old) in Australia. It is taken “on-demand” rather than daily; 30 mg doses are taken one to three hours before intercourse.

The tricyclic antidepressant (clomipramine) has been shown to work better than SSRIs (fluoxetine, paroxetine, sertraline) in some men. These drugs work only for as long as the man continues to take the medication daily.

Taking SSRIs can have some side-effects such as decreased libido (sex drive), nausea, sweating, bowel disturbance and fatigue.

 

What is retrograde ejaculation?

In men with retrograde ejaculation, the muscle at the opening of the bladder, which usually stops semen from entering the bladder during orgasm, does not close normally. When the muscle does not close properly semen flows back into the bladder.

Therefore, little or no semen is discharged from the penis during ejaculation, and the first urination after sex looks cloudy as the semen mixes with the urine.

Retrograde ejaculation is uncommon and usually harmless.

What causes retrograde ejaculation?

Retrograde ejaculation can happen after surgery to the prostate or the neck of the bladder. Diabetes, multiple sclerosis, spinal cord injury, and some medications, in particular medicines for high blood pressure, can also cause retrograde ejaculation. Depending on the cause, retrograde ejaculation may be a temporary or permanent condition.

How is retrograde ejaculation treated?

Retrograde ejaculation typically doesn’t require treatment unless it interferes with fertility. In such cases, treatment depends on the underlying cause. Drugs may work for retrograde ejaculation caused by nerve damage. This can be caused by diabetes, multiple sclerosis, certain surgeries, and other conditions and treatments.

Drugs generally won’t help if retrograde ejaculation is due to surgery that causes permanent physical changes of your anatomy. Examples include bladder neck surgery and transurethral resection of the prostate.

If your doctor thinks drugs you are taking may be affecting your ability to ejaculate normally, he or she may have you stop taking them for a period of time. Drugs that can cause retrograde ejaculation include certain medications for mood disorders and alpha blockers — drugs used to treat high blood pressure and some prostate conditions.

Drugs to treat retrograde ejaculation are drugs primarily used to treat other conditions. They include:

  • Imipramine (Tofranil)
  • Chlorpheniramine and brompheniramine
  • Ephedrine, pseudoephedrine and phenylephrine

These medications help keep the bladder neck muscle closed during ejaculation. While they’re often an effective treatment for retrograde ejaculation, all of these medications can cause side effects. Some of the side effects are minor, but others can be more serious:

  • Some medications used to treat retrograde ejaculation can cause serious reactions when combined with other medications.
  • Certain medications used to treat retrograde ejaculation can increase your blood pressure and heart rate, which can be dangerous if you have high blood pressure or heart disease.

Infertility

If you have retrograde ejaculation, you’ll likely need treatment to get your partner pregnant. In order to achieve a pregnancy, you need to ejaculate enough semen to carry your sperm into your partner’s vagina and into her uterus.

If medication doesn’t allow you to ejaculate semen, you will likely need infertility procedures known as assisted reproductive technology to get your partner pregnant. In some cases, sperm can be recovered from the bladder, processed in the laboratory and used to inseminate your partner (intrauterine insemination). Occasionally, more-advanced assisted reproductive techniques may be needed. Many men with retrograde ejaculation are able to get their partners pregnant once they seek treatment.

 

What is delayed ejaculation?

Delayed ejaculation and anorgasmia describe the inability to ejaculate at will, so that ejaculation (and orgasm) takes much longer than desired, or does not happen at all. This might happen only with intercourse, or in all situations including masturbation (self-stimulation).

The term anejaculation describes when a man does not ejaculate after orgasm. “Orgasm” and “ejaculation” are often thought to be the same, but some men can experience orgasm even though they don’t ejaculate.

What causes delayed ejaculation?

Delayed ejaculation can result from certain chronic health conditions, surgeries and medications. Or it may be caused by substance abuse or a mental health concern, such as depression, anxiety or stress. In many cases, delayed ejaculation is due to a combination of physical and psychological concerns.

Physical causes of delayed ejaculation include:

  • Certain birth defects affecting the male reproductive system
  • Injury to the pelvic nerves that control orgasm
  • Certain infections, such as a urinary tract infection
  • Prostate surgery, such as transurethral resection of the prostate (TURP) or prostate removal
  • Neurological diseases, such as diabetic neuropathy, stroke or nerve damage to the spinal cord
  • Hormone-related conditions, such as low thyroid hormone (hypothyroidism) or low testosterone (hypogonadism)
  • Retrograde ejaculation, a condition in which the semen goes backward into the bladder rather than out of the penis

Psychological causes of delayed ejaculation include:

  • Depression, anxiety or other mental health conditions
  • Relationship problems due to stress, poor communication or other concerns
  • Anxiety about performance
  • Poor body image
  • Cultural or religious taboos
  • Differences between the reality of sex with a partner and sexual fantasies

Medications and other substances that can cause delayed ejaculation include:

  • Some antidepressants
  • Certain high blood pressure medications
  • Certain diuretics
  • Some antipsychotic medications
  • Some anti-seizure medications
  • Alcohol — particularly drinking too much (alcohol abuse or alcoholism)

For some men, a minor physical problem that causes a delay in ejaculation may cause anxiety about ejaculating during a sexual encounter. The resulting anxiety may worsen delayed ejaculation.

How is delayed ejaculation treated?

A change of antidepressant medication may be needed for men who are concerned about this side-effect.

Vibrator stimulation and electrical stimulation of the penis can be used to promote reflex ejaculation in men who can’t ejaculate, but want to father a baby.

Men who are concerned about being unable to ejaculate when there is no medical reason for this difficulty may need long-term individual counselling or therapy