Ejaculatory disorders: premature, delayed and retrograde ejaculation

Ejaculatory disorders include premature ejaculation, delayed ejaculation, retrograde ejaculation, anejaculation, anorgasmia and painful ejaculation. By far the most common is premature ejaculation, which affects 25–30% of men and is the most widespread male sexual disorder of all: some estimates put the figure at around four million men in Italy alone.

Ejaculation is a reflex: a stimulus in the genital area produces a reflex response, the emission of seminal fluid through the urethra. Both physical and psychological components are involved, and the outcome depends on the number and force of the contractions, on the output of the prostate and seminal vesicles, and on the perception of pleasure.

Premature ejaculation

Premature ejaculation is the difficulty or inability to exercise voluntary control over ejaculation. It is the most widespread male sexual disorder.

How it is defined today

The historical definition is that of Masters & Johnson (1960s): a man has premature ejaculation if he ejaculates before his partner reaches orgasm in more than half of intercourse episodes. Other interpretations followed over time, based on the duration of intercourse, the number of thrusts, or the perceived sense of control.

The modern, evidence-based definition rests on three criteria:

• Time (IELT): the intravaginal ejaculatory latency time, the interval between penetration and ejaculation, is under one minute in premature ejaculators
• Control: the inability to delay ejaculation
• Impact: the frustration and distress experienced by the man and his partner as a consequence

Not every rapid ejaculation is premature ejaculation. Many men fear they have it without cause: most men reach orgasm sooner than they would like, particularly under stress or when highly aroused, and men and women biologically differ in how quickly they reach sexual pleasure. Premature ejaculation is only correctly diagnosed when the disorder is persistent and recurrent in every attempt at penetrative intercourse.

The two forms: lifelong and acquired

• Lifelong (primary) — 70% of cases: an inability to control the ejaculatory reflex from the very first sexual experiences, persisting throughout the man's sexual life
• Acquired (secondary) — 30% of cases: the disorder arises in a man who previously had normal ejaculatory control

Causes

The causes differ between the two forms:

• In the lifelong form, a genetic hypothesis is increasingly emerging: some men appear to have altered brain levels of serotonin, a substance central to the ejaculatory mechanism. Performance-related or constitutional anxiety also plays an important role
• In the acquired form, specific factors must be sought: prostatic inflammation, thyroid hormone disorders, stress, family or work conflict, low self-esteem, and guilt associated with sexuality

Diagnosis

Diagnosis rests on:

• A detailed clinical history: habits, behaviour, illnesses, together with a thorough enquiry into the man's sexual life (frequency and type of intercourse)
• Validated questionnaires: the most widely used is the PEDT, which establishes the presence and severity of premature ejaculation through five simple questions
• Andrological examination, including examination of the genital area and a digital rectal examination to assess the prostate
• Laboratory and instrumental tests, to identify any predominant organic component

Treatment

There is no single treatment for premature ejaculation: the approach depends on the factors involved.

The first step is to resolve any organic abnormality — prostatic inflammation, hormonal disorders, neurological alterations. Doing so resolves at least 50–60% of cases.

In the remaining cases, the disorder is durably resolved by combining:

• Cognitive behavioural therapy, with relaxation techniques and strategies to reduce performance anxiety
• Targeted drug therapy

Approved drugs for premature ejaculation

• Dapoxetine (since 2009): the first oral drug approved by the EMA specifically for premature ejaculation. It belongs to the SSRIs (selective serotonin reuptake inhibitors), a class of antidepressants already used off-label for this disorder. Unlike other SSRIs it has a short duration of action (a few hours) and is taken 1 to 3 hours before intercourse
• Topical lidocaine and prilocaine spray (since 2017): indicated for primary premature ejaculation in adult men. It works by reducing the sensitivity of the glans, prolonging the time before ejaculation

Both are prescription-only medicines: the indication and the dosage must be established by the specialist after appropriate clinical assessment.

Delayed ejaculation

This is the condition in which prolonged stimulation is required to achieve ejaculation with an erect penis. It is sometimes associated with anorgasmia. Causes may be psychological or organic: incomplete spinal cord injury, iatrogenic damage to penile innervation, or the use of antidepressant or antipsychotic drugs.

Retrograde ejaculation

This is the total or partial absence of antegrade ejaculation through the urethra, with seminal fluid present in the urine after orgasm: semen flows back into the bladder instead of being expelled. The causes are:

• Neurogenic: spinal trauma, anal and colorectal surgery, abdominal vascular surgery
• Pharmacological: antidepressants, antipsychotics, antihypertensives
• Urological: urethral strictures, endoscopic and open prostate surgery, bladder neck incompetence

Anejaculation

This is the complete absence of ejaculation, both antegrade and retrograde into the bladder. It is usually associated with a normal orgasmic sensation, unaccompanied by any emission of seminal fluid. The cause is generally organic: neurological dysfunction (diabetic neuropathy, spinal trauma, colorectal surgery, retroperitoneal lymphadenectomy) or drug use (antidepressants, antipsychotics, antihypertensives).

Anorgasmia

This is the inability to reach orgasm. It may be induced by psychoactive substances (drugs or medicines) or have a psychological origin. Anorgasmia does not mean the absence of pleasure: it refers only to orgasm.

Painful ejaculation

This is the disorder in which orgasm and ejaculation are accompanied not by pleasure but by pain and burning, which may affect the perineum, the urethra and the urethral meatus. The causes are usually organic: obstruction of the ejaculatory ducts, prostatitis and urethritis, or the use of antidepressant drugs.

Frequently asked questions about ejaculatory disorders

How soon is it considered premature ejaculation?

The reference time criterion is the IELT, the time between penetration and ejaculation: it is under one minute in premature ejaculators. But time alone is not enough: the inability to delay ejaculation and the resulting distress for the man and his partner are equally part of the definition. And the disorder must be persistent and recurrent, not occasional.

Is premature ejaculation a psychological problem?

Not necessarily. In the lifelong form a biological basis is increasingly emerging, linked to brain serotonin levels. In the acquired form, specific organic causes such as prostatitis or thyroid disorders must be sought. A psychological component is almost always present, but it is rarely the only one.

Can premature ejaculation be cured?

Yes. Resolving any organic causes alone resolves at least 50–60% of cases. In the remainder, combining cognitive behavioural therapy with targeted drug therapy durably resolves the disorder. There are drugs approved specifically for this condition, both oral and topical.

What does it mean to have semen in the urine after orgasm?

It is the sign of retrograde ejaculation: seminal fluid flows back into the bladder rather than out through the urethra. The most common causes are neurological, pharmacological, or the consequence of prostate surgery. It should always be assessed by a specialist, not least because it affects fertility.

Is painful ejaculation serious?

It is almost always the symptom of an identifiable organic cause — prostatitis, urethritis, obstruction of the ejaculatory ducts — and should be investigated. It is not a condition to be endured in silence.

Do you recognise any of these disorders? Ask Prof. Natali for a consultation or book an appointment at his practices in Florence and Empoli, Italy.

The information on this page is provided for general educational purposes and does not replace a medical examination, which remains the only diagnostic tool for correct and effective treatment. All medicines mentioned are prescription-only.