Disorders of Male Orgasm and Ejaculation
Overview of Ejaculatory Disorders
Male ejaculatory and orgasmic disorders encompass premature ejaculation (PE) and delayed ejaculation (DE), both requiring distress and loss of ejaculatory control for diagnosis, with treatment centered on behavioral interventions, psychosexual therapy, and off-label pharmacotherapy. 1
Key Definitions
Premature Ejaculation:
- Lifelong PE: Ejaculation within approximately 2 minutes of penetration, poor ejaculatory control, associated bother, present since sexual debut 1
- Acquired PE: Markedly reduced ejaculatory latency from prior sexual experience, with poor control and associated bother 1
- Normal median ejaculatory latency time (ELT) in Western countries is 5-6 minutes 1
Delayed Ejaculation:
- Lifelong DE: Lifelong, consistent, bothersome inability to achieve ejaculation or excessive latency despite adequate stimulation and desire to ejaculate 1
- Acquired DE: Acquired, consistent, bothersome inability to achieve ejaculation or increased latency despite adequate stimulation and desire to ejaculate 1
- Men with latencies beyond 25-30 minutes who report distress, or who cease sexual activity due to partner's request, fatigue, or ejaculatory futility qualify for diagnosis 1
Management of Premature Ejaculation
First-Line Treatment Approach
Behavioral therapy combined with pharmacotherapy provides superior outcomes compared to either modality alone for PE. 1
Pharmacotherapy Options (all off-label):
- SSRIs are the primary pharmacologic treatment, with sertraline causing ejaculatory failure in 14% of men (primarily delayed ejaculation) compared to 1% with placebo 2
- Topical anesthetics can be used to reduce penile sensitivity 3
- Men with comorbid erectile dysfunction should receive ED pharmacotherapy as part of PE management 3
Behavioral Interventions:
- All men seeking PE treatment should receive basic psychosexual education 3
- Graded behavioral therapy is indicated when psychogenic or relationship factors are present 3
- Behavioral therapy is best combined with pharmacotherapy in an integrated treatment program 3
Surgical Management
Surgical management of PE (including dorsal nerve neurotomy, radiofrequency ablation, or hyaluronic acid augmentation) should be considered experimental and only performed in ethical board-approved clinical trials due to risk of permanent penile sensation loss. 1
Management of Delayed Ejaculation
Initial Management Strategy
Referral to a mental health professional with sexual health expertise should be considered for all men with lifelong or acquired DE, as psycho-behavioral strategies enhance psychosexual arousal and remove barriers to sexual excitement. 1
Behavioral modifications to increase arousal may benefit men with DE, including alternative sexual practices, scripts, and sexual enhancement devices. 1
Medication Management
First, review and modify medications that may contribute to DE through replacement, dose adjustment, or staged cessation. 1
Pharmacotherapy options for DE (all off-label):
| Drug | PRN Dosage | Daily Dosage |
|---|---|---|
| Oxytocin | 24 IU intranasal/sublingual during sex | — |
| Pseudoephedrine | 60-120 mg (120-150 minutes prior to sex) | — |
| Ephedrine | 15-60 mg (1 hour prior to sex) | — |
| Midodrine | 5-40 mg (30-120 minutes prior to sex) | — |
| Bethanecol | — | 20 mg daily |
| Yohimbine | — | 5.4 mg three times daily |
| Cabergoline | — | 0.25-2 mg twice weekly |
| Imipramine | — | 25-75 mg daily |
Cabergoline shows promise: In a retrospective study of 131 men, 66.4% reported subjective improvement in orgasm with cabergoline 0.5 mg twice weekly, with longer duration of therapy and concomitant testosterone therapy associated with better response 4
Diagnostic Workup
Check morning testosterone levels in men with DE, as ejaculatory dysfunction increases with progressively lower serum testosterone levels. 1
Consider basic serum studies including electrolytes, lipids, and glycosylated hemoglobin to identify conditions predisposing to neuropathy or vascular disease. 1
In men with biochemically low testosterone and symptoms, offer testosterone replacement therapy per AUA guidelines. 1
Comorbid Erectile Dysfunction
When DE and ED coexist, define the chronology of their relationship—when DE precedes ED, focus on DE management first; treat ED according to AUA ED guidelines. 1
Retrograde Ejaculation
First-line treatment for retrograde ejaculation in men seeking fertility is sympathomimetic medications, with pseudoephedrine 60-120 mg taken 120-150 minutes prior to ejaculation showing the highest success rates for converting retrograde to antegrade ejaculation. 5
Alternative options include:
- Imipramine 25-75 mg daily 5
- Urine alkalinization with urethral catheterization after ejaculation to retrieve sperm from bladder 5
- Assisted reproductive techniques (penile vibratory stimulation, electroejaculation, surgical sperm retrieval) when medical therapy fails 5
For medication-induced retrograde ejaculation, consider dose reduction or medication substitution before adding sympathomimetics. 5
Other Ejaculatory Disorders
Pain with ejaculation/orgasm has multiple potential etiologies and may be part of chronic pelvic pain syndrome—assessment for related contributory diagnoses is warranted. 6
Hematospermia is often benign but distressing—management focuses on detecting potentially reversible etiologies when indicated. 6
Climacturia (urine loss with orgasm after prostate surgery) may benefit from behavioral therapy, physical therapy, and surgical intervention. 6
Management strategies for anhedonic orgasm and post-orgasmic illness syndrome are not well established. 6
Critical Clinical Considerations
No medications for PE or DE have FDA approval—all pharmacotherapy is off-label use. 1
Shared decision-making is fundamental in managing ejaculatory disorders, with involvement of sexual partners when possible to optimize outcomes. 1
Age is one of the most significant factors in DE, combining psychological and physiological processes—age-related increases in latency may be managed with psychological and behavioral approaches aimed at increasing arousal. 1
SSRIs commonly cause sexual dysfunction: sertraline causes decreased libido in 6% of patients (vs 1% placebo) and ejaculation failure in 14% of male patients (vs 1% placebo). 2
A multimodal approach combining psychosexual therapy with medications and/or penile vibratory stimulation likely provides the best outcomes for DE. 7