Skip to main content

Thank you for visiting nature.com. You are using a browser version with limited support for CSS. To obtain the best experience, we recommend you use a more up to date browser (or turn off compatibility mode in Internet Explorer). In the meantime, to ensure continued support, we are displaying the site without styles and JavaScript.

Ejaculatory disorders: pathophysiology and management

Abstract

Ejaculatory dysfunction (EjD) is one of the most common male sexual disorders, yet EjD is still frequently misdiagnosed or overlooked as a result of numerous patient and physician barriers. The wide spectrum of EjD ranges from premature or rapid ejaculation, through delayed ejaculation, to a complete inability to ejaculate—otherwise known as anejaculation—and includes retrograde ejaculation and painful ejaculation. Conventional algorithms for managing ejaculatory disorders are based either on an organic or psychogenic etiology, with the latter more traditionally considered the main cause. This paper reviews physiopathological, diagnostic and therapeutic aspects of ejaculation disorders, with a particular focus on the most prevalent disorder, premature ejaculation.

Key Points

  • Ejaculatory dysfunction is one of the most common male sexual disorders, but is still frequently misdiagnosed

  • The most common ejaculatory dysfunction is premature ejaculation (PE), which affects 5–40% of sexually active men

  • Ejaculation involves cerebral sensory areas, motor centers and several spinal nuclei that are tightly interconnected

  • Diagnosis of PE in clinical practice is straightforward, as it is simply based on patient self report, clinical history, sexual history and examination findings

  • The major objective when diagnosing PE is to quantify the length of time between penetration and ejaculation, although a multidimensional assessment of patients affected with PE, including psychosocial involvement, is also needed

  • Selective serotonin reuptake inhibitors and topical anesthetic creams can provide good efficacy for treating PE, even if a clear understanding of the etiology of lifelong PE is lacking

This is a preview of subscription content

Access options

Buy article

Get time limited or full article access on ReadCube.

$32.00

All prices are NET prices.

References

  1. Rosen R et al. (2003) Lower urinary tract symptoms and male sexual dysfunction: the multinational survey of the aging male (MSAM-7). Eur Urol 44: 637–649

    Article  Google Scholar 

  2. McMahon CG et al. (2006) Ejaculatory disorders. In Standard Practice in Sexual Medicine (Eds Porst H and Buvat J) Oxford: Blackwell Publishing

    Google Scholar 

  3. Jannini EA et al. (2002) Sexological approach to ejaculatory dysfunction. Int J Androl 25: 317–323

    CAS  Article  Google Scholar 

  4. Dunsmuir WD et al. (1996) There is a significant sexual dissatisfaction following TURP. Br J Urol 77: 161A

    Article  Google Scholar 

  5. Rowland DL et al. (2001) Defining premature ejaculation for experimental and clinical investigations. Arch Sex Behav 30: 235–253

    CAS  Article  Google Scholar 

  6. Jannini EA and Lenzi A (2005) Ejaculatory disorders: epidemiology and current approaches to definition, classification and subtyping. World J Urol 23: 68–75

    Article  Google Scholar 

  7. St Lawrence JS and Madakasira S (1992) Evaluation and treatment of premature ejaculation: a critical review. Int J Psychiatry Med 22: 77–97

    CAS  Article  Google Scholar 

  8. Colpi G et al. (2004) EAU guidelines on ejaculatory dysfunction. Eur Urol 46: 555–558

    CAS  Article  Google Scholar 

  9. Masters WH and Johnson VE (1970) Human sexual inadequacy. Toronto; New York: Bantam Books

    Google Scholar 

  10. Waldinger MD et al. (1994) Paroxetine treatment of premature ejaculation: a double-blind, randomized, placebo-controlled study. Am J Psychiatry 151: 1377–1379

    CAS  Article  Google Scholar 

  11. Waldinger MD (2003) Towards evidence-based drug treatment research on premature ejaculation: a critical evaluation of methodology. Int J Impot Res 15: 309–313

    CAS  Article  Google Scholar 

  12. American Psychiatric Association (2000) Diagnostic and statistical manual of mental disorders, fourth edition, text revision: DSM-IV-TR. Washington, DC: American Psychiatric Association

  13. Dail WG (1993) Autonomic innervation of male genitalia. In Nervous control of the urogenital system, 69–102 (Ed Maggi CA) London: Informa Healthcare

    Google Scholar 

  14. Jänig W and McLachlan EM (1987) Organization of lumbar spinal outflow to distal colon and pelvic organs. Physiol Rev 67: 1332–1404

    Article  Google Scholar 

  15. Giuliano F and Clément P (2005) Physiology of ejaculation: emphasis on serotonergic control. Eur Urol 48: 408–417

    Article  Google Scholar 

  16. Andersson KE and Wagner G (1995) Physiology of penile erection. Physiol Rev 75: 191–236

    CAS  Article  Google Scholar 

  17. Grundemar L and Håkanson R (1990) Effects of various neuropeptide Y/peptide YY fragments on electrically-evoked contractions of the rat vas deferens. Br J Pharmacol 100: 190–192

    CAS  Article  Google Scholar 

  18. Zoubek J et al. (1993) A comparison of inhibitory effects of neuropeptide Y on rat urinary bladder, urethra, and vas deferens. Am J Physiol 265: R537–R543

    CAS  PubMed  Google Scholar 

  19. Domoto T and Tsumori T (1994) Co-localization of nitric oxide synthase and vasoactive intestinal peptide immunoreactivity in neurons of the major pelvic ganglion projecting to the rat rectum and penis. Cell Tissue Res 278: 273–278

    CAS  Article  Google Scholar 

  20. Terrone C et al. (2001) Iatrogenic ejaculation disorders and their prevention. Minerva Urol Nefrol 53: 19–28

    CAS  PubMed  Google Scholar 

  21. Gerstenberg TC et al. (1990) Erection and ejaculation in man. Assessment of the electromyographic activity of the bulbocavernosus and ischiocavernosus muscles. Br J Urol 65: 395–402

    CAS  Article  Google Scholar 

  22. McKenna KE et al. (1991) A model for the study of sexual function in anesthetized male and female rats. Am J Physiol 261: R1276–R1285

    CAS  PubMed  Google Scholar 

  23. Coolen LM et al. (2004) Central regulation of ejaculation. Physiol Behav 83: 203–215

    CAS  Article  Google Scholar 

  24. Holmes GM and Sachs BD (1991) The ejaculatory reflex in copulating rats: normal bulbospongiosus activity without apparent urethral stimulation. Neurosci Lett 125: 195–197

    CAS  Article  Google Scholar 

  25. Bergman B et al. (1979) The effect on erection and orgasm of cystectomy, prostatectomy and vesiculectomy for cancer of the bladder: a clinical and electromyographic study. Br J Urol 51: 114–120

    CAS  Article  Google Scholar 

  26. McGlynn JM and Erpino MJ (1974) Effects of vasectomy on the reproductive system and sexual behaviour of rats. J Reprod Fertil 40: 241–247

    CAS  Article  Google Scholar 

  27. Larsson K and Swedin G (1971) The sexual behavior of male rats after bilateral section of the hypogastric nerve and removal of the accessory genital glands. Physiol Behav 6: 251–253

    CAS  Article  Google Scholar 

  28. Allard J et al. (2005) Spinal cord control of ejaculation. World J Urol 23: 119–126

    Article  Google Scholar 

  29. Gréco B et al. (1998) Fos induced by mating or noncontact sociosexual interaction is colocalized with androgen receptors in neurons within the forebrain, midbrain, and lumbosacral spinal cord of male rats. Horm Behav 33: 125–138

    Article  Google Scholar 

  30. Truitt WA and Coolen LM (2002) Identification of a potential ejaculation generator in the spinal cord. Science 297: 1566–1569

    CAS  Article  Google Scholar 

  31. Marson L and McKenna KE (1990) The identification of a brainstem site controlling spinal sexual reflexes in male rats. Brain Res 515: 303–308

    CAS  Article  Google Scholar 

  32. Pompeiano M et al. (1994) Distribution of the serotonin 5-HT2 receptor family mRNAs: comparison between 5-HT2 A and 5-HT2C receptors. Brain Res Mol Brain Res 23: 163–178

    CAS  Article  Google Scholar 

  33. Waldinger MD et al. (1998) Premature ejaculation and serotonergic antidepressants-induced delayed ejaculation: the involvement of the serotonergic system. Behav Brain Res 92: 111–118

    CAS  Article  Google Scholar 

  34. Marson L and McKenna KE (1992) A role for 5-hydroxytryptamine in descending inhibition of spinal sexual reflexes. Exp Brain Res 88: 313–320

    CAS  Article  Google Scholar 

  35. Hillegaart V et al. (1991) Region-selective inhibition of male rat sexual behavior and motor performance by localized forebrain 5-HT injections: a comparison with effects produced by 8-OH-DPAT. Behav Brain Res 42: 169–180

    CAS  Article  Google Scholar 

  36. Fernández-Guasti A et al. (1992) Stimulation of 5-HT1 A and 5-HT1B receptors in brain regions and its effects on male rat sexual behaviour. Eur J Pharmacol 210: 121–129

    Article  Google Scholar 

  37. Hillegaart V et al. (1989) Effects of local application of 5-HT into the median and dorsal raphe nuclei on male rat sexual and motor behavior. Behav Brain Res 33: 279–286

    CAS  Article  Google Scholar 

  38. Piñeyro G and Blier P (1999) Autoregulation of serotonin neurons: role in antidepressant drug action. Pharmacol Rev 51: 533–591

    PubMed  Google Scholar 

  39. Hillegaart V and Ahlenius S (1998) Facilitation and inhibition of male rat ejaculatory behaviour by the respective 5-HT1 A and 5-HT1B receptor agonists 8-OH- DPAT and anpirtoline, as evidenced by use of the corresponding new and selective receptor antagonists NAD-299 and NAS-181. Br J Pharmacol 125: 1733–1743

    CAS  Article  Google Scholar 

  40. Jannini EA et al. (2006) Update on pathophysiology of premature ejaculation: the basis for new pharmacological treatments. EAU-EBU Update series 4: 141–149

    Article  Google Scholar 

  41. Kaplan H (1974) The new sex therapy: treatment of sexual dysfunction. New York: Routledge

    Google Scholar 

  42. Dunn KM et al. (1999) Association of sexual problems with social, psychological, and physical problems in men and women: a cross sectional population survey. J Epidemiol Community Health 53: 144–148

    CAS  Article  Google Scholar 

  43. Waldinger MD (2002) The neurobiological approach to premature ejaculation. J Urol 168: 2359–2367

    Article  Google Scholar 

  44. Colpi GM et al. (1986) Evoked sacral potentials in subjects with true premature ejaculation. Andrologia 18: 583–586

    CAS  Article  Google Scholar 

  45. Xin ZC et al. (1996) Penile sensitivity in patients with primary premature ejaculation. J Urol 156: 979–981

    CAS  Article  Google Scholar 

  46. Vanden Broucke H et al. (2007) Ejaculation latency times and their relationship to penile sensitivity in men with normal sexual function. J Urol 177: 237–240

    Article  Google Scholar 

  47. Screponi E et al. (2001) Prevalence of chronic prostatitis in men with premature ejaculation. Urology 58: 198–202

    CAS  Article  Google Scholar 

  48. Carani C et al. (2005) Multicenter study on the prevalence of sexual symptoms in male hypo- and hyperthyroid patients. J Clin Endocrinol Metab 90: 6472–6479

    CAS  Article  Google Scholar 

  49. Jannini EA et al. (1995) Thyroid hormone and male gonadal function. Endocr Rev 16: 443–459

    CAS  PubMed  Google Scholar 

  50. Sharlip ID (2006) Guidelines for the diagnosis and management of premature ejaculation. J Sex Med 3 (Suppl 4): 309–317

    CAS  Article  Google Scholar 

  51. Waldinger MD and Schweitzer DH (2006) Changing paradigms from a historical DSM-III and DSM-IV view toward an evidence-based definition of premature ejaculation. Part I—validity of DSM-IV-TR. J Sex Med 3: 682–692

    Article  Google Scholar 

  52. Symonds T et al. (2007) Further evidence of the reliability and validity of the premature ejaculation diagnostic tool. Int J Impot Res 19: 521–525

    CAS  Article  Google Scholar 

  53. Wang W et al. (2005) Proposals or findings for a new approach about how to define and diagnose premature ejaculation. Eur Urol 48: 418–423

    Article  Google Scholar 

  54. Rosen RC et al. (2007) Development and validation of four-item version of male sexual health questionnaire to assess ejaculatory dysfunction. Urology 69: 805–809

    Article  Google Scholar 

  55. Waldinger MD et al. (2005) A multinational population survey of intravaginal ejaculation latency time. J Sex Med 2: 492–497

    Article  Google Scholar 

  56. Dinsmore WW et al. (2006) Evaluation of the Sexual Assessment Monitor, a diagnostic device used to electronically quantify ejaculatory latency time: findings from three studies. BJU Int 98: 613–618

    Article  Google Scholar 

  57. Perretti A et al. (2003) Neurophysiologic evaluation of central-peripheral sensory and motor pudendal pathways in primary premature ejaculation. Urology 61: 623–628

    CAS  Article  Google Scholar 

  58. Patrick DL et al. (2005) Premature ejaculation: an observational study of men and their partners. J Sex Med 2: 358–367

    Article  Google Scholar 

  59. Waldinger MD et al. (2004) Relevance of methodological design for the interpretetion of efficacy of drug treatment of premature ejaculation: a systematic review and meta-analysis. Int J Impot Res 16: 369–381

    CAS  Article  Google Scholar 

  60. Waldinger MD et al. (1998) Effect of SSRI antidepressants on ejaculation: a double-blind, randomized, placebo-controlled study with fluoxetine, fluvoxamine, paroxetine and sertraline. J Clin Psychopharmacol 18: 274–281

    CAS  Article  Google Scholar 

  61. Assalin P (1988) Clomipramine in the treatment of premature ejaculation. J Sex Res 24: 213–215

    Article  Google Scholar 

  62. Waldinger MD et al. (2007) The majority of men with lifelong premature ejaculation prefer daily drug treatment: an observation study in a consecutive group of Dutch men. J Sex Med 4: 1028–1037

    CAS  Article  Google Scholar 

  63. McMahon CG and Touma K (1999) Treatment of premature ejaculation with paroxetine hydrochloride as needed: 2 single-blind placebo controlled crossover studies. J Urol 161: 1826–1830

    CAS  Article  Google Scholar 

  64. Waldinger MD et al. (2004) On-demand treatment of premature ejaculation with clomipramine and paroxetine: a randomized, double-blind fixed-dose study with stopwatch assessment. Eur Urol 46: 510–516

    CAS  Article  Google Scholar 

  65. Safarinejad MR (2007) Safety and efficacy of dapoxetine in the treatment of premature ejaculation: a double-blind, placebo-controlled, fixed-dose, randomized study. Neuropsychopharmacology [10.1038/sj.npp.1301500]

  66. Pryor JL et al. (2006) Efficacy and tolerability of dapoxetine in treatment of premature ejaculation: an integrated analysis of two double-blind, randomised controlled trials. Lancet 368: 929–937

    CAS  Article  Google Scholar 

  67. McMahon CG et al. (2005) Efficacy of sildenafil citrate (Viagra) in men with premature ejaculation. J Sex Med 2: 368–375

    CAS  Article  Google Scholar 

  68. Wylie KR and Ralph D (2005) Premature ejaculation: the current literature. Curr Opin Urol 15: 393–398

    Article  Google Scholar 

  69. Mattos R and Lucon A (2005) Tadalafil and slow-release fluoxetine in premature ejaculation-A prospective study. J Urol 173: 239

    Article  Google Scholar 

  70. Sommer F et al. (2005) Are PDE-5 inhibitors a men's health pill? J Urol 173: 338

    Google Scholar 

  71. Busato W and Galindo CC (2004) Topical anaesthetic use for treating premature ejaculation: a double-blind, randomized, placebo-controlled study. BJU Int 93: 1018–1021

    CAS  Article  Google Scholar 

  72. Henry R and Morales A (2003). Topical lidocaine–prilocaine spray for the treatment of premature ejaculation: a proof of concept study. Int J Impot Res 15: 277–281

    CAS  Article  Google Scholar 

  73. Semans JH (1956) Premature ejaculation: a new approach. South Med J 49: 353–368

    CAS  Article  Google Scholar 

  74. De Amicis LA et al. (1985) Clinical follow-up of couples treated for sexual dysfunction. Arch Sex Behav 14: 467–489

    CAS  Article  Google Scholar 

  75. Kim JJ et al. (2004) Effects of glans penis augmentation using hyaluronic acid gel for premature ejaculation. Int J Impot Res 16: 547–551

    CAS  Article  Google Scholar 

  76. McCarty B (1981) Strategies and technique for treatment ejaculatory inhibition. J Sex Ed Ther 7: 20–23

    Article  Google Scholar 

  77. Kamischke A and Nieschlag E (2002) Update on medical treatment of ejaculatory disorders. Int J Androl 25: 333–344

    CAS  Article  Google Scholar 

Download references

Acknowledgements

Charles P Vega, University of California, Irvine, CA, is the author of and is solely responsible for the content of the learning objectives, questions and answers of the Medscape-accredited continuing medical education activity associated with this article.

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Vincenzo Mirone.

Ethics declarations

Competing interests

The authors declare no competing financial interests.

Rights and permissions

Reprints and Permissions

About this article

Cite this article

Bettocchi, C., Verze, P., Palumbo, F. et al. Ejaculatory disorders: pathophysiology and management. Nat Rev Urol 5, 93–103 (2008). https://doi.org/10.1038/ncpuro1016

Download citation

  • Received:

  • Accepted:

  • Issue Date:

  • DOI: https://doi.org/10.1038/ncpuro1016

Further reading

Search

Quick links

Nature Briefing

Sign up for the Nature Briefing newsletter — what matters in science, free to your inbox daily.

Get the most important science stories of the day, free in your inbox. Sign up for Nature Briefing