Ejaculation problems

Ejaculation problems, such as premature ejaculation, are a common cause of sexual problems in men.

Introduction

Ejaculation problems, such as premature ejaculation, are a common cause of sexual problems in men.

There are three main types of ejaculation problems:

  • premature ejaculation
  • retarded ejaculation
  • retrograde ejaculation

These are described in more detail below.

Premature ejaculation

Premature ejaculation is the most common ejaculation problem. It is where the male ejaculates too quickly during sexual intercourse.

Many men are unsure about how long ‘normal’ sex should last before ejaculation. A study looking at 500 couples from five different countries found the average time between a man putting his penis into his partner’s vagina and ejaculation was around five-and-a-half minutes.

However, it is up to the individual and his partner to decide whether or not they are happy with the time it takes for him to ejaculate.

Regularly ejaculating before or within one minute of entering your partner’s vagina would usually be regarded as a medical problem that requires treatment.

Retarded ejaculation

Retarded ejaculation is a delay in achieving ejaculation, or an inability to achieve ejaculation during sexual activity, even though the male wants to and his erection is normal.

Retarded ejaculation is sometimes known as delayed ejaculation or male orgasmic disorder.

Retrograde ejaculation

Retrograde ejaculation is a rarer type of ejaculation problem. It happens when sperm travels backwards and enters the bladder instead of coming out of the end of the urethra (the tube that passes from the bladder, through the penis and through which urine passes).

Retrograde ejaculation patients experience the feeling of an orgasm, but produce no, or very little, semen. The condition does not pose a danger to health, but can affect the ability to father a child (infertility).

Read more about the different types of ejaculation problems and their symptoms.

Treating ejaculation problems

Premature ejaculation can be treated with medication, such as the selective serotonin reuptake inhibitors (SSRIs) type of antidepressant which can also help delay ejaculating.

Couples therapy can be useful in coming up with techniques for partners to practice to help delay ejaculation.

Recommended treatments for retarded ejaculation depend on the underlying cause. If it is thought to be a side effect of medication, switching to an alternative medication will help. However, if the cause is thought to be psychological, counselling may be recommended.

Most men do not require treatment for retrograde ejaculation because they are still able to enjoy a healthy sex life and the condition does not affect their health. Although there is medication that helps restore normal ejaculation in some cases.

However, if you want to have children, you may need fertility treatment to extract a sample of sperm.

Read more about treating ejaculation problems.

What causes ejaculation problems?

Ejaculation problems are complex and can be caused by a number of things, such as:

  • stress
  • relationship problems
  • anxiety; such as a man being anxious that he will lose his erection (erectile dysfunction) causing him to ‘rush’ the intercourse
  • previous traumatic sexual experiences
  • depression
  • some medical conditions or medicines – for example diabetes can cause delayed ejaculation

Some researchers think certain men are more prone to premature ejaculation because of their biological make-up, such as having an unusually sensitive penis.

Retrograde ejaculation is caused by damage to nerves or muscles that surround the neck of the bladder (the point where the urethra connects to the bladder). This damage can often occur as a complication of prostate or bladder surgery.

Read more about the causes of ejaculation problems.

Who is affected

Premature ejaculation is the most common type of ejaculation problem.

A number of surveys have found around 1 in 3 men reported being affected by premature ejaculation. The true figure is probably much higher as many men are reluctant to admit they have this problem.

While less common, retarded ejaculation is probably more of a problem then most people realise. One study found around 1 in 20 people had problems achieving an orgasm over the course of a month during the past year.

Although retrograde ejaculation is rare, it can be a common complication of some types of surgery, such as prostate surgery, or in men with certain health conditions that can damage the nerves, such as diabetes or multiple sclerosis.

Symptoms

Premature ejaculation

The main symptom of premature ejaculation is the inability to control and delay ejaculation for as long as both partners would like.

While there is no definition of how long intercourse should last, in the majority of premature ejaculation cases the man ejaculates before entering his partner’s vagina, or within a minute of entering.

Occasional episodes of premature ejaculation are common and are not a cause for concern. However, if you are finding that around half of your attempts to have intercourse result in premature ejaculation then it might help to get treatment. Read more about treating ejaculation problems.

Types of premature ejaculation

There are two main types of premature ejaculation:

  • primary premature ejaculation (sometimes referred to as 'lifelong') – where a man has had a problem with premature ejaculation since becoming sexually active

  • secondary premature ejaculation – where premature ejaculation develops in a man who has previously ejaculated normally

  • there is an inability to delay ejaculation during sex every time or most times

  • the condition causes feelings of shame or frustration and impacts on quality of life, leading to a man avoiding sexual intimacy

Retarded ejaculation

Retarded ejaculation is classed as either experiencing a significant delay before ejaculation is possible, or being unable to ejaculate at all.

There is no set definition to describe ‘how long is too long’, but a persistent (and unwanted) delay of ejaculation that lasts for 30 to 60 minutes may suggest retarded ejaculation.

Alternatively, if you are unable to achieve ejaculation at least half the times you have sex, you may have retarded ejaculation.

As with premature ejaculation, retarded ejaculation can be either acquired or lifelong. Lifelong retarded ejaculation is less common and affects an estimated 1 in 1,000 men.

Retarded ejaculation can also be classified as:

  • global – where it occurs in all sexual situations
  • situational – where it only occurs in certain situations

For example, you may be able to ejaculate normally when masturbating, but not during sex. Situational retarded ejaculation usually suggests the condition is the result of psychological causes.

Retrograde ejaculation

Apart from the absence of semen, the main symptom of retrograde ejaculation is producing cloudy urine when you first go to the toilet after having sex. The urine appears cloudy due to the semen in it.

Glossary

Discharge is when a liquid such as pus oozes from a part of your body.

Anxiety is an unpleasant feeling when you feel worried, uneasy or distressed about something that may or may not be about to happen.

Pain is an unpleasant physical or emotional feeling that your body produces as a warning sign that it has been damaged.

Blood supplies oxygen to the body and removes carbon dioxide. It is pumped around the body by the heart.

Causes

Causes of ejaculation problems vary depending on the person and the type of problem.

An ejaculation problem can often have physical and psychological causes. For example, if a man has previously had a health condition that made it difficult to maintain an erection, it may now cause anxiety, leading to premature ejaculation.

Primary premature ejaculation

Primary premature ejaculation (where the male has had premature ejaculation since first becoming sexually active) is often psychological. A number of possible psychological causes are discussed below.

Conditioning

Many doctors believe early sexual experiences can influence future sexual behaviour. For example, if a teenager conditions himself to ejaculate quickly to avoid being caught masturbating it may later be difficult to break the habit.

Traumatic sexual experiences

A traumatic sexual experience at an early age can sometimes lead to life-long sexual anxiety and premature ejaculation. Experiences can range from being caught masturbating to sexual abuse.

Upbringing

Men who have had a strict upbringing, where sexual activity is only considered appropriate in certain circumstances, such as after marriage, may find it difficult to relax during sex, or be unable to let go of the belief that sex is wrong or sinful.

Biological reasons

A number of recent studies suggest biology may play a role in some cases of primary premature ejaculation.

Changes to the normal pattern of nerve signals in some men affected by erectile dysfunction could result in their penis being extra sensitive, meaning it takes much less stimulation to make it ejaculate.

Some men with erectile dysfunction have lower than average levels of a hormone called prolactin in their body. Prolactin is known to have a ‘dampening’ affect on sexual arousal so low levels may lead to a man becoming very aroused in a short space of time and ejaculating quickly.

Secondary premature ejaculation

Secondary premature ejaculation (where premature ejaculation develops in a man who has previously had a history of normal ejaculation) can be caused by both psychological and physical factors.

Common physical causes of acquired premature ejaculation include:

The recommended daily levels of alcohol consumption are three to four units of alcohol for men, and two to three units for women.

A unit of alcohol is equal to about half a pint of normal strength lager, a small glass of wine, or a pub measure (25ml) of spirits.

Common psychological causes include:

  • depression
  • stress
  • unresolved problems, conflicts, or issues within a sexual and emotional relationship
  • anxiety about sexual performance (this is often a contributory factor at the start of a new sexual relationship, or when a man has had previous problems with sexual performance)

Retarded ejaculation

Like premature ejaculation, retarded ejaculation can be caused by psychological and physical factors.

Possible psychological causes of retarded ejaculation are similar to those of premature ejaculation – for example, early sexual trauma, strict upbringing, relationship problems, stress, and depression.

Physical causes of retarded ejaculation include:

  • diabetes (usually only type 1 diabetes)
  • spinal cord injuries
  • multiple sclerosis
  • surgery to the bladder or prostate gland
  • increasing age

Many medicines are known to cause retarded ejaculation including:

  • antidepressants](yourmd:/condition/antidepressant-drugs/introduction), particularly [selective serotonin reuptake inhibitors (SSRIs)
  • medications used to treat high blood pressure](yourmd:/condition/blood-pressure-high/introduction) (hypertension), such as [beta-blockers
  • antipsychotics, which are medications used to treat episodes of psychosis (a mental condition where it is difficult for a person to distinguish between reality and their imagination)
  • muscle relaxants, such as balcofen, which is widely used to treat motor neurone disease and multiple sclerosis
  • powerful painkillers, such as naproxen and methadone (which is also widely used to treat people addicted to heroin)

Retrograde ejaculation

Retrograde ejaculation is caused by damage to the nerves or muscles that surround the neck of the bladder (the point where the urethra connects to the bladder).

Usually when you ejaculate, semen is pushed out of your testicles and up through your urethra (the tube that semen and urine pass through). It is prevented from entering your bladder by the muscles around the neck of the bladder, which close tightly at the moment of orgasm.

However, damage to the surrounding muscles or nerves can stop the bladder neck closing, causing the semen to move into the bladder rather than up through the urethra.

Prostate gland or bladder surgery is the most common cause of retrograde ejaculation. Other causes are diabetes, multiple sclerosis, and a class of medicines that are known as alpha blockers, which are often used to treat high blood pressure (hypertension).

Glossary

Discharge is when a liquid such as pus oozes from a part of your body.

Testicles are the two oval-shaped reproductive organs that make up part of the male genitals. They produce sperm and sex hormones.

Blood supplies oxygen to the body and removes carbon dioxide. It is pumped around the body by the heart.

Benign refers to a condition that should not become life-threatening. In relation to tumours, benign means not cancerous.

The urethra is a tube that carries urine from the bladder to the outside of the body.

Inflammation is the body's response to infection, irritation or injury, which causes redness, swelling, pain and sometimes a feeling of heat in the affected area.

Diagnosis

If you have an ejaculation problem, you will usually become aware of it through your own sexual behaviour or discussion with your partner. The next step is to visit your doctor who will discuss the problem with you and either examine you or refer you to a specialist.

Family and medical history

Depending on the nature of your problem, you may be asked questions about your family medical history, and any underlying health conditions you may have, such as diabetes, heart disease, or high blood pressure (hypertension).

You will also be asked about your sexual and emotional health. While you may find it embarrassing to talk about, answering questions about the type and pattern of your symptoms is an important step towards making sure that you receive the most effective treatment.

Read more about the symptoms associated with ejaculation problems.

Your doctor or specialist will want to know if you have had an injury or surgery to your pelvic area, what medications you are taking, and about aspects of your lifestyle, such as how much alcohol you drink.

Further testing

A rectal examination may be carried out to check for an enlarged prostate gland, and to check the nerves of your penis for any damage.

Blood and urine samples may also be taken to check your hormone and cholesterol levels. Your doctor, or specialist, may also carry out a visual examination of the pelvic area to check for injury or infection.

Glossary

Cholesterol is a fatty substance made by the body that lives in blood and tissue. It is used to make bile acid, hormones and vitamin D.

Blood supplies oxygen to the body and removes carbon dioxide. It is pumped around the body by the heart.

Hypertension is when the pressure of the blood in your bloodstream is regularly above 140/90 mmHG.

The heart is a muscular organ that pumps blood around the body.

Treatment

Premature ejaculation

If you have premature ejaculation caused by physical conditions, your doctor should be able to suggest possible treatment options.

Treating premature ejaculation caused by psychological factors can be more challenging, but most men who persevere with treatment have successful outcomes.

Self-help

There are a number of self-help techniques that you may want to try before seeking medical help.

These include:

  • masturbating an hour or two before having sex
  • using a thick condom to help decrease sensation
  • taking a deep breath to briefly shut down the ejaculatory reflex (an automatic reflex of the body during which ejaculation occurs)
  • having sex with your partner on top (to allow them to pull away when you are close to ejaculating)
  • taking breaks during sex and thinking about something boring

Couples therapy

If you are in a long-term relationship, you may benefit from having couples therapy. The purpose of couples therapy is two-fold.

Firstly, couples are encouraged to explore issues that may be affecting their relationship, and given advice about how to resolve them.

Secondly, couples are shown techniques that can help the man to ‘unlearn’ the habit of premature ejaculation. The two most popular techniques are the ‘squeeze technique’ and the ‘stop-go technique’.

In the squeeze technique, the woman begins masturbating the man. When the man feels that he is almost at the point of ejaculation, he signals to the woman. The woman stops masturbating him, and squeezes the head of his penis for between 10 to 20 seconds. She then lets go and waits for another 30 seconds before resuming masturbation. This process is carried out several times before ejaculation is allowed to occur.

The stop-go technique is similar to the squeeze technique except that the woman does not squeeze the penis. Once the man feels more confident about delaying ejaculation, the couple can begin to have sexual intercourse, stopping and starting as required.

These techniques may sound simple, but they do require a lot of practice.

Medication

Selective serotonin reuptake inhibitors (SSRIs)

Selective serotonin reuptake inhibitors (SSRIs) are primarily designed to treat depression, but they also have the useful side effect of delaying ejaculation. Although SSRIs are not licensed to treat premature ejaculation, they are increasingly being prescribed for this use.

SSRIs used for this purpose include:

  • paroxetine
  • sertraline
  • fluoxetine

Some men with premature ejaculation may experience an improvement in their symptoms as soon as treatment begins. However, you will usually need to take the medication for one to two weeks before you notice the full effects of the treatment.

Common side effects of SSRIs include:

However, these are usually mild and should improve after two to three weeks.

Dapoxetine

An SSRI, known as dapoxetine, has been specifically designed to treat premature ejaculation, but it is not currently licensed.

The manufacturers have not yet applied for a licence; it is unclear whether they will do so in the future.

Some specialists in treating erectile dysfunction are providing dapoxetine on an unlicensed basis. This means the specialist is willing to take professional responsibility for prescribing unlicensed medication; this includes any necessary monitoring and follow-up treatment.

You should be aware that the doctor in charge of your care may not be willing to take such a responsibility.

If you are prescribed dapoxetine you are normally recommended to take it one to three hours before having sex.

Retarded ejaculation

As with premature ejaculation, the physical causes of retarded ejaculation can usually be treated. For example, if prescription medication is causing the problem, your doctor may be able suggest alternatives.

There are also a number of alternative medications that can be used if it is thought SSRIs are responsible for causing delayed ejaculation. These include:

  • amantadine – a medication originally designed to treat viral infections
  • buproprion – a medication originally designed to help people stop smoking
  • yohimbine – a medication originally designed to treat erectile dysfunction

These medications help block some of the chemical affects of SSRIs that are thought to contribute towards retarded ejaculation.

Sex therapy

Sex therapy uses a combination of psychotherapy and structured changes in your sex life. This can help to increase your feeling of enjoyment during sex, and help make ejaculation easier.

Some primary care trusts (PCTs) provide a sex therapy service on the NHS, but others do not. Therefore, levels of availability can vary widely depending on where you live.

During sex therapy, you will have the opportunity to discuss any emotional or psychological issues related to your sexuality and relationship, in a non-judgemental way.

Activities may also be recommended for you to try at home while you are having sex with your partner (you should never be asked to take part in any sexual activities during a session with the therapist).

These may include:

  • viewing erotic material prior to having sex, such as videos and magazines, to increase the feeling of sexual stimulation
  • erotic fantasies and ‘sex games’ to make your lovemaking more exciting
  • using lubricating creams, or jellies, to make the physical act of sex more comfortable and relaxing
  • using sexual aids, such as vibrators, to increase pleasure

Retrograde ejaculation

Most men do not require treatment for retrograde ejaculation because they are still able to enjoy a healthy sex life and the condition does not have adverse effects on their health.

If treatment is required (usually due to wanting to father a child) medicines can be used to strengthen the muscles around the bladder neck. Pseudoephedrine (a medicine commonly used as a decongestant) has proved to be effective in achieving this.

However, if the retrograde ejaculation has been caused by significant muscle or nerve damage, treatment may not be possible.

Men who want to have children can have sperm taken from their urine for use in artificial insemination or in-vitro fertilisation (IVF).

Glossary

Local anaesthetic -
A local anaesthetic is a drug injected by needle or applied as a cream, which causes a loss of feeling in a specific area of the body.

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