Delayed Ejaculation in a Man and Premature Orgasm in a Woman: 2 Cases With a Common Suspect

^aDepartment of Sexual Medicine, IQRAA Center for Sexual Medicine, Kozhikkode, Kerala, India
^bDepartment of Psychiatry, IQRAA International Hospital and Research Centre, Kozhikkode, Kerala, India
^cDepartment of Gynecology, IQRAA International Hospital and Research Centre, Kozhikkode, Kerala, India
*Corresponding author: Bishurul Hafi, MD, DNB, Department of Sexual Medicine, IQRAA Center for Sexual Medicine, Kozhikkode, Kerala 673009 India (bishuru@gmail.com).

Prim Care Companion CNS Disord 2021;23(2):20l02746

To cite: Hafi B, Uvais NA, Rabeeh V, et al. Delayed ejaculation in a man and premature orgasm in a woman: 2 cases with a common suspect. Prim Care Companion CNS Disord. 2021;23(2):20l02746.
To share: https://doi.org/10.4088/PCC.20l02746

© Copyright 2021 Physicians Postgraduate Press, Inc.

Delayed ejaculation is a rare form of male sexual dysfunction characterized by marked delay in ejaculation contrary to the patient’s wish, causing serious frustration in the relationship.¹ Delayed ejaculation is poorly defined, and understanding of its pathophysiology is incomplete and not supported by good evidence-based data. Unlike premature ejaculation, no large-scale population studies or experimental research have been conducted yet with regard to delayed ejaculation.

Premature orgasm in women is an extremely rare female sexual dysfunction that is seldom studied due to the low prevalence. Physiologically, premature orgasm is not a concern of women because of the capability of multiple orgasms. However, although the prevalence of this diagnosis in hospital-based studies will be very low, a population-based study² revealed that 40% of respondents reached orgasm faster than intended. For about 3% of the women, the problem was chronic and bothersome.²

Here, we describe a case of delayed ejaculation and a case of premature orgasm, both of which are seldom reported in our region and context.

Case 1

A 35-year-old man who works abroad presented with the complaint of delayed ejaculation during intercourse. He was married for a month and involved in sexual activities daily. His complaint was that he could reach orgasm and ejaculation only once during this period, even after penovaginal intercourse for 30 minutes. He would become tired, and loss of erection would subsequently occur. He was currently with his first sexual partner, but had started masturbating at 16 years of age. The frequency of masturbation increased with age and peaked when he went abroad for work. For the last few years, he was masturbating daily or more. He never had difficulty in reaching orgasm or ejaculating semen during solo practice. Even after marriage, he masturbated occasionally and ejaculated in satisfactory time. There were no physical or psychological comorbidities. His routine blood investigations and hormone profiles were within normal limits. Radiologic examination with ultrasound revealed no abnormalities. He was taught the basics of male sexual response and the importance of stimulation and arousal. He was advised to combine solo stimulation during partnered sexual activities. He started stimulating himself before and during penovaginal penetration according to the need. He could reach orgasm and ejaculate within the preferred time by this simple behavioral modification.

Case 2

A young couple married for 3 years with a 9-month-old child presented to the sexual medicine outpatient department. The husband accused his wife of being selfish and not cooperating during sex after a few minutes of intercourse. She did not allow him to penetrate even once after delivery. While interviewing the wife separately, she confessed that her husband’s allegation was factually true. She expressed her helplessness with regard to prolonged intercourse. She used to reach orgasm during the initial part of the foreplay with slight clitoral stimulation. Following that, she used to lose interest and enter into a refractory period. It would take hours for her to be ready for the next sexual activity. During detailed history taking, it was revealed that although she had no premarital partnered sexual activities, she used to masturbate regularly since 18 years of age. She explained her masturbation as clitoral stimulation without vaginal insertion aided by visual stimulation. She was satisfied in her sexual life even now since clitoral stimulation was the core activity arousing her. Further discussion about her concepts of female sexuality revealed that she was ignorant about the multiple orgasmic potential of women. She revealed a fear of conceiving again with unprotected intercourse and reported dyspareunia while using a condom. She had no physical or psychological comorbidities. Results of routine blood tests, hormone profiles, and ultrasound examination were within normal limits. The context of her issues was explained to the husband, which relieved his frustration. She was educated on the various methods of contraception, of which she chose an oral hormonal method, as well as on female sexual responses and orgasmic potentials. They were advised to engage in liberal use of lubricants, intercourse coupled with other forms of foreplay, and delayed clitoral stimulation post ejaculation. At the next visit, they reported high satisfaction with their sexual life.

Discussion

Masturbation is considered a healthy expression of human sexuality in both sexes. But, the practice remained controversial until the last few decades. In many cultures, mostly religiously driven, sexual self-exploration through masturbation is considered as shameful and problematic. But, it is undeniable that even in those cultures, for the vast majority of human beings, masturbation may be the first sexual experience.³ It can help the person to safely explore and  understand orgasmic pleasure. Studies⁴ have revealed that masturbation has significant influence on body image and vice versa. It has been reported that women with a history of masturbation and noncoital orgasmic responsiveness had higher levels of sexual subjectivity and felt more entitled to sexual pleasure through masturbation, felt more efficacious in achieving pleasure, and reflected more on the sexual aspects of their lives than those who had never experienced a noncoital orgasm.⁵ Further, these women were more expressive in their intimate relationships and more resistant to gendered double standards.⁵ However, a recent study⁶ showed that higher frequency of masturbation in women was related to lower satisfaction with their partner, greater importance of sex, and higher levels of general anxiety/depression.

Orgasm obtained through masturbation is found to be physiologically more intense. The functionality of the circulatory, neural, and muscular systems of the male and female genitalia are maintained by arousal and orgasm (maintenance functions) both in the conscious state and when asleep.⁷ In the male, ejaculations keep sperm morphology and semen volume within normal ranges while leukocyte numbers are increased. Hence, for males without a partner for a physical relationship, masturbation can be a useful practice to maintain health of the reproductive system. However, masturbation is not an absolutely harmless alternative to partnered sex, as shown in a review⁸ of relative health benefits of different sexual activities. It was found that masturbation and anal intercourse were inversely related with psychological and physiologic health indices.⁸ In a Swedish study⁹ of a large representative sample, masturbation was found to have an inverse association with mental health satisfaction in the multivariate analyses that controlled for other sexual behavior frequencies, and partnered sexual behaviors other than penovaginal intercourse were uncorrelated with mental health satisfaction. In a small study¹⁰ of Portuguese women using Perceived Relationship Quality Components Inventory dimensions of satisfaction, intimacy, trust, passion, and love, masturbation frequency was inversely related with love. Another study¹¹ found masturbation to be an independent predictor of use of immature defenses. Higher masturbation frequency (or even the desire for more masturbation) was found to be associated with depression and unhappiness.^12,13 In an analytic study¹⁴ from Iran, children with masturbatory habits were seen to be associated more with oppositional defiant disorder, conduct disorder, some anxiety disorders, motor tics, and other stereotypical behavior. Moreover, there are multiple reports^15,16 suggesting harmful and protective effects of frequency of masturbation with relation to prostate cancer in young men and men in their 50s, respectively.

Perelman and Rowland^17,18 identified 3 factors that disproportionately characterized patients with delayed ejaculation: (1) high-frequency masturbation (age-dependent mean of greater than 3 times per week), (2) idiosyncratic masturbatory style (masturbation technique not easily duplicated by the partner’s hand, mouth, or vagina), and (3) disparity between the reality of sex with a partner and their preferred masturbatory fantasy. Identification of these factors has led to development of a new theory that people with unusual masturbation patterns and fantasy life are more prone to develop delayed ejaculation. Although multiple other psychological and organic factors have been found to be related to the etiopathogenesis of delayed ejaculation, the role of masturbation is clear.¹

Premature orgasm can be caused by attachment of exaggerated importance to sexuality, having sex with feelings of shame, sin or prohibition in unfavorable environments, fear of getting caught or being heard, negative thoughts learned from the family, strict moral codes, lack of sufficient knowledge or experience, and inability to manage extreme sexual arousal and sexual stimulation.¹⁹ In males, masturbation exercises can be tried to help master orgasmic control. But, the reverse scenario was seen in our case and was a result of inexperience and a lack of proper sexuality education.

Conclusion

Human sexuality is a complex process in which orgasm is still under defined. Just as ideas of normative factors about orgasm are still vague, abnormalities in this are largely subjective and perception related. A comprehensive sexuality education focusing on pleasure aspects and promoting a healthy sexual lifestyle will prevent missed concepts and related disorders.

Published online: April 15, 2021.
Potential conflicts of interest: None.
Funding/support: None.
Patient consent: Consent was received from the patients to publish the case reports, and information has been de-identified to protect anonymity.