madman
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*I'll be honest often times we really don't know this delayed ejaculation and orgasmia this is probably the least understood and hardest to deal with problems that clinicians such as myself and in general the clinical world come up against and you know and look there are a variety of potential causes
In this episode, we discuss delayed or absent orgasms. Most guys are familiar with premature ejaculation, a condition in which men achieve an orgasm and ejaculate too soon.
*But what about guys who take too long to achieve an orgasm or cannot achieve one at all?
*How long is too long when it comes to reaching an orgasm?
*What causes delayed or absent orgasms?
*What are the treatment options and how well do they work?
To answer these questions and many more, we turned to a true expert.
Alexander W. Pastuszak, MD, Ph.D., is an Assistant Professor of Surgery - Urology in the Department of Surgery at The University of Utah School of Medicine in Salt Lake City, Utah. Dr. Pastuszak earned his undergraduate degree at Yale University and completed his MD and Ph.D. at the University of California, San Francisco. He completed his urology residency at Baylor College of Medicine and a fellowship in male reproductive medicine at Baylor College of Medicine.
Dr. Pastuszak has authored over 80 peer-reviewed articles and numerous book chapters on men’s reproductive and sexual health, and he is the editor of the textbook entitled Management of Sexual Dysfunction in Men and Women: An Interdisciplinary Approach. He has also been the Section Editor for the journals Sexual Medicine and Current Sexual Health Reports and is Associate Editor of Sexual Medicine Reviews, the Journal of Sexual Medicine, and Fertility and Sterility.
Potential endocrine contributors include:
After orgasm, prolactin normally rises and contributes to the refractory period, the interval before a man can become erect and ready for another orgasm. This association provides a rationale for investigating prolactin, although most men evaluated for delayed ejaculation have normal prolactin levels.
Diabetes, chronic stress, environmental factors, aging, and other conditions can contribute indirectly by lowering testosterone or impairing sexual or neurologic function. The source notes evidence suggesting testosterone may decline by approximately 1% per year after age 30–35, while also emphasizing that the evidence remains unsettled.
Physical injury is a separate issue: unusually forceful or dangerous masturbation can cause actual trauma, whereas masturbation without tissue injury is unlikely to damage the nerves simply because it occurs frequently.
The source emphasizes that the expected visit is generally a conversation, possibly a basic or targeted examination, and selected laboratory testing—not automatically an invasive or highly technical workup.
As the flowchart shows, specialized testing is selected according to the suspected mechanism rather than performed routinely.
Therapy may include:
Potential strategies include:
Some clinicians report subjective improvement in approximately 50–70% of patients treated with these off-label approaches, but this is anecdotal rather than the result of a definitive clinical trial. Improvement usually means the man feels that the experience is more satisfying or that the time required has meaningfully decreased, rather than achieving a precisely measured stopwatch target.
Medication schedules differ:
Its role is mainly acute:
The Sexual Medicine Society of North America (SMSNA) is described as offering:
Costs can rise when specialized testing—such as MRI or other uncommon neurologic assessments—is required, but there is generally no surgical intervention for delayed ejaculation.
*I'll be honest often times we really don't know this delayed ejaculation and orgasmia this is probably the least understood and hardest to deal with problems that clinicians such as myself and in general the clinical world come up against and you know and look there are a variety of potential causes
In this episode, we discuss delayed or absent orgasms. Most guys are familiar with premature ejaculation, a condition in which men achieve an orgasm and ejaculate too soon.
*But what about guys who take too long to achieve an orgasm or cannot achieve one at all?
*How long is too long when it comes to reaching an orgasm?
*What causes delayed or absent orgasms?
*What are the treatment options and how well do they work?
To answer these questions and many more, we turned to a true expert.
Alexander W. Pastuszak, MD, Ph.D., is an Assistant Professor of Surgery - Urology in the Department of Surgery at The University of Utah School of Medicine in Salt Lake City, Utah. Dr. Pastuszak earned his undergraduate degree at Yale University and completed his MD and Ph.D. at the University of California, San Francisco. He completed his urology residency at Baylor College of Medicine and a fellowship in male reproductive medicine at Baylor College of Medicine.
Dr. Pastuszak has authored over 80 peer-reviewed articles and numerous book chapters on men’s reproductive and sexual health, and he is the editor of the textbook entitled Management of Sexual Dysfunction in Men and Women: An Interdisciplinary Approach. He has also been the Section Editor for the journals Sexual Medicine and Current Sexual Health Reports and is Associate Editor of Sexual Medicine Reviews, the Journal of Sexual Medicine, and Fertility and Sterility.
Defining delayed orgasm and absent orgasm
Orgasm and ejaculation are related but distinct processes:- Orgasm is the subjective sensation of sexual climax.
- Ejaculation is the physical expulsion of semen through the urethra and penis.
- They usually occur together, but either can occur without the other. For example, a man may experience orgasm without visible ejaculation after certain procedures, injuries, or medications; retrograde ejaculation occurs when semen enters the bladder rather than leaving through the penis.
- The pleasurable orgasmic sensation is generated by the brain after it processes sensory input from the penis, prostate, anus, and other arousal areas.
Why the problem matters
Although some men initially view prolonged sexual activity as advantageous, delayed or absent orgasm can create substantial difficulties:- Sexual dissatisfaction for the man or partner.
- Pain or physical discomfort during prolonged activity.
- Conflict or strain within the sexual relationship.
- Progressive avoidance of sex when sexual encounters become tiring, stressful, or unrewarding.
Causes and mechanisms
The source presents delayed or absent orgasm as a multifactorial problem involving medication effects, hormones, metabolic or neurologic disease, genital sensation, and psychological or relationship factors.Medication-related inhibition
Medication history is often the most straightforward part of the evaluation because symptoms can be compared with the timing of starting or changing a drug.- Selective serotonin reuptake inhibitors (SSRIs)—a class of antidepressants that increases serotonin activity—are a common contributor to delayed ejaculation or absent orgasm in men. Their increased serotonin presence can inhibit the neural processes involved in orgasm and ejaculation.
- Opioids, including chronic pain medicines, can also prolong the time to ejaculation and orgasm. Tramadol, a weak opioid, is mentioned as an example of a drug that can affect ejaculatory timing.
- Medication-related causes may be managed by reviewing the drug, changing it when medically appropriate, or treating through its sexual side effect under clinician supervision.
Hormonal and neurochemical contributors
The source identifies testosterone and dopamine as major drivers of orgasmic and ejaculatory processes, while prolactin and norepinephrine act as inhibitory influences.Potential endocrine contributors include:
- Low or high testosterone, although the evidence is incomplete and inconsistent.
- Thyroid dysfunction, which may affect sexual function.
- Elevated prolactin, a hormone produced by the pituitary gland, which may inhibit ejaculation in some men.
- Hypogonadism, meaning clinically significant testosterone deficiency, usually produces additional symptoms rather than delayed ejaculation alone.
After orgasm, prolactin normally rises and contributes to the refractory period, the interval before a man can become erect and ready for another orgasm. This association provides a rationale for investigating prolactin, although most men evaluated for delayed ejaculation have normal prolactin levels.
Diabetes, chronic stress, environmental factors, aging, and other conditions can contribute indirectly by lowering testosterone or impairing sexual or neurologic function. The source notes evidence suggesting testosterone may decline by approximately 1% per year after age 30–35, while also emphasizing that the evidence remains unsettled.
Neurologic disease and reduced genital sensation
Orgasm depends partly on sensory signals traveling from the genitals to the nervous system. Damage or disruption anywhere along this pathway can reduce stimulation and delay or prevent orgasm. Possible causes include:- Pelvic or genital trauma.
- Surgery affecting genital or pelvic nerves.
- Spinal injury, slipped discs, or other neurologic insults.
- Diabetes-related neuropathy, although peripheral symptoms in the hands and feet may occur before genital symptoms.
- Multiple sclerosis, in which spinal-cord lesions may produce reduced genital sensation in men.
Psychological, sexual, and relationship factors
Psychological contributors may include:- Performance anxiety.
- Relationship stress.
- Difficulty feeling comfortable or emotionally engaged during sex.
- Internalized fear or other psychological barriers to climax.
Physical injury is a separate issue: unusually forceful or dangerous masturbation can cause actual trauma, whereas masturbation without tissue injury is unlikely to damage the nerves simply because it occurs frequently.
Clinical evaluation
A consultation is usually based primarily on a detailed history rather than an extensive physical procedure. The clinician may ask about:- The approximate time required to reach orgasm or ejaculation.
- Whether orgasm occurs without ejaculation, or ejaculation occurs without orgasm.
- Current and recently changed medications.
- Medical conditions such as diabetes or thyroid disease.
- Testosterone-related symptoms.
- Prior surgery, trauma, spinal problems, or neurologic symptoms.
- Sexual stimulation patterns, pornography, masturbation, and relationship context.
The source emphasizes that the expected visit is generally a conversation, possibly a basic or targeted examination, and selected laboratory testing—not automatically an invasive or highly technical workup.
Evaluation pathway for delayed or absent orgasm
As the flowchart shows, specialized testing is selected according to the suspected mechanism rather than performed routinely.
Specialized testing
- Biophysiometry is a machine-based assessment of penile and more general sensation; it is used infrequently and mainly when a neurologic defect is suspected.
- Magnetic resonance imaging (MRI) of the lumbar and thoracic spine may be considered when symptoms suggest a spinal or neurologic cause, such as a slipped disc or tumor.
- Somatosensory evoked-potential testing—likened in the discussion to an electroencephalogram (EEG) for genital sensory pathways—is also rare because clearly treatable neurologic causes are uncommon.
Treatment options
Addressing psychological and relationship causes
When the presentation appears psychosocial, the usual next step is referral to a qualified sex therapist or psychotherapist rather than expecting a urologist to provide specialized sex therapy. Few urologists are trained to deliver this treatment directly.Therapy may include:
- Cognitive behavioral therapy (CBT), which addresses unhelpful thoughts, anxiety, and behaviors.
- Other specialized psychological approaches, including certain eye-movement-based therapies.
- Partner participation, because sexual expectations, communication, and mutual support can affect treatment success.
Medication strategies
There is currently no United States Food and Drug Administration (FDA)-approved medication specifically for delayed ejaculation. Available drug treatments are off-label, meaning they are prescribed for a purpose not specifically approved on the medication label, and the evidence base is limited.Potential strategies include:
| Situation or medication | Rationale or use |
|---|---|
| SSRI-associated delayed ejaculation | Change the SSRI when medically appropriate, or consider bupropion, an antidepressant that may be substituted for or used to treat through the SSRI effect. |
| Cabergoline | Lowers prolactin and is sometimes used continuously when prolactin is normal, high-normal, or elevated; evidence and guidance remain incomplete. |
| Oxytocin | May be used shortly before sexual activity because it is short-acting and is theorized to facilitate orgasm; evidence is limited. |
| Other reported options | Pseudoephedrine, midodrine, apomorphine, yohimbine, and imipramine have been used in selected cases, generally on the basis of limited studies or case reports. |
Medication schedules differ:
- Some treatments, such as switching to bupropion or using cabergoline, are generally ongoing.
- Oxytocin is discussed as an as-needed treatment shortly before sexual activity because it acts briefly.
- Cabergoline and oxytocin are described as generally well tolerated.
- Vasoconstrictive drugs such as pseudoephedrine, ephedrine, and midodrine require caution in people with hypertension or significant cardiovascular risk because serious cardiovascular events are possible.
- Yohimbine is characterized as a supplement rather than a conventional prescription drug, with variable evidence and generally reported tolerability.
Testosterone is not a routine treatment for isolated delayed ejaculation
A low testosterone result does not automatically justify testosterone therapy for delayed ejaculation. Isolated delayed ejaculation is rarely the only symptom of genuine hypogonadism, and testosterone treatment carries its own risks when used incorrectly. Treatment is more reasonable when the man has a compatible symptom pattern and laboratory-confirmed testosterone deficiency rather than delayed ejaculation alone.Penile vibratory stimulation
Penile vibratory stimulation uses a device to deliver strong, adjustable stimulation to the penis. It may help overcome insufficient stimulation, particularly when genital sensation is genuinely reduced because of a neurologic problem.Its role is mainly acute:
- It can be used during sexual activity to help bring a man closer to orgasm.
- It does not necessarily restore the underlying nerve function or permanently improve sensation.
- When stimulation feels insufficient for psychosocial rather than neurologic reasons, sexual-technique training, cognitive-arousal strategies, psychotherapy, or sex therapy may be more appropriate.
Choosing a clinician and accessing care
Because delayed or absent orgasm is poorly understood and many clinicians have limited experience with it, the recommended specialist is a physician fellowship-trained in male sexual and reproductive health, often a specialized urologist. Primary-care clinicians can begin the evaluation, but the source cautions that they may have limited treatment options, and even many general urologists may be more comfortable treating erectile dysfunction than delayed orgasm.The Sexual Medicine Society of North America (SMSNA) is described as offering:
- A patient-facing educational website, SexHealthMatters.
- A physician finder for locating practitioners with an interest in sexual medicine.
Cost and insurance considerations
Routine evaluation and visits are generally described as commonly covered by insurance, although actual coverage varies. The medications discussed are mostly generic, so out-of-pocket costs may be relatively affordable even when coverage is limited.Costs can rise when specialized testing—such as MRI or other uncommon neurologic assessments—is required, but there is generally no surgical intervention for delayed ejaculation.
Practical takeaways
- Seek evaluation when delayed or absent orgasm causes distress, discomfort, relationship difficulty, or avoidance of sex; the condition is defined by both delay and its impact.
- Do not stop antidepressants, opioids, testosterone, or other medications without discussing the change with the prescribing clinician. Medication adjustment is a clinician-guided decision.
- Expect a detailed discussion first, with targeted examination, blood tests, or imaging only when the history supports them.
- A specialist in male sexual and reproductive health is often the best starting point, with referral to a sex therapist when psychological or relationship factors are suspected.
- Treatment is individualized because no FDA-approved medication exists, evidence for off-label drugs is limited, and improvement is usually judged by greater satisfaction and reduced delay rather than a universal stopwatch threshold.
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