THE SILENT STRUGGLE: A GUIDE TO EJACULATORY DISORDERS FOR PHYSICIANS AND PATIENTS

Male ejaculatory disorders are a group of conditions affecting the timing, direction, or occurrence of ejaculation. These issues can be distressing for both the patient and their partner, impacting sexual satisfaction and sometimes fertility. This blog provides an in-depth look at the common types of ejaculatory disorders, how they present and their evaluation, possible medication and health-related causes, treatment options, and special considerations for teenage patients

Types of Ejaculatory Disorders

Ejaculation is the process of releasing semen at sexual climax, involving an emission phase (loading semen into the urethra) and an expulsion phase (forcible ejection of semen). Disorders can occur when this process is too quick, too slow, goes “backwards,” or doesn’t happen at all. The four major types of ejaculatory dysfunction are premature ejaculation, delayed ejaculation, retrograde ejaculation, and anejaculation. Some experts also include related issues like anorgasmia (inability to reach orgasm) and painful ejaculation in this spectrum, although these are less common. Below is an overview of each major type:

Premature Ejaculation (PE)– This is when ejaculation happens sooner than desired, often with minimal stimulation or shortly after penetration, and is accompanied by a feeling of lost control and distress. A typical definition is ejaculation that occurs within about one minute of vaginal penetration (or even before penetration) in most encounters. PE is the most common ejaculatory disorder – studies indicate up to ~30% of men report experiencing it at some point, though using strict clinical criteria the prevalence is closer to 5%. Lifelong PE starts with a man’s first sexual experiences, whereas acquired PE develops later after a period of normal function. Men with PE often feel frustrated or avoid intimacy due to embarrassment.
Delayed Ejaculation (DE)– DE is essentially the opposite of premature ejaculation. It refers to a markedly prolonged time to reach climax (for example, taking more than ~30–45 minutes of sexual activity to ejaculate, despite adequate stimulation). In some cases, ejaculation might only occur with great difficulty or not at all. Anejaculation, the complete inability to ejaculate semen, can be considered an extreme form or variant of delayed ejaculation. Men with DE may maintain an erection but struggle to “finish,” which can be frustrating and may turn intercourse into a tiring or unfulfilling experience. If a man climaxes without ejaculating fluid, that is a form of anejaculation (sometimes emission fails); and if he cannot climax at all (no orgasm), that is often termed anorgasmia. True DE/anorgasmia is relatively uncommon (under ~5% prevalence). It can be situational (happens in some circumstances or with certain partners but not others) or generalized (happens all the time).
Retrograde Ejaculation– In this condition, semen enters the bladder instead of exiting through the penis during orgasm. Essentially, ejaculation occurs “backward.” The man still reaches orgasm and feels the sensation of climax, but little or no semen comes out externally. According to medical definitions, retrograde ejaculation happens when the bladder neck fails to close during emission, allowing semen to flow into the bladder. Afterwards, the man may notice cloudy urine when he next voids (as the semen mixes with urine). Retrograde ejaculation itself is usually harmless to the man’s health and the pleasurable sensation of orgasm often remains, though some describe the orgasm as less intense. The main consequence is on fertility – since semen isn’t deposited outside, it can cause infertility unless addressed. This disorder is not very common overall, but it frequently occurs in certain contexts (for instance, after specific surgeries or in men with long-standing diabetes).
Anejaculation– This term means no semen is ejaculated at climax. In anejaculation, a man achieves orgasmic sensation (or sometimes even that may be absent), but absolutely no fluid is expelled. It can occur with orgasm (a dry orgasm) or without any orgasmic feeling. Anejaculation can be situational or general, and is often associated with neurological injury or dysfunction. For example, men with spinal cord injuries or certain nerve diseases may have intact erections and libido but cannot ejaculate semen. Anejaculation is a cause of male infertility because no sperm are released. (Importantly, physicians will distinguish true anejaculation from retrograde ejaculation; in retrograde ejaculation the semen is produced but goes backward, whereas in true anejaculation, semen emission fails entirely.)
Other Ejaculatory Issues– Two other issues worth mentioning for completeness are painful ejaculation and hematospermia (blood in the semen). Painful ejaculation (burning or pain with climax) is not a timing issue but a symptom that can accompany disorders like prostatitis (prostate inflammation) or other pelvic problems. Hematospermia, the appearance of blood in semen, can be alarming but is often due to inflammation or infection. These issues are usually signs of underlying conditions rather than standalone ejaculatory disorders, so they require medical evaluation but are beyond the scope of the primary “functional” disorders above.

Each type of ejaculatory disorder has different causes and implications.

Difference Between Erectile Dysfunction and Ejaculatory Dysfunction

While erectile dysfunction (ED) and ejaculatory dysfunction (EjD) are both male sexual disorders, they are distinct conditions that affect different aspects of sexual performance, involve separate neurologic pathways, and often require different treatments. Importantly, one does not necessarily imply the presence of the other.

Functional and Neurologic Differences

Erectile dysfunction refers to the persistent inability to achieve or maintain an erection sufficient for satisfactory sexual performance. Ejaculatory dysfunction, in contrast, involves issues with the timing, amount, direction, or occurrence of semen release during orgasm.

The process of ejaculation is divided into two phases:

Emission: This is the movement of sperm and seminal fluids from the testes, vas deferens, seminal vesicles, and prostate into the posterior urethra. It is primarily mediated by the sympathetic nervous system, specifically from the T10 to L2 spinal segments.
Expulsion: This is the forceful ejection of semen from the urethra, driven by rhythmic contractions of the pelvic floor muscles, bulbospongiosus muscle, and urethra. This phase is controlled by somatic nerves via the pudendal nerve and coordinated with the spinal ejaculatory reflex center at the S2 to S4 level.

Erection, on the other hand, is mediated predominantly by parasympathetic nervous input originating from the sacral spinal cord (S2-S4). It involves vasodilation and increased blood flow into the corpora cavernosa.

Because the autonomic pathways for erection and ejaculation differ, it's possible for a man to have a firm erection but be unable to ejaculate (e.g., in delayed or retrograde ejaculation), or to ejaculate despite incomplete erections (as may occur in premature ejaculation).

Impact of Medications

Medications can have selective effects on either erectile or ejaculatory function. For example:

PDE5 inhibitors (such as sildenafil and tadalafil) enhance nitric oxide-mediated vasodilation, improving erections. However, they have little direct effect on ejaculation, and in some men, especially those with anxiety-induced premature ejaculation, the improved erectile function might paradoxically reduce ejaculatory latency.
SSRIs (selective serotonin reuptake inhibitors) commonly delay ejaculation or even cause anejaculation, but they do not impair erections in most users. This is why they are used off-label to treat premature ejaculation.
Alpha-blockers used for benign prostatic hyperplasia (e.g., tamsulosin) can cause retrograde ejaculation by relaxing the bladder neck but do not cause ED per se.

This divergence explains why treatments targeting one condition may not help, or may even worsen, the other.

Treatment Implications

Managing ED with PDE5 inhibitors may enhance erection quality but does not address premature ejaculation, and for some men with PE secondary to ED, it may unmask the PE once the erection is restored. Conversely, using SSRIs to delay ejaculation in men with PE may lead to anorgasmia or reduced sexual satisfaction, despite preserved erectile function.

Thus, it is important for clinicians to assess and treat ED and EjD as separate but potentially coexisting disorders, tailoring interventions to the individual patient's symptom profile, comorbidities, and therapeutic goals.

Evaluation of Ejaculatory Disorders

When a man reports trouble with ejaculation, whether it’s too fast, too slow, or not at all, a healthcare provider will perform a careful evaluation. This starts with a detailed medical and sexual history interview. The patient will be asked questions such as: How long has this problem been present? Did it begin suddenly or has it been there since your first sexual experiences? Is it present in all situations (with any partner or even during masturbation), or only in certain situations? These questions help distinguish between lifelong vs. acquired disorders and between generalized vs. situational issues. For example, a lifelong inability to ejaculate might suggest a congenital or developmental issue, whereas a new problem might point to a recent medical change or medication.

The physician also reviews medications and lifestyle (since many drugs or excessive alcohol, etc., can affect ejaculation – more on that later) and ask about psychological factors or relationship issues that might be contributing. Because stigma or embarrassment can hinder open discussion, a good provider creates a comfortable environment for the patient to share these details. Both patient and if applicable their partner should feel free to describe how the issue affects them, since partner feedback can provide clues (for instance, whether the issue occurs only with certain types of sexual activity).

A physical examination will be done next, focusing on the genital area and potentially a neurological exam. The physician will check the penis and testicles for any structural problems (such as abnormal development, masses, or signs of prior surgery). They may also assess secondary sexual characteristics and perform a digital rectal exam to evaluate the prostate, especially if pain or blood in semen is reported.

Depending on the findings, several tests may be ordered:

Laboratory tests: A hormone panel (for example, testosterone levels) is common to check for hormonal imbalances. Thyroid function may be tested if there’s suspicion of thyroid disease (since an overactive thyroid can sometimes cause premature ejaculation, while an underactive thyroid can contribute to delayed ejaculation ). If the patient has other symptoms of diabetes (or risk factors for it), blood sugar testing might be done because diabetes can damage nerves involved in ejaculation. If chronic prostatitis or infection is suspected (for painful ejaculation or blood in semen), urinalysis or semen culture might be performed. In cases of anorgasmia or suspected neurological issues, additional neurological workup might be considered.
Semen analysis: If fertility is a concern or if the man reports little to no fluid on ejaculation, an analysis of the semen (if any is obtained) can be revealing. For instance, a very low volume of semen could suggest either that it went backwards into the bladder or that a blockage is preventing semen from coming out. If no ejaculate is produced at all, the clinician might ask for a post-ejaculate urine sample – basically, the patient is asked to masturbate to climax (or engage in sexual activity) and then urinate, and that urine is tested for the presence of sperm. Finding a high number of sperm in the urine confirms retrograde ejaculation . On the other hand, if no sperm or semen components are found anywhere, it could indicate true anejaculation or perhaps an obstruction preventing any semen from being emitted.
Imaging studies: In some cases, especially if an anatomical blockage is suspected, a transrectal ultrasound (TRUS) may be performed. TRUS can visualize the ejaculatory ducts and seminal vesicles. For example, a cyst or calcification blocking the ejaculatory duct can cause a man to have normal erections and orgasmic sensation but little or no semen release. Imaging can also detect if the seminal vesicles are enlarged (which might happen if they’re producing fluid that isn’t getting expelled). If neurological causes are suspected (like a spinal cord lesion), other imaging like an MRI might be indicated by a specialist.
Other specialized tests: Sometimes specialized evaluations like vibratory stimulation tests or neurological reflex tests are done in research or complex cases, but these are not routine. In the context of psychological causes, a psychosexual evaluation with a therapist or questionnaires might be employed to gauge anxiety, depression, or relationship factors contributing to the dysfunction.

Overall, the evaluation aims to determine what type of ejaculatory disorder is present and why it is happening. Often, the cause can be multi-factorial (for instance, a mild nerve issue and a medication side effect and some performance anxiety all layering together). With a clear picture from the history, exam, and any necessary tests, the provider can then identify the contributing factors and plan appropriate treatment. We’ll next look at some known causes – starting with medications – and then other health conditions that can lead to or worsen ejaculatory problems.

Medications That Can Cause or Worsen Ejaculatory Disorders

Multiple medications (both prescription and over-the-counter) can affect sexual function, including ejaculation. Physicians are very mindful of this, because a patient’s drug regimen is often a reversible cause of ejaculatory issues. Here we’ll break down some common medication culprits by the type of ejaculatory problem they might induce or exacerbate:

Medications and delayed ejaculation/anorgasmia: A well-known side effect of certain antidepressant drugs is difficulty reaching orgasm or ejaculating. Selective serotonin reuptake inhibitors (SSRIs), the most commonly prescribed antidepressants, frequently cause ejaculatory delay or even complete inability to climax in men. In fact, studies have found anywhere from 5% to up to 70% of patients on SSRIs/SNRIs report impaired orgasm (the wide range depends on the specific drug and dosage). This effect is so consistent that low-dose SSRIs (for example, paroxetine or sertraline) are actually used therapeutically to treat premature ejaculation because they delayorgasm. Other antidepressants: serotonin-norepinephrine reuptake inhibitors (SNRIs) like venlafaxine can similarly cause delayed ejaculation. Older tricyclic antidepressants (e.g., clomipramine) are notorious for causing difficulty ejaculating or anorgasmia in men. If a patient started an antidepressant and then noticed new-onset delayed ejaculation, the drug is a prime suspect.

Other psychoactive medications can do this as well. Antipsychotic drugs (used for conditions like schizophrenia or bipolar disorder) often cause sexual side effects. Men on antipsychotics may experience erectile dysfunction, reduced sexual desire, and notably “inhibited or retrograde ejaculation” (meaning very delayed or seemingly absent ejaculation). Antipsychotics work by blocking dopamine, and by doing so they can blunt the pleasure/reward circuits and increase a hormone (prolactin) that suppresses sexual function. This can lead to difficulty achieving orgasm and sometimes a dry or retrograde ejaculation. Some mood stabilizers and anti-seizure medications (e.g., gabapentin, topiramate) have also been associated with orgasmic dysfunction in men.

Medications and premature ejaculation: Interestingly, there aren’t many medications that cause one to ejaculate too quickly – in fact, it’s more common for drugs to slow or inhibit ejaculation. However, certain substances that increase arousal or anxiety might indirectly lead to quicker ejaculation in some individuals. For example, excessive use of stimulants (like amphetamines or cocaine) can heighten sympathetic nervous system activity and possibly reduce ejaculatory control (though chronic use of such drugs more often causes erectile or libido problems). Another scenario is when a man with erectile dysfunction uses ED drugs (PDE5 inhibitors like sildenafil); if he’s suddenly able to have a firm erection after a period of difficulty, he might find himself climaxing faster simply due to excitement or long build-up – but this is not a direct pharmacological effect of the drug, more a situational outcome. Overall, there is no prominent prescription medication that routinely causes premature ejaculation as a side effect. (On the contrary, as noted, medications are often used to treat premature ejaculation by slowing things down.)
Medications and retrograde ejaculation or anejaculation: Certain drugs can interfere with the emission phase of ejaculation, leading to retrograde flow or a dry orgasm. The main culprits are medications that relax the bladder neck or affect nerve signals of the sympathetic nervous system. Alpha-1 blocker drugs used for prostate enlargement (BPH) or sometimes high blood pressure are a classic cause. For instance, tamsulosin (Flomax®) and similar drugs (alfuzosin, silodosin, etc.) are very effective for improving urine flow in BPH by relaxing the prostate and bladder neck. The flip side is that a relaxed bladder neck may not fully close during ejaculation, so semen can go into the bladder. Many men on these drugs notice reduced semen volume or complete absence of ejaculate. In clinical studies, abnormal ejaculation (mostly retrograde or reduced-volume ejaculation) occurs in a notable percentage of patients on tamsulosin – one analysis found up to ~7–15% incidence of ejaculatory dysfunction, and it’s dose-dependent. The alpha-blocker silodosin has an even higher rate of causing virtually dry orgasms in men (because it’s very specific in blocking the receptors in the seminal tract). These effects are reversible if the medication is stopped. Another class of medication, 5-alpha-reductase inhibitors (e.g., finasteride or dutasteride used for hair loss or BPH), can sometimes decrease the volume of semen or cause “dry” ejaculation as well. Though reported rates are relatively low (perhaps 2–7% of users), some men taking finasteride have noted ejaculatory changes or difficulty.

Additionally, certain blood pressure medications can contribute. Older antihypertensives like methyldopa or clonidine (central alpha-2 agonists) and thiazide diuretics are more infamous for causing erectile dysfunction, but they have also been linked to delayed or reduced ejaculation in some cases. Beta-blockers(like propranolol, atenolol) mainly lower libido or cause erection issues, but a few patients report trouble ejaculating on them as well – it’s hard to disentangle whether it’s due to reduced overall sexual arousal or a direct effect. Newer blood pressure meds (ACE inhibitors, ARBs like valsartan, etc.) tend to have fewer sexual side effects; in fact, valsartan was noted to possibly improve sexual function compared to beta-blockers.

Other drugs and substances: Opioid pain medications (e.g., long-term use of morphine, oxycodone, or methadone) suppress the hormonal axis and libido, often leading to erectile dysfunction and sometimes difficulty ejaculating. They can indirectly cause anejaculation by lowering testosterone significantly, resulting in low sexual drive and weak orgasms. Some patients on chronic opioids or certain anti-anxiety sedatives report a dulling of orgasm intensity or inability to climax. Excessive alcohol use is another factor – while a drink or two might reduce anxiety (which can delay ejaculation somewhat), heavy alcohol use is a depressant that can cause erection problems and numb sensation, sometimes preventing orgasm altogether . On the flip side, alcohol abuse over time can also cause peripheral neuropathy (nerve damage) that might impair the ejaculatory reflex. Recreational drugs vary: marijuana in high doses may suppress sexual function; stimulants as mentioned can cause chaotic effects on performance.

In any patient with an ejaculatory disorder, a thorough medication review is essential. Often, simply adjusting the dose or switching to an alternative drug can improve the situation if a medication side effect is suspected. For example, if an SSRI is causing anejaculation in a depressed patient, the physician might lower the dose, switch to a different antidepressant with fewer sexual side effects, or add a medication like bupropion to counteract it (bupropion can improve orgasmic function in some cases ). If tamsulosin for BPH caused troublesome retrograde ejaculation, a urologist might try a less selective alpha-blocker (like alfuzosin) or an alternative therapy for BPH that spares ejaculation. Never stop a prescription medication without consulting your physician, but do bring up any sexual side effects – healthcare providers are used to these conversations and can often find a solution.

Health Conditions and Diseases That Can Cause/Worsen Ejaculatory Disorders

Beyond medications, many underlying health conditions or lifestyle factors can lead to ejaculatory dysfunction. It’s important for both patients and physicians to recognize these, because treating the underlying condition can often improve the sexual symptoms. Here we discuss various causes by linking them to the type of ejaculatory disorder they might cause or aggravate:

Psychological and Emotional Factors: Emotional wellbeing is a huge determinant of sexual function. Anxiety– especially performance anxiety – is a common cause of premature ejaculation and can also contribute to delayed ejaculation. A man who is overly anxious about pleasing his partner or worried about ejaculating too soon might actually rush sex unintentionally, leading to PE. Conversely, anxiety or mental distractions can make it hard to focus enough to climax, contributing to DE. Depression and stress are also key factors: depression often lowers libido and blunts pleasure (some men with depression report difficulty achieving orgasm even before any medication is started). General life stress can preoccupy the mind and reduce sexual relaxation, increasing the risk of premature ejaculation or inhibiting ejaculation. Relationship problems or poor communication with a partner may manifest as sexual dysfunction; for instance, unresolved conflicts might subconsciously inhibit a man’s ability to let go and orgasm. Past sexual trauma or conditioning can play a role too – for example, a man who as a teenager habitually masturbated very quickly (perhaps due to fear of being caught) may have “trained” himself to climax rapidly and later struggle with PE. On the other hand, someone who uses certain patterns (like specific pornography or techniques) might find “real life” sex less stimulating, leading to delayed ejaculation with a partner. In summary, mental health conditions (anxiety disorders, depression, PTSD) and psychological factors are frequently at the root of ejaculatory disorders, especially in younger men. Addressing these via counseling or therapy can be a key part of treatment (more on that later).
Erectile Dysfunction (ED): Although ED is a separate issue (difficulty achieving/maintaining an erection), it can indirectly cause ejaculatory problems. Men with borderline erections might develop a habit of hurrying to ejaculate before losing the erection, leading to a pattern of PE. This is a known association: about one-third of men with ED also complain of rapid ejaculation – essentially, anxiety about the erection drives them to finish quickly. Treating the ED (with appropriate therapy or medications) often consequently improves the ejaculatory control in these cases. On the flip side, men with ED might also have difficulty ejaculating at all if they cannot sustain arousal (you obviously need an adequate erection and arousal period to reach climax). So, erectile issues and ejaculatory issues often coexist and each can influence the other.
Diabetes Mellitus: Diabetes, especially when poorly controlled, is a major organic cause of ejaculatory dysfunction. Chronically high blood sugar can cause neuropathy, damage to nerves, including those that control the bladder neck and the nerves involved in orgasmic sensation. In men, long-term diabetes is a common cause of retrograde ejaculation – the neuropathy prevents proper closing of the bladder neck and impairs the coordinated muscle contractions of emission. Men with diabetic neuropathy might notice their ejaculation gradually becoming “drier” over time. Diabetes can also diminish sensation and reflexes, leading to DE/anejaculation in some cases (it might take a man a very long time to feel enough stimulation to climax, or he may stop being able to ejaculate at all). Good blood sugar control and neuropathy treatments are important, but if neuropathy has set in, the retrograde ejaculation might be permanent. However, as we’ll discuss in treatment, there are ways to work around it for fertility or to attempt to improve antegrade ejaculation (forward release).
Neurological Diseases and Injuries: The process of ejaculation is coordinated by the nervous system (spinal cord centers and peripheral nerves). Thus, conditions that affect the nervous system can cause ejaculatory problems. For instance, a spinal cord injury, depending on its level and completeness, often leads to anejaculation – many men with paraplegia or quadriplegia cannot ejaculate normally (though some can still have reflex erections and even reflex orgasms). Specialized techniques like vibratory stimulation are used in these cases to help obtain semen (see treatments below). Multiple sclerosis (MS), a disease where the immune system attacks the nervous system, can lead to either PE (if demyelination causes hypersensitivity) or more commonly DE (if nerve signals are slowed or disrupted) – sexual dysfunction is common in MS patients due to both physical and psychological burdens. Parkinson’s disease and other neurodegenerative disorders can also impact ejaculation (sometimes causing delayed ejaculation or anejaculation). Any surgery or injury that harms the pelvic nerves – for example, certain surgeries for colorectal cancer or a severe pelvic fracture – can result in ejaculatory dysfunction. A notable example is retroperitoneal lymph node dissection (RPLND) surgery (often done for testicular cancer): this can damage the sympathetic nerves that cause emission, frequently leading to anejaculation or retrograde ejaculation post-operatively. Men undergoing such procedures are usually counseled about the risk to fertility and ejaculation beforehand.
Prostate and Urethral Conditions: The health of the prostate gland and urethra can influence ejaculation. Prostatitis, which is inflammation or infection of the prostate, can cause painful ejaculation and sometimes contribute to premature ejaculation (the irritation might provoke urgency in climax). Chronic prostatitis/chronic pelvic pain syndrome often presents with discomfort during or after ejaculation. Benign prostatic hyperplasia (BPH) itself (the condition of enlarged prostate common in older men) usually doesn’t directly cause ejaculatory dysfunction, but the treatments for BPH, as noted, often do (medications like alpha-blockers or surgical treatments can cause retrograde ejaculation by altering the bladder neck or prostate). Surgery on the prostate or bladder neck is a major cause of retrograde ejaculation: for example, transurethral resection of the prostate (TURP) for BPH leads to retrograde ejaculation in a majority of cases. Similarly, radical prostatectomy (complete removal of the prostate for cancer) results in anejaculation because the structures that produce the bulk of the semen (prostate, seminal vesicles) are removed – after this surgery, a man will have dry orgasms permanently. Surgeries on the bladder (for congenital issues or cancer) can also disrupt normal ejaculation if they affect the bladder neck.
Hormonal Imbalances: Hormones play a role in sexual function. Low testosterone levels (e.g., in hypogonadism) are more commonly linked to low sex drive and erectile issues, but severe testosterone deficiency might also reduce the pleasure of orgasm and make ejaculation more difficult or less satisfying. Men with very low T sometimes report weaker or delayed orgasm. Conversely, unusually high levels of testosterone have been observed in some men with premature ejaculation (though this is not typically something that would be intentionally lowered; it’s more of a correlation noted in research, not a common clinical scenario). Thyroid disorders are a treatable medical cause: as mentioned, an overactive thyroid (hyperthyroidism) has been associated with premature ejaculation, while an underactive thyroid (hypothyroidism) is associated with delayed ejaculation . Treating the thyroid condition often helps resolve the ejaculatory symptom. Elevated prolactin (a hormone from the pituitary) can cause sexual dysfunction too; men with prolactin-secreting tumors often have low desire and sometimes anejaculation. Lowering prolactin with medication can improve sexual function in those cases.
Aging and general health: Simply getting older can change a man’s sexual responses. It’s typical for older men to require more stimulation and time to achieve ejaculation, and for the force and volume of ejaculation to decrease with age . This is considered a normal part of aging rather than a disorder, as long as it isn’t bothersome. However, age-related health issues (like cardiovascular disease) can indirectly affect blood flow and nerve function related to sexual health. Poor overall health and obesity have been linked to higher incidence of sexual dysfunction, including ejaculatory issues. Lifestyle factors like lack of exercise or chronic fatigue can reduce sexual performance.
Structural or congenital issues: In rare cases, a man might be born with an anatomical problem affecting ejaculation. For example, an ejaculatory duct obstruction (due to a cyst or malformation) can prevent semen from being expelled – the man in that case produces sperm and prostatic fluid but it can’t get out, leading to either a very low volume ejaculation or none at all (which would be diagnosed via imaging). Men with congenital absence of the vas deferens (as seen in some carriers of cystic fibrosis gene) have no path for sperm to travel from the testicles, resulting in infertility and very low semen volume (essentially all they ejaculate is just the small prostatic fluid). While these conditions are uncommon, they exemplify how physical blockages or absences can cause anejaculation without affecting the orgasm sensation.
Miscellaneous conditions: Certain chronic illnesses such as kidney disease or advanced liver disease can dampen sexual function in general. Stroke survivors might experience sexual changes including DE due to neurological damage . Autoimmune diseases or chronic pain conditions can also indirectly cause issues due to pain, fatigue, or the medications used to treat them (e.g., opioids as mentioned). In men with fertility problems, sometimes undiagnosed ejaculatory dysfunction is an underlying issue (like an undetected retrograde ejaculation causing “dry” semen samples).

In summary, many health conditions can underlie ejaculatory disorders. The good news is that by identifying these – whether it’s a thyroid imbalance, high blood sugar, a new medication, or psychological stress – we can often address the root cause and improve the ejaculatory function.

The last step is discussing how these disorders can be treated or managed once identified.

Treatment of Ejaculatory Disorders

Treatment for ejaculatory disorders is highly dependent on the type of disorder and its causes. In all cases, a frank discussion between the patient (and possibly his partner) and the physician is important to set realistic goals and expectations. Often a combination of approaches (medical, behavioral, and sometimes surgical) yields the best results . Let’s go through the main disorders and their treatments:

Treating Premature Ejaculation (PE)

Behavioral and Psychological Techniques: The first-line approach for many men with PE involves behavioral strategies and sex therapy. Techniques such as the “start-stop technique” or “squeeze technique” have been used for decades – these involve either the man or his partner pausing stimulation when he feels close to climax, or squeezing the base of the penis briefly to diminish the urge, then resuming, to help learn control. Counseling with a sex therapist can address anxiety, performance pressure, or relationship factors contributing to PE. Many men find that just discussing the issue openly and practicing relaxation techniques during sex improves their control. If pornography habits or early conditioning are factors, a therapist might work with the patient on retraining the sexual response (for example, taking more time during masturbation, using stop-start methods to build tolerance). Importantly, involving the partner in therapy can improve outcomes – it becomes a team effort rather than a source of blame.

Medications for PE: Medical therapy can be very effective for premature ejaculation. The mainstay is the off-label use of SSRIs (antidepressants we discussed earlier). Taken daily, drugs like paroxetine, sertraline, or fluoxetine can significantly prolong the time to ejaculation for many men. On-demand use (taking a pill a few hours before sex) also helps some men, though daily dosing tends to have a stronger effect. One particular SSRI, dapoxetine, was specifically developed for PE and is approved in many countries (not in the U.S. yet) for on-demand use. Another older antidepressant, clomipramine (a tricyclic), can be taken a few hours before intercourse to delay ejaculation – though its side effects profile is less favorable. It’s important to note these medications are being used for their side effect (delayed orgasm), so if a man is already on one of them for depression/anxiety, adding another might not help – usually it’s one or the other. The physician will choose based on the man’s health and preferences; for example, if someone wants medication only when needed, they might look into off-label dapoxetine (not available in the US) or use a short-acting SSRI as needed.

Another category is topical anesthetics. These are creams or sprays (often containing lidocaine and/or prilocaine) applied to the glans (head) of the penis shortly before intercourse to reduce sensitivity. They can be quite effective at delaying ejaculation by numbing the sensation a bit. One example is a metered-dose spray that’s actually FDA-approved for PE in some regions. Caution is needed to follow instructions (usually apply, wait 10-15 minutes, then wipe off excess) to avoid numbing the partner or losing the erection due to too much desensitization. When used correctly, topical agents have been shown to help men last longer without significantly impairing the pleasure of orgasm.

For men who have both ED and PE, treating the ED with PDE5 inhibitors (Viagra®/Cialis® type drugs) can sometimes indirectly help with PE as well because it reduces anxiety about losing the erection and allows for continued activity even after an initial climax (some men can have a second round more easily with the help of these drugs). There is also some evidence that combining a PDE5 inhibitor with an SSRI can be synergistic in tough cases of PE.

Other options: There is ongoing research into novel treatments like tramadol (an analgesic that oddly can delay ejaculation at low doses) or oxytocin blockers, but these are not standard. Pelvic floor exercises (Kegel exercises) have been suggested to help some men gain more voluntary control over ejaculation, and there’s little downside to trying them. Injections of filler (like hyaluronic acid) into the penis to reduce sensitivity have been experimented with.but this is not mainstream and carries risks. Overall, most patients with PE find a combination of behavioral techniques and either an SSRI or a topical agent to be effective in significantly improving their sexual experience. The goal is to reach a point where the man feels in control of when he climaxes, leading to greater confidence and less performance anxiety, which in turn further helps the issue.

Treating Delayed Ejaculation and Anejaculation

Address Underlying Causes First: With delayed ejaculation (DE) or anejaculation, the approach starts with identifying and fixing any underlying cause. If a medication is to blame (like an SSRI or antipsychotic), adjusting or switching that medication can often resolve the problem. If low testosterone is a factor, testosterone replacement might improve energy and orgasmic function. For hypothyroidism-induced DE, thyroid hormone supplements would address it. In cases of extreme pornography conditioning or psychological inhibition, therapy to recalibrate the response (possibly involving the partner) is key.

Therapy and Gradual Training: For psychogenic (mind-related) cases of DE – say a man who can only orgasm during masturbation but not with his partner – sex therapists often guide a graded program to bridge the gap. This might involve having the man incorporate the partner gradually (for example, first reaching climax with the partner present, then with the partner touching, then during intercourse in a less pressured way, etc.). Reducing performance pressure is crucial; the more the man “obsesses” about finishing, the harder it can become. Sometimes just taking the focus off orgasm as the goal, and enjoying intimacy in other ways, can ironically make it easier to eventually climax.

Medical Treatments for DE: Unlike PE, there is no single FDA-approved pill to accelerate ejaculation, but various off-label attempts have been made:

Changing antidepressants: If an SSRI is necessary for mood, adding bupropion (an atypical antidepressant that can boost dopamine/norepinephrine) has been shown to help counter sexual side effects in some patients. Bupropion on its own tends to have a lower incidence of sexual dysfunction and may even increase libido slightly.
Dopaminergic agents: Since orgasm involves a dopamine rush, medications that enhance dopaminergic activity have been tried. One is cabergoline, a drug that lowers prolactin and boosts dopamine; it has shown some benefit in case series for anorgasmia, especially if the patient had high prolactin levels. Another is amantadine (a Parkinson’s drug) in low doses, or apomorphine, but evidence is limited.
Stimulants: Psychostimulant medications (like methylphenidate or modafinil) theoretically might help by increasing arousal and focus, but they can also increase anxiety, so results vary.
Alpha-agonists: Medications that have the opposite effect of alpha-blockers, i.e., that tighten the bladder neck and promote emission, are used in some anejaculation cases. Pseudoephedrine (the decongestant) or midodrine (a blood pressure drug) can increase sympathetic tone and have been used to try to induce ejaculation, particularly in men with spinal cord injuries or diabetic neuropathy. Similarly, imipramine (a tricyclic antidepressant) has both serotonergic and alpha-agonist effects and has been tried in retrograde ejaculation to help propel semen forward.
Others: Small studies have looked at agents like oxytocin (the bonding hormone) nasal spray to see if it aids orgasm, or cyproheptadine (an antihistamine/serotonin blocker) to counter SSRI effects, but these are not widely used. Yohimbine, an old aphrodisiac, has had mixed results. Essentially, these pharmacological attempts are often hit-or-miss and used on a trial basis when no other cause is found.

Mechanical and Assisted Ejaculation Methods: For men with certain neurological causes (like spinal cord injury) where medication isn’t effective, there are specialized techniques:

Penile Vibratory Stimulation (PVS): This is a device that provides high-frequency vibration to the penis, specifically to stimulate the genital reflex arcs. It can trigger ejaculation in a significant number of men with upper spinal cord injuries. It often needs to be done under guidance (sometimes in a fertility clinic setting if the goal is to collect sperm for reproduction).
Electroejaculation: This is usually a last-resort method where under anesthesia, a probe is used rectally to deliver electrical stimulation to the prostate/seminal vesicles, inducing ejaculation. It’s typically used in paraplegic or quadriplegic men when vibratory methods fail and sperm is needed for fertility treatments.
If an ejaculatory duct obstruction is diagnosed (e.g., via TRUS), a minor surgery (transurethral resection of the ejaculatory ducts) can sometimes restore the pathway and allow ejaculation.

Counseling and Adaptation: For some men, especially older men who are not distressed by delayed ejaculation (except perhaps their partner is more so), a part of management may be educating and finding ways to work with it. For instance, a man who always takes 30+ minutes might integrate more extended foreplay or focus on satisfying his partner in other ways without the strict need for simultaneous orgasm. If both partners are informed and communicative, DE doesn’t have to ruin intimacy. When distressing, though, it should be addressed as above.

Treating Retrograde Ejaculation

Retrograde ejaculation (RE) is bothersome mainly if the man or couple is trying to conceive, since it prevents sperm from reaching the partner. If fertility is not a concern, and the man is not troubled by the reduced fluid (some men actually don’t mind not having to clean up semen after sex), treatment might not be necessary at all – reassurance that it isn’t harmful is key. However, if treatment is desired (for fertility or personal preference), here are approaches:

Address the cause if possible: If a medication (like an alpha-blocker) is causing retrograde flow, stopping it or switching drugs may solve the issue. If diabetes is a factor, optimizing blood glucose control is important, although longstanding neuropathy might not be fully reversible.
Medications to promote antegrade ejaculation: Drugs that increase the tone of the bladder neck can be used. Pseudoephedrine (yes, the common decongestant) is often tried – taken about 30-60 minutes before sexual activity, it can tighten the bladder neck and sometimes result in some forward ejaculation. It doesn’t always work, but it’s a relatively safe and easy therapy. Imipramine, mentioned above, is another option that can have a similar effect. Midodrine, a vasopressor, can be used especially in diabetic cases. These medications have to be used with caution (e.g., pseudoephedrine can raise blood pressure, so not suitable for men with severe hypertension or heart issues without physician supervision).
Fertility-focused treatments: If pregnancy is the goal, one strategy is to harvest sperm from the urine after orgasm. This involves making the urine alkaline beforehand (to protect sperm from acidity) – for example, taking sodium bicarbonate – and then the man masturbates to orgasm, and the subsequent urine is collected. Labs can process this urine to retrieve viable sperm for use in intrauterine insemination (IUI) or IVF. This is a bit of a process but can be successful. If that is not sufficient, physicians might go to more invasive sperm retrieval techniques (like extracting sperm from the testicles), but that’s usually for cases where other methods fail.

Unfortunately, if retrograde ejaculation is due to a prior surgery that permanently altered anatomy (like a TURP or bladder neck incision), medications may not fully restore forward ejaculation. In such cases, using fertility treatments or simply adapting to dry orgasms is the route. The man should be reassured that orgasm without visible ejaculation still counts – the pleasure can remain, and it does not harm him. Sometimes just understanding that can reduce any anxiety or self-consciousness about it.

General Tips and Teenage Patient Considerations

Open Communication: No matter the disorder, education and communication are therapeutic. Men (and particularly teenage boys) may not know what’s “normal” and may feel embarrassed by their issue. Just learning that these conditions are common and treatable can relieve a lot of stress. Physicians should explain the condition in clear terms to the patient (and parents, if it’s an adolescent and appropriate) to demystify it.

Lifestyle and Support: Improving overall health can improve sexual health. Regular exercise, a balanced diet, quitting smoking, and moderating alcohol can all help sexual function. If a man is overweight, weight loss might boost testosterone and confidence. These general health measures are often encouraged alongside any specific treatment.

Teenage Ejaculatory Disorders: In teens and young men, the most common issue by far is premature ejaculation. It often stems from the natural high excitement and lack of sexual experience in this age group. A teenager may climax very quickly during first sexual encounters – this is actually quite normal and tends to improve with age and practice. It’s important for young men to know this so they don’t develop shame or anxiety that can worsen the problem. Basic advice for teens might include: masturbate ahead of time (so that the second time is slower), use condoms (to reduce sensation a bit), and communicate with their partner about taking it slow. Formal medication treatments for PE are usually not first-line in very young men; instead, reassurance and simple techniques are preferred. However, if a teen has severe anxiety or other psychological contributors, a referral to counseling can be beneficial early on.

It’s also worth noting that delayed ejaculation is less common in teenage males. A teenager having trouble ejaculating at all could be a sign of a psychological block (such as extreme anxiety, fear of pregnancy, etc.) or possibly a side effect of a medication (for example, some teens are on SSRIs for anxiety/depression and may experience this side effect). If a teenager cannot ejaculate, a thorough evaluation is warranted to rule out any congenital issues or neurological problems, though those are rare. Sometimes, excessive use of pornography in adolescence can lead to difficulty with real-life partners; sex education and possibly temporarily reducing porn consumption might help “reset” the arousal pathways.

Retrograde ejaculation in adolescents is rare since it’s usually caused by surgeries or long-term diabetes – a teenager would typically only have it if they had a specific surgery affecting the bladder neck or a severe diabetic neuropathy at a young age (which would be unusual). Anejaculation in a teen could occur in the context of a spinal cord injury or a significant neurological condition. Those cases would likely already be under medical care for the primary condition, and specialists would guide management (for example, using vibration devices for sperm retrieval if future fertility is desired).

In summary for teens: premature ejaculation is common and often improves with time, and young men should be educated that sexual skills (like any other skills) improve with experience – it’s not a permanent “dysfunction” in many cases. Patience, the right guidance, and reducing performance pressure are key. Any less common issues in a teen (like inability to ejaculate) should be evaluated by a physician to check for any medical cause, but often a psychological component is involved and can be helped with therapy.

Conclusion

Ejaculatory disorders in men encompass a range of conditions – from finishing too fast, to taking too long or not at all, to the semen going the wrong way. These issues can significantly affect quality of life, self-esteem, intimacy, and fertility. The good news is that modern medicine offers many ways to evaluate and treat these conditions. The approach is holistic: identifying medical or psychological causes, adjusting medications or lifestyle factors, and applying targeted therapies (behavioral techniques, counseling, and/or medications).

For patients, the takeaway is that you should not suffer in silence or embarrassment. These are common medical issues – premature ejaculation alone affects millions of men – and physicians are trained to help with compassion and expertise. For physicians, the key is to ask patients about sexual function and create a nonjudgmental space for discussion, as many patients won’t volunteer these problems unless asked. A thorough workup can uncover treatable causes like a medication side effect or a thyroid imbalance, and even when no clear cause is found, there are evidence-based treatments that can greatly improve the situation.

Ultimately, with proper evaluation and a personalized treatment plan, most men with an ejaculatory disorder can achieve better control and more satisfying sexual experiences. Whether you’re a teenager anxious about finishing too quickly, or an older gentleman frustrated with new-onset changes, remember that these conditions are both common and treatable. Don’t hesitate to reach out to your phsyician – a healthier and happier sex life could be well within reach.

References

Shindel AW, et al. Disorders of Ejaculation: An AUA/SMSNA Guideline. J Urol. 2022. (Executive summary of definitions and prevalence of premature and delayed ejaculation)
Urology Associates – Denver. Ejaculatory Dysfunction at a Glance. (Overview of types: premature, delayed, retrograde, anejaculation, and evaluation methods)
European Association of Urology (EAU) Guidelines 2023 – Section on Sexual and Reproductive Health. (Spectrum of ejaculation disorders including painful ejaculation and hematospermia)
AUA Guideline Panel Definition. Retrograde Ejaculation. (ICD-11 definition and causes of semen flowing into bladder)
AUA Guideline Panel Definition. Anejaculation. (Absence of seminal ejaculation, often neurologic causes)
Cleveland Clinic – Delayed Ejaculation. (Causes of delayed ejaculation: neurological conditions, hypothyroidism, medications, etc.)
University of Utah Health – Ejaculatory Disorders. (Retrograde ejaculation diagnosis and causes: diabetes, medications for BP or mood, prostate surgery, spinal injury)
Australian Prescriber – Mathews M, et al. Drug-induced sexual dysfunction in men and women. (Antidepressants causing inhibited orgasm; antipsychotics causing delayed or retrograde ejaculation)
Australian Prescriber – Mathews M, et al. (Antipsychotics and sexual dysfunction via dopamine blockade and hyperprolactinemia)
British Journal of Urology Intl. – Rajfer J. Finasteride and sexual side effects review. (Incidence of ejaculatory problems in men on finasteride ~2–7%)
Boston Univ. Medical Center – Ejaculation Problems: Too Fast, Too Slow or Not at All? (Medscape reference noting premature ejaculation is most common sexual dysfunction in men <40)
LloydsPharmacy Online Physician (UK) – What Is Premature Ejaculation? (Teen conditioning and inexperience contributing to PE)
EAU Guidelines 2023 – Pathophysiology and Risk Factors for PE. (Lists hyperthyroidism, prostate inflammation, and other factors in PE)
EAU Guidelines 2023 – Pathophysiology and Risk Factors for DE/Anejaculation. (Mentions SSRIs, antihypertensives, antipsychotics as causes of delayed ejaculation)
Althof S, et al. Treatment strategies for premature ejaculation. Ther Adv Urol. 2013. (Use of SSRIs, topical anesthetics, and behavioral therapy for PE – evidence of efficacy)
Cleveland Clinic – Delayed Ejaculation. (Age-related changes: older men may need more stimulation, decreased force/volume of ejaculation)
NHS (UK) – Ejaculation problems. (General patient-oriented overview of premature, delayed, and retrograde ejaculation and their causes)
Carosa E, et al. Hyperthyroidism and sexual function in men. J Clin Endocrinol Metab. 2003. (Association of hyperthyroid state with premature ejaculation, improved after treating thyroid)
Arafa M, El Tabie O. Medical treatment of retrograde ejaculation in diabetic patients. J Sex Med. 2008. (Use of pseudoephedrine to achieve antegrade ejaculation in diabetic men with retrograde ejaculation)
NIH (MedlinePlus) – Anorgasmia in males. (General discussion on inability to orgasm/ejaculate, causes and management)