Ejaculatory Disorders (Male)
Rapid (or premature) ejaculation is the commonest male sexual function concern. One-third of men feel they have rapid ejaculation. Contrary to popular myth, this remains stable across the age spectrum.1 Defining rapid ejaculation depends on each couple and their sexual interaction. For a heterosexual couple, does she have her orgasm with intercourse only, or is she orgasmic with “outercourse”: manual, oral, self, or other non-intercourse stimulation? The length of time that intercourse lasts is between 4 - 7 minutes for the average Canadian couple. Independent of the length of time of intercourse, is she (and he) satisfied with their sexual activity?
Men with rapid ejaculation often ejaculate unintentionally before, or immediately after the moment of penetration. This can be very distressing for both the man, who wishes nothing more than to last longer; and his partner, who in their own frustration might blame him for intentionally not attending to her needs.
Traditional treatment, the “stop-start” technique developed by Masters and Johnson12, uses graduated masturbation exercises to help the man recognize the stage of ejaculatory inevitability and reduce the amount of stimulation to remain below this threshold. These exercises are detailed in Bernie Zilbergeld’s book.
While initially successful in 90% of men, longer term maintenance remains much lower13 when traditional sex therapy methods are used alone.
While single men can be taught these exercises alone, they often have difficulties in generalizing gains in ejaculatory delay to their partners. Men who have difficulties in forming intimate relationships because of their anxiety about delayed ejaculation will often benefit more from assertiveness training before starting sex therapy.
Couple sex therapy involves helping the couple understand the physiological basis for rapid ejaculation, and that it is not something the man is doing intentionally to frustrate the partner. Acknowledging the partner’s feelings (often of frustration, at times of anger), and dealing with these is a cornerstone of therapy. Expanding the couple’s sexual repertoire beyond intercourse ways for both to achieve pleasure allows the negative pressures to abate. Then starting with the man self-pleasuring initially alone, he stimulates himself nearly to orgasm 3 times, before ejaculating the 4th time. Through practice, he gradually gains the ability to pull back from the point of ejaculatory inevitability. Once this is achieved, the partner can be introduced, initially with their dry hand, then with lubricant, and eventually with genital contact. Having the partner on top initially puts the least pressure to ejaculate on the man, but can be frustrating for the woman as she is asked to provide a “silent vagina” and not move to her own rhythms initially. Gradually both members of the couple can start to thrusts, and eventually move to the male superior position, in which the man finds it most difficult to control ejaculation.
The SSRI antidepressants cause significant delayed ejaculation, often limiting adherence in depressed patients. Using this side-effect as a therapeutic tool has significantly improved the treatment of rapid ejaculation.14,15 Clomipramine is slightly more effective than SSRI’s, but causes more side-effects. Paroxetine and sertraline may be more effective than fluoxetine or fluvoxamine. Most clinicians integrate low dose SSRI’s with sex therapy. They can be used on a prn basis 2 - 4 hours before anticipated intercourse, or if this fails, then on a daily basis.
Delayed ejaculation is rarer than rapid orgasm, with somewhat less than 1 in 10 men complaining of inability to ejaculate with a partner.1 A man who has never had an orgasm (through intercourse, masturbation or nocturnal emissions) requires a thorough evaluation for secondary causes. Perhaps the commonest cause of secondary delayed ejaculation is the use of SSRI’s as mentioned above. Any new onset of delayed ejaculation necessitates a thorough medical and medication review.7
Partners are often more frustrated with delayed ejaculation than the patient in feeling that they are somehow not attractive, or adept enough as lovers to help him ejaculate. Treatment involves helping the couple understand the physiology and psychology of delayed ejaculation. Consideration of medication changes if possible can be helpful. Cyproheptadine, both an histamine as well as serotonin antagonist, can act as an antidote.
Often couples with delayed ejaculation do not present for therapy until the issue of infertility arises. Many of these men can ejaculate on their own, but not with their partner present. Fertility can be achieved through the use of a 3-cc syringe to allow the couple to insert semen intra-vaginally on their own, or through intrauterine insemination in the physician’s office. Men who have suffered a quad- or paraplegic injury can be stimulated with vibrators, or mild electrical stimulation.14
Therapy focuses on increasing the pleasure of the process of lovemaking, rather than the anxiety-producing goal of ejaculation. This can then be linked to a behavioural process of stimulus intensification to allow the man to ejaculate initially in any way while in his partner’s presence, and then gradually closer to their genitals.