Delayed ejaculation, also known as impaired ejaculation, is a condition in which a man has persistent difficulty or inability to achieve an orgasm and ejaculate, despite having sexual desire and stimulation. Delayed ejaculation affects approximately 4% of sexually active men, as compared to 20-30% for premature ejaculation.

Typically, a man is able to reach orgasm within several minutes of penetrative sexual intercourse. In delayed ejaculation, however, orgasm and ejaculation can only be achieved after prolonged intercourse of 20-30 minutes or longer. Sometimes, men are unable to ejaculate at all (anejaculation).

Delayed ejaculation can be lifelong (present from the time of sexual maturity) or acquired (only occurring after a period of normal sexual functioning). It can also be generalized (under all circumstances) or situational (under certain circumstances eg. different partner or type of sexual stimulation).

Ranging from mild to severe, the symptoms of delayed ejaculation are:

• Able to ejaculate only after prolonged intercourse of 20-30 minutes or longer
• Often ceasing sexual activity due to exhaustion, physical irritation, loss of erection or as requested by partner
• Unable to ejaculate during intercourse, but able to during fellatio or manual stimulation
• Only able to ejaculate during self-stimulation when alone
  Unable to ejaculate at all

The causes of delayed ejaculation can be classified under psychological, medication-related or physical, or a combination of these factors.

Psychological causes include:

• Depression, anxiety or other mental health conditions
• Relationship issues eg. stress or poor communication
• Performance anxiety
• Differences between the reality of sex with a partner and one’s own sexual fantasies
• Cultural or religious taboos

Medications and other substances include:

• Anti-depressive, antipsychotic and anti-seizure medications
• Anti-hypertensive medications
• Opioid painkillers such as morphine
• Excessive alcohol use or alcoholism

Physical causes include:

• Urinary tract infection
• Prostate surgery
• Hormone-related conditions, such as hypothyroidism or low testosterone
• Birth defects affecting the reproductive system
• Pelvic nerve injury
• Neurological diseases, such as diabetic neuropathy, stroke or spinal cord damage
• Retrograde ejaculation, a condition in which semen travels backward into the bladder instead of outside the penis

A detailed medical history and a physical examination are necessary. Laboratory tests include:

• Blood tests for cholesterol profile, diabetes, testosterone levels and thyroid function
• Urine tests for signs of diabetes, urinary tract infection or other underlying health conditions

Treatment of any underlying cause can in many cases resolve the delayed ejaculation. Any potential medications that can contribute to delayed ejaculation should be stopped or changed.

There are certain medications which are supposedly able to help with delayed ejaculation, but they can be unreliable and have little effect, if any. As such, the mainstays of treatment are psychotherapy and sex counselling.

Psychotherapy involves analysing past and current factors that can directly result in delayed ejaculation, including previous unpleasant sexual experiences, underlying psychological issues, performance anxiety, etc.

Sex counselling is done either alone or with both partners, and involves sex education and goal-oriented tasks and exercises intended to help a man achieve orgasms earlier during sexual intercourse.

Left unaddressed, delayed ejaculation can result in the following complications:

• Stress or anxiety about sexual performance
• An unsatisfactory sex life for either or both partners. This could potentially snowball into relationship or marital problems
• Male infertility (unable to conceive with partner)