Delayed ejaculation
Synonyms and keywords: Retarded ejaculation

# Overview
Delayed ejaculation, also known as retarded ejaculation and ejaculation incompetence, is the inability to ejaculate or persistent difficulty in achieving orgasm despite the presence of normal sexual desire and sexual stimulation. Normally a man achieves orgasm within 2-4 minutes of active thrusting during sexual intercourse, whereas a man with delayed ejaculation either does not orgasm at all or orgasms after prolonged intercourse which might last 30-45 minutes or more. In most cases delayed ejaculation presents the condition in which the man can climax and ejaculate only during masturbation, but not during sexual intercourse.

# Causes

## Psychological causes of delayed ejaculation
Psychological causes of delayed ejaculation might include numerous factors that prevent a man from achieving orgasm during sexual intercourse. One cause could be watching pornography to the extent that one becomes dependent on visual stimulation. The absence of these vivid and explicit images during regular intercourse could make ejaculation difficult or impossible.

## Physical causes
One of the main causes of delayed ejaculation is adaptation to a certain masturbatory technique. The sensations a man feels when masturbating may bear little resemblance to the sensations he experiences during intercourse. Both pressure, angle and grip during masturbation can make for an experience so different from sex with a partner that the ability to ejaculate is reduced or eliminated.
Physical causes of delayed ejaculation may imply some diseases and conditions which affect a man's ability to orgasm.. These include many neurological (for example stroke or damage to the back or spinal cord) and endocrine diseases (diabetes), prostate problems, some allergies and high blood pressure. As well difficulty in achieving orgasm can result from pelvic surgery that involved trauma to pelvic nerves which are responsible for orgasm.  Some men report a lack of sensation in the nerves of the glans penis, which may or may not be related to external factors, including a history of circumcision.
Delayed ejaculation might be a side effect of some medications, usually of some antidepressants. Another reason for delayed ejaculation is excessive use of alcohol. In this case physical and psychological causes might co-exist. Alcohol addiction often implies psychological disorders which cause a man to become nervous and jealous without any reason. Thus two causes join and deepen the problem.

# Differential Diagnosis
- Another medical condition
- Alcoholic neuropathy
- Diabetic
- Psychological issues
- Traumatic surgical injury
- Multiple sclerosis
- Dysfunction with orgasm
- Substance/medication use
- Antidepressants
- Antipsychotics
- Alpha sympathetic drugs
- Opioid drugs
- Vilazodone

# Epidemiology and Demographics

## Prevalence
The prevalence of delayed ejaculation is unknown. 

# Risk Factors
- Age (older than 50 years)

# Natural History,Complications and Prognosis

## Complications
Delayed ejaculation causes a great deal of complications for a man who suffers from it as well as for his partner. To be precise in some cases delayed ejaculation can even contribute to sexual satisfaction of female partner who can orgasm for a few times during long lasting intercourse. However, after some time this is likely to become annoying for both a woman and a man who in spite of all efforts cannot achieve orgasm or achieves it after very long time. With the course of time the situation gets worse: both partners begin avoiding sex contacts which do not result in orgasm. Consequently, both partners suffer from sexual dissatisfaction and become likely to lose sexual desire. Divorces and breakups are especially widespread among those couples who plan to have children but cannot conceive due to the male partner's inability to ejaculate inside the vagina.

## Prognosis
The following factors are signs of better outcome: having sexual desire, being in love with the sexual partner, being eager to get rid of the problem, absence of deep psychological problems, short duration of the disorder and having satisfying sexual experiences before.
Success of treatment for delayed ejaculation caused by medication recovery totally depends on whether the physician can discontinue the medication.

# Treatment
Treatment of delayed ejaculation depends on severity of the disorder and on its causes. For instance, a condition with no ejaculation at all may require urology, while e.g. absence of ejaculation only in sexual intercourse may be solved by sex therapy.

## Urology
If a man has never had ejaculation through any kind of sexual stimulation (such as vaginal or anal intercourse, oral sex, masturbation, wet dreams) then he should consult a urologist in order to find out whether there is a physical abnormality and then get necessary treatment which depends on the abnormality revealed.

## Sex therapy
If the disorder is not so severe and a man can ejaculate through some form of stimulation, he should apply to a sex therapist specializing in this area. This is very important in cases when a man can ejaculate through any form of stimulation but intercourse. Usually treatment for this disorder includes both partners.
Therapy usually involves homework assignments and exercises intended to help a man get used to orgasm through vaginal intercourse i.e through the way he is not accustomed to.
Commonly the couple is advised to go through three stages. At the first stage a man masturbates in the presence of his partner. Sometimes this is not an easy matter as a man might be used to orgasm alone. After a man learns to ejaculate in the presence of his partner, the couple gets to another stage where the man's hand is replaced with the hand of his partner. Step by step a man learns to ejaculate closer and closer to the vagina. In the final stage a woman inserts her partner's penis into her vagina as soon as she realizes he is about to ejaculate. Thus a man gradually learns to ejaculate inside the vagina.
The therapy described above clearly applies to a treatment of this problem within a heterosexual context. Since especially young men often are ashamed of acknowledging their problem, or anyway do not have a partner yet, some authors recommend alternatives to this start-stop technique. By training the ischiocavernosus muscle, young men can quickly train to hold an erection on their own.

## Other
If relationships in a couple are found problematic, therapy intended to enhance emotional intimacy might be required as preliminary step.
Some sexologists recommend sex toys such as the fleshlight to train the patient to respond to vaginal stimulation. This is especially effective in cases where the masturbatory technique is the source of the problem.
In some cases hypnosis can help with the problem, especially if a partner does not want to participate in therapy.
Naturally, if delayed ejaculation is caused by a disease, the disease is first of all treated. In those cases when delayed ejaculation is a side effect of medication the man's physician is to review other medication options.
In the case of alcohol addiction a man should get necessary treatment intended to help treat his addiction.
For many people it has proven to be the case that overly frequent masturbation on the part of the man is the root cause of his delayed vaginal ejaculation. Ceasing masturbation for a few days is often an effective and easy way to achieve more rapid orgasm during intercourse, because doing this will stop sensitization of the nerves in the penis. Also, different positions and rates of pelvic motion on the part of the female can be instrumental in achieving simultaneous orgasm.

# Diagnostic Criteria

## DSM-V Diagnostic Criteria for Delayed Ejaculation

# Prevention
First of all a man should have healthy attitude towards sexuality and his sexual response. He should be fully aware of the fact that anxiety and fears cannot contribute to a normal and satisfying sexual experience.
A man who wants to avoid ejaculation problems should concentrate on the pleasure he gets rather than worrying about when and whether his ejaculation is going to occur. The partner should also be tactful and should not put pressure on the man by asking him whether he has ejaculated or not. Instead a partner should create a relaxed atmosphere in which a man will feel free and enjoy sexual pleasure without worrying about ejaculation. And of course, open discussing of anxieties and fears contribute to better sexual relationships and normal sexual satisfaction.