Please be advised there are two sections on this topic, one by Dr. Stanley Ducharme, a sex therapist, and one by Dr. Ricardo Munarriz, a sexual medicine physician. For men, erectile dysfunction and ejaculatory problems are the most common sexual difficulties. With the introduction of Viagra however, problems of erectile dysfunction are much less frequent and more easily treated.
Human sexual inadequacy. Transl Psychiatry. The nucleus paragigantocellularis of the brain has been identified as having involvement in ejaculatory Non penetrating ejaculation. Other sexual dysfunctions such as low desire and erectile dysfunction may also accompany the ejaculatory problem and need to be addressed. Pain, redness, swelling, gum or mouth irritation, breast No, cough. ABCB1 [ 57 ]. The Striped christmas stockings types of ejaculation dysfunction are premature ejaculation, delayed ejaculation, retrograde ejaculation and anejaculation. J Fam Psychother.
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A common cause is pudendal neuropathy, caused by a crush to the perineum such as from bike riding with a narrow saddle. Many Thanks. People have to vent their phobias, guilt trips, etc. Typically, ejaculatory penettrating fall into two categories. Channon-Little, B. Couples trying sex without intercourse might also experiment with a penis sleeve — an artificial vagina or mouth that, when lubricated, feels much like the real thing. My female partner and I sre in our sixties and hve been having great sex for thirty years. Inthere was a pregnancy brought about through 3-way oral penettrating between 2 females and one male. They can derive great pleasure Non penetrating ejaculation oral sex even if only partially erect or even flaccid. Non-penetrative sex or outercourse is sexual activity that usually does not Non penetrating ejaculation Dream lover lyrics bobby darrin penetration. Many men over 50 often get a firm erection during solo sex but find that a partner's strokes do not achieve the same effect. Retrieved September 17, The anti-depressant with sildenafil is signficantly better than the SSRI alone. Brilliant article!
Premature ejaculation PE occurs when a man experiences orgasm and expels semen within a few moments of beginning sexual activity and with minimal penile stimulation.
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Please be advised there are two sections on this topic, one by Dr. Stanley Ducharme, a sex therapist, and one by Dr. Ricardo Munarriz, a sexual medicine physician.
For men, erectile dysfunction and ejaculatory problems are the most common sexual difficulties. With the introduction of Viagra however, problems of erectile dysfunction are much less frequent and more easily treated. In contrast, ejaculatory problems continue to be commonplace among men and often create feelings of shame and embarrassment for those men who struggle with this difficulty. When does an ejaculation problem become a disorder?
This is a subjective question and is based on the level of distress that is experienced by the man or his partner. The time from initiating sexual activity to ejaculation varies from one individual to another.
This time period is called the ejaculatory latency. What may be a problem for one man may be acceptable to another. Typically, ejaculatory disorders fall into two categories. These are: delayed ejaculation and early ejaculation. This column will explore some of the psychological factors and treatment options related to these two distinct male dysfunctions.
In the vast majority of cases, the most effective therapeutic approach for ejaculatory dysfunction is a combination of biologic and psychologic therapy. In this way, both the emotional and physical aspects of the problem can be addressed. From an emotional standpoint, it is important to understand the history and background of the individual. Issues such as depression, anxiety, past sexual experiences, psychological trauma and relationship history are important considerations that need to be discussed early in the evaluation.
Regardless of the psychological issues, a good medical or urologic work-up is always encouraged before embarking on a behavioral treatment program. In this manner, any medical considerations that contribute to the problem can to be understood from the onset.
From a medical perspective, ejaculatory dysfunction is often considered to be a nerve related issue. In such cases, penile sensitivity may be evaluated using various instruments that produce vibration. In addition, a medical history is obtained paying particular attention to any previous neurologic injury or trauma to the penis.
Other sexual dysfunctions such as low desire and erectile dysfunction may also accompany the ejaculatory problem and need to be addressed. The psychological definition of delayed ejaculation refers to the inability to have an ejaculation during sexual intercourse. Interestingly enough, ejaculatory issues are rarely defined as a dysfunction if they occur only during masturbation. As a result, an important diagnostic question for sex therapists is the context in which the problem occurs.
Does this difficulty occur with self-stimulation, with all partners or with specific partners? This question will ultimately be important as a treatment program is designed and implemented. Problems of delayed ejaculation tend to be somewhat rare and not well understood by psychologists and sex therapists.
In addition, they are not well understood by most medical doctors and urologists. It is not unusual for doctors to minimize the dysfunction and to dismiss it. For many men, finding the right professional, who has experience and realizes the seriousness of the problem may be one of the most difficult aspects in the treatment process.
In many cases, the man himself may tend to delay treatment or to minimize the distress of the situation. At other times, there is the hope that ejaculatory problems will disappear without proper treatment.
Unfortunately however, problems such as delayed ejaculation seldom disappear without professional intervention. For many men, feelings of shame prevent them from seeking medical and professional help. In spite of the lack of information regarding delayed ejaculation, the most successful approach, for sex therapists, is to engage both members of the couple into addressing the problem.
Resolving the problem is most successful when both partners can work together as a team toward a successful solution. If the man is in a relationship, he needs the support and understanding of his partner. This helps to insure a successful treatment. Overcoming an ejaculation problem when under stress and pressure from a partner is extremely difficult for any man. Ejaculatory problems can have a devastating affect on self-esteem. Men with ejaculation problems undoubtedly have feelings of inadequacy, feelings of failure and a negative view of themselves.
They feel that they have little to offer in a relationship and to tend to avoid emotional and physical intimacy. Over time, partners become frustrated and communication becomes strained. Thus, resentments, anger and feelings of rejection often accompany an ejaculation problem. Ejaculation problems may also contribute to a low libido and lack of interest in sexual activity. Without ejaculation, sex can become a source of frustration and devoid of satisfaction.
As a result, sexual activity can be perceived as more work than pleasure. In some cases, the woman may not be interested in sexual intimacy because of her frustration and anger at the situation. Ultimately in such cases, couples agree to avoid sexual contact rather than face the emotional pain of another sexual failure. For some men, there may be additional psychological issues that underlie an ejaculatory dysfunction.
For example, there may be issues of performance anxiety related to infertility, fears of rejection or the desire to please a partner. Early psychological trauma can also be a significant factor. If sexual abuse of the man has occurred, these can have a direct correlation to the sexual dysfunction itself. Sex can serve as a trigger to bring back painful emotional feelings and memories from the past.
Ignoring these important emotional issues can lead to difficulties resolving the problem or to a future re-occurrence of the sexual dysfunction. Traditional behavioral sex therapy for delayed ejaculation is as follows: the man begins by masturbating, then starts intercourse when he is almost ready to ejaculate; the procedure continues with the man beginning intercourse earlier and earlier.
The partner may assist the man to masturbate and maintains a supportive and encouraging attitude. Sensitivity may be improved with the use of androgens such as testosterone or by using a vibrator.
In contrast to delayed ejaculation, early ejaculation difficulties are much more common and frequently seen in sexual medicine clinics.
The literature suggests that early ejaculation is the most common of any male sexual difficulties. It is certainly one of the most stressful.
By definition, early ejaculation is an ejaculation that occurs before it is desired. Typically, the ejaculation has become inevitable either during foreplay or in the first moments following penetration.
In spite of his best efforts, the man experiences a sense of helplessness in controlling his ejaculation. A significant amount of distress from the man or his partner almost always accompanies an early ejaculation. The partner feels equally unsatisfied and frustrated. Psychologists and sex therapists tend to view ejaculatory control as a skill that is mastered via masturbation during adolescence and early adulthood.
As a result, most men ejaculate quickly in their early sexual years when they are young and inexperienced. With masturbation, the adolescent or young man learns various techniques that allow him to maintain a high level of arousal without ejaculating. As the young man becomes sexually active with a partner, these skills can then be transferred to his new sexual encounters.
As the man becomes more sexually experienced, latency of ejaculation increases although not always to the satisfaction of the man and his partner. In addition to early sexual experiences, family attitudes toward sexuality as well as cultural and religious beliefs all play a role in sexual development and ejaculatory control. For example, when a boy is young he may feel rushed or ashamed about masturbation; he may feel guilty because of religious or cultural values; he may feel conflicted regarding self-pleasuring.
Such circumstances may provide the groundwork for future problems with sexual desire, erections or ejaculation. In other cases, these early messages may lead to areas of conflict regarding trust and intimate relationships. Although less common, some men develop early ejaculatory problems later in life. After years of satisfying sexual experiences, these men suddenly find themselves struggling to maintain ejaculatory control.
Sometimes, these problems develop with a new partner, after a divorce, during periods of stress or when dealing with infertility issues. At other times, there may be no clear precipitating events to the onset of a early ejaculation pattern.
Essentially, treatment for these cases is similar to younger men but psychological issues are probably even more critical to address. As mentioned, the most effective approach is a combination of psychological assistance and medical intervention. In this way, the man can quickly achieve positive sexual experiences and gain a sense of confidence. Urologists and other medical doctors typically treat early ejaculation with a combination of medications and creams. Anti-depressant medications such as Paxil and Zoloft are often prescribed and are taken by the patient 2 hours prior to sexual activity.
If this is not effective, the patient is further instructed to take the medication on a daily basis rather than before sexual activity. The dosages are usually adjusted as the patient progresses. Viagra is also prescribed for many men with early ejaculation. Viagra helps to maintain the erection after ejaculation and reduces the refractory time before a second erection can be obtained. These medications may be combined with various creams aimed at reducing sensitivity.
After successful intercourse and renewed confidence, men begin to learn the signs of pending ejaculation and ultimately learn to gain increased control. Sex therapy for early ejaculation includes learning a behavioral program designed to improve self-control. In a therapeutic program, the first step is usually education. The partner must also understand that the man is not being selfish and that ejaculatory control is unsatisfying for him as well.
These techniques, originally developed by Masters and Johnson, require patience, practice and a commitment to solving the problem. Specific instructions are adapted to the individual and unique characteristics of each patient. With the instructions from the therapist, the patient begins a series of daily masturbatory exercises designed to help him understand his ejaculation pattern and gain control.
Then my wife started to progress through menopause so we had additional challenges. Over time, partners become frustrated and communication becomes strained. You're right Submitted by Michael Castleman M. He didn't penetrate meaning he didn't go inside my vagina but our genitals were just close. So I mostly wait for her to initiate and then respond eagerly. But if you smoke, are overweight, drink a lot, eat steak every day, and don't exercise, your chances of having problem-free erections at age 60 are significantly reduced.
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Ejaculation Problems: Too Fast, Too Slow or Not at All? » Sexual Medicine » BUMC
Delayed ejaculation DE is a poorly defined and uncommon form of male sexual dysfunction, characterized by a marked delay in ejaculation or an inability to achieve ejaculation.
It is often quite concerning to patients and their partners, and sometimes frustrates couples' attempts to conceive. This article aims to review the pathophysiology of DE and anejaculation AE , to explore our current understanding of the diagnosis, and to present the treatment options for this condition. Despite the many publications on this condition, the exact pathogenesis is not yet known. The history is the key to the diagnosis. Treatment should be cause-specific.
There are many approaches to treatment planning, including various psychological interventions, pharmacotherapy, and specific treatments for infertile men. An approved form of drug therapy does not exist. A number of approaches can be employed for infertile men, including the collection of nocturnal emissions, prostatic massage, prostatic urethra catheterization, penile vibratory stimulation, probe electroejaculation, sperm retrieval by aspiration from either the vas deferens or the epididymis, and testicular sperm extraction.
Despite the confusion in terminology, men diagnosed with DE experience difficulties in ejaculation and orgasm. Sometimes both may occur during self-masturbation or manual, oral, vaginal, or anal stimulation by the partner. In that document, the terminology DE is meant to describe any and all of the ejaculatory disorders that result in a delay or absence of ejaculation. Ejaculatory latency is defined as the time it takes for a man to achieve ejaculation. For research purposes, this is often defined as the intravaginal ejaculation latency time IELT , which is the time taken by a man to ejaculate during vaginal penetration.
The Third International Consultation on Sexual Medicine defined DE as an IELT threshold beyond 20 to 25 minutes of sexual activity, as well as negative personal consequences such as bother or distress [ 5 ]. The to minute IELT criterion was chosen primarily because it represents a threshold of more than 2 standard deviations above the mean found in population-based studies of IELT.
Perelman [ 6 , 7 ] criticized this time frame for ignoring 2 important findings: a most men seeking help for DE pursue treatment because of its impact on coitus, and b most men's IELT range is approximately 4 to 10 minutes [ 8 , 9 , 10 ]. There seems to be a general agreement that low rates of DE are reported in the literature, and it appears to be the least common form of male sexual dysfunction.
Nonetheless, DE appears to be positively related to age [ 18 , 19 , 20 ], and its prevalence differs among races [ 17 ].
While some women enjoy the prolonged IELT, others may experience pain, question their own attractiveness, or suspect the partner's infidelity [ 21 ]. Ejaculation involves emission, bladder neck closure, and expulsion ejaculation proper.
In emission, seminal fluid is delivered to the posterior urethra. During expulsion, the bulbocavernosus muscle, synchronized with the pelvic floor muscles, contracts to expel semen in an antegrade fashion through the anterior urethra. Generally, this reflex is controlled by both sympathetic and somatic neural inputs, as well as sensory inputs. Many neurotransmitters such as serotonin, dopamine, and norepinephrine play roles in ejaculatory physiology. Orgasm is a purely cerebral experience that usually, but not always, coincides with ejaculation.
On one hand, it was argued that DE may be caused by psychosexual, psychosocial, or relationship problems. On the other hand, it has been argued that DE is caused by genetic, neurobiological, endocrine, anatomic, and infectious factors, or may be drug-induced.
Many of these etiologic factors are not supported by good evidence-based data, but rather are based on case reports and case series. These etiological factors—organic and psychogenic etiologies—are neither independent nor mutually exclusive and may well interact with each other, and their pathological effects may vary between individuals [ 1 , 2 , 13 ]. Multiple proposed psychogenic factors may contribute to the pathogenesis of DE Table 1. Althof [ 23 ] summarized these proposed psychogenic factors into 4 theories based on empirical support:.
This theory was proposed by Masters and Johnson [ 24 ] and Bancroft [ 25 ]. This theory perceives DE as being due to insufficient penile or mental stimulation, often associated with aging or diminished penile sensation.
The main predictions of this theory were supported by findings from multiple studies [ 26 , 27 , 28 ]. Rowland et al [ 26 ] reported that men with DE had no apparent somatic etiology and experienced less sexual arousal than normal men. Additionally, Xia et al [ 28 ] noted that patients with primary DE appeared to have penile shaft, rather than glans, hyposensitivity and hypoexcitability. This theory stated that some men with DE tend to prefer unusual methods of masturbation over heterosexual intercourse with their partner.
Perelman and Rowland [ 14 ] and Perelman [ 30 ] identified 3 factors that disproportionately characterized patients with DE: a high-frequency masturbation age-dependent mean of greater than 3 times per week , b idiosyncratic masturbatory style masturbation technique not easily duplicated by the partner's hand, mouth, or vagina , and c disparity between the reality of sex with a partner and their preferred masturbatory fantasy.
It conceptualizes DE as a subtle and disguised sexual desire disorder masquerading as DE. According to this concept, these patients mainly prefer solo masturbation, rather than partnered sex. And 4 the fourth theory considers DE as an outgrowth of a psychic conflict, making it psychodynamic in origin. The following conflicts have been reported: a different types of fear see Table 1 ; b hostility toward one's partner; c unwillingness to give oneself; and d guilt from a strict religious upbringing [ 23 ].
An age-dependent increase in the prevalence of DE was reported in various studies [ 33 , 34 , 35 ]. This finding may be related to decreased penile sensitivity with age, which has been attributed to possible ultrastructural or degenerative age-related changes in the penile receptors [ 36 , 37 , 38 ], leading to progressive axonal sensory loss [ 39 , 40 ]. Other factors include age-related comorbidities, such as depression, diabetes, or late-onset hypogonadism [ 19 ], or medical, surgical, or radiation therapy for a number of age-related diseases that can affect ejaculatory function [ 41 , 42 ].
Additionally, some researchers have hypothesized that DE is caused, at least in part, by slower bulbocavernous reflexes and reduced spinal stimulation associated with aging [ 43 , 44 ].
DE is marked by etiological complexity it is multifactorial and many cases are idiopathic , and a range of severity from DE to AE [ 1 , 5 , 45 ]. In addition, ejaculatory latency is greatly variable [ 8 , 10 ]. Unfortunately, a Finnish twin study showed that genetics influenced premature ejaculation PE , but not DE [ 46 ]. These results suggest that this topic may warrant further investigation. Patients who receive serotonergic antidepressants frequently report sexual dysfunction.
The significant heterogeneity in the occurrence and the presentation of SSRI-related sexual dysfunction may suggest underlying genetic factors [ 50 ]. Table 2 summarizes the results of these studies. These findings require replication before firm conclusions can be drawn. The finding of significant variability in IELT values among the general population—from 0. Men with a genetically determined higher ejaculatory threshold set point could sustain more prolonged and intense sexual stimulation and could exert more control over ejaculation [ 64 ].
Accordingly, life-long primary DE with a very high set point, like lifelong PE, is considered to be primarily a neurobiological variant. Presumably, affected individuals suffer from a susceptibility that interacts with a variety of psychosocial, environmental, cultural, and medical risk factors to result in DE [ 6 ].
A full discussion of each factor is beyond the scope of this review. New etiologies continue to be added to the list of causes. The prevalence of ejaculatory dysfunction appears to increase as time elapses after radiation therapy. However, the influence of these neurological factors on ejaculation is due to more than just neurological reasons, as the accessory sexual glands and pathway for semen are removed or injured during radical pelvic surgery.
Moreover, sexual dysfunction is a multidimensional construct of numerous bio-psychosocial factors that can be influenced by surgery in a variety of ways, including impacts to a patient's cosmetic appearance, psychological state, preoperative radiation, stoma formation in rectal cancer, surgical complications, and increased age. In a population-based study [ 73 ] inability to reach orgasm with masturbation was slightly more prevalent Erectile dysfunction, PE, and painful ejaculation are the leading sexual symptoms of urogenital infections.
Urogenital infections can produce scarring and obstruction anywhere in the male reproductive tract. Once again, there is weak evidence of an association between hyperprolactinemia and DE [ 78 ]. Different medications may interfere with either central or peripheral control of ejaculation, potentially affecting the IELT Table 3. A list of an assessment steps that might be helpful in the evaluation of the patient is presented in Fig.
Ejaculation occurs in the genitals, whereas orgasm is a central sensory event with significant subjective variation. Ejaculation and orgasm usually occur together, but not always. The sensation of orgasm in the absence of antegrade ejaculation suggests retrograde ejaculation, absence of puberty, or genital tract obstruction. The evaluation may involve determining whether DE is lifelong or acquired and global or situational. If a man is only able to ejaculate through masturbation, it is important to assess whether he has an idiosyncratic masturbatory style [ 7 , 21 ].
Physicians need to carefully balance the risk of missing serious causes with the wise use of often scarce and costly investigative resources, especially in developing countries. Sometimes the diagnosis of the risk factor s unfolds over time and across several episodes of care. In addition, the etiologic diagnostic process can also extend across multiple specialties and in different locations. There are many approaches to treatment planning.
A rigid treatment plan is not suitable for all patients. Factors that affect the choice of treatment strategies may include:. This implies the active involvement of other specialties in the management of the condition. These factors have been shown to affect professional behavior [ 82 ].
In these cases, treatment should be cause-specific. Neurogenic AE is usually irreversible, and thus the patient might be counseled to seek alternative methods to improve patient and partner satisfaction. A positive cremasteric reflex in patients with SCI suggests intact emission, and patients should be encouraged to attempt ejaculation or to explore possible retrograde ejaculation [ 83 ].
Unfortunately, in the latter study, ejaculatory dysfunction was not one of the inclusion criteria. Autonomic and somatic nerve preservation is indispensable to minimize postoperative sexual sequelae regardless of the surgical approach posterior, lateral, anterior, or perineal dissection. Men of reproductive age should be informed of the risk of infertility due to AE following radical pelvic surgery and the need for sperm harvesting and assisted reproductive techniques.
For example, a patient's preference preference regarding the partner's participation is more critical to successful outcomes than the partner's attendance at all office visits [ 90 ]. And 8 success depends on the patient's willingness and capacity to follow various interventions [ 6 ]. Paying special attention to psychogenic factors may additionally reinforce the therapeutic success of some patients. These include but not limited to: a cognitive behavioral therapy and sex education; b masturbatory retraining and adjustment of sexual fantasies; c psychotherapy targeting the areas of conflict and sensate focus exercises; d altering one's orientation from oneself to one's partner; e sexual anxiety reduction by teaching the individual mindfulness and breathing techniques, progressive relaxation, and increasing sensory tolerance; f couples' sex therapy and the use of interactional techniques; and g the sexual tipping point model, which emphasizes the utility of a biopsychosocial-cultural perspective combined with special attention to the patient's narrative.
Treatment is patient-centered and holistic, and integrates a variety of therapies as needed [for more details see ref. Generally, these psychological maneuvers appear to be effective in case reports and case series but none have been properly evaluated in large-scale studies. However, an approved drug does not exist. These medications facilitate ejaculation by different mechanisms of action Table 4 , have limited success, and may lead to significant side effects.
The choice of drug should be guided by etiologic factors, illness characteristics DE or AE , the patient's preferences, the clinical evidence, and the physician's comfort with different drugs. Of interest is the recent single-case report of the successful oral administration of 60 mg of lisdexamfetamine dimesylate a prodrug that is converted by the liver to the active dextroamphetamine.