Our Greatest Wealth Is Health

Andrew Siegel MD   4/2/2022

This entry is a long overdue response to a request that I cover the topics of absent ejaculation and inability to orgasm.

It is important to make the distinction between ejaculation and orgasm:  Ejaculation is the physical act of contraction of the pelvic floor muscles and expulsion of semen, whereas orgasm is the associated feeling of pleasure that usually accompanies ejaculation.  The two are not the same, although the terms are often used synonymously. Ejaculation takes place in the genitals, orgasm in the mind. It is entirely possible to ejaculate without experiencing an orgasm and to orgasm without ejaculating.  The ideal situation is when the two components are perfectly aligned, when they go “hand in hand.” (Cute, right?)

Just Right

In the perfect world, ejaculation and orgasm are “just right,” meaning occurring on a timely basis (not too rapidly nor too slowly), nor too meekly, nor absent.  Problems with ejaculation and orgasm include the following: rapid ejaculation, delayed ejaculation, absent ejaculation, skimpy ejaculation, weak ejaculation, diminished ejaculatory sensation, lack of orgasm, and post-orgasmic illness syndrome (POIS). Some would refer to these issues as “jizasters.”

Although rapid ejaculation is typically a problem of younger men, many of the other ejaculation issues correlate with aging, weight gain, the presence of lower urinary tract symptoms due to prostate enlargement, and erectile dysfunction. With aging there is a decline of sensory nerve function, weakening of pelvic floor muscles, and diminished reproductive gland fluid production. Furthermore, medications and surgery used to treat prostate issues may profoundly affect ejaculation.

Rapid ejaculation

This is when ejaculation occurs before, upon, or shortly after vaginal penetration, prior to one’s desire to do so, with minimal voluntary control. It is the most common form of ejaculatory and sexual dysfunction. It often happens in under 60 seconds and leads to dissatisfaction, distress and frustration of the rapid ejaculator and his partner.  In a study of over 1500 men, The Journal of Sexual Medicine reported that the average time between penetration and ejaculation for a premature ejaculator was 1.8 minutes, compared to 7.3 minutes for non-premature ejaculators.

Rapid ejaculation can be psychological and/or physical. It may occur because of over-sensitive genital skin, hyperactive reflexes, extreme arousal, or infrequent sexual activity. Other factors are genetics, guilt, fear, performance anxiety, inflammation and/or infection of the prostate or urethra, and use of alcohol and recreational drugs. Lifelong rapid ejaculation is thought to have a strong biological component. Acquired rapid ejaculation can be biological, based on inflammation/infection of the reproductive tract or psychological, based upon situational stressors. Rapid ejaculation can sometimes be related to erectile dysfunction, with the rapid ejaculation brought on by the desire to climax before losing the erection.

A variety of measures can be used to overcome this problem. Slowing the pace of pelvic thrusting and varying the angle and depth of penetration before the “point of no return” is reached may dissipate the feeling of imminent ejaculation. Pausing thrusting with resumption once the ejaculatory sensation subsides is another alternative. The squeeze technique, originated by Masters and Johnson, consists of withdrawal prior to ejaculation, squeezing the head of the penis until the feeling of ejaculation passes, and then resumption of intercourse.  An alternative is pausing thrusting and doing a sustained pelvic muscle contraction to short-circuit the rapid ejaculation.

Thick condoms, or alternatively, topical local anesthetics can be applied to the penis before intercourse to decrease sensitivity. Pre-emptive masturbation prior to engaging in sexual intercourse may help delay ejaculation with sexual intercourse. Erectile dysfunction medications can be helpful for acquired rapid ejaculation due to erectile dysfunction and can also help one achieve a second erection after climax. Selective serotonin reuptake inhibitors (SSRI), commonly used for depression, anxiety, etc., have a side effect of substantially delaying ejaculation and are often used therapeutically for rapid ejaculation. These include, among others, Zoloft, Paxil, Prozac, Luvox, Celexa and Lexapro.

Delayed ejaculation

In this situation, ejaculation occurs only after a prolonged time following penetration. Some men are unable to ejaculate at all, despite having a rigid and durable erection. Time from penetration to ejaculation exceeding 25 minutes and causing distress to the delayed ejaculator or partner meets the criteria for this diagnosis.  Delayed ejaculation is poorly understood and is hampered by the absence of clearly effective treatments, unlike its rapid ejaculation counterpart.

Delayed ejaculation can be problematic for both the delayed ejaculator and his partner, resulting in frustration, exhaustion, and soreness for both partners. The sexual partner often feels distress and responsibility because of the implication that the problem may be their fault and that they are inadequate in terms of attractiveness or enabling a climax. The combination of not being able to achieve sexual “closure,” the inability to enjoy the mutual intimacy of ejaculation and denying the partner the gratification of knowing that they can bring their man to climax is a perfect storm for a stressful relationship. As tempting as it is to think that delayed ejaculation is an asset in terms of pleasing one’s partner, marathon performances have serious shortcomings.

Interestingly, some men with this condition can ejaculate in an appropriate amount of time with masturbation. As well, some men can ejaculate in a normal time frame with manual or oral stimulation from their partner although they cannot do so with sexual intercourse.

Underlying medical conditions may factor in: hypothyroidism is strongly associated with delayed ejaculation, whereas hyperthyroidism is associated with rapid ejaculation. Certain conditions—diabetes, spinal cord injury, multiple sclerosis, etc.—that disrupt the communication between the spinal ejaculatory center and the brain/penis may play a role.  Psychological and relationship issues may also affect ejaculation timing. In general, delayed ejaculation occurs more commonly with aging, thought to be based upon declining peripheral nerve function and genital skin changes. Since serotonin and dopamine as well as oxytocin, prolactin, and other chemicals are involved with ejaculation, any drug that modifies the levels of these chemicals may affect ejaculation timing. Selective serotonin reuptake inhibitors are the most widely prescribed drugs for depression and are notorious for their effect on delaying ejaculation, and are, in fact, used for the treatment of premature ejaculation as mentioned above.

One solution is to avoid ejaculation for several days prior to intercourse, the same line of reasoning used for managing premature ejaculation by masturbating immediately before intercourse. Modifying sexual positions may increase arousal and lead to more timely ejaculation. If one is using a selective serotonin reuptake inhibitor, another possibility is to consider switching to an alternative such as bupropion. Sexual counseling using sensate focus therapy or cognitive behavioral therapy has proven to be of benefit to some patients. Penile vibratory stimulation stimulates sensory nerves involved in the ejaculatory reflex and has the potential to intensify arousal.

Delayed ejaculation is one of the most difficult and challenging sexual dysfunctions to treat. Although numerous medications have been trialed, none are FDA approved and results have been underwhelming, including bupropion, cabergoline, and testosterone. A recent pilot study of amphetamine with dextroamphetamine (Adderall), a central nerve stimulant typically used for ADHD, has shown potential promise. On-demand use of a low dose resulted in more than half of the subjects showing improvement, with average intercourse latency time decreasing from 41 minutes to 11 minutes and average masturbation latency time decreasing from 20 to 11 minutes.  Side effects included insomnia and jitters.

Skimpy ejaculation

Skimpy ejaculatory volume is common with aging as the reproductive organs “dry out” to some extent. It also occurs commonly with prostate medications that either reduce reproductive gland secretions (Finasteride and Dutasteride) and/or cause the semen to be ejaculated backwards (retrograde ejaculation–I like to use the term “injaculation”) into the urinary bladder (Flomax, Uroxatral, Rapaflo, etc.). Even though ejaculation is backwards, sensation tends to be unchanged.  Surgery for benign enlargement of the prostate (Greenlight laser, transurethral prostatectomy, etc.) often gives rise to retrograde ejaculation. This is not harmful to one’s health and whatever semen is released will be urinated out. Radiation therapy to the prostate can also cause diminished ejaculation.

Weak ejaculation

Young men can often forcefully ejaculate a substantial volume of semen in an arc that may be several feet in length, associated with an intense orgasm.  The aging male typically has a more lackluster experience with a smaller volume of semen weakly dribbling out of the penis. Weak ejaculation clearly correlates with aging, weakened pelvic floor muscles and erectile dysfunction.

Absent ejaculation

Absent ejaculation occurs with surgical removal of the male reproductive organs, as occurs with radical prostatectomy and radical cystectomy for prostate and bladder cancer, respectively. It may also occur in the presence of neurological disorders that affect ejaculation, including diabetes. In these circumstances, orgasm can still be experienced, although the ejaculation is “dry.”

Anorgasmia

Although much more common in females, this occurs in men on a rare basis. One is able to ejaculate but does not experience the feelings of release of sexual tension and intense pleasure. The root cause may be physical or psychological. 

Post-orgasmic illness syndrome (POIS)

This is a rare disorder in which a cluster of negative symptoms are experienced following ejaculation. These include a flu-like state with fatigue, nasal congestion and burning eyes, as well as difficulty concentrating, irritability, depressed mood, and generalized malaise.

Optimizing Ejaculation and Orgasm

1. Healthy lifestyle: Wholesome and nutritious eating habits and maintaining a healthy weight, regular exercise, adequate sleep, alcohol in moderation, avoidance of tobacco, and stress management will help keep all organs and tissues functioning well, including one’s ejaculatory “apparatus.” 
2. Pelvic floor muscle training:  The pelvic floor muscles play a key role in ejaculation. The bulbocavernosus muscle engages when one has an erection and becomes maximally active at the time of ejaculation. It is a compressor muscle that surrounds the spongy erectile tissue that envelops the urethra and contracts rhythmically at the time of ejaculation, sending wave-like pulsations rippling down the urethra to forcibly propel semen, providing the power behind ejaculation. Pelvic floor muscle training can help one control the timing of ejaculation as well as enable forceful ejaculation. Readers are directed to the Male Pelvic Fitness book and PelvicRx DVD as excellent resources for learning how to properly pursue pelvic floor muscle training.
3. Breathe deeply and slowly: During sexual activity there is a tendency for shallow and rapid breathing and breath holding because of excitement and increasing sexual tension. Depth and rhythm of breathing may affect ejaculation with deep, full breaths optimal.
4. Stay sexually active: All body parts need to be used on a regular basis, including our reproductive organs. Keep the erectile and ejaculatory muscles fit by using them as nature intended.  Use it or lose it!

Wishing you the best of health,

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Dr. Andrew Siegel is a physician and urological surgeon who is board-certified in urology as well as in female pelvic medicine and reconstructive surgery.  He is an Assistant Clinical Professor of Surgery at the Rutgers-New Jersey Medical School and is a Castle Connolly Top Doctor New York Metro Area, Inside Jersey Top Doctor and Inside Jersey Top Doctor for Women’s Health. His mission is to “bridge the gap” between the public and the medical community. He is a urologist at New Jersey Urology, the largest urology practice in the United States.  He is the co-founder of PelvicRx and Private Gym.  His latest book is Prostate Cancer 20/20: A Practical Guide to Understanding Management Options for Patients and Their Families. 

Video trailer for Prostate Cancer 20/20

Preview of Prostate Cancer 20/20

Andrew Siegel MD Amazon author page

PROSTATE CANCER 20/20 is now available at Audible, iTunes and Amazon as an audiobook read by the author (just over 6 hours). 

Dr. Siegel’s other books:

THE KEGEL FIX: Recharging Female Pelvic, Sexual, and Urinary Health

Video on THE KEGEL FIX

MALE PELVIC FITNESS: Optimizing Sexual and Urinary Health

PROMISCUOUS EATING— Understanding and Ending Our Self-Destructive Relationship with Food

FINDING YOUR OWN FOUNTAIN OF YOUTH: The Essential Guide to Maximizing Health, Wellness, Fitness and Longevity

Tags: absent ejaculation, Andrew Siegel MD, anorgasmia, Delayed ejaculation, ejaculation, orgasm, post-orgasmic illness syndrome, premature ejaculation, sexual climax, skimpy ejaculation, weak ejaculation

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