Lifelong Delayed Ejaculation

Psychological Approach

According to the classical psychological view, lifelong delayed ejaculation is attributed to fear, anxiety, hostility, and relationship difficulties (85-87). Many different manifestations of anxiety and fear have been hypothesized, including fears of death and castration, fear of loss of self resulting from loss of semen, fear of castration by the female genitals, fear that ejaculation would hurt the female, fear of being hurt by the female, performance anxiety, unwillingness to give of oneself as an expression of love, fear of impregnating the female, and guilt secondary to a strict religious upbringing.

The psychological ideas and explanations may have face validity in some individual cases, but there are no well-controlled studies that support a generalization of any of the various psychological hypotheses. The psychological, cultural, and religious factors that may lead to lifelong delayed ejaculation clearly requires further investigations.

Neurobiological Approach

Waldinger (1,5) postulates that lifelong delayed ejaculation is part of the biological variability of the IELT in men. According to this view, there is a variability in the extent of delayed ejaculation, from mildly delayed to severely delayed and lastly a failure of ejaculation. I suggest that this biological variability is related to genetic factors. In case this is true, it means that men may be born with a biological vulnerability to develop delayed ejaculation. Whether environmental factors affect the neurobiological vulnerability remains to be understood.

From animal and human studies, it is known that in particular it is the ser-otonergic system which is involved in ejaculation. On the basis of animal studies, I suggest that lifelong delayed ejaculation is related to a hyperfunction of the 5-HT2C receptor and/or a hypofunction of the 5-HT1A receptor. Whether dopa-mine and oxytocine play a role in lifelong delayed ejaculation remains to be elucidated.

Unfortunately there is no drug treatment available for delayed ejaculation in men. In animals, the 5-HT1A receptor agonist, 8-OH-DPAT, fastens the ejaculation latency, but such selective 5-HT1A agonists are not yet available for safe human use. Another possibility is a selective blockade of the 5-HT2C receptor. However, in a stopwatch controlled study in men with premature ejaculation, the 5-HT2C receptor blocking antidepressants, nefazodone and mirtazapine, did not lead to either delayed ejaculation or a faster ejaculation time.

Treatment of Lifelong Delayed Ejaculation

With every man presenting with delayed ejaculation, it is essential to obtain a full sexual and medical history and clinical examination of the patient. It is important to find out the situations in which ejaculation is impaired (location, sexual activity, specific partner), the frequency with which ejaculation is inhibited, the degree of delay of orgasm, whether the complaint existed from the first sexual encounters (lifelong) or occurred later in life (acquired), and whether orgasm and ejaculation are both lacking.

Various treatments have been used to treat men with delayed ejaculation: Vibratory and electrical stimulation, a variety of sexual exercises, and a range of psychotherapeutic techniques (88-91). These treatments have been used separately or in combination with one or more others. Research on the effectiveness of these treatments is limited to uncontrolled studies on individual patients or short series of patients (92). Controlled studies are not available.

By vibratory stimulation (93) of the penis an ejaculation can be induced. The percentage of success to cure lifelong delayed ejaculation, however, is unknown. Electrical stimulation (94) of the internal ejaculatory organs by a transrectal electrical probe (electro-ejaculation) is mainly used to obtain semen in paraplegic men. This intervention is extremely painful in men with normal sensation and is not an option to treat lifelong delayed ejaculation. Masturbation exercises have been extensively used in the treatment of delayed ejaculation. Kaplan (85) describes a method in which a period of undemanding sensate focus exercises is followed by a period in which a man masturbates, initially alone and subsequently in circumstances in which he becomes gradually closer to his female partner. Once the patient has had an orgasm in the presence of his partner, he masturbates in a number of steps in which the penis is closer to the vagina during masturbation. Finally, he enters the vagina and combined coital and manual stimulation is then used to induce ejaculation. Apart from masturbation exercises, individual psychodynamic psychotherapy, marital therapy, rational emotive therapy, and social skills training have been used to treat delayed ejaculation. Because controlled studies are not available, it is very difficult to evaluate the results. The overall impression of these different approaches is that some patients are actually cured after treatment although most patients are only somewhat improved or unchanged. In the absence of comparative studies, it is not possible to compare the effectiveness of different treatments. A major methodological impairment is that in most studies, outcome is assessed by means of a single statement ("improved," "cured," or "unchanged"), more specific information on ejaculation is lacking, and that treatment has not been standardized in most studies. Because of these methodological deficiencies, no firm conclusion or recommendation on the optimal treatment approach can be given (92). Currently, the best way to treat men with lifelong delayed ejaculation is to inform patients beforehand that success of psychotherapy cannot be guaranteed, but that it may be worth trying, as effective drug treatment is not yet available. At present, a combination of masturbation exercises and general therapeutic interventions may have a chance for success.

In spite of the above-mentioned treatment options, it is generally believed that lifelong retarded ejaculation is difficult to treat. In my opinion, continuous psychological, cultural of religious factors prohibiting sexual feelings may perhaps lead to a release of stress hormones that might disturb the full development of or even damage cerebral areas and neuronal pathways that are important for the ejaculation process. This might be one of the reasons that although psychological factors may heavily contribute to retarded ejaculation, psychotherapy alone is often hardly effective. Further research of lifelong retarded ejaculation is of utmost importance to unravel the neurobiology and interaction with psychological factors of this distressing ejaculatory disorder.

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Responses

  • marjorie
    What is transrectal electrical stimulation for delayed ejaculation?
    3 years ago

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