International Journal of STD & AIDS 2006; 17: 7–13 retarded ejaculation: BASHH Special Interest Daniel Richardson BSc MRCP and David Goldmeier MD FRCP, on behalf of the BASHH Special Interest Group for Sexual Dysfunction Jane Wadsworth Clinic, Jefferiss Wing, St Mary’s Hospital, London W2 1NY, UK Summary: We present the British Association of Sexual Health and HIV (BASHH)special interest group in sexual dysfunction recommendations for the managementof retarded ejaculation. The recommendations outline the physiology, prevalence,definitions, aetiological factors and patient assessment for this sexual problem. Wesuggest treatment strategies, recommendations for management and an auditableoutcome.
Keywords: retarded ejaculation, recommendations, management, BASHH 448 they assessed and treated in an 11-year period.3Helen Kaplan stated that her sample size was too Sexual climax in men usually has two contempora- insignificant to report.4 Studies from the late 1970s neous components – orgasm, an intensely pleasur- provided estimates of prevalence ranging from able subjective feeling, together with semen being 4% to 10%.5,6 Population samples from the 1990s ejaculated from the penis. It has been postulated quoted lower rates ranging from 0% to 3%.7–9 There that the various constituents of semen entering are some later, albeit bias studies, which found the posterior urethra creates a ‘pressure chamber’ rates of 20–39% in homosexual men, and HIV- within the posterior urethra.1 This triggers the infected men.10–12 A 2003 prospective cross-sec- closure of the neck of the bladder and subsequent tional sample of men attending general practi- rhythmical coordinated reflex contractions of the tioners in London reported a rate of 11%.13 striated pelvic muscles, and antegrade ejaculation In ‘sexual dysfunction in the US: prevalence and of semen. The physiological process of ejaculation predictors’, Laumann and colleagues analysed data is under autonomic control via the hypogastric collected in the national health and social life (sympathetic) and pudendal (parasympathetic) survey, and generated prevalence and calculated nerves.1 The exact site of the generation of associated risk factors for sexual dysfunctions.14 orgasmic pleasure within the brain is unknown.
This epidemiological analysis looked at represen- In these recommendations we concentrate on tative sample of American men aged 18 and 59 men who have difficulty with ejaculation, which years. They found that 7.8% (97/1246) of men may or may not be associated with subjective reported retarded ejaculation occurring for at least Retarded ejaculation (also known as the male A more detailed population-based study in the orgasmic disorder, inhibited ejaculation, impaired UK of 5000 16–44-year-old men found that 5.3% ejaculation, delayed ejaculation, ejaculatory incom- said that they had experienced an inability to reach petence, anejaculation, impaired orgasm, inhibited orgasm for at least one month in the past year, but male orgasm, ejaculatory overcontrol) is defined by only 2.9% had experienced the problem for at least the American Psychiatric Association (APA) as: six months in the past year, suggesting that the ‘.the persistent or recurrent difficulty, delay in, or problem affects many men some of the time.15 absence of attaining orgasm following sufficientsexual stimulation, which causes personal distress.’2 AetiologyThe conventional causes are shown in Table 1. A meta-analysis, which included 560 men, stratified Most texts state that retarded ejaculation is rare.
causation as: spinal cord injury (68.9%), retro- Masters and Johnson reported only 17 cases out of peritoneal lymph node dissection (20.7%), diabetesmellitus (2.1%), trauma/retroperitoneal surgery (0.9%), multiple sclerosis (0.4%), bladder neck surgery (0.2%) unknown or idiopathic (7.1%).16 Table 2 Age as a predictor for retarded ejaculation14 Transurethral resection of prostateBladder neck inscision There is a progressive loss of the fast-conduction peripheral sensory axons, which begins to be apparent in the third decade of life, which may result in a degree of age-related degenerative changes, resulting in difficulty in achieving the Other factors which are suggested to have an effect upon the ageing effect of sexual function are:peripheral vascular disease, diabetic neuropathy, psychiatric illness and lifestyle issues (smoking, alcohol, physical inactivity, boredom and lone- liness).23 Decreased sensitivity of the penis with age has been reported and may contribute to theincrease in ejaculation times seen with age.25 Despite this, Laumann, in his cross-sectional population-based epidemiological survey, couldnot identify age as a predictor of retarded ejacula-tion (Table 2); however, this study excluded men who were not sexually active or over 60 yearsold.14 It is biologically plausible that men with retardedejaculation have slower bulbo-cavernous reflexes,lesser penile sensitivity, reduced spinal stimulation and a higher penile sensory threshold than func-tional men. Indeed, Brindley and Gillan found the Mullerian and Wolfferian duct malformation are bulbo-cavernosus or glandipudendal reflex to be embryonic abnormalities, which would plausibly absent in two out of nine men with complete lead to a physiological inability for a man to ejaculate.24 Persistence of a small remnant of the Shull and Spenkle suggest that inadequate sexual Mullerian duct may lead to a cyst forming between stimulation may be the problem.18 There is evi- the ejaculatory ducts.26 This can cause obstructed dence that men have ‘autosexual orientation’: they and diminished ejaculate, which may impede the prefer manual stimulation by their own hand trigger for ejaculation by the absence of ‘filling of rather than partnered sex (of any kind) because the posterior urethra’ and reduced ‘prostatic they know how to optimally manipulate them- chamber pressure’.1 Congenital anomalies of the selves.19,20 Furthermore, men who experience con- Wolffian duct may be either sporadic with a stant (as opposed to varied) sexual stimulation via localized defect in the proximal part of the vas a mechanism of habituation are probably less likely deferens, or there may be a generalized maldeve- to achieve ejaculation and orgasm over time.21 lopment due to a systemic genetic abnormality.27 There are some data describing men who develop The latter is usually associated with the cystic an ‘idiosyncratic style’ of genital stimulation dur- fibrosis gene.28 Ejaculatory duct obstruction or ing masturbation, thus disabling their ability to ejaculatory failure due to pelvic nerve damage ejaculate during penetrative sexual intercourse.19,22 may follow correction of an imperforate anus.
Pelvic surgery may affect a man’s ejaculatory There is evidence that as men age, sexual organs function. Radical prostatectomy, whereby the atrophy, diminished testosterone levels, delay in seminal vesicles are removed, results in loss of attaining erections, reduced erection quality, longer ejaculation (along with erectile function and in achieving and maintaining a full erection and orgasm).26 Nerve-sparing procedures were sub- decline in intensity of orgasm all can occur.23 sequently developed to avoid postoperative loss Recommendations for the management of retarded ejaculation of sexual function.29 Trans-urethral resection of understood the effect of alcohol on sexual perfor- the prostate (a common surgical procedure for mance: ‘Alcohol provokes the desire, but takes benign prostatic hypertrophy) and bladder neck away the performance.’ (Shakespeare, Macbeth; surgery have both been shown to cause retarded Act II, Scene 3). Isotretinon (accutane), episilon aminocaproic acid, acetazolamide and naproxenhave all been reported to cause retarded ejacula-tion.38–40 Monoamine oxidase inhibitors (antide- pressants) and guanethidine (antihypertensive) The ability to ejaculate is impaired by spinal cord have been shown in small series to cause retarded injury. Unlike erectile function, the ability to ejaculate increases with descending levels of spinal Selective serotonin re-uptake inhibitors (SSRIs), injury.30 The ability to ejaculate is severely im- tricyclic antidepressants, alpha blockers have all paired by spinal cord injuries and is dependent upon the level and completeness of the injury.30 placebo-controlled trials to retard ejaculation in Less than 5% of men with complete upper motor men with premature ejaculation compared with neurone lesions retain the ability to ejaculate.
Sexual problems in multiple sclerosis include erectile dysfunction, ejaculatory disorders and Shull and Spenkle commented that: ‘If the literatureis searched long enough, almost any and every psychological problem can be associated with male A case control study of 95 men with type 1 diabetes shows a statistical relationship between complica- tions of diabetes and ‘orgasmic dysfunction’.32,33 ambivalent about his commitment to a sexualrelationship may ‘hold back’ as a way of ‘assumingpower’ in a troubled relationship.60 Kaplan shares this view, proposing that some men with thisproblem are overcontrolled individuals and resist Many pharmacological agents have been shown to ‘letting themselves go’ because of hostile feelings cause retarded ejaculation (Table 3). In fact, all of the drugs approved for the treatment of depression Blandy takes a more practical (situational) view.
or obsessive–compulsive disorder, with the excep- He considers, ‘ythe creaking bed, the thin parti- tion of nefazodone, and bupropion and possibly tion or the toddlers wandering about in search of escitralopram have been reported to be associated a ‘glass’ of watery’ are powerful inhibitors of with ejaculatory or orgasmic difficulty.34,35 Antic- orgasm and ejaculation. He also considers pain holinergic, antiadrenergic, antihypertensive and as an inhibitory experience: a prepuce, which psychoactive drugs are also common causes of becomes painfully stretched over an erect penis, There are no published data on the effects of thiazide diuretics on ejaculation: however, thesedrugs reduce serum zinc, which may interfere with testosterone metabolism.37 There is a surprisinglack of quality scientific evidence for alcohol’s effect upon ejaculation: Shakespeare, however, This should include an assessment of whether theproblem is ejaculatory, orgasmic or both. Asso-ciated personal, social or cultural issues as well as a Table 3 Drugs known to be associated with retarded ejaculation brief psychiatric and medical history should be attained. Careful consideration of prescribed and non-prescribed drugs, including alcohol and the presence of desire and erectile difficulties, should Atypical antidepressants (Trazodone)Beta blockersBaclofen BenzodiazepinesMono-amine oxidase inhibitors An assessment of the penis and other sexual characteristics is necessary. A careful examination of the nervous system should be carried out to exclude peripheral neuropathy, autonomic dys- function (by means of lying and standing blood pressure) and spinal cord pathology.
cyproheptadine and yohimbine, which successfullyreversed their ejaculatory problem64 (Level of A serum glucose and investigation of nervous disease should be undertaken as appropriate.
Bupropion is a serotonin/norepinephrine/dopa- We consider that all new patients merit at least a mine re-uptake inhibitor and has been investigated 30 minute–1 hour consultation time for their first in men with SSRI-induced sexual dysfunction with appointment: however, we are aware that due to differing results.65–67 Despite this, bupropion has local clinic time constraints and waiting times, this been reported to cause a reversal of SSRI-induced retarded ejaculation66 (Level of evidence III).
Buspirone, a 5HT1A agonist, has been reported in a prospective study of depressed men and women with generalized sexual dysfunction toreverse the sexual dysfunction side-effects of SSRIs including retarded ejaculation68 (level of Clearly, treatment depends upon a correct diag- nosis, which requires a detailed medical and sexual Cyproheptadine is a serotonin and histamine history, physical examination and appropriate agonist which has successfully been reported to physiological investigations and imaging, to iden- reverse the retarded ejaculation caused by imipra- tify organic causes such as drugs, pelvic surgery, mine, nortryptiline, fluoxetine, fluvoxamine andclomipramine69–73 (Level of evidence III). Of note, cyproheptadine has a tendency to cause drowsi-ness, which may affect sexual functioning.74 Cy- proheptadine has also been reported to reversecitralopram-induced retarded ejaculation75 (level of Retarded ejaculation as a consequence of drug evidence III). Yohimbine is an alpha-2 adrenergic therapy for other conditions (e.g. depression) needs antagonist. Yohimbine has been reported to reverse to be carefully considered and discussed with the retarded ejaculation caused by clomipramine, patients on an individual level. Cessation (partial fluvoxamine, fluoxetine, sertraline and paroxe- or permanent) of potentially causative pharmaco- tine74,76,77 (level of evidence III).
logical agents requires discussion with their psy-chiatrist or general practitioner.
A variety of drugs are reported to have efficacy in men with retarded ejaculation taking antide-pressants. The drugs reported have been suggested Sex and psychotherapy texts recommend medita- to facilitate ejaculation by either a central dopami- tive relaxation combined with psychotherapy.78 nergic or antiserotonergic mechanism. Most reports Other authors recommend the addition of viewing concentrate on the management of SSRI-induced erotic films, sex play, erotic fantasies, sexually retarded ejaculation (Table 4). Discussion with stimulating literature or magazines, and masturba- the patient’s psychiatrist or general practitioner tory exercises.60,79 Munjack and Kanno report a success rate for sex therapy between 42% and 82% treatment of depression or anxiety disorders, in a meta-analysis36 (level of evidence IV).
which may include drug holidays, may be con- Bancroft assumes in his therapeutic methods that inadequate stimulation is the ‘block’ to ejaculation, Amantadine induces the release of dopamine as he recommends the use of, ‘vigorous stimulation centrally. There have been two reports of using using a lubricating jelly or cream to overcome amantadine to treat fluoxetine-induced retarded the block’.80 This technique follows on that once ejaculation62,63 (level of evidence III). A small a man can ejaculate extra-vaginally, his penis is retrospective cohort study of men with SSRIs- then introduced closer and closer to the vaginal associated sexual dysfunction used amantadine, opening, introducing short periods of vaginal entryinto the procedure (level of evidence IV).
Hawton discusses that during masturbatory exercises with the partner, the man must be trained Table 4 Adjunctive pharmacotherapy for SSRI-induced retardedejaculation24 to concentrate on genital stimulation.79 He alsorecommends the male-superior position as he postulates that this often facilitates ejaculation.
Hawton, Bancroft and Winzce recommend the use of vibrators to increase sexual arousal60,79,80 (level Practical aspects of therapy are outlined clearly by Jannini and colleagues.81 They advise that any fears or anxieties such as fear of pregnancy and SSRI=selective serotonin re-uptake inhibitors sexually transmitted diseases should be discussed Recommendations for the management of retarded ejaculation at the outset. Hypnosis has been described as a useful adjunct to therapy82 (level of evidence IV).
Evidence obtained from meta-analysis of randomized Delmonte described a meditative relaxation meth- od together with brief supportive psychotherapy Evidence obtained from at least one randomized controlled for both partners in a report of two couples.78 Sex play as a treatment for retarded ejaculation has Evidence obtained from at least one well-designed been described anecdotally in a small cohort83,84 Evidence obtained from at least one well-designed Evidence from well designed non-experimental studies such as comparative studies, correlation studies and case Evidence obtained from expert committee reports or Retarded ejaculation is an uncommon problem, opinions and/or clinical experiences of respected which may present to genitourinary medicine settings. The definition of this condition does notappear to have reached consensus among alltherapists and researchers. There are few casereports and case-controlled studies describing possible aetiological factors and associations; how- 1 Levin RJ. The mechanism of human ejaculation – a critical ever, well constructed, hypothesis testing trials for analysis. J Sex Relat Ther 2005;20:123–31 these factors have not been done. It seems clear that 2 American Psychiatric Association. Diagnostic and Statistics many psychoactive drugs may cause retarded Manual of Mental Disorders. 4th edn. Washington, DC: ejaculation. Careful consideration of drug-induced sexual problems needs to be considered when 3 Masters WH, Johnson VE. Human Sexual Inadequacy. Boston: prescribing such agents and awareness of possible antidotes. Although the literature is lacking in 4 Kaplan HS. The New Sex Therapy. New York: Brunner Mazel, quality scientific evidence for the management of 5 Frank E, Anderson C, Rubenstein D. Profiles of couples this condition, a wealth of anecdotal and expert seeking sex therapy and marital therapy. Am J Psychiat opinion is available, particularly from psycho- logists and psychosexual therapists. Surely, there- 6 Nettelbladt P, Uddenberg N. Sexual dysfunction and sexual fore, an eclectic approach is needed for patients satisfaction in 58 married Swedish men. J Psychosom Med presenting with this condition, which includes 7 Fugl-Meyer AR, Sjogren Fugl-Meyer K. Sexual disabilities, screening for possible identifiable organic and problems and satisfaction in 18–74 year olds Swedes. Scand J psychosocial factors, clear discussion with patients and their partners, and subsequent tailoring of 8 Lindal E, Stephansson JG. The lifetime prevalence of psychosexual dysfunction among 55–57 year olds in Iceland.
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 In men with concomitant erectile dysfunction, the erectile dysfunction should be treated first 11 Catalan J, Klimes I, Day A, Garrod A, Bond A, Gallwey J.
 The risks and benefits of all treatment options The psychosocial impact of HIV infection in gay men. Acontrolled investigation and factors associated with psy- should be discussed with patients prior to any intervention. Patient and partner satisfaction is 12 Rosser BR, Metz ME, Bockting WO, Buroker T. Sexual difficulties, concerns and satisfaction in homosexual men:  Management of patients should be decided on a an empirical study with implications for HIV prevention.
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9433 the killers within

9433 The Killers Within 8/6/02 11:18 AM Page 291 acknowledgments To embrace a field as broad and complex as drug-resistant bacteria,with all the microbiology it entails, then try to make it simple, clear,and compelling, we needed a lot of wise counsel. J. Glenn Morris Jr. of the University of Maryland’s Baltimore Veterans Affairs MedicalCenter was one such guru; we are grateful not only for h

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