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Retarded ejaculation


Abstract and Figures

Retarded ejaculation (RE) has a relatively low prevalence (<3%), yet this condition results in considerable distress, anxiety, and lack of sexual confidence for those suffering from it. Furthermore, men with partners often experience impairment of both the sexual and nonsexual aspects of their relationships, with such negative effects compounded when procreation is a consideration. The definition of RE is ambiguous, due to the variability and paucity of data regarding normal coital ejaculatory latency. RE is influenced by both biogenic and psychogenic components, which may vary over time both between and within individuals. While specific pathophysiology can often be identified, further elucidation of the biogenic components of this dysfunction will require greater understanding of the physiological mechanisms underlying ejaculation. Yet, the most useful strategies for understanding RE will integrate rather than isolate the various biogenic and psychogenic aspects of this dysfunction. Evidence based evaluation and treatment protocols for this disorder are lower than for other sexual dysfunctions, but reports suggest better treatment efficacy when the etiology is predominantly psychogenic. As with erectile dysfunction (ED) and premature ejaculation (PE), if safe and efficacious oral pharmaceuticals are eventually developed for this condition, the treatment algorithm is likely to undergo significant alteration. Even then, however, the most effective treatments are likely to result from a combination treatment that integrates sex coaching with pharmacotherapy.
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World J Urol
DOI 10.1007/s00345-006-0127-6
Retarded ejaculation
Michael A. Perelman · David L. Rowland
© Springer-Verlag 2006
Abstract Retarded ejaculation (RE) has a relatively
low prevalence (<3%), yet this condition results in con-
siderable distress, anxiety, and lack of sexual conW-
dence for those suVering from it. Furthermore, men
with partners often experience impairment of both the
sexual and nonsexual aspects of their relationships,
with such negative eVects compounded when procre-
ation is a consideration. The deWnition of RE is ambig-
uous, due to the variability and paucity of data
regarding normal coital ejaculatory latency. RE is
inXuenced by both biogenic and psychogenic compo-
nents, which may vary over time both between and
within individuals. While speciWc pathophysiology can
often be identiWed, further elucidation of the biogenic
components of this dysfunction will require greater
understanding of the physiological mechanisms under-
lying ejaculation. Yet, the most useful strategies for
understanding RE will integrate rather than isolate the
various biogenic and psychogenic aspects of this dys-
function. Evidence based evaluation and treatment
protocols for this disorder are lower than for other sex-
ual dysfunctions, but reports suggest better treatment
eYcacy when the etiology is predominantly psycho-
genic. As with erectile dysfunction (ED) and prema-
ture ejaculation (PE), if safe and eYcacious oral
pharmaceuticals are eventually developed for this con-
dition, the treatment algorithm is likely to undergo sig-
niWcant alteration. Even then, however, the most
eVective treatments are likely to result from a combi-
nation treatment that integrates sex coaching with
Retarded ejaculation (RE) is probably the least com-
mon, and least understood of all the male sexual dys-
functions. RE is one of the diminished ejaculatory
disorders (DED), which is a subset of male orgasmic
disorders (MOD) [1]. Diminished ejaculatory disorders
is a collective term for an alteration of ejaculation and /
or orgasm that ranges from varying delays in ejacula-
tory latency to a complete inability to ejaculate, aneja-
culation, and retrograde ejaculation, as well as
reductions in volume, force, and the sensation of ejacu-
lation. Similar to the term “premature ejaculation,” the
most commonly used term—“retarded ejaculation”—is
sometimes avoided because of its pejorative associa-
tions. In fact, the abbreviation “EjD” has been sug-
gested as a less stigmatized term, encompassing all
disorders of ejaculation [1].
The American Psychiatric Association’s diagnostic
and statistical manual of mental disorders, fourth edi-
tion, text revision (DSM-IV-TR) deWnes RE as the
persistent or recurrent delay in, or absence of, orgasm
after a normal sexual excitement phase during sexual
activity that the clinician, taking into account the
M. A. Perelman (&)
Department of Psychiatry,
Reproductive Medicine and Urology,
NY Presbyterian Weill Cornell Medical Center,
70E. 77th st., Suite 1C, New York, NY 10021, USA
D. L. Rowland
Department of Psychology,
Valparaiso University, Valparaiso, IN 46383, USA
World J Urol
person’s age, judges to be adequate in focus, intensity,
and duration. The disturbance causes marked distress
or interpersonal diYculty; it should not be better
accounted for by another Axis I disorder or caused
exclusively by the direct physiologic eVects of a sub-
stance or a general medical condition [2]. Similarly, the
World Health Organization 2nd consultation on sexual
dysfunction deWnes RE as the persistent or recurrent
diYculty, delay in, or absence of attaining orgasm after
suYcient sexual stimulation, which causes personal dis-
tress [3].
Failure of ejaculation can be a lifelong (primary) or
an acquired (secondary) problem. It can be global and
happen in every sexual encounter or it may be inter-
mittent or situational. Many men with secondary RE
can masturbate to orgasm, whereas others, for multiple
reasons, will or cannot. Interestingly, correlational evi-
dence suggests that masturbatory frequency and style
may be predisposing factors for RE, since a substantial
portion of men who present with coital RE typically
report high levels of activity using an idiosyncratic mas-
turbatory style [48].
Similar to men with other types of sexual dysfunc-
tion, men with RE indicate high levels of relationship
distress, sexual dissatisfaction, anxiety about their sex-
ual performance, and general health issues—signiW-
cantly higher than sexually functional men. In addition,
along with other sexually dysfunctional counterparts,
men with RE typically report lower frequencies of coi-
tal activity [9]. A distinguishing characteristic of men
with RE—and one that has implications for treat-
ment—is that they usually have little or no diYculty
attaining or keeping their erections—in fact they are
often able to maintain erections for prolonged periods
of time. Yet, despite their good erections, they report
low levels of subjective sexual arousal, at least com-
pared with sexually functional men [10].
Prevalence of RE
In general, RE is reported at low rates in the litera-
ture, rarely exceeding 3% [1, 11, 12]. Since the begin-
ning of sex therapy, RE was seen as a clinical rarity,
with Masters and Johnson [13] initially reporting only
17 cases. Apfelbaum reported 34 cases [14] and Kap-
lan fewer than 50 cases [15] in their respective prac-
tices. However, based on clinical experiences, some
urologists and sex therapists are reporting an increas-
ing incidence of RE [1, 12, 16]. The prevalence of RE
appears to be moderately and positively related to
age, which is not surprising in view of the fact that
ejaculatory function as a whole tends to diminish as
men age.
Just as a pathophysiological etiology should not be
assumed without a thorough medical investigation, a
psychogenic etiology should not be assumed without
an appropriate psychosexual history. Of course, bio-
genic and psychogenic etiologies are neither indepen-
dent nor mutually exclusive classiWcations—not only
do the categories themselves overlap, but also the
causes of sexual dysfunctions often include a mix of
factors involving both domains.
In some instances, a somatic condition may account for
RE, and indeed, any procedure or disease that disrupts
sympathetic or somatic innervation to the genital
region has the potential to aVect ejaculatory function
and orgasm. Thus, spinal cord injury, multiple sclerosis,
pelvic-region surgery, severe diabetes, and medications
that inhibit -adrenergic innervation of the ejaculatory
system have been associated with RE [1719]. Never-
theless, sizable portions of men with RE exhibit no
clear somatic factors that account for the disorder.
It is essential to distinguish those factors that are
“physiological” from those that are “pathophysiologi-
cal.” “Physiological” refers to factors that are biologi-
cally inherent to the system, through genetic and normal
maturational processes. “Pathophysiological” refers to
those factors that occur through disruption of the nor-
mal physiological processes, through disease, trauma,
surgery, medication, etc. Pathophysiological causes of
RE are far more readily identiWable; they generally sur-
face during a medical history and examination, and they
typically stem from predictable sources: anomalous ana-
tomic, neuropathic, endocrine, and medication (iatro-
genic). All types of RE show age-related increases in
prevalence, independent of age, increased severity with
lower urinary tract symptoms [20, 21]. Commonly used
medications, particularly antidepressants, may delay
ejaculation as well. A comprehensive list of such phar-
macological agents may be found in Perelman et al. [1].
More diYcult to identify are inherent physiological
factors that account for variation in ejaculatory latency
and thus might play a role in RE. Low penile sensitiv-
ity, most often associated with aging [22, 23], may exac-
erbate diYculty with reaching orgasm, but it is an
unlikely primary cause. Alternatively, variability in the
sensitivity of the ejaculatory reXex may be a factor.
More likely, however, ejaculatory response and latency
are inXuenced by central (cognitive-aVective-arousal)
processes than dominated by the simple hardwiring of
the spinal reXex components [24].
World J Urol
Multiple psychosocial explanations have been oVered
for RE, with unconscious aggression, unexpressed
anger, and malingering recurring as themes. In addi-
tion, pregnancy fears have been emphasized, as profes-
sional referral has often been tied to the female
partner’s wish to conceive. Masters and Johnson [13]
were the Wrst to suggest an association between RE
and religious orthodoxy, positing that certain beliefs
may limit the sexual experience necessary for develop-
ing the knowledge necessary to learn to ejaculate or
may result in an inhibition of normal function.
Religious orthodoxy may play a role in RE for some
men, but the majority of men with RE do not fall into
this category. A number of relevant behavioral, psy-
chological, and relationship factors appear to contrib-
ute to diYculty reaching orgasm for these men. For
example, men with RE sometimes indicate greater
arousal and enjoyment from masturbation than from
intercourse. This “autosexual” orientation may involve
an idiosyncratic and vigorous masturbation style—car-
ried out with high frequency. Apfelbaum [14] labels
this as a desire disorder speciWc to partnered sex. Perel-
man [48] deWnes “idiosyncratic masturbation as a
technique not easily duplicated by their partner’s hand,
mouth, or vagina”. SpeciWcally, many men with RE
engage in self-stimulation that is striking in the speed,
pressure, duration, location and intensity necessary to
produce an orgasm, and dissimilar to what they experi-
ence with a partner [6, 8, 25]. Almost universally, these
men failed to communicate their preferences for stimu-
lation to either their doctor or their partners, because
of shame, embarrassment, or ignorance. Thus, they
may predispose themselves to diYculty with a partner
and experience secondary RE. Disparity between the
reality of sex with the partner and the sexual fantasy
(whether or not unconventional) used during mastur-
bation is another potential cause of RE [26, 27]. This
disparity takes many forms, such as partner attractive-
ness and body type [5, 10], sexual orientation, and the
speciWc sex activity performed. In summary, high-fre-
quency idiosyncratic masturbation, combined with fan-
tasy/partner disparity, may well predispose men to
experiencing problems with arousal and ejaculation.
The above patterns suggest that RE men may lack
suYcient levels of physical and/or psychosexual arousal
during coitus to achieve orgasm. Apfelbaum [14] has
suggested that the couple interprets the man’s strong
erectile response as erroneous evidence that he suY-
ciently aroused to attain orgasm. Consistent with this
idea, Perelman posits that inadequate arousal may be
responsible for increased anecdotal clinical reports of
RE for men using oral medications for the treatment
for ED [16]. While most men using phosphodiesterase
inhibitors type 5 (PDE-5s) experienced restored erec-
tions and coitus with ejaculation, others experienced
erection without adequate psycho-emotional arousal.
That is, they did not experience suYcient erotic stimu-
lation before and during coitus to reach orgasm, con-
fusing their erect state as an indication of sexual
arousal when it primarily indicated vasocongestive suc-
cess [26].
Finally, the evaluative/performance aspect of sex
with a partner often creates “sexual performance anxi-
ety” for the man, a factor that may contribute to RE.
Such anxiety typically stems from the man’s lack of
conWdence to perform adequately, to appear and feel
attractive (body image), to satisfy his partner sexually,
to experience an overall sense of self-eYcacy, and to
measure up against the competition [28, 29
]. Anxiety
surrounding the inability to ejaculate may draw the
man’s attention away from erotic cues that normally
serve to enhance arousal. This “ejaculatory perfor-
mance” anxiety interferes with the erotic sensations
of genital stimulation, resulting in levels of sexual
excitement and arousal that are insuYcient for cli-
max (although more than adequate to maintain an
An integrated biopsychosocial approach
Comprehending the factors that account for variation
in latency to ejaculation following vaginal intromission
is key to understanding any MOD. As with many bio-
behavioral responses, variation in ejaculatory latency is
undoubtedly under the control of both biological and
psychological-behavioral factors. One contemporary
way of conceptualizing the interaction of these systems
has been proposed by those who study evolutionary
psychology [30]. The ejaculatory latency range for each
individual may be biologically set or predisposed (e.g.,
via genetics), but the actual timing or moment of ejacu-
lation within that range depends on a variety of contex-
tual, psychological-behavioral, and relationship-
partner variables [25]. Such thinking is clearly sup-
ported by the fact that ejaculatory latency in men with
ejaculatory disorders (either PE or RE) is often quite
diVerent during coitus than during masturbation [31].
The most useful approach to understanding biobe-
havioral responses is that of integrating—rather than
isolating—the biological and psychological-behavioral
components, with the goal of identifying those organis-
mic elements—peripheral and/or central—that con-
tribute to and explain variation in the response.
Genetic predispositions are likely to aVect the typical
World J Urol
speed and ease of ejaculation for any particular organ-
ism; however, some components are undoubtedly inXu-
enced by the past experiences and present contexts in
which the response is occurring. Retarded ejaculation,
then, is best understood as an endpoint or response
that represents the interaction of biological, psycholog-
ical, relationship and cultural factors.
The diagnostic evaluation of ejaculatory dysfunction
should focus on uncovering potential physical and spe-
ciWc psychological/learned causes of the disorder.
The sexual tipping point™ model
Perelman’s [32] sexual tipping point™ (STP) model
oVers a clinically useful heuristic for evaluating the role
both biogenic and psychosocial factors play in deter-
mining the etiology of sexual dysfunction (SD) gener-
ally, and RE in particular [8]. The STP is the
characteristic threshold for an expression of a sexual
response for any individual, which may vary dynami-
cally within and between sexual experiences. There is
variable expression of this response, which may be
inhibited or facilitated due to a mixture of both psycho-
genic and biogenic factors, as the mind and body can
both inhibit and excite sexual response (Fig. 1). The
speciWc threshold for the sexual response is determined
by these multiple factors for any given moment or cir-
cumstance, with one factor or another dominating as
others recede in importance. For instance, every man,
whether he experiences a “normal” ejaculatory
latency, or premature or retarded ejaculation, has a
multidimensional predetermined “ejaculatory tipping
point” (EjTP) [25]. Appropriate assessment requires
an appreciation of the interdependent inXuence of all
these factors on the endpoint dysfunction for a particu-
lar individual, at a particular moment in time.
Medical history
A genitourinary examination and medical history may
identify physical anomalies associated with ejaculatory
dysfunction as well as contributory neurologic, endo-
crinologic, or erectile factors. Attention should be
given to identifying reversible urethral, prostatic, epi-
didymal, and testicular infections. Particularly with sec-
ondary RE, adverse pharmaceutical side eVects—most
commonly from serotonin-based prescriptions—should
be ruled out.
Fig. 1 The multifactorial etiology of RE. The sexual tipping point™: the characteristic threshold sexual response for any individual that
may vary within and between any given sexual experience
World J Urol
While recognizing the likelihood of ejaculatory vari-
ability and appreciating other potential organic compo-
nents, clinicians should also note relevant psychosocial
determinants. To this end, a focused psychosexual
evaluation is critical and typically begins by diVerenti-
ating this sexual dysfunction from other sexual prob-
lems and reviewing the conditions under which the
man is able to ejaculate. The developmental course of
the problem—including predisposing issues of religios-
ity—and variables that improve or worsen perfor-
mance, particularly those related to psychosexual
arousal, should be noted. Perceived partner attractive-
ness, the use of fantasy during sex, anxiety-surrounding
performance, and coital and masturbatory patterns all
require exploration. Consistent with this last inquiry,
the patient should be asked: (1) “What is the frequency
of your masturbation?” (2) “How do you masturbate?”
Additional questions may be used to give greater spec-
iWcity to the potential role of masturbation in the disor-
der and to clarify these and other relevant etiological
If orgasmic attainment had been possible previously,
the clinician should review life events/circumstances
temporally related to orgasmic cessation—events in
question might include pharmaceuticals, illness, or a
variety of life stressors and other psychological factors
previously highlighted.
Since many men attempt their own remedies, the
patient’s previous approaches to improving ejaculatory
response should be investigated, including the use of
herbal or folk therapies, prior treatments, and home
remedies (e.g., using particular cognitive or behavioral
strategies). Information regarding the partners’ per-
ception of the problem and their satisfaction with the
overall relationship is often helpful. Once this body of
knowledge is complete, an appropriate treatment plan,
developed in conjunction with the couple, can be
Treatment strategies for sexual dysfunction (SD) in
general and RE speciWcally may be conceptualized as
balancing the STP; this process most often beneWts
from cooperation of the sexual partner. Discussion of a
potential biologic predisposition is often helpful in
reducing patient and partner anxiety and mutual
recriminations, while simultaneously assisting the for-
mation of a therapeutic alliance with the urologist [6].
Masters and Johnson [13] were among the Wrst to
advocate speciWc exercises as part of the treatment for
RE. Current sex therapy approaches to RE continue to
emphasize the importance of masturbation in the treat-
ment of RE; however, much of the focus now is on
masturbatory retraining, integrated into sex therapy [1,
14, 27, 3335]. As characterized by Perelman, mastur-
bation serves as a type of “dress rehearsal” for sex with
a partner. By informing the patient that his diYculty is
merely a reXection of “not rehearsing the part he
intended to play,” the stigma associated with this prob-
lem can be minimized and cooperation of both the
patient and partner can be evoked.
Of course, masturbation retraining is only a means
to an end, and the goal of most current therapeutic
techniques for RE (either primary or secondary) is not
merely to provide more intense stimulation, but rather
to stimulate higher levels of psychosexual arousal and,
eventually, orgasm within the framework of a satisfy-
ing experience.
Primary RE
Men with primary anorgasmia, like their female counter-
parts, typically need help in determining their sexual
arousal preferences through self-exploration and stimu-
lation. Masturbation training may use a modiWcation of
the model described by Barbach [36] for women,
although for men the use of vibrators, recommended by
some urologists, is rarely necessary [37]. Progressing
from neutral sensations to the ability to identify and
experience pleasurable sensations is encouraged, but this
need not be aimed at achieving orgasm, at least initially.
Typically, self-stimulation techniques incorporating
fantasy can be used to achieve incremental increases in
arousal. Fantasy can help block-inhibiting (often criti-
cal) thoughts—often a signiWcant step that might other-
wise result in interference with the progression of
sexual arousal. An important component in the treat-
ment of any type of RE is the removal of “demand” or
“performance” anxiety [14]. To reduce anxiety, treat-
ment may include recognition of RE men’s over eager-
ness to please their partners, validation of (though not
necessarily encouragement of) the man’s autosexual
orientation, removal of stigmas suggesting hostility or
withholding toward their partner, and general anxiety
reduction techniques such as relaxation and desensiti-
zation. Finally, like a previously anorgasmic woman,
the man is taught to eVectively communicate his pref-
erences to his partner so that both their needs are
incorporated into the sexual experience.
Secondary RE and the management of resistance
Therapy for secondary RE follows a strategy similar to
that of primary anorgasmia. However, the clinician or
World J Urol
urologist should counsel these patients to suspend mas-
turbatory activity and limit orgasmic release to only the
desired activity, which is typically coitus. Advice to
temporarily reduce and/or discontinue masturbation
for any length of time (e.g., 14–60 days) is usually met
with signiWcant resistance by the patient. As a result,
the clinician will need to provide strong support and
encouragement to the patient to ensure that he adheres
to this suspension. In addition to suspending masturba-
tion, the patient should be encouraged to use fantasy
and bodily movements during coitus, which help
approximate the thoughts and sensations previously
experienced in masturbation. Resistance is minimized
and the success of the process enhanced when the part-
ner is supported by the urologist and understands that
the alteration in coital style represents temporary suc-
cessive steps to reaching a long-term goal of mutual
coital harmony and satisfaction.
Sometimes the issue of masturbation interruption
must be compromised and negotiated with the patient.
A man who continues to masturbate, for example, may
be encouraged to alter the style of masturbation
(“switch hands”) and to approximate (in terms of
speed, pressure, and technique) the stimulation likely
to be experienced through manual, oral, or vaginal
stimulation by his partner [8].
Partner issues
To increase satisfactory outcomes from treatment, the
partner needs to cooperate with the therapeutic pro-
cess, Wnding ways to pleasure the man that enhance
arousal and that can be incorporated into the couple’s
lovemaking. Sexual fantasies may have to be realigned
so that thoughts experienced during masturbation bet-
ter match those occurring during coitus. EVorts to
increase the attractiveness and seductive/arousing
capacity of the partner and to reduce the disparity
between the man’s fantasy and the actuality of sex with
his partner may be useful, as signiWcant disparity tends
to characterize more severe and recalcitrant RE and
relationship problems, with a consequent poorer treat-
ment prognosis [4, 5].
While a number of other partner related issues may
aVect a males’ ejaculatory interest and capacity, two
require special attention: fertility/conception and
anger/resentment. Under either circumstance, it is
often a signiWcant challenge to any health care provider
(HCP) to identify a process that allows a couple to
experience coital ejaculation while simultaneously
maintaining a therapeutic rapport with both. Regard-
ing conception, the pressure of the woman’s “biologi-
cal clock” is often the initial treatment driver. The
woman—and often the man as well—usually meet any
potential intrusion on their plan to conceive with
strong resistance. If the urologist or other HCP sus-
pects the patient’s RE is related to fear of conception,
he may inquire about the patient’s ability to experience
a coital ejaculation with contraception (including con-
doms) but not during “unprotected” sex. Such a “test
can serve as a powerful diagnostic indicator: if the RE
occurs with high probability only during unprotected
sex, the HCP can assume that conception is a primary
factor causing/maintaining RE. Under such circum-
stances, the HCP must Wnd an acceptable way to refo-
cus the treatment, at least temporarily, on the
underlying issues responsible for his ambivalence.
Resolving this issue typically requires individual con-
sultations with the man and occasionally with the part-
Whether related to fertility or not, the man’s anger
(expressed/unexpressed) toward his partner may be an
important intermediate causational factor and must be
ameliorated through individual and/or conjoint consul-
tation. Anger acts as a powerful anti-aphrodisiac, and
while some men avoid sexual contact entirely when
angry at a partner, others attempt to perform, only to
Wnd themselves only modestly aroused and unable to
maintain an erection/and or reach orgasm. While the
man’s assertiveness should be encouraged, the HCP
should also remain sensitive and responsive to the
impact of this change on the partner—the object of the
newly expressed anger—and the resulting alteration in
the couple’s equilibrium.
As treatment progresses, interventions may be expe-
rienced as mechanistic and insensitive to the partner’s
needs and goals. In particular, many women respond
negatively to the impression that the man is essentially
masturbating himself with her various body parts, as
opposed to engaging in the type of connected lovemak-
ing she may prefer. This perception is exacerbated
when men need actual pornography/erotica rather than
mere fantasy to distract themselves from negative
thoughts and emotions in order to function sexually.
Indeed, because these men are often quite disconnected
emotionally from their partners, the HCP must help the
partner become comfortable with the idea of postpon-
ing gratiWcation of her needs. Once the patient has pro-
gressed to a level of functionality, the urologist can then
encourage greater sensitivity on the man’s part.
Treatment eYcacy and conclusion
While anecdotally viewed by urologists as a diYcult-to-
treat sexual dysfunction, some sex therapists have
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reported good success rates, in the neighborhood of
70–80% [13, 35]. This disparity in success rates may
reXect clinically diVerent treatment populations. Fur-
thermore, although this review has concentrated on the
use of counseling methods, a number of pharmacologi-
cal agents have been used oV-label to facilitate orgasm
in patients taking SSRI antidepressants and other
drugs known to delay or inhibit ejaculatory response.
Although not approved by regulatory agencies for the
treatment of RE, the anti-serotonergic agent cyprohep-
tadine and the dopamine agonist amantadine have
been used with moderate success in this population of
patients [38]. However, the lack of large, controlled
studies with these and other ejaculatory-facilitating
agents suggests a high ratio of adverse eVects to poten-
tial eYcacy. Furthermore, a lack of eYcacy in men with
RE may result, in part, from the potentially strong psy-
chological and relational contributions to this dysfunc-
tion. Nevertheless, as research continues to uncover
greater understanding of the ejaculatory process, the
likelihood of Wnding pro-ejaculatory agents increases.
Finally, the treatment for RE described herein
would typically consume more of the urologist’s time
than treating other SD symptoms such as ED. Depend-
ing on comfort level, preference, resources, and avail-
ability, the urologist may choose to treat the man with
RE or refer him to a sex therapist colleague [34]. As
with PE and ED, should safe and eVective pharmaco-
logical options become available for RE, treatment for
this dysfunction will undergo a major paradigm shift,
with combination drug and sex therapy protocols likely
producing the greatest eYcacy and best outcomes in
terms of patient satisfaction [39]. In the future, urolo-
gists might consider the STP model to conceptualize a
treatment in which sex coaching and sexual pharma-
ceuticals are integrated into diagnosis—addressing
physiological, psychological, and cultural elements all
in one—and thereby achieving a more satisfactory
eYcacious treatment, [68, 32, 40].
1. Perelman M, McMahon C, Barada J (2004) Evaluation and
treatment of ejaculatory disorders. In: Lue TF (ed) Atlas of
male sexual dysfunction, Current Medicine LLC, Philadel-
phia, pp 127–157
2. American Psychiatric Association (2000) diagnostic and sta-
tistical manual of mental disorders, fourth edition, text revi-
sion (DSM-IV-TR). American Psychiatric Association,
Washington 2000
3. McMahon CG, Meston C, Abdol et al (2004) Disorders of or-
gasm in men and women, ejaculatory disorders in men. In: Lue
TF, Basson R, Rosen RC, et al (eds) Sexual medicine: sexual
dysfunction in men and women. Health Publications, UK
4. Perelman MA (2001) Integrating sildenaWl and sex therapy:
unconsummated marriage secondary to ED and RE. J Sex Ed
Ther 26(1):13–21
5. Perelman MA (2002) FSD partner issues: expanding sex ther-
apy with sildenaWl. J Sex Marit Ther 28:195–204
6. Perelman MA (2005) Idiosyncratic masturbation patterns: a
key unexplored variable in the treatment of retarded ejacula-
tion by the practicing urologist. Abstract # 1254. J Urol
173(suppl 4):340
7. Perelman MA (2006) Masturbation is a key variable in the
treatment of retarded ejaculation by health care practitio-
ners. Abstract #120. J Sex Med 3(1):51–52
8. Perelman MA (2006) Unveiling retarded ejaculation. Ab-
stract #1337. J Urol 175(suppl 4): 430
9. Rowland DL, Van Diest S, Incrocci L, Slob AK (2005) Psy-
chosexual factors that diVerentiate men with inhibited ejacu-
lation from men with no dysfunction or with another
dysfunction. J Sex Med 1:221–228
10. Rowland DL, Keeney C, Slob AK (2004) Sexual response in
men with inhibited or retarded ejaculation. Int J Impotence
Res: J Sex Med 16:270–274
11. Lauman EO, Paik A, Rosen RC (1999) Sexual dysfunction in
the United States: prevalence and predictors. JAMA 238:
12. Simons J, Carey MP (2001) Prevalence of sexual dysfunc-
tions: results from a decade of research. Arch Sex Res
13. Masters WH, Johnson VE (1970) Human sexual inadequacy.
Little Brown, Boston
14. Apfelbaum B (2000) Retarded ejaculation; a much-misun-
derstood syndrome. In: Lieblum SR, Rosen RC (eds) Princi-
ples and practice of sex therapy, 2nd edn, Guilford Press, New
York, pp 205–241
15. Kaplan H (1995) The evaluation of sexual disorders: psycho-
logic and medical aspects. Brunner/Mazel, New York
16. Perelman MA (2003). Regarding ejaculation: delayed and
otherwise [letter]. J Androl 24:496
17. Witt MA, Grantmyre JE (1993) Ejaculatory failure. World J
Urol 11:89–95
18. Master VA, Turek PJ (2001) Ejaculatory physiology and dys-
functions. Urol Clin North Am 28:363–375
19. Vale J (1999) Ejaculatory dysfunction. BJU Int 83:557–563
20. Rosen R, Altwein J, Boyle P, et al (2003) Lower urinary tract
symptoms and male sexual dysfunction: the multinational
survey of the aging male (MSAM-7). Eur Urol 44:637–649
21. Blanker MH, Bosch JL, Broeneveld FP, et al (2001) Erectile
and ejaculatory dysfunction in a community-based sample of
men 50 to 78 years old: prevalence, concern, and relation to
sexual activity. Urol 57:763–768
22. Rowland DL (1998) Penile sensitivity in men: an overview of
recent Wndings. Urology 52:1101–1105
23. Paick JS, Jeong H, Park MS (1998) Penile sensitivity in men
with early ejaculation. Int J Impot Res 10:247–250
24. Motofei I, Rowland DL (2005) The neurophysiology of ejac-
ulation: developing perspectives. BJU Int 96:1333–1338
25. Perelman MA (2006) A new combination treatment for pre-
mature ejaculation: a sex therapist’s perspective. J Sex Med
26. Perelman MA (2001) SildenaWl, sex therapy, and retarded
ejaculation. J Sex Educ Ther 26:13–21
27. Perelman MA (1994) Masturbation revisited. Contemp Urol
28. Zilbergeld B (1993) The new male sexuality. Bantam Books,
New York
29. Althof SE, Lieblum SR, Chevert-Measson M, et al (2004)
Psychological and interpersonal dimensions of sexual func-
World J Urol
tion and dysfunction. In Lue TF, Basson R, Rosen R, et al
(eds) Sexual medicine: sexual dysfunctions in men and wom-
en, 21st edn. second International Consultation on Sexual
Dysfunctions: Paris, France pp 73–116
30. Gaulin SJC, McBurney DH (2004) Evolutionary psychology,
2nd edn. Pearson Prentice-Hall, Upper Saddle River, pp 1–24
31. Rowland DL, deGouvea Brazao C, Strassberg D, Slob AK
(2000) Ejaculatory latency and control in men with premature
ejaculation: a detailed analysis across sexual activities using
multiple sources of information. J Psychosom Res 48:69–77
32. Perelman MA (2006) The sexual tipping point: a model to
conceptualize etiology, diagnosis, and combination treatment
of female and male sexual dysfunction. J Sex Med 3(suppl 1):
52. Abstract 121
33. Sank LI (1998) Traumatic masturbatory syndrome. J Sex
Marital Ther 24:37–42
34. Perelman MA (2003) Sex coaching for physicians: combina-
tion treatment for patient and partner. Int J Impot Res
15(suppl 5):S67–S74
35. Perelman MA (2004) Retarded ejaculation. In: Mulhall J (ed)
Current sexual health reports. Current Science, Philadelphia
36. Barbach LG (1974) For yourself: a guide to female orgasmic
response. Doubleday, New York
37. Perelman MA (2007) Combination treatment for retarded
ejaculation. Editorial comment on manuscript #URL-D-05–
00241 entitled: Assessment of penile vibratory stimulation as
a management strategy in men with secondary retarded or-
gasm. Urology (in press)
38. McMahon C, Abdo C, Incrocci L, et al (2004) Disorders of
orgasm and ejaculation in men. J Sex Med 1:58–65
39. Perelman MA (2001) The impact of the new sexual phar-
maceuticals on sex therapy Curr. Psychiatry Rep 3:195–
40. Perelman MA (2005) Combination therapy: integration of
sex therapy and pharmacotherapy. In: Balon R, Seagraves R
(eds) Handbook of sexual dysfunction. Marcel Dekker,
New York
... [1] Tuy nhiên, tác động của bệnh lại rất đáng kể vì có thể khiến cả chồng và vợ mất đi cảm giác hạnh phúc và thỏa mãn tình dục, và quan trọng hơn "không thể có con" khi sinh sản là một trong những mục tiêu của quan hệ tình dục. [2] Chúng tôi trình bày 1 trường hợp không có thai tự nhiên sau 15 tháng lập gia đình ở 1 bệnh nhân (BN) bị rối loạn không xuất tinh (XT) kèm cong dương vật, mà nguyên nhân liên quan đến tâm lý và hành vi tình dục của BN từ lúc dậy thì; đồng thời tổng quan y văn về hiếm muộn nam liên quan đến chậm và không XT. ...
... [8] (2) Giả thuyết 2 nhấn mạnh vai trò của thủ dâm và đời sống tình ái mộng tưởng (erotic fantasy life). [2,9,10] Perelman và cs. ghi nhận 3 đặc điểm thủ dâm có liên hệ với nguy cơ chậm và không XT: ...
- Đặt vấn đề: Chậm và không xuất tinh (XT) là rối loạn tình dục ít gặp (1 - 4% nam giới), tác động tiêu cực trên đời sống tinh thần và tình dục của cả nam lẫn nữ, và có thể gây hiếm muộn. Chúng tôi trình bày 1 trường hợp hiếm muộn do không XT và tổng quan y văn về hiếm muộn nam liên quan đến chậm và không XT. - Bệnh án lâm sàng: BN nam sinh năm 1991, lập gia đình 12/2018, không thể XT và đạt đỉnh khoái cảm khi quan hệ tình dục (2 - 3 lần/tuần) dù có thể duy trì cương kéo dài. BN thủ dâm gần như mỗi ngày khi độc thân và 3 - 4 lần/tuần từ khi lập gia đình, theo cách đặc thù của mình. XT và đạt đỉnh khoái cảm khi thủ dâm với dương vật vẫn mềm. Tinh dịch đồ và nội tiết tố sinh dục nam huyết thanh trong giới hạn bình thường. Dù dương vật bị cong về mặt bụng khoảng 30o, BN không bị trở ngại khi quan hệ ngã âm đạo. - Kết luận: Không XT khi quan hệ liên quan đến tâm lý và hành vi thủ dâm từ lúc dậy thì, dẫn đến hiếm muộn khi lập gia đình là tình huống bất thường, hiếm gặp. Giải thích nguyên nhân và tư vấn tâm lý tình dục cho BN để thay đổi thói quen tình dục là cần thiết, tuy nhiên, hiệu quả cần thời gian lâu dài, sự hợp tác của BN và cả người vợ, và có thể khó đánh giá. Giải pháp trước mắt là áp dụng các kỹ thuật hỗ trợ sinh sản để giải quyết nhu cầu có con của cặp vợ chồng này. Abstract - Introduction: Delayed ejaculation and anejaculation are rare male sexual dysfunctions (1 - 4%), which has negative impact on both male and female sexual life and could lead to infertility. We presented a male infertility due to anejaculation and reviewed the medical literature regarding this problem. - Study patients: A 29 - years - old man, who got married in Dec 2018, complained of anaejaculation and lack of orgasm in sexual intercourses (2 - 3 times/week) even though he could maintain a prolonged erection. This man masturbated in his own way nearly everyday when he was a bachelor and 3 - 4 times/week since marriage. He could achieve orgasm and ejaculation under masturbation with little penile erection. His semen analysis and sexual hormone profile were within the normal physiological range. Although his penis is curved ventrally up to 30o, he had no problem via vaginal coitus. - Conclusions: Anejaculation during sexual intercourse which might be related to idiosyncratic and frequent masturbation behavior since puberty and during marital life is rare and abnormal cause ofinfertility in this young couple. Medical investigation and sexual consultation seem necessary to modify patient’s sexual attitude and habit, however, its effectiveness takes time and needs a close cooperation of this man and his wife. Short - term medical interventions should be assisted reproductive techniques to meet urgent desire of this couple.
... Psychological intervention can also identify and address a patient's psychological conflict with ejaculation that could stem from a variety of sources including discord between partners, fear that ejaculation will impregnate their partner, strife with relinquishing control, or phobia of success [60,61]. Counselors may help the patient identify interpersonal factors or psychological barriers that are negatively impacting sexual function such as communication issues between partners or anxiety related to sexual activity [62]. Therapy should also aim to destigmatize the condition [62]. ...
... Counselors may help the patient identify interpersonal factors or psychological barriers that are negatively impacting sexual function such as communication issues between partners or anxiety related to sexual activity [62]. Therapy should also aim to destigmatize the condition [62]. ...
Full-text available
Delayed orgasm (DO) is defined as increased latency of orgasm despite adequate sexual stimulation and desire. Anorgasmia (AO) is characterized as the absence of orgasm. Etiologies of DO/AO include medication-induced, psychogenic, endocrine, and genitopelvic dysesthesia. Given the multifactorial complex nature of this disorder, a thorough history and physical examination represent the most critical components of patient evaluation in the clinical setting. Treating DO/AO can be challenging due to the lack of standardized FDA-approved pharmacotherapies. There is no standardized treatment plan for DO/AO, though common treatments plans are often multidisciplinary and may include adjustment of offending medications and sex therapy. In this review, we summarize the etiology, diagnosis, and treatment of DO/AO.
... Despite the lifelong vs acquired distinction, few differences between these subgroups have thus far been identified. Based on one study, the prevalence of men with lifelong DE is lower than that of men with acquired DE, constituting approximately 25% and 75% of DE cases, respectively [21]. Other differences that have been identified are hardly surprising. ...
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Men with delayed ejaculation are often categorized into lifelong and acquired subtypes, yet little is known about similarities and differences between these groups. In this study, we examined whether delayed ejaculation subtypes differed on various demographic, diagnostic, relationship, and sexual activity/satisfaction variables. We drew 140 men reporting moderately-severe to severe difficulty reaching ejaculation during partnered sex (occurring during ≥75% of sexual events) from a convenience sample of over 3000 respondents obtained through an opt-in, multinational, online survey. Respondents were further classified as having lifelong or acquired delayed ejaculation based on self-report. A series of alpha-adjusted analyses of covariance were then made between subtypes on subsets of variables. In addition, the extent to which two potential confounding variables, age and erectile function, might have been responsible for subtype differences was explored. Results indicated that compared with men with acquired delayed ejaculation, men with lifelong delayed ejaculation were younger (28.6 vs 44.7 years, η²p = 0.30, P < 0.001), reported greater delayed ejaculation symptomology (4.31 vs 3.98, P < 0.01, η²p = 0.02), were less likely to attribute their problem to a medical issue or medication (1.7% vs 12.2%, P < 0.05), and more likely to masturbate for anxiety/distress reduction than for pleasure. In contrast, delayed ejaculation subtype differences related to masturbation frequency, pornography use during masturbation, and condom use disappeared when age and erectile functioning differences were statistically controlled. Overall, lifelong and acquired delayed ejaculation subtypes showed more similarities than differences. Findings worthy of clinical note were the lower level of endorsement of medical issues/medication by the lifelong subtype, their higher level of delayed ejaculation symptomology, and—despite a high level of anxiety/distress reported by both groups—their particular vulnerability to anxiety/distress as indicated by their strong motive to masturbate for anxiety/distress reduction (44.3% vs 19.6%, P < 0.05). Other differences between delayed ejaculation subtypes were better explained by group differences in age and erectile function than by subtype membership per se.
... Currently, in the DSM-V manual, the following sexual dysfunctions are included: delayed ejaculation, erectile disorder, hypoactive sexual desire disorder in men, and premature ejaculation. Delayed ejaculation occurs in 1% to 4% of the world's population [2][3][4]. Erectile dysfunction is expected to account for nearly 322 million cases by 2025 [5]. The prevalence of hypoactive sexual desire disorder in men worldwide is unknown; however, 14.4% of men in Portugal, Croatia, and Norway reported a distressing lack of sexual desire lasting at least 2 months [6]. ...
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Mindfulness practice and mindfulness-based interventions are widely known, especially for women's sexuality. However, it is currently unknown how this practice affects the experience of male sexuality, possibly due to the existence of pharmacological treatments that are usually the first choice of treatment for men. The objectives of this study are to explore the influence of mindfulness on different components of men's sexuality from a scoping review of relevant scientific articles existing in the literature. A literature search from 2010 to 2022 was carried out in the electronic databases MEDLINE, Embase, PsycINFO, Web of Science, Scopus, PubMed, Dialnet, SciELO Citation Index, and Redalyc. Out of the 238 studies, 12 that met the defined selection criteria were selected. The analysis of these studies seems to indicate that the practice of mindfulness favours different variables of male sexuality, such as satisfaction and sexual functioning or genital self-image. Mindfulness-based interventions represent a valuable and promising contribution. No adverse effects were detected from the review of scientific articles considered in this work. Nevertheless, more randomized studies with active control groups are necessary to establish the benefits of mindfulness-based interventions in sex therapy for men.
Objective: To identify atypical masturbatory behaviors (AMB) and to reveal their effects on both sexual and masturbational erection hardness in men with erectile dysfunction (ED). Methods: Patients with ED and healthy controls were questioned about their masturbation habits. Accordingly, "rubbing in a prone position," "pressure on penis," and "masturbation through clothes" were included in the traumatic masturbation syndrome (TMS) group. Erection hardness score (EHS) is used to measure the erectile functions during masturbation (mast), foreplay (presex), and sexual intercourse (sex), separately. Results: The data of 448 participants, 266 (59%) from the patient group, and 182 (41%) from the control group were analyzed. The mean ages were 30 years in both groups (p = 0.734). The rate of "rubbing in a prone position" and "penile pressure" while masturbating was higher in patients than the controls (10.2% vs. 6%, p = 0.024 and 8.6% vs. 3.3%, p = 0.0002, respectively). Patients had 2.2-fold (odds ratio, 2.21; 95% confidence interval, 1.40-3.47; p = 0.001) increased risks of having at least one AMB, compared with controls. In the secondary analysis, the patient group was divided into 2 subgroups according to having TMS (ED + TMS) or not (ED). The percentage of patients with EHS≥3 during masturbation was higher than those during sex and presex in the "ED + TMS" group (60.2%, 38.8%, and 37.2%, respectively, p = 0.0001; n = 98). Comparing the percentage of patients with EHS≥3 during mast, presex, and, sex was found to be similar in the "ED" group (58.9%, 56.5%, and 56%, respectively, p = 0.753; n = 168). Conclusion: Atypical masturbatory behaviors are more common in young men presenting with erectile dysfunction. These patients have higher erection hardness scores during masturbation compared to partnered sex.
Toàn văn tập 1 số 3 (2022)
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Steve, a married, 25-year-old, orthodox Jewish man was referred by his psychiatrist for sex therapy following 3 years of unconsummated marriage. The psychiatrist was treating Steve for depression, anxiety, and intrusive violent obsessive thoughts with psychoactive medications, including paroxetine (Paxil) and buspirone (BuSpar). The patient described erectile dysfunction (ED) and retarded ejaculation (RE). The couple's child (age 2) was conceived through artificial insemination with semen provided by the patient via masturbation. At the time of referral, Steve's spouse Susan (23 years old) was taking fertility drugs and artificial insemination was planned again. The couple was treated previously by a sex therapist, improving Susan's orgasmic capacity, but the marriage remained unconsummated. Unbeknownst to the previous therapist, the patient was secretly masturbating in an idiosyncratic and compulsive manner-a frequent cause of RE. Alteration of Steve's masturbation style and frequency was a necessary, but insufficient, intervention of this current treatment. Steve began obtaining erections and achieved penetration with his spouse, but remained coitally anorgasmic. Alternative formats (individual/conjoint) were required to strategically manage the treatment process. Successful therapy required maintaining rapport and congruence with the referring psychiatrist who continued pharmacotherapy using different psychoactive agents. Management of fertility issues, artificial insemination, pregnancy, the birth of a second child, and Jewish ritual law further complicated the therapy. Additionally, sildenafil (Viagra) was used to augment the cognitive-behavioral sex therapy, resulting in a more robust and powerful treatment. Eventually the couple consummated their marriage, and Steve was able to ejaculate intravaginally on a regular basis.
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MASTURBATION IS A KEY VARIABLE IN THE TREATMENT OF RETARDED EJACULATION BY HEALTH CARE PRACTIONERS Michael A. Perelman, PhD Introduction and Objectives: New pharmaceuticals have increased the number of patients presenting for treatment of sexual dysfunctions, including retarded ejaculation (RE). There are no FDA approved pharmaceutical treatments for RE, a reportedly difficult-to-treat dysfunction. A study was carried out to identify variables that could improve a practicing health care practionner’s (HCP) capacity to understand and treat RE. Methods: A 6-year retrospective chart review was conducted of the 85 men diagnosed as REs, who had been referred for sex therapy by their urologist. Key variables previously unexplored by their urologists were identified. Results: These 85 men, both partnered and single, ranged in age from 19 to 77 years; mean age 37. 50% had tried a PDE-5 inhibitor, as many urologists had not differentiated ED from RE. Some men with concomitant ED improved their erections, but there was no improvement in their RE. Some men experienced RE as a treatment emergent symptom secondary to PDE-5 use. 25% of the men were diagnosed with a “global,”and “life-long” RE; the remainder were “situational.” 75% of the men could masturbate to orgasm. A significant number of REs were high-frequency masturbators. Notably, over 35% reported masturbating at least every other day or more. More than 25% reported masturbating 6-14 times per month. Less than 2% of the sample who masturbated, did so less than 4 times per month on average. A robust pattern emerged: high-frequency masturbation correlated highly with the presentation of RE. Further, over 40% of the men masturbated using an idiosyncratic style. An idiosyncratic style was defined as a technique not easily duplicated by their partner’s hand, mouth, or vagina. Almost universally, these men had failed to communicate their preferences to either their doctor or their partners, because of shame, embarrassment, or ignorance. Finally, 20% of the men used a variant sexual fantasy during masturbation that was not usually incorporated into sex with theirpartner. Conclusions: The data strongly suggested that high-frequency, idiosyncratic masturbation and fantasy/partner disparity predispose RE. Failure to assess these factors may account for much of the perceived difficulty in treating RE. Identifying and using counseling techniques to alter these patterns could enhance the practicing HCP’s ability to improve their patient’s orgasmic capacity. Once new drugs are developed to increase the ease and speed of ejaculatory latency, combination drug and sex therapy protocols may produce the best treatment outcome.
Ten years of research that has provided data regarding the prevalence of sexual dysfunctions is reviewed. A thorough review of the literature identified 52 studies published in the 10 years since an earlier review by Spector and Carey (Arch. Sex. Behav. 19(4): 389–408, 1990). Community samples indicate a current prevalence of 0%–3% for male orgasmic disorder, 0%–5% for erectile disorder, and 0%–3% for male hypoactive sexual desire disorder. Pooling current and 1-year figures provides community prevalence estimates of 7%–10% for female orgasmic disorder and 4%–5% for premature ejaculation. Stable community estimates of the current prevalence of other sexual dysfunctions remain unavailable. Prevalence estimates obtained from primary care and sexuality clinic samples are characteristically higher. Although a relatively large number of studies has been conducted since the earlier review, the lack of methodological rigor of many studies limits the confidence that can be placed in these findings.