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Review of delayed ejaculationThe BASHH special interest group on sexual dysfunction has issued a set of guidelines for the treatment and management of delayed ejaculation. This was published in the Journal of STD and AIDS 2006, volume 13, pages 7 to 13. The article begins by referring to the fact that orgasm and ejaculation are not the same event, although they are usually contemporaneous. One theory is that pressure building up as semen enters the posterior urethra triggers the ejaculatory reflex, while the associated feeling of pleasure which we know as orgasm is generated in the brain, although the specific area where this happens is not known. In any event, we do know is that the inability to ejaculate, and the associated failure to experience orgasm, is much more common than has previously been thought. Up until 2003, it was believed that the percentage of men experiencing delayed ejaculation in the general population was around 1% or less. A study in 2003 amongst general practitioners in London revealed that the real rate was closer to 11%. Whatever the actual figure, it's clear that many men are experiencing delayed ejaculation and these husbands or boyfriends can't ejaculate during sexual intercourse a problem for many men at any one time. The conventional causes of delayed ejaculation are listed as spinal-cord injury, surgery, diabetes, multiple sclerosis, and other: the latter group being the one that is most problematic to doctors, since there is no obvious cause for this kind of delayed ejaculation except the psychological or the psychosocial factors that come into play in all relationships. Nonetheless, the special interest group do make the observation that it is in fact biologically plausible that men who experience delayed ejaculation have slower bulbo-cavernosus or glandipudendal reflexes, lower penile sensitivity, or a higher sensory threshold. There is a limited amount of scientific evidence which suggests that in some men who cannot ejaculate the bulbo-cavernosus reflex is completely absent. But the reality is that the majority of men with delayed ejaculation are not suffering from inadequate sexual stimulation or deficient reflexes; their problem is that they have somehow come to prefer manual stimulation – i.e. masturbation by themselves – to any form of sexual stimulation from a partner, including sexual intercourse. One of the reasons for this, as we now well-know, is the habit that some men develop during the teenage years of masturbating in an idiosyncratic fashion with hard stimulation that desensitizes them to the level of stimulation typically found during sexual intercourse with a partner. In attempting to cover all possible causes of delayed ejaculation, the special interest group also make the observation that age may be a factor: sexual organs atrophy, testosterone levels fall, erections become harder to achieve… and so on. But sex after fifty can be just as good as at any other age: to attribute delayed ejaculation to changes in male physiology with age is false reasoning. There may be an association between age and longer lasting sex, but there is probably not a causative correlation between age and delayed ejaculation. It's certainly a factor, however, that many pharmacological agents do cause ejaculatory difficulties. These include alpha blockers, beta-blockers, tranquillizers, antidepressants, opiates and more. I think it's true to say that the majority of men with ejaculation difficulties, the cause will lie in the social, or psychological, arena in the broadest sense. This would include relationship difficulties, lack of sexual education, social difficulties, and personality traits. The most common psychological theory is that a man who does not ejaculate is in some way holding back as a way of taking power in a relationship where there are feelings of hostility or a fear of intimacy towards the partner. Treatment for delayed ejaculation varies according to the supposed cause. Where a man is taking drugs that may cause retarded ejaculation, it's possible to change the medication he's taking, or perhaps even to use one of a number of drugs such as Buspirone or Buproprion which are reputed to facilitate ejaculation. These tend to be serotonin/norepinephrine/dopamine reuptake inhibitors and have been reported as causing a reversal of SSRI induced retarded ejaculation. Psychological therapies of all kinds been recommended for the treatment of delayed ejaculation, including meditation, relaxation, psychotherapy, stimulation from erotic films and masturbatory exercises. Depending on the therapy chosen, success rates vary up to 80% plus. One of the most successful therapies, by John Bancroft, relies on the assumption that there is a kind of block in place preventing ejaculation, and that if a man can achieve vaginal ejaculation through vigorous stimulation, then this block may be broken. In my own experience I believe there is an element of truth in this, in that once a man has achieved ejaculation close to or intra-vaginally, I have seen the whole syndrome of delayed ejaculation unravel. But there are many practical aspects to therapy that need to be considered, including fears and anxieties about pregnancy or sexually transmitted diseases, and in particular the relationship issues that may be playing a part in maintaining a man's ejaculatory inability. In essence an eclectic approach to the treatment of retarded ejaculation is needed, but treatment generally can be successful if the key to releasing both a man's psychological and physical inhibitions can be found. |