Delayed or Absent Ejaculation: Causes and How to Manage It

When delayed ejaculation comes up, many people laugh and say, "Lucky you, everyone wants to last longer." But men who actually have it don't feel that way. Some take so long that both they and their partner become tired, sore or lose the mood. Some can't ejaculate inside their partner at all, even though they want a child. Delayed ejaculation is a problem that deserves care just as much as premature ejaculation.

What is delayed ejaculation?

According to DSM-5-TR, delayed ejaculation means ejaculation that is markedly delayed, or does not happen, on almost every occasion of sex with a partner, for at least 6 months, and causes distress, despite adequate stimulation and a desire to ejaculate.

There is no fixed number of minutes. In practice, many men go beyond 25–30 minutes without ejaculating, or stop because they are tired.

Patterns that may occur:

• Can ejaculate during masturbation but not with a partner: the most common
• Cannot ejaculate in any situation (anejaculation)
• Reaching orgasm but no semen comes out: this may be retrograde ejaculation (semen going back into the bladder), which is a different condition

Common causes

Physical causes and medicines

• SSRI and SNRI antidepressants are a very common cause. Read When antidepressants affect your sex life
• Other medicines, such as some antipsychotics, opioid painkillers and some alpha-blocker prostate medicines
• Diabetes, which damages nerves
• Low testosterone or an underactive thyroid. See Symptoms of low testosterone
• Pelvic or prostate surgery, spinal cord injury
• Alcohol and recreational drugs
• Getting older, as nerve sensitivity naturally declines

Behavioural and psychological causes

• Very specific masturbation habits, such as strong pressure or high speed, a particular position, or always needing porn, which means stimulation from a real partner isn't enough
• Performance anxiety, focusing so hard on "having to finish" that you can't
• Fear of pregnancy or infection
• Guilt about sex from your upbringing
• Distance, conflict or reduced attraction with your partner

Delayed ejaculation

Body and medicines

• SSRI/SNRI antidepressants
• Diabetes, low testosterone, low thyroid
• Pelvic surgery, alcohol
• Increasing age

Behaviour and mind

• Very specific masturbation style
• Pressure to finish
• Fear of pregnancy or STIs
• Distance from partner

DSM-5-TR definition: almost every time, for at least 6 months, and causing distress.

Effects that are often overlooked

• Both partners become tired, sore or irritated
• Your partner may feel they are not attractive
• The relationship becomes tense and sex gets avoided
• Couples who want a baby may have trouble conceiving. See Semen analysis

Diagnosis

The doctor takes a detailed history: whether it has been lifelong or came on later, whether it happens in every situation or only with a partner, masturbation patterns, medicines and the relationship. Then comes a physical examination, and possibly blood tests such as blood sugar, testosterone, thyroid and prolactin. If you reach orgasm but no semen comes out, a urine test after orgasm may be done to check for retrograde ejaculation.

Care and treatment

The AUA/SMSNA guideline (2020) states that no medicine is yet approved specifically for delayed ejaculation, so care focuses on the cause:

1. Review your medicines with the prescribing doctor, who may lower the dose, switch the medicine or add another. Never stop medicine on your own.
2. Treat other conditions, such as controlling diabetes, and treating low testosterone or an underactive thyroid once confirmed.
3. Adjust masturbation habits: gradually reduce pressure and speed, use lubricant and rely less on porn, so your body responds to stimulation closer to that of a real partner.
4. Sex therapy: reduce anxiety, adjust expectations, communicate with your partner and practise techniques like Sensate Focus.
5. Increase stimulation, for example using a vibrator on the genitals, which helps some men.
6. Off-label medicines, such as cabergoline or bupropion, have limited evidence, and a doctor will consider them case by case.

1. 1Review medicinesWith the prescriber; never stop on your own
2. 2Treat other conditionsControl diabetes; treat confirmed hormone or thyroid problems
3. 3Adjust masturbationLess pressure and speed, less reliance on porn
4. 4Sex therapyReduce anxiety, talk with partner, sensate focus
5. 5Other optionsMore stimulation, or medicines as assessed individually

AUA/SMSNA (2020): no medicine is approved specifically for delayed ejaculation.

When to see a doctor, and how the clinic can help

• Delayed ejaculation for several months that causes distress or affects your relationship
• It started after beginning a new medicine
• You also have diabetes, numbness in your hands or feet, or lower desire
• You are planning to have children
• You reach orgasm but no semen comes out, or your urine is cloudy after sex

At Dr. Kris Clinic we assess the physical, medicine-related, hormonal and psychological sides, do blood tests as needed, coordinate with the doctor who prescribes your current medicines, and provide sexology counselling for individuals and couples, at the clinic in Surat Thani or online, with consultations in English available. Read more about when to talk to a sexologist in When to see a clinical sexologist.