World J Urol (2005) 23: 68–75

DOI 10.1007/s00345-004-0486-9

T O P I C P A PE R

Emmanuele A. Jannini Æ Andrea Lenzi

Ejaculatory disorders: epidemiology and current approaches

to definition, classification and subtyping

Received: 16 November 2004 / Accepted: 8 December 2004 / Published online: 18 May 2005
Ó Springer-Verlag 2005

Abstract Ejaculatory disorders (disorders of emission, ical and pathophysiological discoveries in sexual medi-
ejaculation and orgasm) are the most frequent sexual cine have made it clear that organic causes or
complaint. Conventional algorithms on ejaculatory dis- comorbidities can be found in the great majority of cases
orders are based on an organic or psychogenic dichot- of male erectile dysfunction and ejaculatory disorders
omy, with the latter being traditionally considered the [1].
main etiological cause. The scope of this review is to The ability to control the timing of sexual pleasure
propose a new classification of ejaculatory disorders, (ejaculation) is for many couples a prime aspect of sex-
with special emphasis on epidemiology and subtyping of ual pleasure. Ejaculation occurring sooner or later than
the most frequent: premature ejaculation (PE). There is desired can lead to other sexual disturbances, such as
growing agreement on definition, diagnosis, and treat- erectile dysfunction, hypoactive sexual desire, sexual
ment options. In many cases, ejaculatory disorders can aversion and female anorgasmia [2]. On the basis of
be classified by psycho-neuro-uro-endocrine symptoms. sexual anamnesis, the various disorders are relatively
Epidemiological data, new classifications and subtyping, easy to differentiate. Notes on andrological and sex-
together with new diagnostic procedures and the avail- ological history should always include information
ability of pharmacological aids, place this topic in the about the ability to ejaculate, frequency of nocturnal
mainframe of sexual medicine. This will soon demolish emission, and the ability to experience orgasm. As sexual
the barriers to seeking help perceived by patients suf- health must now be considered an essential part of
fering ejaculatory disorders. individual health, as advised by the World Health
Organisation, knowledge of the taxonomy of ejaculation
Keywords Premature ejaculation Æ Delayed disorders is the basis for the various treatment options
ejaculation Æ Retrograde ejaculation Æ Anorgasmia Æ currently available.
Medical sexology At the end of the sexual act, three distinct physio-
logical events, emission, ejaculation, and orgasm, nor-
mally develop in the male [3]. Each of these functions
may malfunction, leading to a sexual symptom with
Introduction heavy relational consequences (Table 1). Retrograde
ejaculation (RE) regards the emission phase, premature,
When sexology began as a science, impotence and delayed and absent ejaculation are symptoms of the
ejaculatory disorders were exclusively considered as ejaculatory phase and male anorgasmia affects the pos-
psychological disorders. However, recent pharmacolog- sibility of enjoying a full orgasmic experience. As these
three functions share many aspects of their neurological
control and are coordinated events, they have been
E. A. Jannini (&)
Course of Endocrinology and Medical Sexology,
grouped as ‘‘ejaculatory disorders’’ [4]. However, their
Department of Experimental Medicine, University of L’Aquila, epidemiology (Fig. 1), etiology, pathogenesis, taxono-
Coppito, Bldg. 2 Room A2/54, 67100 L’Aquila, Italy mies, diagnosis, and therapies are different.
E-mail: jannini@univaq.it
Tel.: +39-862-433530
Fax: +39-862-433523
Disorders of emission
A. Lenzi
Chair of Endocrinology,
Department of Medical Physiopathology, Emission is the coordinated contraction of smooth
1st University of Rome ‘‘La Sapienza’’, 00161 Rome, Italy, muscle cells of the male genital tract involving testicular
 69

Table 1 Taxonomy of ejaculatory disorders RE should be suspected in men with absent ejaculate or
an ejaculate of less than 1 ml. Diagnosis is confirmed by
A Emission phase disorders the detection of substantial numbers of sperm in the
1 Retrograde ejaculation urine after ejaculation.
B Ejaculation phase disorders RE can be classified as congenital, acquired or idio-
1 Premature ejaculation pathic. Various anatomic and congenital anomalies can
2 Deficient ejaculation
a Delayed occasionally cause RE [7]. Diabetic autonomic neurop-
ejaculation athy may lead to problems with emission and ejaculation
b Anejaculation [8]. The true incidence of RE is difficult to estimate. It
C Orgasm disorders ranges from 0.3 to 2% of patients attending fertility
1 Anorgasmia
2 Postorgasmic
clinics [9], but may be as high as 18% in men with
illness syndrome azoospermia [10]. Diminished or retrograde ejaculation,
as well as anejaculation, may occur in up to a third of
male subjects with diabetes [11]. Retrograde ejaculation
is more frequently associated with damage to the
innervation of the internal urethral sphincter during
prostatectomy or following retroperitoneal lymph node
dissection [12]. When a drug-induced dry ejaculation
occurs, there is usually no sperm in the urine. RE has
often been reported in association with antipsychotics
[13, 14].

Disorders of ejaculation

Ejaculation is properly defined as the expulsion of semen

from the urethra. It is a reflex response in which the
serotoninergic system at the hypothalamic level acts as a
suppressor of the ejaculatory reflex [15]. In fact, both
Fig. 1 The epidemiology of ejaculatory disorders. Homogenous serotonin reuptake inhibitors and serotonin agonists
data on the prevalence of ejaculatory disorders do not exist. Data
were obtained from different sources and are not comparable. RE determine the extension of ejaculatory latency [16, 17].
(retrogade ejaculation), data on infertile men; PE (premature
ejaculation), DE (delayed ejaculation), anejaculation and anorgas-
mia are referred to the general population Premature ejaculation

Only after reliable contraceptives became available, the

tubules, efferent ducts, epididymis, and vasa deferentia sexual and feminist revolution of the mid 1960s, and the
and the secretion of seminal fluid due to rhythmic con- ‘‘discovery’’ of the female orgasm, did PE become
tractions of the seminal vesicles and prostate. The nor- important in the cohort of symptoms connected with
mal emission process is dependent upon the anatomical male sexual performance. Previously, as sex was con-
and functional integrity of the urinary bladder neck and sidered almost exclusively only as the means for repro-
posterior urethra. Closure of the urethral sphincter duction, ejaculation before a given time was not thought
prevents retrograde flow of semen to the bladder and of as pathological. In fact, Kinsey rejected the notion
directs the flow forward. that PE is a sexual dysfunction when, in his historic
Any anatomical, traumatic, neurogenic, or drug-in- survey on human sexuality, he found that 75% of men
duced interference with the integrity of the internal ejaculated within 2 min of penetration [18].
sphincter of the urethra may favor RE, the symptom
related to the emission phase. A decrease in emission
may be due to ineffective peristaltic contractions of the Definition
vas deferens, epididymis and prostate. Patients may
complain of normal or less intense ejaculation or orgasm There is no commonly accepted definition of PE [19].
with no ejaculate [5]. Retrograde, or dry, ejaculation Depending on the study, any ejaculation occurring
occurs when there is a sensation of orgasm and con- within 1 min [20], 2 min [21], 3 min [22], or even 7 min
traction of the ischeo- and bulbo-cavernosus muscles of penetration [23] has been considered as premature.
at the basis of the penis, but no semen is ejaculated. Others specify the number of penile thrusts, considering
This is due to an incomplete closure of the bladder’s from 8–15 thrusts as a criterion for PE [24]. Both of
internal sphincter leading to back ejaculation into the these approaches are easily quantifiable and objective,
bladder (retrograde). Patients may complain of a dry but the rationale for the time of penetration or the
ejaculation followed by ‘‘white urine’’ when voiding [6]. number of strokes used as diagnostic criterion has never
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been offered. Other authors considered partner satis- Despite its very high prevalence, PE is not often a
faction: Masters and Johnson suggested that a man reason for medical or sexological consultation. In a re-
experienced PE if he was unable to delay his ejaculation cent survey of 447 men attending a London general
until his partner was sexually satisfied in at least 50% of practitioner, the prevalence of PE was only 3.7% [34].
their coital connections [25]. As most women take longer However, a comparable survey performed by German
to reach orgasm than men, the majority of men are family physicians reports the more realistic prevalence of
therefore ‘‘precocious’’. Furthermore, this definition 66% [35]. In any case, lack or loss of sexual desire [a
does not take PE in homosexual couples into account, it poorly defined condition, frequently masking erectile
defines an individual pathology on the basis of the sex- dysfunction (ED) or PE] was a much more frequent
ual responsiveness of the partner, and the 50% figure cause of seeking medical help. This is due to both cul-
chosen by the authors appears to be arbitrary. tural reasons and the erroneous belief that effective
PE has been more recently considered as the persis- pharmacological treatments for PE do not exist.
tent or recurrent inability to voluntarily delay ejacula- Data from the USA National Health and Social Life
tion [26, 27] upon or shortly after penetration or with Survey reveal a prevalence of 21% for PE in men aged
minimal sexual stimulation or as ‘‘an ejaculation from 18 to 59 [36]. Results of the international survey
occurring sooner than desired, either before or shortly (Global Study of Sexual Attitudes and Behaviors,
after penetration, causing distress to either one or both GSSAB) investigating attitudes, behaviors, beliefs and
partner’’ [28]. Both of these definitions are substantially satisfaction among 27,500 men and women aged 40–
subjective in nature, and the latter, using the partner’s 80 years showed that the average prevalence of PE is the
satisfaction as the parameter, has the same limits as same around the world: 21% [37]. However, GSSAB
Masters and Johnson’s original definition. The comment cannot be considered a true epidemiological study. Sex is
of the DSM-III-R and later editions is an intelligent so greatly characterized by culture and religion that the
reminder of the symptom’s clinical characteristics: ‘‘the same word may have totally different meanings in dif-
clinician must take into account factors that affect ferent countries. This study should be used, from an
duration of the excitement phase, such as age, novelty of epidemiological point of view, as a poll surveying peo-
the sexual partner or situation, and frequency of sexual ple’s attitudes towards sex and diseases. In addition, its
activity’’ [29]. figure of 21% does not reflect the general population of
The absence of a clear, popular and widely accepted sexually active men. In fact, the survey considers only
definition of PE allows a ‘‘patient-dependent’’ definition people in their forties or above, when the incidence of
and a ‘‘patient-decided’’ diagnosis. This is risky, because PE is thought to be much lower. When considering
diagnosis and possible therapy might be based on solely young, sexually inexperienced men (18–25 years), the
subjective parameters, which are clearly influenced by incidence probably increases by between 50 and 75%. It
culture, religion, policy, society, and media—all aspects should also be considered that older people are more
far from a medical definition. likely than the young to ask for professional help.
To overcome these problems, a simple objective Teenagers generally ask only for limited counseling
method to define PE was proposed by Waldinger in 1994 (sexually transmitted diseases, contraception). Sex is
[30]. The ‘‘intravaginal ejaculation latency time ‘‘ (IELT) always considered, even if incorrectly, to be healthy and
is the time from the start of vaginal intromission to the normal in the young.
start of intravaginal ejaculation. For research purposes, Interestingly, GSSAB shows that PE increases from
but also for clinical assessment and therapeutic moni- an incidence of 20% of men in their forties to 30% of
toring, this method could be considered the most objec- those in their sixties. This may be due to greater
tive in an evidence-based sexual medicine [31]. awareness in maturity, to a relative increase in relational
Ejaculation before intromission (ejaculatio ante portas) problems (partner’s menopause, widowed), or to the
has an IELT rating of 0. However, as determination of higher frequency of ED.
the average ejaculation time in the general population has In a selected population of 755 Italian subjects
been lacking since Kinsey’s survey [18], a clear chrono- attending an outpatient clinic for sexual dysfunction, PE
logical cut-off is not available, although it is needed to was confirmed as being age-dependent. Patients report-
develop a broad consensus on the definition of PE. ing PE were younger and showed a higher prevalence of
anxiety symptoms when compared to the rest of the
sample [38].
Epidemiology The prevalence of PE does not appear geographically
homogeneous [39]. This can be explained by considering
Early ejaculation or PE is a frequent sexual complaint, cultural, religious, and political as well as organic fac-
probably the most common, affecting from 5 to 40% of tors. PE is most frequently (29.1%) reported by men in
sexually active men depending on age [32, 33]. It is East Asia (China, Indonesia, Japan, Korea, Malaysia).
widespread in adolescents, young adults, and other There are cultural reasons for this. In East Asia, the
sexually naive males. For this reason, not all authors sexual importance of the female orgasm has traditionally
agree to classify PE as pathological in youth or during been high: this is the region of the Kamasutra and
early sexual experiences. Tantra. Premature ejaculation is also frequently per-
 71

ceived as a great problem where ejaculation is identified if commonly used, is overtly inappropriate in the clas-
in the Yang male vital principle. However, organic evi- sification of sexual dysfunction. In agreement, we added
dence can be drawn from the fact that these countries that, irrespective of the ultimate cause, all sexual dys-
are characterized by a lower frequency of sex (at least functions are per se stressful and a source of psycho-
one sexual intercourse per week: Japan: 21%, China: logical disturbances [4, 54] even if some men and couples
32% vs 74% in Italy). It is well know that low ejacula- can accommodate their sexual problems. All cases of PE
tion frequency can exacerbate PE [40, 41]. are thus or become psychogenic and capable of pro-
In non-European, highly-civilized western countries, voking a psycho-relational imbalance. While it is clear
such as the USA and Canada, the prevalence of PE is that all behavioral dysfunctions may negatively influence
only two points lower (27%). Historical evidence sug- organic processes (psycho-somatic evidence), it is also
gests that the reason for this may be that the feminist plain that a disease or a symptom of the body may affect
and sexual revolutions in the 1960s were particularly behavior (somato-psychic evidence). Body-mind cross-
effective in changing the sexual behavior of these socie- talk is particularly important in sexual behavior in
ties. general, and particularly in ejaculatory control. In sex-
The lowest prevalence of PE was reported in Middle ual medicine, diagnosis should be the search for possible
Eastern/African countries (Algeria, Egypt, Morocco, causes of sexual symptoms, in order to provide, when
South Africa, Turkey) (17.3%). In this case too, socio- possible, an etiological therapy, but should never re-
psychological causes may explain the finding. These are spond to the classic dichotomy organic/psychogenic.
male-dominant societies, where female sexuality is tra- This dichotomy does not exist in reality. It was created
ditionally neglected. For this reason, in the Muslim pre- to provide clients for psychosexologists, at a time when
western societies that are patriarchal, with low female sexual medicine was far from its current evidence-based
social impact, PE may not be perceived as a disease, but, capabilities. It is also dangerous to label a patient as
at least in some cases, as a manifestation of virility. ‘‘psychogenic’’ (=crazy, in his perception). In addition,
The European prevalence of PE is in between the two as there is not yet a test (psychometric, instrumental,
extremes. This is the world’s most representative region, biochemical, etc) to demonstrate that a given case of PE
demonstrating a good balance between female social is psychogenic in nature, the term ‘‘psycho-genic’’
requirements, religious beliefs, awareness of sexual dys- (=generated by the mind) must be considered simply as
functions, willingness to admit sexual failure, hope of a hypothesis. Finally, it cannot be ‘‘diagnosed by
obtaining professional help. No differences in PE prev- exclusion’’, or ‘‘by subtraction’’, as frequently and
alence are seen when comparing protestant, northern acritically postulated: in the absence of a clear organic
countries (20.7%) with catholic, southern countries dysfunction, psychogenic dysfunction is inferred. In fact,
(21.5%). In a study of 110 consecutively enrolled Dutch there is no proof that we know all the physiopatholog-
men with lifelong PE, 80% ejaculated within 30 s, 10% ical processes controlling ejaculation.
between 30 and 60 s, and 10% ejaculated between 1 and For all of these reasons, we suggest that PE should be
2 min [42]. Interestingly, these IELTs were independent classified as organic (with a known, prevalent physical
of age and duration of the relationship. Other, different etiology) or non-organic or, better, idiopathic (with
patient populations need to be investigated with the unknown cause). In the latter group, social, cultural,
IELT-stopwatch method to show if there are cultural psychological, and relational factors may play a role as a
differences connected with this complaint. cause or a consequence of the sexual symptom (Table 2).
In both forms, PE is always accompanied by profound
psychological involvement with a strong emotional and
Classification interpersonal impact, which should be taken into ac-
count during therapy.
PE, along with ED, hypoactive sexual desire, or dyspa- Psychological processes should now be thought of as
reunia is a symptom rather than a disease. In fact, it inextricably bound with the organic ejaculation function
occurs as a central (imbalance of serotoninergic neuro- and dysfunction processes. This holistic approach allows
transmission [1]) or peripheral (short frenum of prepuce, PE to be considered as a psycho-neuro-uro-endocrine
penile hypersensitivity and reflex hyperexcitability [24, disorder affecting the couple.
43, 44, 45]) neurobiological disorder, as an uro-genital
pathology [prostatitis: 46, 47, 48, 49], and as a symptom Subtyping
of thyroid hyperfunction [38, 50]. PE is usually classified
on the basis of its etiology into organic and psychogenic. In clinically placing a patient with PE, it is essential that
Furthermore, important efforts have been performed to the spatiotemporal modalities of the symptom’s
further differentiate psychological pathogeneses of sex- appearance are identified, as well as its comorbidity with
ual symptoms (actual-neurotic, psychoneurotic, psy- other sexual dysfunctions (Table 2). It is clear that PE is
chosomatic, and functional) [51]. However, even if the not a unique clinical entity, and it must therefore be
evidence that the brain and its function is the first sexual subtyped [55]. The simplest way to subclassify PE is to
organ cannot be denied, in his meritorious work Sachs consider whether the symptom begins when a male first
[52, 53] has argued that the adjective psychogenic, even becomes sexually active (primary, lifelong), or occurs
72

Table 2 Taxonomy of
premature ejaculation. * Note A Cause*
that the causes can be con- 1 Organic
causes (or co-morbidities), or, a Neurobiological
in the case of some b Urological
psychorelational factors, c Endocrine
consequences of PE d Pharmacological
2 Non-organic (idiopathic)
a Functional (experiences, education)
b Constitutive (psychological constitution)
c Stress-induced (acute or chronic)
d Psychosexual skill deficit
B) Onset
1. Primary (lifelong)
2. Acquired (after a period of normal ejaculatory control)
C Time
1 Ante portas (before penetration)
2 Intra moenia (during penetration)
D Type
1 Absolute (irrespective of partners or context, generalized)
2 Relative (to a partner or a context, situational)
E Co-morbidities
1 Simple (in absence of other sexual symptoms)
2 Complicated (in presence of other sexual symptoms)
a With erectile dysfunction
b Due to erectile dysfunction

after a period of normal ejaculatory control (acquired). sexual life. A continuing problem with deficient ejacu-
PE can be absolute (irrespective of partners or context, lation is usually taken personally by the partner, who
generalized) or relative (to a partner and/or context, begins to feel less attractive, sexy, and sexually adequate.
situational). Ejaculation may take place before pene- Marital stress, sexual dissatisfaction, inhibited sexual
tration (ante portas) or suddenly during coitus (intra desire, and avoidance of sexual contact may result if the
moenia). It can be found in the absence (simple) or symptom is not addressed and remedied.
presence (complicated) of other sexual symptoms. In the
majority of cases, PE is the only complaint presented.
However, the possibility of coexistence with other sexual Ejaculatory insufficiency
problems should always be investigated. Hypoactive Delayed ejaculation (DE), or ejaculatory insufficiency, is
sexual desire may lead to PE, due to an unconscious an inhibition of the ejaculatory reflex, with absent or
desire to abbreviate the unwanted penetration. Addi- reduced seminal emission and impaired ejaculatory
tionally, reduced time to ejaculation is a common early contractions, possibly with reduced or absent orgasm.
manifestation of ED, or may occur with an unstable Estimates of DE incidence range from 1–4% of sexually
erection due to fluctuation in penile blood flow. In this active men. Men with DE may be able to ejaculate with
case, the subject may ejaculate early to hide the weak- great effort and after a prolonged intercourse (30–
ness of the erection. This possibility should be taken into 45 min), or are unable to ejaculate in some circum-
account when evaluating patients with PE. The lack of stances. The symptom can occur both during intercourse
ejaculatory control may generate reactive hypoactive and with manual stimulation in the presence or absence
sexual desire, as well as impotence due to anxiety arising of a partner (relative or absolute DE, respectively). If
from poor sexual performance. These complications ejaculation is totally absent, the condition is called male
must be evaluated when subtyping and diagnosing PE. anorgasmia (see above). Even though it has been con-
But, it is important to bear in mind that subtyping does sidered a psychorelational symptom, DE is often asso-
not mean diagnosing: acquired, situational PE ante ciated with drug therapy [56, 57, 58, 59], with infection/
portas can be due to organic factors in the same way as inflammation of the prostate and seminal vesicles or
primary absolute PE. Sexual anamnesis is important to with painful ejaculation.
evaluate the patient, but not to decide his diagnostic
label.
Impotentia ejaculationis

Deficient ejaculation The condition of a man who has never ejaculated

through any form of stimulation, such as ‘‘wet dreams’’,
Even though much rarer than PE, the delay in or masturbation, or coitus (primary or complete anejacu-
impossibility of reaching ejaculation and/or orgasm is a lation, or impotentia ejaculationis), occurs in 0.14% of
clinical symptom which may seriously impair a couple’s the general population, according to Kinsey [18], and in
 73

less than 2% of cases of male infertility [60]. However, in organic forms must be cured by the physician. Not only
a group of 486 patients with disturbed sexual potency, is division into these mutually exclusive groups inap-
anejaculation occurred in 15% of cases [61]. These pa- propriate in most cases, it is also based on inadequate
tients originated from differing social and intellectual grounds. The consequence is that the most frequent
levels, but a feature common to them all was a strict sexual dysfunction, despite the fact that it can be suc-
upbringing. Other psychological factors underlying this cessfully treated with drugs, is currently under-diag-
condition are poorly defined. In fact, psychosexual nosed and under-treated. However, it is now clear that
counseling and/or psychotherapy are not as effective as ejaculatory disorders are symptoms of many physical
in other types of non-organic sexual dysfunction. Ane- diseases which need medical diagnosis. Conversely, the
jaculation, in contrast to DE, appears to be mainly use of a ‘‘pill’’ without a holistic approach which takes
caused by organic etiologies: it is usually associated with account of both the patient’s personal and interpersonal
spinal cord injury, diabetes mellitus, myelitis, or multiple sexual history and the profound impact that medical
sclerosis, with the first being the most common cause treatment may have on the couple is reductive and often
[62]. Approximately 90% of men with a spinal cord in- unsuccessful [69].
jury are in fact unable to ejaculate during sexual inter-
course [63]. Iatrogenic causes are retroperitoneal lymph Acknowledgements We are indebted to Mss. Marie-Hélène Hayles
node dissection and the use of certain drugs. and Rosaria Caruso for help with the English. Our compliments
and gratitude to Paola Minelli and Sabrina Luccarini for the sec-
It is important not to confuse the classification of retarial work. This paper has been partially supported by the
anejaculation with that of RE. In the latter, orgasm is Italian Ministry of Education grants.
usually present, even if blunted, while anejaculation al-
ways coincides with anorgasmia (even if the reverse is
not true). References

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