Understanding and Managing Men’s Orgasmic Difficulties

[madman]

INTRODUCTION

This review discusses 2 ejaculation disorders that represent disturbances in psychosexual responding, premature ejaculation (PE) and delayed/ inhibited ejaculation (DE). Both disorders are related to the timing/occurrence of ejaculation (ie, ejaculation latency [EL]) during partnered sex, and men with either condition can often be treated successfully and achieve (or regain) a satisfying sex life.

These 2 conditions are discussed separately, touching briefly on definition, prevalence, cause/ risk, diagnosis, and treatment. Although a holistic approach is taken for each problem—considering biological, psychological, relationship, and cultural issues—various therapeutic tools may be more suited to or preferred by some patients and practitioners than others. However, efficacy and patient satisfaction—outcomes that are clearly intertwined—remain the primary concerns of treatment.


*Ejaculation/Orgasm as Part of the Sexual Response Cycle in Men


*Conceptualizing the Problem of Ejaculatory Disorders


DISCUSSION: PREMATURE EJACULATION

*Defining Criteria, Premature Ejaculation Subtypes, and Prevalence
-Defining diagnostic criteria
-Lifelong versus acquired premature ejaculation
-Prevalence of premature ejaculation

*Risk Factors for and Cause of Premature Ejaculation
-Biological factors
-Psychological factors
-Interplay between biological and psychological factors
-Relationship and cultural factors

*Treating Premature Ejaculation
-Assessment/diagnosis

Treatment Options Overview
*Pharmacologic options
-Topical ointments, creams, gels, and sprays
-Oral medications/Treatment regimens
-Neurotransmitter reuptake inhibitors (Including SSRIs)
-Daily dosing/On-demand
-Other pharmacologic options
-Treatment of PE and comorbid ED

*Surgical approaches

*Psychobehavioral treatment options
-Behavioral approaches
-Cognitive approaches
-Relationship approaches

*Taking a Multimodal Approach


DISCUSSION: DELAYED EJACULATION

*Defining Criteria, Delayed Ejaculation Subtypes, and Prevalence
-Defining diagnostic criteria
-Lifelong versus acquired delayed ejaculation
-Prevalence of delayed ejaculation

*Risk Factors for and Cause of Delayed Ejaculation
-Physiologic/pathophysiologic risk factors
-Psychological and relationship factors

*Treating Delayed Ejaculation
-Assessment and diagnosis

Overview of Treatment Options
*Pharmacologic options

*Psychobehavioral approaches
-Behavioral approaches
-Cognitive approaches
-Relationship approaches

*Integrating Treatment Options




SUMMARY

A Multimodal Treatment Framework for Ejaculatory Disorders

An integrated treatment approach toward ejaculatory disorders—either PE or DE—could follow any number of paths, and practitioners will undoubtedly have their own preferences and methods. Although avoiding specific formulas, one approach might use a multisession program (perhaps 3–6 sessions) that draws from a modified PLISSIT model, a well-known model having 4 levels of intensity beginning with Permission, continuing with Limited Information, Specific Suggestions, and Intensive Therapy.48Although much of the progression through these sessions would focus on “content” (the information, skills, and techniques conveyed to the patient), within any treatment environment, the practitioner must also attend to “process” issues that ensure a strong working alliance with the patient/couple.21,47 Building such rapport is particularly important when sensitive sexual issues are involved and includes expressing empathy, genuineness, and positive regard; developing the patient’s motivation to change and adherence to treatment protocols; and supporting a strong sense of self-efficacy for the patient and partner.47,49

 

[madman]

Fig. 1. Sample distribution of ejaculatory latencies, illustrating men with short, typical, and long latencies.

 

[madman]

Table 1 Comparison and contrast of premature and delayed ejaculation

 

[madman]

Table 2 Examples of useful assessment instruments for premature ejaculation and relationship functioning

 

[madman]

Table 3 Some advantages and disadvantages of various treatment options for premature ejaculation

 

[madman]

Table 4 Putative negative effects of various medications on erectile/arousal and ejaculatory function in men

 

[madman]

Table 5 Possible steps in the evaluation of delayed ejaculation

 

[madman]

Box 1 Quick reference link for pharmacologic efficacy in premature ejaculation treatment (see paper)

Box 2 Quick reference link for behavioral efficacy in premature ejaculation treatment (see paper)


Box 3 How physically challenging is having sex and might this account for acquired delayed ejaculation?

*For a man weighing 155 pounds, intercourse (top position) burns an estimated 120 to 150 calories assuming about 30 minutes of activity. Heart rate is around 110 to 120 bpm during orgasm.

*For a man weighing 180 pounds, intercourse burns an estimated 140 to 170 calories assuming about 30 minutes of activity. Heart rate may increase by another 10% to 15%.

*For a man weighing 200 pounds, intercourse burns an estimated 150 to 180 calories assuming about 30 minutes of activity. Heart rate may increase by 30% over the man weighing 155 pounds, perhaps as high as 130 to 140 bpm during orgasm.

*How do the aforementioned parameters compare with other physical activities? Caloric use during sex is equivalent to about 30 minutes of leisure cycling, kayaking, or brisk pace walking. Heart rate during orgasm equates with the bpm for moderately intense exercise for a 50-year-old man.

Box 4 Sample questions that might be asked of patients with suspected delayed ejaculation

*Has the problem been lifelong? Recent? Developed over a period of time?

*Related to any other life events? Situation specific? Illnesses? Or more generalized?

*Can the man masturbate to orgasm?

*Has there been a noticeable increase in ejaculatory latency during masturbation?

*What are the current sexual practices, in terms of coital and masturbation frequency

*Are there situations when the man is able to ejaculate with the partner (eg, masturbation, using erotic materials, specific fantasies, and so forth).

 

[madman]

KEY POINTS

*Premature ejaculation (PE) and delayed/inhibited ejaculation (DE) may result from a mix of biological and psychogenic factors

*Medical issues should be investigated when the problem has recently been acquired

*Addressing ejaculatory latency may be the immediate concern, but communication between sexual partners is important to mutual sexual satisfaction

*Treatment success for PE based on an integrated approach is high. Treatment success for DE based on psychobehavioral strategies is moderate

 

[madman]

Regarding Premature Ejaculation

*PE may be a lifelong condition that typically has no clear cause or pathophysiology

*PE may be an acquired condition of recent pathophysiologic or relationship origin

*PE is a very manageable condition

*Patients/couples can select from a range of treatment options

*Attention to psychological and relationship issues may improve treatment outcomes



Regarding Delayed Ejaculation

*DE may be either lifelong or acquired; the former is poorly understood

*Treatment options are limited as no approved pharmacologic options are available

*Motivated patients or couples may realize significant benefits from behavioral, cognitive, and relationship strategies under the guidance of a specialist

*These procedures help enhance arousal, remove barriers to arousal, and ensure mutual sexual satisfaction