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Ejaculatory Disorders: Pathophysiology and Management

Authors: Carlo Bettocchi, MD ; Paolo Verze, MD ; Fabrizio Palumbo, MD ; Davide Arcaniolo, MD ; Vincenzo Mirone, MDFaculty and Disclosures


Summary and Introduction


Ejaculatory dysfunction (EjD) is one of the most common male sexual disorders, yet EjD is still frequently misdiagnosed or overlooked as a result of numerous patient and physician barriers. The wide spectrum of EjD ranges from premature or rapid ejaculation, through delayed ejaculation, to a complete inability to ejaculate—otherwise known as anejaculation— and includes retrograde ejaculation and painful ejaculation. Conventional algorithms for managing ejaculatory disorders are based either on an organic or psychogenic etiology, with the latter more traditionally considered the main cause. This paper reviews physiopathological, diagnostic and therapeutic aspects of ejaculation disorders, with a particular focus on the most prevalent disorder, premature ejaculation.


As has been previously established, a normal sexual response cycle comprises four interactive, nonlinear stages: desire, arousal, orgasm and resolution. In males, orgasm usually coincides with ejaculation, but represents a distinct cognitive and emotional cortical event. Ejaculatory dysfunction (EjD) is one of the most common male sexual disorders. Fertility is a major concern for younger men, while EjD can cause considerable distress to men of all ages. In a recent survey of 12,815 men aged 50-80 years, 46% reported an ejaculatory disturbance within the previous 4 weeks and 59% were particularly bothered by it, especially when occurring concomitantly with lower urinary tract symptoms.[1]

The wide spectrum of EjD ranges from premature or rapid ejaculation, through delayed ejaculation, to a complete inability to ejaculate —known as anejaculation—and includes retrograde ejaculation and painful ejaculation.[2] Delayed ejaculation (DE), or ejaculatory insufficiency, is defined as the inhibition of the ejaculatory reflex, with absent or reduced seminal emission and impaired ejaculatory contractions, possibly occurring concomitantly with reduced or absent orgasm. Delayed ejaculation affects approximately 4% of sexually active men.[3] Retrograde ejaculation, the most medically concerning disorder of sperm emission, occurs in 75% of men who have undergone transurethral resection of the prostate and, to a lesser extent, following bladder neck incision, owing to iatrogenic bladder neck incompetence in both cases.[4]

The most common EjD is premature ejaculation (PE).[5,6] According to the authors of a comprehensive review of the literature, PE affects 5-40% of sexually active men.[7] This disorder is most frequently reported by adolescents or young adults, and affects more men from East Asia and fewer men from Middle Eastern and African countries than in other regions. The European prevalence seems to lie between that of East Asia and Middle Eastern and African countries.[6]

Still, epidemiological data on PE have been difficult to accrue owing to the lack of a globally accepted definition of the disorder.[5] Criteria have been published that define any ejaculation occurring in 1 min, 2 min, 3 min or even 7 min from penetration, or 8-15 penile thrusts, as premature. 6 Alternatively, the European Association of Urology disorders of ejaculation guidelines, published in 2004, define PE as the inability to control ejaculation for a “sufficient” length of time before vaginal penetration.[8] Although there is no universally accepted meaning of a “sufficient” length of time, this should include those patients who are not able to delay ejaculation for more than a few coital thrusts, or even before vaginal penetration.[8] Masters and Johnson[9] have suggested that a man has PE if he is unable to delay his ejaculation until his partner is sexually satisfied in at least 50% of their sexual approaches.

The absence of a consensus medical definition for PE encourages a “patient-dependent” definition and a “patient-decided” diagnosis.[6] This approach is risky, because diagnosis and possible therapy would then be based solely on subjective parameters, which are clearly influenced by culture, religion, policy, society, and the media—all aspects that greatly deviate from a medical definition.[6] Hence, in 1994, Waldinger et al.[10] proposed a simple objective method to define PE termed the intravaginal ejaculation latency time (IELT), which is the time from the start of vaginal intromission to the start of intravaginal ejaculation. For clinical assessment and therapeutic monitoring, this method could be considered the most objective in evidence-based sexual medicine.[11]

In 2000, the Diagnostic and Statistical Manual of Mental Disorders, version 4 (DSM-IV) expanded the definition of PE to be persistent or recurrent ejaculation with minimal sexual stimulation before, upon, or shortly after penetration and before the person wishes it, and noted an association with marked distress or interpersonal difficulty.[12] In accordance with this definition, PE presents with three components: a short time interval between penetration and ejaculation, the inability to control ejaculation and distress for the man or for the couple.

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