Q What would cause a man, who can get and maintain a good erection, have trouble or actually not able to ejaculate while having intercourse? Is this common? Can it occur in Gay as well as heterosexual men?
Most often, the man who is sexually aroused but is unable to ejaculate intravaginally is suffering from retarded ejaculation, now officially called Male Orgasmic Disorder. This condition has been called by many names, such as inhibited male orgasm, delayed ejaculation, and ejaculatory over-control, to name a few .(1, 2, 3) Surprisingly, many medical professionals have not heard of this disorder.
Research on this disorder is sparse and mostly old. Consequently, there is a paucity of data on the prevalence of RE. Based on these data, we may infer an incidence of 3% to 7% of the adult male population in the United States, (4, 14) but it is likely that the number of men affected is greater than suspected. (1) Although it is seldom mentioned in the literature, gay men also suffer delayed or retarded ejaculation.
The DSM IV TR uses "Male Orgasmic Disorder" as the current term to describe what was formerly known as Retarded Ejaculation. "The essential feature of Male Orgasmic Disorder is a persistent or recurrent delay in, or absence of, orgasm following a normal sexual excitement phase. In judging whether the orgasm is delayed, the clinician should take into account the persons age and whether the stimulation is adequate in focus, intensity and duration. The disturbance must cause marked distress or interpersonal difficulty". (3) Organic causes, which are rare, must be excluded.
The most common presentation of Male Orgasmic Disorder is the male who has no problem attaining or maintaining an erection. He is not, however, able to reach orgasm during intercourse but can with his partner's oral or manual stimulation. Some men after prolonged noncoital stimulation can quickly penetrate and reach coital orgasm. Some can ejaculate only with masturbation and a very small group, only experience ejaculation nocturnally.
Usually, Male Orgasmic Disorder presents as situational, relating to a specific person or circumstance relevant to the sexual activity. The more severe case of this disorder is the generalized form, where the man has never ejaculated in his entire life, regardless of the intensity of the sexual stimulation or its source. In such a man, the problem is not dependent on the specific situation or relationship. (6)
The pathogenesis of Male Orgasmic Disorder is rarely organically based and is probably similar to the difficulty of starting the urinary stream (sometimes known as bashful bladder), globus hystericus, and some forms of constipation.( 7) These functions are all autonomic-mediated reflexes. Emotional arousal, whether from psychological conflict, involuntary defense mechanisms or other sources of unconscious conflict can inhibit this autonomic reflex. (8, 9)
Organic etiologies of retarded ejaculation are rare. Autonomic neuropathy from diabetes, spinal cord lesions, regardless of origin and multiple sclerosis can interfere with neural transmission between the brain and the genitals. (6, 7, 10, 15) Absent or delayed ejaculation can be a result. Retroperitoneal surgeries may cause retrograde or complete ejaculatory failure. Testosterone is known to modulate sexual function. Moderately low testosterone levels may inhibit the ejaculatory reflex while sparing erectile function.
Without question, the most common presentation of complete ejaculatory failure or delay is iatrogenic. It has long been suggested that serotonin has a dampening effect on sexual function.(11) It is therefore not surprising that the selective serotonin reuptake inhibitors (SSRIs) are the most common cause of drug-induced ejaculatory delay or absence, and can also cause problems with libido and erectile function. (5, 12, 13) The drugs most commonly named in this connection include Prozac, Paxil, and Zoloft.
Q What techniques are used to treat this disorder?
Once side effects of medications are excluded, a psychological etiology is almost a certainty. A cognitive behavioral approach can be successfully used to facilitate treatment by means of two basic principles. The first is a series of highly individualized behavioral prescriptions used to establish an association between the penetrative sexual act and ejaculation. The second and most crucial step is pairing intense stimulation with distraction from ejaculatory vigilance. (9)
Since most retarded ejaculators can ejaculate under some circumstances, progressive desensitization can bring the ejaculatory reflex to the desired goal of ejaculation during penetration or coitus. The behavioral prescriptions to accomplish this are highly individualized. Lone masturbation is prohibited once the man is reliably able to ejaculate in the presence of his partner. Finally coitus with simultaneous partner stimulation allows the man to "signal" when orgasm is near and allow coital thrusting to bring about actual orgasm.
To reduce autonomic over-stimulation, which can suppress the ability to release the ejaculatory reflex, the patient is taught different methods of distraction to be used during stimulation. The distraction could be in the form of imagery, fantasy, erotic literature or videos, talking or creating fantasy or an "erotic scene" to be acted out. The absorption in erotic activity or fantasy is an ideal way of attenuating ejaculatory over monitoring and releasing the ejaculatory reflex.
The author notes a personal case study to illustrate a critical part of the treatment of Male Orgasmic Disorder. M was a 37 year old male married to a 29 year old female. For the entire seven years of their marriage he was not able to ejaculate in her presence. They related one success which confused them. Every year M. and his wife would accompany his father-in-law on a hunting trip. The hunting "camp" was the cramped sleeping quarters of an oversized tent. On one occasion, as they were lying very close to her father, M's wife sexually teased him and finally performed oral sex on him. With abject fear that his father-in-law may wake up, M. rapidly became "lost" in the pleasure of the sexual experience and ejaculated quite easily. Once they understood the significance of the distraction provided by the presence of the father, treatment resulted frequent vaginal ejaculation and much hoped for conception.
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medicine and rehabilitation (3rd. ed.) (pp. 724-745). Philadelphia, PA; Saunders
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