Definition

In DSM-IV, male orgasmic disorder (formerly called inhibited male orgasm) is defined as persistent or recurrent delay in, or absence of, orgasm following a normal sexual excitement phase during sexual activity that the clinician, taking into account the person’s age, judges to be adequate in focus, intensity, and duration. The DSM-IV criteria for male orgasmic disorder are presented in

Table 66-2. Although there is some subjective judgment involved in just what length of time is required to constitute delayed orgasm, most men with this disorder who are seen in clinical practice complain of the absence of rather than delay in orgasm.

Diagnostic Issues

The majority of men who seek treatment for inhibited orgasm show a pattern of situational, rather than global, inability to reach orgasm. Perhaps the most common syndrome is when the man can reach orgasm in his own masturbation, or during manual or oral stimulation by his partner, but cannot have orgasm intravaginally during intercourse. Other men complain of being able to reach orgasm only occasionally. Often, these are older men who are having sex quite frequently. This type of case is best not treated, but the patient is simply given reassurance that orgasm need not occur every time he makes love. An explanation of normal aging changes in sexual response will often deal with the concerns of this type of patient.

Nearly all men who suffer from inhibited orgasm have a history of previously being able to reach orgasm normally. Lifelong inhibited orgasm is quite rare.

In the majority of men, male orgasmic disorder is actually secondary to another sexual problem. The most common presentation is the man with hypoactive sexual desire and inhibited orgasm. These men typically are having sex in response to coercion from their partners. If a man really does not want to have sex, and is doing so only in response to pressure from a partner, he may not become aroused enough to reach orgasm, even though he is able to maintain an erection. A man with this symptom pattern should not be treated for male orgasmic disorder, as treatment will usually fail. Instead, treatment should focus on his hypoactive sexual desire or the relationship conflict. Similarly, a man whose inability to reach orgasm coexists with erectile failure should be treated for the erection problem; orgasmic function usually returns when the erectile problem is resolved.

Another major diagnostic issue concerns possible physiological and pharmacological etiology of male inhibited orgasm. In contrast to premature ejaculation, there is abundant empirical evidence that a large number of medical conditions and medications cause inhibited male orgasms (Bancroft 1989; Buffum 1992; Kedia 1983; Segraves and Segraves 1993). In our clinical experience, most men complaining of inhibited orgasms have a medication-induced orgasmic delay. Although the DSM-IV criteria would exclude men with medication or medical causes of inhibited orgasm from receiving this diagnosis, strict application of the criteria would exclude nearly all men who currently present for treatment with this problem. A combination of psychotherapeutic and psychopharmacological procedures frequently provides good results with these medically compromised patients.

Prevalence

Population studies reveal that male orgasmic disorder is by far the rarest male dysfunction. Epidemiological studies have found prevalence rates varying from 0% to 10%, with results from most studies clustering near the lower end of this range (Bancroft 1989; Dekker 1993; Spector and Carey 1990). The majority of men with inhibited ejaculation who are identified in these studies of the general population probably suffer from a medical condition or are taking a medication that produces this side effect and would be excluded from DSM-IV classification on this basis (Dekker 1993). Among men seeking treatment at sex therapy clinics, various investigators (Bancroft 1989; Dekker 1993; Spector and Carey 1990) have found inhibited orgasm to occur in 0% to 13% of patients. Failure to exclude inhibited orgasm secondary to hypoactive sexual desire probably accounts for the higher figures found in some studies (e.g., Dekker 1993).

Etiology

Psychological causes of inhibited orgasm are thought to be similar to those for erectile failure. The concepts of performance anxiety and the spectator role have been stressed in the sex therapy literature. In this formulation, once a man begins to focus on trying to reach orgasm, he stops being an aroused participant in his sexual activity and instead becomes an unaroused, self-critical observer. Dekker (1993) also suggested that men who do not reach orgasm have distressed marriages or high levels of anxiety and hostility, but these relationships have not been consistently found.

A number of physiological conditions inhibit orgasm. Low testosterone levels or elevated prolactin levels can interfere with orgasm. Any neurological disease that reduces peripheral sensation or impairs functioning of the sympathetic nervous system, along with injuries to the spinal cord itself, can cause orgasmic difficulties (Segraves and Segraves 1993). Similarly, one aspect of the postconcussion syndrome may be an inability to reach orgasm (Kosteljanetz et al. 1981). Men with mild neurological conditions may lose the ability to have orgasm while maintaining erectile function, as the orgasm reflex seems to be more fragile than the erection reflex. Inhibited orgasm is also seen following surgical interventions (e.g., sympathectomy, retroperitoneal lymphadenectomy, abdominoperitoneal or anterior resection of the rectum, aortoiliac reconstruction, surgical procedures for bladder cancer). Although transurethral prostatectomy produces retrograde ejaculation in most patients, orgasm itself is not inhibited (Segraves and Segraves 1993).

As was previously discussed regarding premature ejaculation, pharmacological agents that are sedating, inhibit sympathetic arousal, or raise serotonin levels markedly inhibit and may totally prevent orgasm in men. These agents include alcohol, antihypertensives, antidepressants, and antianxiety and antipsychotic medications (Bancroft 1989; Buffum 1992; Nitenson and Cole 1993; Segraves and Segraves 1993). Investigators in double-blind, placebo-controlled studies have not established definitive rates of interference with orgasm for the pharmacological agents noted to have this effect; however, a listing of pharmacological agents with the potential to interfere with orgasm is provided in

Table 66-3.

In summary, research evidence suggests that a careful assessment of medical and medication status is very important in understanding the cause of inhibited male orgasms. In the relatively uncommon absence of any such factors, performance anxiety appears to be the major psychological issue involved in inhibited orgasm.