This is what's actually going on when a man can't orgasm

“I am a 40-year-old man and at times I have trouble ejaculating. I seem to build up to the point of ejaculation, but then it subsides, and yet I remain erect. I masturbate once in a while and actually ejaculate,” James narrates when he visits the sexology clinic. 

James is worried because at the age of 40, he is yet to get married and pressure is building up for him to settle down in marriage.  

“People cannot understand why, despite having a good job, a house, and a car, I’m not married. I fear disclosing the issue to my parents or siblings,” he confides.

“They think I am irresponsible, that I do not want to bear the responsibility of being a husband and a father,” he laments, “I feel like I am sliding into depression, I can no longer think straight, I can’t sleep, I am very disturbed.” 

James has had three girlfriends before and each of them dumped him because he could not finish the job. 

“After almost one hour of trying to orgasm, they get tired and frustrated,” James says, “one told me that at some point she felt the thing had turned into a rape, the pleasure was gone and the mechanical rubbing was becoming painful.”

James’ problem is medically called delayed ejaculation. It is estimated that millions of men across the globe have the problem but do not seek treatment. In many cases, they are men who started off with normal sex when they were young but somewhere along the way it became difficult to ejaculate. A fewer number, like James, suffer the problem right from the time they start being intimate. 

“You know people talk of witchcraft and sometimes it crosses my mind that someone could have bewitched me,” James says.

In reality, however, delayed ejaculation is just another sexual dysfunction and it has many causes. Any disease or accident that damages nerves and blood vessels in the lower back or inside the pelvis can cause delayed ejaculation. Road traffic accidents, diabetes, and some inherited nerve diseases can cause the problem.

In some cases, delayed ejaculation is caused by medicines that are taken for other disease. These could be blood pressure, psychiatric, prostate or drugs for any other chronic ailments.

Then there are problems relating to hormones. Testosterone, the hormone that gives the male stamina, can be the cause when there is a deficiency. Others include thyroid hormones and another one called prolactin.

There are also cases where the anxiety and depression that accompany sex problems exacerbate the dysfunction. Like with any other sex problem, psychological distress that, in the first place, is caused by the sex failure, only work to worsen the problem.

An interesting cause of delayed ejaculation is relationship problems. There are cases where a man will fail to ejaculate with one partner. This is called situational DE. It shows that there are subconscious unresolved issues in the relationship. The generalised type of DE is where it happens with any partner. 

“All that is well-understood doctor but for me I just need treatment and it is urgent,” James says. I nodded with understanding. Getting to understand the background was however important for James so as relate the treatment design to the problem.

Because of the myriad causes of DE, the first step in managing it is a thorough medical evaluation. I, therefore, subject James to a detailed medical history, physical examination, and a number of laboratory tests.

As fate would have it, however, we could not identify the cause of the problem. Whatever the case, I booked James for therapy. From experience, any man with DE needs therapy. Secondly, I advised him to get into a relationship at an appropriate time. Once in a relationship we would put him on medicines that stimulate ejaculation. In a number of cases, the problem remains resolved after a few months of drug-induced ejaculation. 

At the same time, James would have to wean himself off masturbation over time so that he concentrates on his partner. Sometimes combining both makes it difficult to resolve DE. 

“Which woman would want to knowingly marry a man who cannot ejaculate? You must be joking doctor,” James responded to my treatment plan.

“That is why for a start you will be on medicine to aid the ejaculation,” I explained. 

And with that James stood to leave the consultation room. He requested to first go reflect on the advice, he was unsure it would work. Long-term sexual problems cause some level of hopelessness and it is normal for patients to seek care but then not trust that the solution offered would help. Fortunately, many come back to the clinic to try out the treatments.