Can low testosterone (hypogonadism) cause premature ejaculation in a male patient of reproductive age?

Low Testosterone Does Not Cause Premature Ejaculation—It Actually Protects Against It

Low testosterone (hypogonadism) does not cause premature ejaculation; in fact, the opposite is true: higher testosterone levels are associated with premature ejaculation, while low testosterone is linked to delayed ejaculation. 1, 2, 3

The Testosterone-Ejaculation Relationship

The evidence consistently demonstrates that testosterone plays a facilitatory role in the ejaculatory reflex, meaning higher levels accelerate ejaculation while lower levels delay it 1, 3:

In Young Men (Ages 25-40)

• Men with premature ejaculation have significantly higher total and free testosterone levels compared to men without ejaculatory dysfunction 1
• The prevalence of hypogonadism is lowest (12%) in men with premature ejaculation 1

In Older Men (Ages 55-70)

• Men with delayed ejaculation have significantly lower testosterone levels 1
• The prevalence of hypogonadism is highest (26%) in men with delayed ejaculation 1

The Continuum Effect

• Ejaculatory function exists on a spectrum from severe premature ejaculation to anejaculation 3
• Testosterone levels progressively decrease as you move from premature ejaculation toward delayed ejaculation and anejaculation 3
• This relationship remains significant even after adjusting for age and libido (HR = 0.75 for PE vs. 1.83 for DE) 1

Secondary Premature Ejaculation: The Exception

There is one specific scenario where low testosterone may contribute to premature ejaculation—secondary (acquired) premature ejaculation in men who previously had normal ejaculatory control 4, 2:

• Men with secondary PE have significantly lower testosterone concentrations compared to those with lifelong PE 2
• In testosterone-deficient men with secondary PE, testosterone replacement therapy increased intravaginal ejaculation latency time by 4.8-fold (compared to only 1.8-fold with dapoxetine) 2
• This suggests that when a man develops PE after previously having normal control, and he has documented hypogonadism, testosterone deficiency may be a contributing factor 2

Clinical Algorithm for Ejaculatory Dysfunction

If Patient Presents with Premature Ejaculation:

1. Determine if lifelong (primary) or acquired (secondary) 4

   • Lifelong PE: Do not measure testosterone—it is unlikely to be low and treatment focuses on SSRIs, topical anesthetics, or behavioral therapy 4
   • Secondary PE: Proceed to step 2

2. For secondary PE only: Measure morning total testosterone (8-10 AM) 4, 5

   • If testosterone >300 ng/dL: Hypogonadism is not the cause; pursue other etiologies 4
   • If testosterone <300 ng/dL: Repeat measurement and measure LH/FSH 4, 5

3. If confirmed hypogonadism in secondary PE: Consider testosterone replacement therapy 2

   • Expected outcome: 4.8-fold increase in ejaculatory latency time 2
   • Monitor for improvement at 3 months 5

If Patient Presents with Delayed Ejaculation:

1. Always measure morning testosterone (8-10 AM on two separate occasions) 4, 1

   • Delayed ejaculation has the strongest association with low testosterone among all ejaculatory disorders 1, 3

2. If testosterone <300 ng/dL: Measure LH/FSH to distinguish primary from secondary hypogonadism 4, 5

3. Initiate testosterone replacement therapy if confirmed hypogonadism 6

   • Transdermal testosterone gel 40.5 mg daily is first-line 4
   • Alternative: Testosterone cypionate 100-200 mg IM every 2 weeks 5

Critical Pitfalls to Avoid

• Never assume low testosterone causes lifelong premature ejaculation—the evidence shows the opposite relationship 1, 3
• Do not routinely check testosterone in men with lifelong PE—it wastes resources and may lead to inappropriate treatment 4, 1
• Do not prescribe testosterone to eugonadal men with PE—this could theoretically worsen the condition given testosterone's facilitatory role 4, 7
• Always distinguish between primary and secondary PE—only secondary PE may have a hormonal component 4, 2

The Biological Mechanism

Both central and peripheral mechanisms explain testosterone's facilitatory effect on ejaculation 1:

• Centrally: Testosterone modulates serotonergic and dopaminergic pathways that control the ejaculatory threshold 1
• Peripherally: Testosterone influences smooth muscle contractility in the vas deferens and seminal vesicles 1
• The relationship is independent of other hormones (prolactin, TSH) and psychopathology 3

Summary of Evidence Quality

The most recent and highest-quality evidence comes from the 2025 European Association of Urology guidelines 4, which do not list premature ejaculation as a symptom of hypogonadism. The primary symptoms of hypogonadism are decreased libido and erectile dysfunction 4, 8. The research evidence consistently shows that low testosterone is associated with delayed ejaculation, not premature ejaculation 1, 2, 3, 6, 7.