The GP Guide: How to diagnose and treat ejaculatory disorders

8 min

Ejaculatory disorders result from a disrupted mechanism of ejaculation — emission, ejaculation or orgasm.

The most common ejaculatory disorder is premature ejaculation1 but problems with ejaculation also include delayed ejaculation, anorgasmia, retrograde ejaculation, anejaculation and painful ejaculation. 

This article guides GPs on how to diagnose and treat these ejaculatory disorders, and when to refer to a specialist.  

What causes premature ejaculation and other ejaculatory disorders? 

The causes of ejaculatory dysfunction are numerous and multifactorial. They include psychogenic, congenital, anatomic, neurogenic and endocrinological causes, infection, and medications (antihypertensive, psychiatric (SSRIs), α-blocker). 

What is the GP’s role in diagnosing and managing ejaculatory disorders? 

GPs are typically the first point of contact for men with a disorder of ejaculation and they play a role in diagnosis, treatment and referral. GPs should also offer brief counselling and education as part of routine management.

Patients may find it uncomfortable or embarrassing to bring up ejaculation issues with their doctor.

GPs can make it easier by approaching the topic with patients directly, for example, “Many men experience sexual difficulties. If you have any difficulties, I am happy to discuss them.”

What is premature ejaculation?

Premature ejaculation (PE) is ejaculation that occurs sooner than desired.

How to diagnose premature ejaculation

PE is a self-reported diagnosis and can be based on sexual history alone. But it’s useful to assess medical, psychological and physical factors to determine what is causing PE. 

How to treat premature ejaculation 

The underlying cause guides the management of PE. Treatment decision-making for PE should consider aetiology, patient needs and preferences, the impact of the disorder on the patient and his partner, and whether fertility is an issue.

Treatment options for premature ejaculation

Patients may find these techniques difficult to maintain long-term.

Oral pharmacotherapy

For common SSRI dosing regimes, see our clinical summary guide.

A side-effect of some selective serotonin reuptake inhibitors (SSRIs) and tricyclic antidepressants is delayed ejaculation, so they are commonly prescribed for PE. Except for dapoxetine hydrochloride, all other SSRIs are used off-label for treating PE. 

PDE-5 inhibitors are used as treatment if PE is related to ED.

For all drug treatments, GPs should start low and titrate slow. Trial for three to six months and then slowly titrate down to cessation. If PE reoccurs, trial the drug again. If one drug is not effective, trial another.

Reducing penile sensation

These therapies can be used in combination.

Treating primary premature ejaculation 

For primary PE, most men require ongoing treatment to maintain normal function. First-line treatments are SSRIs and reducing penile sensation. Behavioural techniques and/or psychosexual counselling can be used as second-line treatments. 

Treating secondary premature ejaculation 

Many men return to normal function following treatment for secondary PE. 

Behavioural techniques and/or counselling are the initial treatments. But if PE is secondary to ED, manage the primary cause first.  

SSRIs, reducing penile sensation and/or PDE5 inhibitors are second-line treatments. 

When to refer to a specialist

For a general assessment, refer to a GP, endocrinologist or urologist who has an interest in sexual medicine.

How to treat other ejaculatory disorders

Delayed ejaculation

Delayed ejaculation occurs when an ‘abnormal’ or ‘excessive’ amount of stimulation is required to achieve orgasm with ejaculation. It often occurs with concomitant illness and is also associated with ageing.

Delayed ejaculation can have a psychosexual cause, for example, if there is an idiosyncratic masturbatory style.

Anorgasmia (no orgasm)

Anorgasmia is the inability to reach orgasm. The cause is usually psychological. Some men experience nocturnal or spontaneous ejaculation.

Retrograde “dry” ejaculation (orgasm with no ejaculation)

Retrograde ejaculation occurs when semen passes backwards through the bladder neck into the bladder.

Little or no semen is discharged from the penis during ejaculation and men experience a normal or decreased orgasmic sensation.

Causes include prostate surgery and diabetes. The first urination after sex looks cloudy as semen mixes into the urine.


Anejaculation is the complete absence of ejaculation, due to a failure of semen emission from the prostate and seminal ducts into the urethra. It is usually associated with normal orgasmic sensation.

Painful ejaculation

Painful ejaculation is an acquired condition where painful sensations are felt in the perineum or urethra and urethral meatus.

There are multiple causes including ejaculatory duct obstruction, post-prostatitis, urethritis and autonomic nerve dysfunction.


Delayed ejaculation
Health practitioners
Painful ejaculation
Premature ejaculation
Retrograde ejaculation

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