Causes of ejaculation problems vary depending on the person and the type of problem.

An ejaculation problem can often have physical and psychological causes. For example, if a man has previously had a health condition that made it difficult to maintain an erection, it may now cause anxiety, leading to premature ejaculation.

Primary (lifelong) premature ejaculation

A number of possible causes are discussed below.

Conditioning

Many doctors believe early sexual experiences can influence future sexual behaviour. For example, if a teenager conditions himself to ejaculate quickly to avoid being caught masturbating, it may later be difficult to break the habit.

Traumatic sexual experiences

A traumatic sexual experience at an early age can sometimes lead to lifelong sexual anxiety and premature ejaculation. Experiences can range from being caught masturbating to sexual abuse.

Upbringing

Men who have had a strict upbringing, where sexual activity is only considered appropriate in certain circumstances, such as after marriage, may find it difficult to relax during sex, or be unable to let go of the belief that sex is wrong or sinful.

Biological reasons

A number of recent studies suggest biology may play a role in some cases of primary premature ejaculation.

Changes to the normal pattern of nerve signals in some men affected by erectile dysfunction could result in their penis being extra sensitive, meaning it takes much less stimulation to cause ejaculation.

Genetic influences

Studies have recently suggested men with a first-degree relative (father, brother or son) who experiences premature ejaculation are more likely to have the problem themselves. But a definite genetic association has not yet been proved.

Secondary (acquired) premature ejaculation

Acquired premature ejaculation (where premature ejaculation develops in a man who has previously had a history of normal ejaculation) can be caused by both psychological and physical factors.

Common physical causes include:

• diabetes 
• multiple sclerosis 
• prostate disease 
• high blood pressure 
• thyroid problems – an overactive or underactive thyroid gland 
• using recreational drugs
• drinking too much alcohol

The recommended daily levels of alcohol consumption are three to four units of alcohol for men, and two to three units for women.

A unit of alcohol is equal to about half a pint of normal strength lager, a small glass of wine, or a pub measure (25ml) of spirits.

Common psychological causes include:

• depression 
• stress 
• unresolved problems, conflicts or issues within a sexual and emotional relationship
• anxiety about sexual performance (this is often a contributory factor at the start of a new sexual relationship, or when a man has had previous problems with sexual performance)

Delayed ejaculation

Like premature ejaculation, delayed ejaculation can be caused by psychological and physical factors.

Possible psychological causes of delayed ejaculation are similar to those of premature ejaculation – for example, early sexual trauma, strict upbringing, relationship problems, stress, and depression.

Physical causes of delayed ejaculation include:

• diabetes (usually only type 1 diabetes)
• spinal cord injuries
• multiple sclerosis
• surgery to the bladder or prostate gland
• increasing age

Many medicines are known to cause delayed ejaculation, including:

• antidepressants, particularly selective serotonin reuptake inhibitors (SSRIs)
• medications used to treat high blood pressure (hypertension), such as beta-blockers
• antipsychotics, which are medications used to treat episodes of psychosis 
• muscle relaxants, such as balcofen, which is widely used to treat motor neurone disease and multiple sclerosis
• powerful painkillers, such as methadone (which is also widely used to treat people addicted to heroin)

Retrograde ejaculation

Retrograde ejaculation is caused by damage to the nerves or muscles that surround the neck of the bladder (the point where the urethra connects to the bladder).

Usually when you ejaculate, semen is pushed out of your testicles and up through your urethra (the tube that semen and urine pass through). It is prevented from entering your bladder by the muscles around the neck of the bladder, which close tightly at the moment of orgasm.

However, damage to the surrounding muscles or nerves can stop the bladder neck closing, causing the semen to move into the bladder rather than up through the urethra.

Prostate gland or bladder surgery is the most common cause of retrograde ejaculation. Other causes are diabetes, multiple sclerosis, and a class of medicines known as alpha blockers, which are often used to treat high blood pressure (hypertension).

Glossary

Discharge

Discharge is when a liquid such as pus oozes from a part of your body.

Testicle

Testicles are the two oval-shaped reproductive organs that make up part of the male genitals. They produce sperm and sex hormones.

Blood

Blood supplies oxygen to the body and removes carbon dioxide. It is pumped around the body by the heart.

Benign

Benign refers to a condition that should not become life-threatening. In relation to tumours, benign means not cancerous.

Urethra

The urethra is a tube that carries urine from the bladder to the outside of the body.

Inflammation

Inflammation is the body’s response to infection, irritation or injury, which causes redness, swelling, pain and sometimes a feeling of heat in the affected area.

If you have an ejaculation problem, you will usually become aware of it through your own sexual behaviour or discussion with your partner. The next step is to visit your GP who will discuss the problem with you and either examine you or refer you to a specialist.

Family and medical history

Depending on the nature of your problem, you may be asked questions about your family medical history and any underlying health conditions you may have, such as:

• diabetes
• heart disease
• high blood pressure (hypertension)

You will also be asked about your sexual and emotional health. While you may find it embarrassing to talk about, answering questions about the type and pattern of your symptoms is an important step towards making sure that you receive the most effective treatment.

Read more about the symptoms associated with ejaculation problems.

Your GP or specialist will want to know if you have had an injury or surgery to your pelvic area, what medications you are taking, and about aspects of your lifestyle, such as how much alcohol you drink.

Further testing

A rectal examination may be carried out in people over 50 years old to check for an enlarged prostate gland. Your blood pressure and heart rate may also be measured.

Blood and urine samples may be taken to check your hormone and cholesterol levels. Your GP, or specialist, may also carry out a visual examination of the pelvic area to check for injury or infection.

Glossary

Cholesterol

Cholesterol is a fatty substance made by the body that lives in blood and tissue. It is used to make bile acid, hormones and vitamin D.

Blood

Blood supplies oxygen to the body and removes carbon dioxide. It is pumped around the body by the heart.

High blood pressure

Hypertension is when the pressure of the blood in your bloodstream is regularly above 140/90 mmHG.

Heart

The heart is a muscular organ that pumps blood around the body.

Ejaculation problems, such as premature ejaculation, are common sexual problems in men.

The three main problems are:

• premature ejaculation 
• delayed ejaculation 
• retrograde ejaculation 

These are described in more detail below.

Premature ejaculation

Premature ejaculation is the most common ejaculation problem. It is where the male ejaculates too quickly during sexual intercourse.

Many men are unsure about how long ‘normal’ sex should last before ejaculation. A study looking at 500 couples from five different countries found the average time between a man putting his penis into his partner’s vagina and ejaculation was around five-and-a-half minutes.

However, it’s up to the individual and his partner to decide whether or not they’re happy with the time it takes for him to ejaculate. There is no definition of how long intercourse should last.

Occasional episodes of premature ejaculation are common and not a cause for concern. However, if you’re finding that around half of your attempts to have intercourse result in premature ejaculation, it might help to get treatment.

Most men with this problem won’t have always had it – they’ll have previously ejaculated normally. This may be referred to as ‘secondary’ premature ejaculation.

It’s less common for the man to have always experienced premature ejaculation (since becoming sexually active) – this is known as ‘primary’ or lifelong premature ejaculation. It affects around one in 50 men in England. In most cases of lifelong premature ejaculation:

• there is an inability to delay ejaculation during sex every time or most times
• the condition causes feelings of shame or frustration and impacts on quality of life, causing the man to avoid sexual intimacy

Delayed ejaculation

Delayed ejaculation (male orgasmic disorder) is classed as either:

• experiencing a significant delay before ejaculation is possible
• being unable to ejaculate at all even though the male wants to and his erection is normal

There is no set definition to describe ‘how long is too long’, but a persistent (and unwanted) delay of ejaculation that lasts for 30 to 60 minutes may suggest delayed ejaculation.

Alternatively, if you are unable to achieve ejaculation at least half the times you have sex, you may have delayed ejaculation.

As with premature ejaculation, delayed ejaculation can be either acquired or lifelong. Lifelong delayed ejaculation is less common and affects an estimated one in 1,000 men.

Delayed ejaculation can occur in all sexual situations, or just in certain situations – for example, you may be able to ejaculate normally when masturbating, but not during sex. When delayed ejaculation only happens in certain situations, there’s usually a psychological cause.

Retrograde ejaculation

Retrograde ejaculation is a rarer type of ejaculation problem. It happens when sperm travels backwards and enters the bladder instead of coming out of the end of the urethra (the tube through which urine passes).

The main symptoms of retrograde ejaculation include:

• producing no semen, or only a small amount, during ejaculation
• producing cloudy urine (because of the semen in it) when you first go to the toilet after having sex

Men with retrograde ejaculation still experience the feeling of an orgasm and the condition does not pose a danger to health. However, it can affect the ability to father a child (read about infertility).

Treating ejaculation problems

Premature ejaculation can be treated with medication, such as the selective serotonin reuptake inhibitors (SSRIs) type of antidepressant, which can help delay ejaculating.

Couples therapy, a form of counselling, can be useful in coming up with techniques for partners to practice to help delay ejaculation.

Recommended treatments for delayed ejaculation depend on the underlying cause. If it is thought to be a side effect of medication, switching to an alternative medication will help. However, if the cause is thought to be psychological, counselling may be recommended.

Most men do not require treatment for retrograde ejaculation because they are still able to enjoy a healthy sex life and the condition does not affect their health. In some cases, medication may be used to help restore normal ejaculation.

However, if you want to have children, you may need fertility treatment to extract a sample of sperm.

Read more about treating ejaculation problems.

What causes ejaculation problems?

Ejaculation problems are complex and can be caused by a number of things, including:

• stress
• relationship problems
• anxiety – such as a man being anxious that he will lose his erection (erectile dysfunction), causing him to ‘rush’ the intercourse
• previous traumatic sexual experiences
• depression
• some medical conditions or medicines – for example, diabetes can cause delayed ejaculation

Some researchers think certain men are more prone to premature ejaculation because of their biological make-up, such as having an unusually sensitive penis.

Retrograde ejaculation is caused by damage to nerves or muscles that surround the neck of the bladder (the point where the urethra connects to the bladder). This damage can often occur as a complication of prostate or bladder surgery.

Read more about the causes of ejaculation problems.

Who is affected

Premature ejaculation is the most common type of ejaculation problem.

A number of surveys have found around one in three men reported being affected by premature ejaculation. The true figure is probably much higher as many men are reluctant to admit they have this problem.

While less common, delayed ejaculation is probably more of a problem then most people realise. One study found around one in 20 people had problems achieving an orgasm over the course of a month during the past year.

Although retrograde ejaculation is rare, it can be a common complication of some types of surgery, such as prostate surgery, or in men with certain health conditions that can damage the nerves, such as diabetes or multiple sclerosis.

If you have ejaculation problems caused by physical conditions, your GP should be able to suggest possible treatment options.

Treating ejaculation problems caused by psychological factors can be more challenging, but most men who persevere with treatment have successful outcomes.

Premature ejaculation

Self-help

There are a number of things you can try yourself before seeking medical help, such as:

• masturbating an hour or two before having sex
• using a thick condom to help decrease sensation
• taking a deep breath to briefly shut down the ejaculatory reflex (an automatic reflex of the body during which ejaculation occurs)
• having sex with your partner on top (to allow them to pull away when you are close to ejaculating)
• taking breaks during sex and thinking about something boring

Couples therapy

If you are in a long-term relationship, you may benefit from having couples therapy. The purpose of couples therapy is two-fold.

First, couples are encouraged to explore issues that may be affecting their relationship, and given advice about how to resolve them.

Second, couples are shown techniques that can help the man to ‘unlearn’ the habit of premature ejaculation. The two most popular techniques are the ‘squeeze technique’ and the ‘stop-go technique’.

In the squeeze technique, the woman begins masturbating the man. When the man feels that he is almost at the point of ejaculation, he signals to the woman. The woman stops masturbating him, and squeezes the head of his penis for between 10 to 20 seconds. She then lets go and waits for another 30 seconds before resuming masturbation. This process is carried out several times before ejaculation is allowed to occur.

The stop-go technique is similar to the squeeze technique except that the woman does not squeeze the penis. Once the man feels more confident about delaying ejaculation, the couple can begin to have sexual intercourse, stopping and starting as required.

These techniques may sound simple, but they do require a lot of practice.

Medication to treat premature ejaculation

Selective serotonin reuptake inhibitors (SSRIs)

Selective serotonin reuptake inhibitors (SSRIs) are primarily designed to treat depression, but they also have the useful side effect of delaying ejaculation. Although SSRIs are not licensed to treat premature ejaculation, they are increasingly being prescribed for this use.

SSRIs used for this purpose include:

• paroxetine
• sertraline
• fluoxetine

Some men with premature ejaculation may experience an improvement in their symptoms as soon as treatment begins. However, you will usually need to take the medication for one to two weeks before you notice the full effects of the treatment.

Common side effects of SSRIs include:

• fatigue
• feeling sick and being sick
• diarrhoea 
• excessive sweating

However, these are usually mild and should improve after two to three weeks.

Dapoxetine

An SSRI, known as dapoxetine, has been specifically designed to treat premature ejaculation.

From November 2013, dapoxetine (Priligy) became the first medication to be licensed for premature ejaculation in the UK and local NHS authorities can choose to prescribe it on the NHS.

Dapoxetine acts much faster than the SSRIs mentioned above and can be used ‘on demand’. If you are prescribed dapoxetine, you will usually be advised to take it one to three hours before having sex, but not more than once a day.

Dapoxetine is not suitable for all men diagnosed with premature ejaculation. For example, it is not recommended for some men with heart, kidney and liver problems. Dapoxetine can also interact with other medications, such as other antidepressants.

Common side effects of dapoxetine include headaches, dizziness and feeling sick.

Topical anaesthetics and condoms

The use of topical anaesthetics such as lidocaine or prilocaine can be helpful but can be transferred and absorbed to the vagina, causing decreased sensation. Condoms can also be used and are effective, particularly when combined with local anaesthesia.

Delayed ejaculation

Sex therapy

Sex therapy is a form of counselling that uses a combination of psychotherapy and structured changes in your sex life. This can help to increase your feeling of enjoyment during sex, and help make ejaculation easier.

Some clinical commisioning groups (CCGs) provide a sex therapy service on the NHS, but others do not. Therefore, levels of availability can vary widely depending on where you live.

You can also pay privately for sex therapy. Prices for a single session can vary from around £50 to £80. For information about private sex therapists in your local area you should visit the College of Sexual and Relationship Therapists website.

The relationship counselling service Relate also offers sex therapy at a number of its centres; you would be expected to pay for each session.

During sex therapy, you will have the opportunity to discuss any emotional or psychological issues related to your sexuality and relationship, in a non-judgemental way.

Activities may also be recommended for you to try at home while you are having sex with your partner (you should never be asked to take part in any sexual activities during a session with the therapist).

These may include:

• viewing erotic material before having sex, such as videos and magazines, to increase the feeling of sexual stimulation
• erotic fantasies and ‘sex games’ to make your lovemaking more exciting
• using lubricating creams or gels to make the physical act of sex more comfortable and relaxing
• using sexual aids, such as vibrators, to increase pleasure

Read more information about what a sex therapist can do.

Switching medication

There are a number of medications that can be used if it is thought SSRIs are responsible for causing delayed ejaculation. These include:

• amantadine – a medication originally designed to treat viral infections
• buproprion – a medication originally designed to help people stop smoking
• yohimbine – a medication originally designed to treat erectile dysfunction

These medications help block some of the chemical effects of SSRIs that are thought to contribute towards delayed ejaculation.

Retrograde ejaculation

Most men do not require treatment for retrograde ejaculation because they are still able to enjoy a healthy sex life and the condition does not have adverse effects on their health.

If retrograde ejaculation is caused by using a certain medication then normal ejaculation will usually return once the medication is stopped. Speak to your GP before you stop taking prescibed medication.

If treatment is required (usually because of wanting to father a child), medicines can be used to strengthen the muscles around the bladder neck. Pseudoephedrine (a medicine commonly used as a decongestant) has proved to be effective in treating retrograde ejaculation caused by diabetes or surgery.

However, if the retrograde ejaculation has been caused by significant muscle or nerve damage, treatment may not be possible.

Men who want to have children can have sperm taken from their urine for use in artificial insemination or in-vitro fertilisation (IVF).

Glossary

Local anaesthetic

A local anaesthetic is a drug injected by needle or applied as a cream, which causes a loss of feeling in a specific area of the body.