The Causes of Delayed Ejaculation

Erectile Dysfunction (ED) & Delayed Ejaculation

What is delayed ejaculation?

If you’re a man who can’t get aroused enough to ejaculate you have delayed ejaculation. This can happen to men of any age but is more common in older men. Some estimates suggest one man in twelve has this problem at any one time.

Is delayed ejaculation just something to do with growing older?

Not necessarily. There are many causes of delayed ejaculation, both emotional (mental / psychological) and physical. The latter include:

  • Excessive alcohol and smoking
  • Exhaustion
  • Damage to the brain or spinal-cord
  • Low testosterone levels
  • Liver or kidney failure
  • Multiple sclerosis and other diseases of the nervous system like Parkinson’s disease
  • Radiation therapy to the testicles or prostate for cancer
  • Having had a stroke
  • Prostate or bladder surgery

Delayed ejaculation isn’t something you should expect to happen as you get older. Certainly older men need more physical stimulation during sex, but that does not mean you have delayed ejaculation. The crucial determinant for a diagnosis is that you can’t ejaculate at all.

What causes delayed ejaculation?

There are some well known illnesses which cause delayed ejaculation. These include 

  • Diabetes
  • Hyperlipidemia (high cholesterol levels)
  • High blood pressure
  • Hypogonadism (a disorder of the testicular endocrine system)
  • Atherosclerosis (hardening of the arteries) Certainly some of these effects can be remedied by taking medication to keep the condition under control. There are many medication on the market which cause erectile dysfunction as a side-effect. These should be discussed with your doctor in case there is an alternative available.

    What’s the most likely cause of delayed ejaculation?

    A common cause of delayed ejaculation is damage to any of the tissues of the the penis or pelvic region through atherosclerosis, vascular disease, and neurologic disease (damage to the nerve cells). 

    Aspects of lifestyle like a high fat diet, smoking, and low levels of exercise, both of which contribute to heart disease and vascular problems, also raise a man’s risk of experiencing delayed ejaculation. This is explained in this book.

    Surgery (especially prostatectomy and bladder surgery for cancer) are likely to damage nerves and arteries near the penis, and this can cause delayed ejaculation. Needless to say, any injury to the pelvic regions in general or the penis, spinal cord, prostate and bladder in particular, can lead to delayed ejaculation by harming nerves, smooth muscles, arteries, and fibrous tissues of the corpora cavernosa.

    Many common medicines such as drugs to treat blood pressure, antihistamines, antidepressants, tranquilizers, some appetite suppressants, and even anti-acid drugs may produce delayed ejaculation as a side effect.

    But the really important thing to know is that psychological factors such as stress, anxiety, depression, low self-esteem, and sexual anxiety caused by fear of sexual failure, are at the root of a large proportion of delayed ejaculation. And to make this more complicated, men whose delayed ejaculation is caused by physical problems usually have emotional reactions such as stress, anxiety, guilt, depression. And finally, other causes of delayed ejaculation are smoking, which may affect the blood flow in the veins and arteries of the penis, and hormonal problems including low testosterone.

    Cause of erectile dysfunction

    Many cases of erectile dysfunction are caused by problems in the relationship. Sexual problems can grow to the point where they cause a man to suffer from loss of his erection. Sexual therapy is most effective when both sexual partners go to therapy. Some of the emotional causes of erectile dysfunction include:

  • Feeling stressed from work situations, family circumstances or other life events 
  • Being nervous about sex, anxiety caused by a bad experience such as shame or humiliation, or a previous case of impotence
  • Relationship problems
  • Depression
  • Feeling depressed
  • Being self-conscious about sex or fearing your partner’s reaction to you or your sexual abilitiesIt’s worth looking some more at the various treatment methods available for erectile dysfunction

    John Tomlinson and David Wright investigated the impact of erectile dysfunction on men and their partners, as well as investigating the effects of treatment with sildenafil.

     They conducted their study on 40 men who had erectile dysfunction and attended a clinic in the British National Health Service; they investigated the men’s experience of erectile dysfunction and their expectations of sildenafil, and its impact on both them and their relationships. In the abstract of their paper they state, perhaps unsurprisingly, that erectile dysfunction caused marked distress in all the men who experienced it, and also had a profound effect on their self-esteem and their relationships.

    Sildenafil seemed to cause a great improvement in the men’s well-being when it worked, but if sildenafil did not work, men developed an even lower level of self-esteem, the treatment failure perhaps serving to confirm their lack of self-worth. This clearly means that professionals who prescribe sildenafil need to be conscious of the possible consequences of this course of treatment.

    In the body of their article the authors go into more detail about these issues: they start by making the observation that despite a high prevalence, and plenty of awareness about the importance of emotional and psychological issues as cause of the ED, there has been little research into the impact of the condition and the effect of its treatment on either men who suffer from it or their partners.

    For example, studies into the quality of life experienced by men with ED have often involved the use of questionnaires that have not always been sensitive to the impact of ED on a man’s well-being; for example, one review of over 400 scientific studies on the frequency of impotence and ED simply dismissed the psychological impact of the condition by stating broadly that “Erectile dysfunction is a common condition… [and]… has a negative impact on the quality of life,” but failed to elucidate what the impact might be.

    Despite this unsatisfactory body of work, some studies have been more sympathetic to men suffering from the condition.

    For example, the Sexual Dysfunction Association discovered that just over 60% of men who took part in an online survey agreed that ED reduced their self-esteem; just under 30% reported that their relationships had been adversely affected; and just over 20% claimed that their relationship had come to an end simply because of the erectile dysfunction.

    At the time of this review — 2004 — there was considerable social stigma around the condition, with impotence serving as a prolific source of jokes, the social stigma thereby inhibiting men even more from either confiding in others or obtaining treatment from healthcare professionals.

    It’s interesting to reflect that sildenafil has now been around for many years, and in that period of time what’s become very clear is that the initial assumptions made for the drug — i.e. that it was a “cure-all” for erectile dysfunction — were unrealistic; a proportion of men who take the drug find that it does not work for them.

    The focus of this study was on the men themselves rather than on their partners, but it does provide interesting insights into the effect of the condition. As mentioned above, 40 men who had been prescribed sildenafil at a men’s health clinic agreed to take part in an exploration of the psychological impact of ED and its treatment.

    These men were selected from 302 referrals to the clinic in a 12 month period: these referrals were divided into two groups, one consisting of men for whom sildenafil had been successful, and the other consisting of men where the use of sildenafil had not produced a successful outcome.

    It should be made clear at this point that whether or not treatment was successful was determined by the patient’s interpretation of the criteria of success provided by the authors of the paper: success was defined as achieving successful vaginal intercourse, while failure was defined as an inability to complete the act of intercourse because of failure to generate an erection which was firm enough to penetrate the man’s partner.

    From the men in each of these groups, 20 were selected to take part in the study, making a total of 40 participants. The men ranged in age from 22 to 72 years, although the median was just under 52 years. All the men had been prescribed sildenafil at the men’s clinic, with an introduction to the treatment method which ensured that their existing expectations were not altered by the consultation.

    By using a system of semi structured interviews, the two authors of the paper were able to explore a whole range of issues around the men’s experience of both ED and taking sildenafil. The men were interviewed by the same consultant who had prescribed medication for them, with the interviews being audiotaped, and conducted in line with a protocol which was flexible enough to allow the inclusion of new issues raised by any of the participants.

    The data gathered were subjected to a thematic analysis, so that any themes which emerged during the course of the initial interviews could be explored in greater depth in subsequent interviews. It’s hardly surprising that most men’s first reaction to the experience of erectile dysfunction is a sense of being emasculated.

    Both sex therapists and the layman alike know that being able to maintain an erection and being able to adequately one’s female partner is regarded by most men as a fundamental cornerstone and indicator of both virility and masculinity. This is expressed by the men’s clear association between being able to obtain an erection and being a man. It isn’t only the penis that’s a fundamental sign of masculinity; the ability of that penis to become erect is just as important, if not more so.

    In many cases a man who cannot get an erection will experience depression. If he is not already in a relationship, a man may find his ability to form new relationships appears to be severely diminished: the logic seems to go something like this; “If a man can’t get an erection, he’s not a man, therefore no woman would have any respect for him; in any case it would be pointless trying to chat her up because if he were able to get her into bed he couldn’t do anything about it.”

    This is representative of a clear decline in the men’s sexual self-confidence, which interestingly enough not only impacted on their sexual relationships, but on their day-to-day relationships with other significant people, including work colleagues and friends.

    Often this loss of confidence would be disguised externally, while the man felt internally that he wasn’t as good as the men around him. Unsurprisingly, this led to a common sense of isolation and despondency; a feeling which was made worse by the prevalent belief that erectile dysfunction is a condition which only affects men over a certain age, thereby leading younger men with ED to infer that they were “old before their time”.

    It’s equally unsurprising that erectile dysfunction caused these men to feel very concerned about the impact of the condition on their relationships. It is a common characteristic of men to believe that they have a duty to satisfy their partner sexually, so it’s no surprise to hear that about a quarter of the men in the study thought that they were letting down their partners by their inability to engage in sexual intercourse.

     Indeed, 15% of them were so concerned about the possible impact of erectile dysfunction that they began to think their partners would desert them: the association here was that if a man couldn’t keep an erection he wouldn’t be able to keep a woman.

    To make this worse, around 40% of the men felt unable to discuss the condition with their partners, probably because they found it easier to avoid the issue or because they felt demeaned by their inability to obtain an erection.

    It’s interesting that many of the men in the study believe that the administration of sildenafil would cause them to gain an instant erection without any difficulty immediately before sexual intercourse started; in general the expectations were too high, including for example the belief that sildenafil would produce a full or uncontrollable erection, or that it would have a 100% success rate. Like the media reporting of the drug’s possible impact on ED, the expectations of the men before treatment appeared to be unrealistic.

    Those men for whom it actually worked felt pleased and even elated at their ability to achieve an erection — this is the real impact of what these men termed “a return to manhood”: a sense of well-being and confidence; a sense being able to satisfy whatever sexual needs his partner expressed; a recapturing of a sense of manhood and masculinity.

    It is therefore no surprise that when treatment with sildenafil was unsuccessful, the men’s perception of the failure was massively impacted by their previous expectations. If, for example, they had believed that all that was necessary to achieve a firm erection was to take one pill, their hopes would fall, and then if a second failure ensued, they would report feelings like bereavement, grief for the loss of their masculinity, or even a sense that they would never be able to have sex again.

    The researchers report that “considerable disappointment” was a common reaction to the failure of treatment, and some men in the study for whom sildenafil was ineffective felt devastated; others regarded the treatment as a failure because they hadn’t understood there needs to be a certain element of planning in taking sildenafil, and they felt that sex had become unspontaneous, planned, or clinical.

    All in all, the study revealed that most men with ED are more deeply shocked than most health care practitioners have previously understood, with their sense of self-esteem and their sense of masculinity being particularly devastated. It doesn’t matter what the cause of ED might be, its impact is more or less the same in every case — a severely damaged sense of masculinity, a profound reduction in a man’s feeling of self-worth, and a reduction in his sense of value to his partner, as well as a profound loss of self-esteem about his place in wider society.

    The researchers conclude from this that it is not adequate to treat a man in isolation; details of his sexual relationship should be obtained, and perhaps as later researchers have demonstrated, the partner should be involved in decisions around treatment and explanations of what may be expected.

    The men for whom sildenafil did not work at this time probably didn’t receive advice and counseling which would have given them a higher chance of success, because subsequent work has demonstrated that it can take up to 8 doses for sildenafil to have its full effect, and that persistence is often necessary for treatment to become effective. At this time, men who didn’t have this information might experience one or two failures of treatment, which would have the undesirable effect of reinforcing their sense of worthlessness.

The Hidden Erection Problem In Young Men

A study in Western Australia on male erectile dysfunction found that one quarter of men had erection problems, and one in twelve had severe erectile difficulty.

The study was conducted by sending postal questionnaires to randomly selected men in the electoral roll. In summary, before we look at the detail of the study, these are the basic facts: 42% of questionnaires were returned to the researchers, so the sample was to some extent self-selected. Among adult men in WA, the occurrence of any erection problem and severe erectile dysfunction was, respectively, 25.0% and 8.5%.

As you might expect, the frequency of erection problems increased with age. Astonishingly, thirty-eight percent of married men and men who had partners experienced erection problems (severe erection problems 19.1%). There was little difference between white collar and blue collar workers; the most disturbing fact of all was that the vast majority of the men had had erection problems for over a year, but only a meagre 14% had asked for or received any treatment.

Erectile dysfunction (erection problems) means that a man is consistently and perhaps recurrently unable to achieve an erection hard enough for penetration and sexual intercourse. The researchers wanted to conduct a survey on erection problems among men in Western Australia, and used the Electoral Roll for June 2001 as the source for the men they questioned.

They selected men by age and location, using 14 random samples of 302 men in and outside Perth. They sent out a reply-paid questionnaire by mail and in it asked questions on medical history and medical treatment, social status, sexual behavior and sexual function. The men were classified as blue or white collar workers and assessed for social deprivation. The data was collected using the International Index for Erectile Function, which is also called the Sexual Health Inventory for Men.

4,228 questionnaires were posted, and 1,580 (89.3%) returned with a full set of answers. These 1,580 men were aged between 20.1 and 99.6 years. For the purpose of this study they were grouped by age. Erection problems occurred in 25% of the whole sample, and and an astonishing 8.5% of these men reported severe erection problems.

Both the frequency of occurrence and the severity of erection problems increased very significantly with age, particularly after a man reached 50 years of age. But even 15% of the young men aged between 20 and 29 years had erectile problems – and surprisingly, this was less than the men in the next older age groups.

Perhaps unsurprisingly, there was a decline in sexual activity in men of 60 years and older; over 70 years of age, sexual activity declined sharply. But a significant number of the men over 60 (42.6%) and over 70 (25.7%) were sexually active.

There are many interesting facts in this survey beyond those related to erection problems. For example, while about three quarters of the men were married or living with sexual partners, only three quarters of these men were sexually active.

Of the ones who were sexually active, just over 60% said they were having sex on a regular basis. Of the other quarter who were not living with a wife or partner, 53.9% were sexually active – and indeed 39.2% of these men said they had sexual intercourse on a regular basis.

A majority of the men were employed, though 36.8% had retired on grounds of age and 6.8% had retired on the grounds of ill-health.

The highest incidence of erectile problems occurred in clerical, sales, and service workers, but the occurrence of erection problems wasn’t really much different between blue collar and white collar workers. What is less surprising is that erection problems occurred most often in men from economically deprived areas. We know stress is a potent factor in causing a loss of a man’s sense of male power, so there is nothing surprising about that.

Most of the men (a massive 89.1%) with erection problems had had  their difficulties for more than 1 year, and a whopping 74.8% had had erection problems for more than two years; unbelievably 12.2% said they had been suffering for more than 10 years. And the longer it went on, the worse it got. Yet only 90 men (a meager 14.1%) had ever looked for and got any treatment.

Most studies on erection problems have looked at men aged between 40 and 70 years, but this study covered a much bigger range. To this extent, then, it represents the entire spectrum of adult men in WA. You have to assume that this is typical of the results in much of the Western World, and it is truly shocking.

When you look at the detail, it seems odd that men in the 20 – 29 age group appeared to have more erection problems than the 30 – 39 years age group. Possible explanations include commonplace stress of early adulthood such as new relationships, new work responsibilities, and stress linked to leaving home. Among men aged between 40 and 69 years, erection problems occurred in 33.0% of men, while sever erection problems occurred in 8.6%. In fact, the age of a man is far more important than any other factor in determining whether a man has an erection problem.

Both the frequency and the severity of erection problems increase with age. And since the older age groups were under-represented in the study, the true frequency of erection problems and of severe erection problems in men may have been higher than the recorded levels of 25.1 and 8.5%.

[These figures are so high they seem hard to believe….but this is what the study found.]

Australian demography is changing rapidly, and the proportion of men aged 65 years and older will increase dramatically in the years to come – which means erection problems will pose huge clinical and socioeconomic burdens on healthcare providers and social support services in the years ahead – if men choose to seek help, which currently they are not doing.

The majority of the participants in the Western Australia Men’s Health Study, from where these results are taken, were married or had partners, even though an astonishing 25% or more of these men were not enjoying an active sex life. Of the men aged 70 years and older, a fair proportion remained sexually active.

All these findings matched the results from the Global Study of Sexual Attitudes and Behaviors, a large scale project in which over thirteen thousand men from 30 countries were asked about their sexual behavior. Over 84% of men in this study aged between forty and eighty said they’d had sexual intercourse within the 12 months preceding the study. Among the men who were sexually active, about half said they had sexual intercourse regularly.

When the authors compared men who had never been married with those who were married or had partners, they found, perhaps unsurprisingly, that having never been married was significantly associated with an increased chance of having erection problems; in short, fewer married men have erection problems than non-married men, though which is cause and which effect remains unclear.

Analysis of the results of the study also showed that being separated or divorced may be one of the predisposing factors for erection problems. (Though once again, of course, whether the erection problems were a cause of, or simply unrelated to, separation and divorce, is unclear. In other studies, it has been shown that men with severe erection problems are much more likely to be single, without regular sexual partners.

Erection problems have previously been associated with lower socioeconomic status. The current study demonstrated that erection problems occurred in a smaller proportion of men who were in full- or part-time employment compared to the unemployed.

Clerical, sales and service workers had the highest frequency of erection problems, although there were few other correlations of note between erection problems and occupational group. There was no difference between “blue collar” and “white collar” workers in this respect.

Of the 468 men in the study who reported on the length of time for which they had endured erection problems, 47.9% had had the problem for between one and five years. This matches other studies in the general population, where 55% of men with the problem were found to have had erectile dysfunction of one sort or another for this period. The current authors’ observation that men who had had it for longer also had more severe problems is neither surprising nor novel.

In spite of erection problems being a common and often long-standing condition, only 14.1% of the men with erection problems had ever received any treatment. This suggests that there is an urgent need for sexual education and awareness information at every level. And certainly, if it’s true that the longer the erection problems continue, the worse they get, then men with any erection problem should get professional assistance as soon as possible so that therapeutic intervention can be started in the milder stages of erectile dysfunction.

It’s also important to remember that erection problems may indicate cardiovascular and endothelial disease – so once again, there is a clear incentive for erection problems to be comprehensively investigated. In this study in WA, erectile dysfunction was found to be apparently under-diagnosed and grossly undertreated. Whether or not this is true – and if it is, whether or not it applies to the rest of the world – remains to be seen.
 The Journal of Sexual Medicine

Volume 5 Issue 1 Page 60-69, January 2008

To cite this article: Kew-Kim Chew MBBS, FRCPEdin, FRCPGlasg, Bronwyn Stuckey MBBS, FRACP, Alexandra Bremner BSc(Hons), GradDipAppStats, PhD, Carolyn Earle BSc, PGradDipHithSci, Konrad Jamrozik MBBS, D Phil (2008) Male Erectile Dysfunction: Its Prevalence in Western Australia and Associated Sociodemographic Factors
The Journal of Sexual Medicine 5 (1) , 60–69 doi:10.1111/j.1743-6109.2007.00548.x