Ejaculatory Dysfunction

AUTHOR: DR. JOSHUA GONZALEZ
ILLUSTRATIONS BY EVA HILL

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What happens when cumming doesn’t work out the way we think it will?

There are all types of common ejaculatory problems: You can pop prematurely or cum too late or sometimes not at all. Sometimes individuals jizz backwards; and sometimes they can even experience severe pain when they climax. Since ejaculation is such a big part of the sexual experience, it’s time we knew more about what can happen when ejaculation goes wrong.

We all have a lot of misconceptions about what constitutes a normal time to ejaculate.  Maybe it’s because we watch too much porn; maybe it’s because we exaggerate our sexual proclivities when discussing these issues with our friends and inflate how great our stamina is. Whatever the reason, we are often misguided when it comes to ejaculation and often overestimate what is normal.

In a large observational study of males and their partners, the median time to ejaculation was 7.3 minutes (Patrick 2005). That means that half of the more than 1,500 men studied ejaculated in under 7.3 minutes! How’s that myth-busting for you? Despite all the PornHub,  the average time to ejaculation is under 10 minutes (Patrick 2005). Patients who don’t last the 20 - 30 minutes often come to see me because think they have a problem.

So how do we characterize real premature ejaculation (PE)?

PE is characterized by ejaculation which always or nearly always occurs prior to or within one minute of penetration or the inability to delay ejaculation on all or nearly all penetrations. To qualify as PE, the ejaculatory issue should cause negative or uncomfortable personal consequences such as distress, frustration and/or the avoidance of sexual intimacy (Althof).

As I wrote in my previous piece on ED, many of the definitions we use in sexual medicine are based on a heterosexual model.  Historically, this is just the way sex has been studied. To be clear, that does not mean that non-heterosexuals can’t premature ejaculate. I find it more useful when talking about ejaculation with patients to understand PE as ejaculation that occurs within one minute of sexual activity. That means oral or anal sex, and even masturbation. PE can happen in any of these scenarios and it happens to a lot of guys.

Premature ejaculation is the most common male sexual dysfunction. Depending on the population, the prevalence has been reported as high as 30% (Carson 2006). Many incorrectly assume it’s a young man’s problem, but premature ejaculation can occur at any age (Rosen 2004).

PE comes in two primary types: congenital and acquired. You might be born with it, or it could occur later in life. Those with the congenital version have a problem controlling their ejaculation their whole life, even from their first attempts at masturbation. Those with the acquired type experience a period of normalcy and suddenly develop an inability to delay time to ejaculation. Both types can be equally distressing and negatively impact a person’s self-esteem or cause relationship issues.

A Cure To Cum?

Despite the prevalence of PE, there are currently no FDA-approved treatments,  meaning all the medical treatments we prescribe to manage PE are considered off-label.  

There are several ways to approach dealing with PE:

  • First is to physically decrease penile sensitivity. This can mean using a condom or a topical anesthetic spray. These treatments can be useful, but patients often find them cumbersome and sometimes report they interfere with intimacy.

  • A common prescribed treatment for PE is a family of drugs known as selective serotonin reuptake inhibitors (SSRIs). Commonly known as antidepressants, a side effect of SSRIs is delayed ejaculation. For patients with PE, we use this side effect to our advantage! These medications are effective when used on-demand just before sex play, and as daily treatments. If PE exists alongside erectile dysfunction, which commonly occurs, then phosphodiesterase-5 inhibitors (Viagra, Cialis, etc.) can be helpful.  

  • The pain medication, tramadol, is also used for PE. This treatment is most often used on-demand and essentially dampens the brain’s processing of the genital stimulation that leads to PE.

  • Other treatments, including Botox injections, are under study as we speak.

  • Finally, some non-medical approaches that can be helpful in PE include pelvic floor physical therapy, sex therapy, psychotherapy, and cognitive-behavioral therapy.

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Missing The Mark: When Cum Doesn’t Come Out Correctly

There are a whole host of conditions known as diminished ejaculatory disorders that include delayed ejaculation (DE), retrograde ejaculation (RE), and anejaculation. The diminished ejaculatory disorders are not as well studied as PE, but it may be helpful here to understand how they are defined.

Delayed Ejaculation is thought to be an inhibition of the ejaculatory reflex that results in absence or reduced seminal fluid and impaired ejaculatory contractions.  DE occurs much less often than PE, with a prevalence of less than 5% (Perelman 2006, Jannini 2005). DE can happen to you at any age but does seem to be more common as one gets older.

There isn’t an exact definition on what constitutes delayed, but an inability to ejaculate after 25-30 minutes has been suggested as a reasonable parameter (Di Sante 2016, McMahon 2014). Psychological factors such as anxiety, depression, prior sexual trauma, and interpersonal relationship issues can sometimes contribute to DE.

Biological factors including hormonal issues, the use of certain medications, alcohol or illicit drugs, previous pelvic surgery, radiation, or trauma, diabetes, and neurological diseases. Treating DE often requires identification of one or more of these factors and addressing them. A variety of medical therapies have also been prescribed to treat DE but, like is the case with PE, none are FDA-approved. These treatments include the use of testosterone, Parkinson’s drugs, certain anti-depressants and stimulants. The efficacy of these individual treatments are limited to small studies so there is no consensus on which is most effective.

Retrograde Ejaculation is a condition in which part or all of the ejaculate fluid is expelled into the bladder instead of out the tip of the penis. Gross, right? That’s the reaction I get from most patients when I explain RE. What’s misunderstood is that RE is not painful or dangerous or even gross! The incidence of retrograde ejaculation ranges from 0.3%-2% among patients attending fertility clinics, the population in which RE is usually studied.

RE occurs when there is an incomplete closure of the bladder’s internal sphincter leading to backward flow of semen during ejaculation. Those with RE will often report whitish urine when they urinate after sex (this is where I usually get the gross response).

The cause of RE is not always obvious, but certain medications like those used for enlarged prostates are known culprits. Prostate surgeries can also induce RE, which is something every guy should be (but isn’t always) told prior to these procedures.  Treating RE can be challenging because no treatments have been shown to be that effective. Stimulants have been tried, so has injection of bulking agents such as collagen. But the data on all the therapies for RE are limited.

Anejaculation is the inability to ejaculate at all. Those with this condition produce sperm normally but cannot expel seminal fluid despite adequate stimulation. Anejaculation occurs in a very small number of patients, less than 0.2% of the general population (Kinsey 1948). Anejaculation, like DE, can be caused by biological and psychological factors. It is often accompanied by normal orgasmic sensation. In other words, you feel all the pleasure of orgasm but nothing comes out. This can be a strange concept as we often associate orgasm with busting a wad out of a penis, but the truth is, the two are related but not mutually exclusive. Anejaculation can cause distress in some, but not in others. It can be especially distressing or problematic for people with penises who are trying to get their partners pregnant.

When Splooging Makes You Suffer

Painful ejaculation can be a life ruiner. Imagine if every time you cum you experience agonizing pain! What an awful feeling. After a while, you probably wouldn’t be too interested in having sex or even masturbating. This is what I see all the time in the patients I treat with painful ejaculation. People with this issue can develop a host of problems including erectile dysfunction, low libido, and depression and/or anxiety.

The incidence of painful ejaculation has been estimated at 1-10% (Ilie 2007).  Thankfully, painful ejaculation is not always a permanent thing. In fact, it’s most often an intermittent problem. It can be caused by trauma, infection or inflammation of the genital or urinary organs, obstruction of the ejaculatory ducts, tightness in the muscles or connective tissues of the pelvic floor and certain neurological conditions. Sometimes it is a combination of one or more of these issues. Treatments  range from anti-inflammatories, antibiotics, pain medications, antidepressants, physical therapy and sometimes surgery.

Painful ejaculation can occur in lots of different places and present in different ways.  Sometimes patients report pain in their testicles, penis, near their rectum, in the lower abdomen or groin area and can be accompanied by a change in urination or bowel habit. Sometimes it occurs with blood in the semen, sometimes it doesn’t; however, no matter how the pain presents, it is never normal.

Bashful About Busting?

Below are some takeaways from this lesson on ejaculation.  

  • Ejaculatory disorders are quite common.

  • Ejaculation can vary from person to person and change as we age. How we cum isn’t a static thing.

  • Changes in ejaculation only become a problem when they cause you distress. If you’re not bothered, then it’s not a dysfunction and you don’t need help.

  • But if the way you cum is stressing you out or negatively affecting you or your relationship, seek medical attention. There are usually things that can be done to help.

  • Pain with ejaculation isn’t normal. Sometimes it’s a momentary thing but if it continues to occur, it’s worth talking to your doctor.

Have more questions on this topic? Write us anytime at info@thesexed.com, and we’ll do what we can to help!




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