Ejaculatory Dysfunction: When Things “Cum” Out All Wrong

Ejaculatory dysfunction comes in all shapes and sizes. You can cum prematurely, too late or not at all. Sometimes people experience severe pain during climax and some people even ejaculate backwards. Since ejaculation is a huge part of a satisfying sexual experience and healthy sexual function, it’s important to understand what happens when ejaculation goes wrong and what we can do to make it right. 

There are a lot of misconceptions about what is considered normal timing when it comes to cum. Blame it on porn, or locker room talk, or braggadocio, but men have been known to exaggerate when it comes to sexual proclivity or stamina. Because of this, we are often misinformed when it comes to ejaculation, and we often overestimate what’s normal. 

In a large observational study of males and their partners, the median time to ejaculation came in at 7.3 minutes (Patrick 2005). In other words, half of the more than 1,500 men studied ejaculated in less than 7.3 minutes! How’s that for a myth-buster? Despite what PornHub may have you think, the average time for a man to come is under 10 minutes (Patrick 2005). I often have patients come to see me because they can’t last 20 to 30 minutes or longer and they think there’s a problem. I assure them that there is no problem!

But  Premature Ejaculation (PE) is real. So how do you know if you have it? PE is characterized by ejaculation that always or nearly always occurs prior to or within one minute of penetration or is characterized by the inability to delay ejaculation on all, or nearly all, penetrations. In addition to this definition, the inability to delay ejaculation must cause uncomfortable or negative personal consequences, including frustration, distress and/or the avoidance of sexual intimacy to qualify as PE (Althof).

As I’ve previously written, many of the definitions we use in sexual medicine are based on a heterosexual model. This is the way that sex has been studied historically, but non-heterosexuals can experience PE as well, and I like to broaden this definition a bit. When talking about ejaculatory health, I find it useful to characterize PE as ejaculation that occurs within one minute of sexual activity, including anal sex, oral sex and even masturbation. PE is common in these situations, and it happens to a lot of men.

In fact, PE is the most common sexual dysfunction for males. The prevalence of PE has been reported as high as 30% depending on the population (Carson 2006). While many people consider PE to be a young man’s problem, PE can occur at any age (Rosen 2004). 

When it comes to PE, there are two primary types – acquired and congenital. Simply put, that means that you may acquire the dysfunction at some point in your life (acquired) or you may be born with it (congenital). Individuals with the congenital version have always had a problem with controlling their ejaculations even from their first time masturbating. People who have the acquired type have experienced normal ejaculations at some point in their lives, but then they suddenly develop the inability to control or delay their ejaculations. Both types can be equally problematic and affect a person’s self-esteem and relationships.

There are currently no FDA-approved treatments for PE despite the prevalence of the problem, which means that the medical treatments that doctors prescribe are considered off-label. 

Despite the lack of an FDA-approved treatment, there are many ways to deal with PE:

1. Often, we first try to physically decrease the sensitivity of the penis. We can do this by using a topical anesthetic spray or a condom. Although these treatments can be effective, patients sometimes find them to be onerous and they report that these interventions can interfere with intimacy.

2. You may have heard of selective serotonin reuptake inhibitors (SSRIs) in relation to depression. However, this family of drugs known as antidepressants are also commonly prescribed to treat PE since a side effect of SSRIs is delayed ejaculation. For those who suffer from PE, these side effects are not negative at all! These medications can be taken daily, or they can be used right before sexual activity. It’s common for patients to experience PE as well as erectile dysfunction. In these cases, phosphodiesterase-5 inhibitors (drugs like Viagra and Cialis) can be helpful, too.

3. A pain medication called tramadol can also be used to help PE. This on-demand treatment basically dampens your brain’s processing of the genital stimulation that can lead to PE.

4. Injections with the drug Botox are currently undergoing studies and may become a useful treatment in the future.

5. Non-medical interventions may be helpful for PE as well. Pelvic floor therapy, cognitive-behavioral therapy, psychotherapy and sex therapy can all be helpful in reducing the instances of PE and reducing the negative effects for those who suffer from it.

Delayed Ejaculation  (DE), retrograde ejaculation (RE) and anejaculation are all conditions that are known as diminished ejaculatory disorders. Unfortunately, these types of disorders have not been studied as much as PE, but it’s useful to understand how they are defined. 

DE is understood to be the inhibition of the ejaculatory reflex that results in reduced seminal fluid, the absence of seminal fluid and/or impaired ejaculatory contractions. With a prevalence of less than 5%, DE is not as common as PE (Perelman 2006, Jannini 2005). And while DE can happen at any age, the instances of DE become more common with increased age.

There’s no concrete definition as to what constitutes DE, but it has been suggested that the threshold should be set at the inability to ejaculate after 25- to 30-minutes of sexual stimulation (Di Sante 2016, McMahon 2014). Some factors that can contribute to DE may include depression, anxiety, past sexual trauma and relationship issues.

Biological issues can also be at play with DE, including alcohol or illicit drug use, the use of some medications, prior pelvic surgery, trauma, radiation exposure, neurological diseases and diabetes. Although there are many medical interventions available to treat DE, like PE, none are FDA-approved.

Available treatments include certain drugs for Parkinson’s disease, some anti-depressants, certain stimulants and the administration of testosterone. There have only been small studies done on the efficacy of these interventions so there is no broad consensus on which ones work best. 

Retrograde Ejaculation (RE) is when all or part of the ejaculate is expelled into the bladder instead of out through the tip of the penis. Most of my patients freak out a little when I explain RE to them, but it really isn’t painful, dangerous, or gross at all. The incidence of RE ranges from 0.3% to 2% among patients that attend fertility clinics which is the population most frequently studied for RE.

RE occurs when the bladder’s internal sphincter does not close all the way, which causes the flow of semen to travel backward during an ejaculation. Those who experience RE often tell me that their urine is a whitish color when they go to the bathroom after sex. 

It’s not always obvious what the cause of this ejaculatory disfunction is, but we know that certain medications, including prescriptions for enlarged prostates, often contribute to instances of RE. Surgeries on the prostate can also cause RE which unfortunately is something that’s not always disclosed to patients prior to undergoing prostate surgery. There are no treatments that have been shown to be effective for RE. Stimulants and the injection of bulking agents like collagen have been tried as treatments, but data on these and other RE treatments are limited.

Anejaculation is the inability to ejaculate at all. Patients with this condition can produce sperm normally, but they cannot expel the semen even when they have proper stimulation. Only 0.2% of the population experience anejaculation, making it a relatively uncommon condition (Kinsey 1948). Like DE, anejaculation can be caused by a mix of physical and psychological factors. Luckily, anejaculation often occurs with normal orgasmic sensation, so patients are able to enjoy a full orgasm they just don’t have the ejaculate to show for it. That can be a strange and incongruous concept since we mostly associate an orgasm with cum, but even though the two are related, they don’t have to occur together. While some patients are distressed by anejaculation, others are not. However, it’s particularly problematic for those individuals who are trying to impregnate their partners. 

When ejaculation causes pain, it can severely affect a person’s life. Agonizing pain is the absolute opposite of the intense pleasure you’re supposed to feel during ejaculation. Those who experience painful ejaculation often become disinterested in sex or masturbation. It can also lead to a concurrence of other sexual function issues including erectile dysfunction, low libido, anxiety and depression. 

Painful ejaculation has been estimated to occur in 1% to 10% of men (Ilie 2007). The good news is that painful ejaculation is often a condition that isn’t permanent. This ejaculatory dysfunction can be brought on by a number of causes, including obstruction of the ejaculatory ducts, tightness in the pelvic floor muscles or connective tissues, infection, trauma or inflammation of the urinary or genital organs and some neurological conditions. Often, one or more of these issues occur at the same time. To treat this ejaculatory disfunction, we often administer antibiotics, pain medications and anti-inflammatory drugs or we suggest physical therapy. In some cases, surgery becomes necessary. 

The pain felt from painful ejaculation can occur in different places on your body. Many patients say that they feel pain in their testicles, near their rectum, in the lower abdomen, in the groin area and in their penis. This pain can also be accompanied by changes in bowel movements or urination. Occasionally, but not always, patients will see blood in their semen when painful ejaculation occurs. The important thing to remember is that pain during ejaculation is never normal and it should always be followed up with a visit to your doctor.

It can be difficult to talk about ejaculatory issues, but as a urologist and sexual health professional, I can assure you – we’ve heard it all before. Ejaculatory disfunctions are really quite common and there are many treatments that can help. If you experience any changes in the timing of your ejaculations or volume of your semen, or you experience pain when you orgasm, it’s wise to be open and honest with your healthcare practitioner. We’re here to help!

References:

Althof SE, McMahon CG, Waldinger MD, Serefoglu EC, Shindel AW, Adaikan PG, Becher E, Dean J, Giuliano F, Hellstrom WJ, Giraldi A, Glina S, Incrocci L, Jannini E, McCabe M, Parish S, Rowland D, Segraves RT, Sharlip I, Torres LO. An update of the International Society of Sexual Medicine's guidelines for the diagnosis and treatment of premature ejaculation (PE). J Sex Med. 2014 Jun;11(6):1392-422.

Patrick DL, Althof SE, Pryor JL, Rosen R, Rowland DL, Ho KF, McNulty P, Rothman M, Jamieson C. Premature ejaculation: an observational study of men and their partners. J Sex Med. 2005 May;2(3):358-67. 

Carson C, Gunn K. Premature ejaculation: definition and prevalence. Int J Impot Res. 2006 Sep-Oct;18 Suppl 1:S5-13. Review. 

Rosen RC et al (2004) The Premature Ejaculation Prevalence and Attitudes (PEPA) Survey: A Multi-National Survey. J. Sex Med 1 (Supp 1): 57-58 

Di Sante S, Mollaioli D, Gravina GL, Ciocca G, Limoncin E, Carosa E, Lenzi A, Jannini EA. Epidemiology of delayed ejaculation. Transl Androl Urol. 2016 Aug;5(4):541-8.

McMahon CG. Management of ejaculatory dysfunction. Intern Med J. 2014 Feb;44(2):124-31. 

Kinsey AC, Pomeroy WR, Martin CE. Sexual behavior in the human male. 1948. Am J Public Health 2003;93:894-8. 

Perelman MA, Rowland DL. Retarded ejaculation. World J Urol 2006;24:645-52. 

Jannini EA, Lenzi A. Ejaculatory disorders: epidemiology and current approaches to definition, classification and subtyping. World J Urol 2005;23:68-75.

Ilie CP, Mischianu DL, Pemberton RJ. Painful ejaculation. BJU Int. 2007 Jun;99(6):1335-9. Epub 2007 Apr 6. Review.