What Causes Delayed Ejaculation and Anejaculation? How Are They Treated?

When ejaculation problems are mentioned, the first thing that usually comes to mind is premature ejaculation. Yet at the other end of the spectrum lies a condition that is discussed far less, but can be just as distressing: delayed ejaculation and its more advanced form, anejaculation. In this picture, despite adequate stimulation and desire, the man finds it very difficult to reach ejaculation, or cannot reach it at all.

This article covers its causes, how it differs from similar conditions, the assessment process and treatment approaches, including for couples who wish to have a child.

What are delayed ejaculation and anejaculation?

Delayed ejaculation means that, despite adequate sexual stimulation and the wish to ejaculate, ejaculation is markedly delayed, becomes infrequent or does not occur at all. Diagnosis rests less on a time threshold than on whether it causes distress to the man and the relationship and has been present in most encounters for several months.

The condition may be lifelong or acquired, beginning later in a man who previously ejaculated without difficulty; it may occur in every situation or only in certain ones, for example with masturbation but not with a partner. This distinction gives important clues about the likely causes.

How it differs from absent orgasm and retrograde ejaculation

Ejaculation is the expulsion of semen; orgasm is the sensation of climax that accompanies it. Although usually simultaneous, they are separate processes:

• Anejaculation: Semen is not expelled. The man may or may not experience the sensation of orgasm.
• Anorgasmia (absent orgasm): The sensation of climax is absent; sometimes orgasm is not felt even though ejaculation occurs.
• Retrograde ejaculation: Orgasm occurs but semen passes backwards into the bladder; the man describes a "dry orgasm", and urine after intercourse may be cloudy.

Retrograde ejaculation is covered in a separate article. What matters here is that the complaint "no semen comes out" does not always mean delayed ejaculation, and that the distinction can be made with a simple urine test.

Medical causes: medicines, nerve damage and hormones

There is often no single cause. The medical headings most often encountered in the clinic are as follows:

• Medicines: Some antidepressants, particularly the groups acting on serotonin, are known to delay ejaculation. Some psychiatric medicines, strong painkillers and certain prostate medicines can also play a part.
• Diabetes and nerve damage: Long-standing, poorly controlled diabetes can affect the nerves governing ejaculation, as can neurological conditions such as multiple sclerosis.
• Surgery and the spinal cord: Spinal cord injury, surgery on the lymph nodes at the back of the abdomen, and pelvic and prostate surgery can affect ejaculation.
• Hormonal factors: Low testosterone, an underactive thyroid and raised prolactin can affect both sexual desire and ejaculation.
• Age and alcohol: Reduced penile sensitivity with age and heavy alcohol use can delay ejaculation.

Where a medicine is involved, the most important rule is this: the medicine should not be stopped or reduced without consulting the doctor who prescribed it. In psychiatric treatment in particular, stopping abruptly can lead to relapse.

Psychological and relationship factors, and masturbation habits

Where a medical cause does not explain the picture, psychological and relationship factors play an important role:

• Performance anxiety and "spectatoring": Watching oneself from the outside during intercourse can stop arousal building to a climax.
• Problems within the relationship: Unresolved conflict, issues of trust or reduced attraction.
• Pressure to conceive: Intercourse planned around a calendar can make ejaculation harder.
• Depression, stress and guilt: Negative beliefs about sexuality can also contribute.

Masturbation habits deserve separate attention. In men who have developed an idiosyncratic technique over the years, such as a very tight grip, high speed or a particular position, stimulation with a partner may not reach that level. Frequent, intense consumption of visual content can also create a mismatch between real intimacy and expectation. These are not flaws but habits that can be relearned.

How is the assessment carried out?

The assessment begins with a detailed conversation conducted in confidence:

• Is the problem lifelong or acquired; does it occur in every situation, or only with a partner?
• Is orgasm experienced; is urine cloudy after intercourse?
• Which medicines are being taken, and since when?
• Is there a history of diabetes, neurological disease, surgery or spinal cord injury?

A genital and basic neurological examination follows; depending on the findings, blood sugar, testosterone, thyroid and prolactin levels are checked. Where a dry orgasm is described, urine after ejaculation is checked for sperm to identify retrograde ejaculation. In couples who wish to have a child, a semen analysis is added.

Treatment approaches

Treatment is planned according to the cause identified and the man's expectations; current guidelines recommend a cause-focused, multifaceted approach:

• Addressing the cause: If a thyroid, prolactin or testosterone disorder is found, it is treated first; in diabetes, better blood sugar control can slow nerve damage.
• Adjusting medication: If a medicine affects ejaculation, a dose adjustment, a change of timing or a switch to another group can be considered with the prescribing doctor.
• Sex therapy: Aims to reduce anxiety, strengthen communication and direct attention towards bodily sensations; where possible, it involves the partner.
• Adjusting masturbation habits: Gradually changing grip, speed and frequency can ease adaptation to a partner.
• Medication: The use of certain medicines to facilitate ejaculation has been reported; however, the scientific evidence in this area is limited and the decision is made on an individual basis.

In pictures linked to habits and anxiety in particular, change emerges gradually.

Fertility options for couples who wish to have a child

In anejaculation, sperm production is often normal; the problem lies in the expulsion of sperm. Several options are therefore available:

• Semen obtained by masturbation: Where ejaculation fails only with a partner, insemination can use such a sample.
• Vibratory stimulation: A medical vibration device applied to the penis can obtain semen, particularly in men with spinal cord injury.
• Electroejaculation: Can be applied under anaesthesia if vibratory stimulation is not effective.
• Retrieving sperm from urine: Where retrograde ejaculation is also present, sperm can be separated from urine collected after ejaculation.
• Retrieving sperm from the testicle: If other methods fall short, IVF with surgically retrieved sperm is considered.

The method is chosen jointly, according to the cause, the female partner's age and the couple's preferences.

When should a doctor be consulted?

Assessment is advised in these situations:

• Ejaculation that has been markedly delayed or absent for several months and is causing distress
• Noticing a change in ejaculation after starting a new medicine
• No semen despite orgasm, or cloudy urine after intercourse
• Impaired ejaculation with diabetes, neurological disease, spinal cord injury or after pelvic surgery
• Possible hormonal signs such as reduced desire, breast enlargement or nipple discharge
• No pregnancy in a couple wishing to conceive because of anejaculation

Delayed ejaculation and anejaculation sit at the opposite end of the spectrum from premature ejaculation; rarely discussed, they can in most cases be addressed. Establishing the cause is the foundation of the right treatment plan, and couples who wish to have a child have more than one option available. Assoc. Prof. Zülfü Sertkaya practises in urology and andrology in Istanbul; assessment and treatment planning in delayed ejaculation and anejaculation are carried out with individual assessment and confidentiality.

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