The GP Guide: How to diagnose and treat ejaculatory disorders

Ejaculatory disorders result from a disrupted mechanism of ejaculation — emission, ejaculation or orgasm.

The most common ejaculatory disorder is premature ejaculation¹ but problems with ejaculation also include delayed ejaculation, anorgasmia, retrograde ejaculation, anejaculation and painful ejaculation. 

This article guides GPs on how to diagnose and treat these ejaculatory disorders, and when to refer to a specialist.  

What causes premature ejaculation and other ejaculatory disorders? 

The causes of ejaculatory dysfunction are numerous and multifactorial. They include psychogenic, congenital, anatomic, neurogenic and endocrinological causes, infection, and medications (antihypertensive, psychiatric (SSRIs), α-blocker). 

What is the GP’s role in diagnosing and managing ejaculatory disorders? 

GPs are typically the first point of contact for men with a disorder of ejaculation and they play a role in diagnosis, treatment and referral. GPs should also offer brief counselling and education as part of routine management.

Patients may find it uncomfortable or embarrassing to bring up ejaculation issues with their doctor. GPs can make it easier by approaching the topic with patients directly, for example, “Many men experience sexual difficulties. If you have any difficulties, I am happy to discuss them.”

What is premature ejaculation?

Premature ejaculation (PE) is ejaculation that occurs sooner than desired. There are two types: primary (lifelong) and secondary (acquired). 

In primary PE: 

• The patient has never had control of ejaculation — PE is present from the first sexual experience
• There is a lower set point for ejaculatory control
• Underlying disease is unlikely.
   

In secondary PE:

• The patient could previously control ejaculation — PE represents a significant reduction in latency time occurring later in life
• Erectile dysfunction (ED) is commonly associated.
   

In clinical terms, premature ejaculation is defined as²:

• An intravaginal ejaculatory latency time of less than about one minute (for primary PE) or about three minutes (for secondary PE)
• An inability to delay ejaculation on nearly all occasions
• Negative personal consequences such as distress.

How to diagnose premature ejaculation

PE is a self-reported diagnosis and can be based on sexual history alone. But it’s useful to assess medical, psychological and physical factors to determine what is causing PE. 

Sexual history

First, establish the presenting complaint i.e. linked with ED. Then, review sexual history to determine:

• Intravaginal ejaculatory latency time
• Onset and duration of PE
• Previous sexual function
• History of sexual relationships
• Perceived degree of ejaculatory control
• Degree of patient and partner distress
• If fertility is an issue.

Medical factors

GPs should assess general medical history and check more specifically for:

• Prescription and non-prescription medications
• Urogenital, neurological or surgical trauma
• Prostatitis or hyperthyroidism, although these are uncommonly associated.

Psychological factors

Psychological factors can contribute to ejaculatory disorders. These include:

• Depression
• Anxiety
• Stressors
• Religious or cultural taboos or beliefs about sex.

Physical examination

GPs should perform the following:

• General examination
• Penile and testicular examination, including a rectal examination if PE occurs with painful ejaculation
• A neurological assessment of the genital area and lower limb.

For detailed information, refer to our step-by-step guide to performing male genital examinations.

How to treat premature ejaculation 

The underlying cause guides the management of PE. Treatment decision-making for PE should consider aetiology, patient needs and preferences, the impact of the disorder on the patient and his partner, and whether fertility is an issue.

Treatment options for premature ejaculation

Erectile dysfunction treatment

If PE is associated with ED, treat the primary cause. For example, prescribe PDE5 inhibitors.

Behavioural techniques

Behavioural techniques include: 

• ‘Stop-start’ and ‘squeeze’ techniques
• Extended foreplay
• Pre-intercourse masturbation
• Cognitive distractions
• Alternate sexual positions
• Interval sex
• Increased frequency of sex. 

Patients may find these techniques difficult to maintain long-term.

Psychosexual counselling

Psychosexual counselling addresses the issue that has created the anxiety or psychogenic cause. It can also introduce methods to improve ejaculatory control, for example, meditation, relaxation, hypnotherapy and neuro-biofeedback.

Oral pharmacotherapy

A side-effect of some selective serotonin reuptake inhibitors (SSRIs) and tricyclic antidepressants is delayed ejaculation, so they are commonly prescribed for PE. Except for dapoxetine hydrochloride, all other SSRIs are used off-label for treating PE. 

For common SSRI dosing regimes, see our clinical summary guide.

PDE-5 inhibitors are used as treatment if PE is related to ED.

For all drug treatments, GPs should start low and titrate slow. Trial for three to six months and then slowly titrate down to cessation. If PE reoccurs, trial the drug again. If one drug is not effective, trial another.

Reducing penile sensation

There are three main options for reducing penile sensation:

• Topical applications — local anaesthetic gels or creams can diminish sensitivity and delay ejaculation. However, excess use can be associated with a loss of pleasure, orgasm and erection. Apply 30 minutes prior to intercourse to prevent trans-vaginal absorption or use a condom if intercourse occurs sooner
• Lignocaine spray — this should be used with a condom to prevent numbing the partner’s genitalia
• Condoms — Using condoms can diminish sensitivity and delay ejaculation, especially condoms containing anaesthetic.

These therapies can be used in combination.

Treating primary premature ejaculation 

For primary PE, most men require ongoing treatment to maintain normal function. First-line treatments are SSRIs and reducing penile sensation. Behavioural techniques and/or psychosexual counselling can be used as second-line treatments. 

Treating secondary premature ejaculation 

Many men return to normal function following treatment for secondary PE. 

Behavioural techniques and/or counselling are the initial treatments. But if PE is secondary to ED, manage the primary cause first.  

SSRIs, reducing penile sensation and/or PDE5 inhibitors are second-line treatments. 

When to refer to a specialist

For a general assessment, refer to a GP, endocrinologist or urologist who has an interest in sexual medicine.

Other specialists GPs may need to refer to:

• A urologist if a lower urinary tract disease is suspected
• An endocrinologist if a hormonal problem is diagnosed
• A counsellor, psychologist, psychiatrist or sexual therapist for psychosexual issues
• A fertility specialist if fertility is an issue.

How to treat other ejaculatory disorders

Delayed ejaculation

Delayed ejaculation occurs when an ‘abnormal’ or ‘excessive’ amount of stimulation is required to achieve orgasm with ejaculation. It often occurs with concomitant illness and is also associated with ageing.

Delayed ejaculation can have a psychosexual cause, for example, if there is an idiosyncratic masturbatory style.

Treatment³:

• Aetiological treatment: managing the underlying condition or concomitant illness e.g. androgen deficiency
• Medication modification: consider an alternative agent or a ‘drug holiday’ from causal agent
• Psychosexual counselling

Anorgasmia (no orgasm)

Anorgasmia is the inability to reach orgasm. The cause is usually psychological. Some men experience nocturnal or spontaneous ejaculation.

Treatment⁴:

• Psychosexual counselling
• Medication modification
• Pharmacotherapy: pheniramine maleate, pseudoephedrine or cyproheptadine may help but have a low success rate
• Managing testosterone levels.

Retrograde “dry” ejaculation (orgasm with no ejaculation)

Retrograde ejaculation occurs when semen passes backwards through the bladder neck into the bladder. Little or no semen is discharged from the penis during ejaculation and men experience a normal or decreased orgasmic sensation.

Causes include prostate surgery and diabetes. The first urination after sex looks cloudy as semen mixes into the urine.

Treatment⁵:

• Counselling to normalise the condition
• Pharmacotherapy: restoration of antegrade ejaculation and natural conception is possible but treatment may not be successful
• Medication modification
• Encouraging the patient to ejaculate when his bladder is full to increase bladder neck closure
• Vibrostimulation, electroejaculation, or sperm recovery from post-ejaculatory urine: this can be used when other treatments are not effective in order to retrieve sperm for assisted reproductive techniques (ART)
• Post-ejaculatory urinalysis: to check sperm and fructose.

Anejaculation 

Anejaculation is the complete absence of ejaculation, due to a failure of semen emission from the prostate and seminal ducts into the urethra. It is usually associated with normal orgasmic sensation.

Treatment⁵:

• Counselling
• Medication modification
• Vibrostimulation or electroejaculation: used when other treatments are not effective, to retrieve sperm for ART
• Pharmacotherapy: dopamine receptor agonists, serotonin antagonists, oxytocin and drugs that increase noradrenaline
• Manage testosterone levels
• Post-ejaculatory urinalysis
• MRI or ultrasound of seminal vesicles and post-ejaculatory ducts, usually via the rectum.

Painful ejaculation

Painful ejaculation is an acquired condition where painful sensations are felt in the perineum or urethra and urethral meatus. There are multiple causes including ejaculatory duct obstruction, post-prostatitis, urethritis and autonomic nerve dysfunction.

Treatment:

• Aetiological treatment: implement disease-specific treatment
• Behavioural techniques: if no physiological process is identified, patients can use relaxation techniques e.g. ejaculation in conditions when muscles can be relaxed, or fantasy for distraction
• Psychosexual counselling
• Transurethral resection of the ejaculatory duct
• Urine analysis: first pass urine — chlamydia and gonorrhoea urine PCR test; midstream urine MC&S
• Cultures of semen (MC&S)
• Cystoscopy
• Consider MRI and transrectal ultrasound to assess for ejaculatory duct obstruction.
   

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Ejaculatory Disorders