Another medical condition. The major differential diagnosis is between delayed ejacu- lation fully explained by another medical illness or injury and delayed ejaculation with a psychogenic, idiopathic, or combined psychological and medical etiology. A situational aspect to the complaint is suggestive of a psychological basis for the problem (e.g., men who can ejaculate during sexual activity with one sex but not the other; men who can ejac— ulate with one partner but not another of the same sex; men with paraphilic arousal pat— terns; men who require highly ritualized activity to ejaculate during partnered sexual activity). Another medical illness or injury may produce delays in ejaculation independent of psychological issues. For example, inability to ejaculate can be caused by interruption of the nerve supply to the genitals, such as can occur after traumatic surgical injury to the lumbar sympathetic ganglia, abdominoperitoneal surgery, or lumbar sympathectomy.
Ejaculation is thought to be under autonomic nervous system control involving the hypo- gastric (sympathetic) and pudendal (parasympathetic) nerves. A number of neurodegen- erative diseases, such as multiple sclerosis and diabetic and alcoholic neuropathy, can cause inability to ejaculate. Delayed ejaculation should also be differentiated from retro— grade ejaculation (i.e., ejaculation into the bladder), which may follow transurethral pros- tatic resection.
Substance/medication use. A number of pharmacological agents, such as antidepres- sants, antipsychotics, alpha sympathetic drugs, and opioid drugs, can cause ejaculatory problems.
Dysfunction with orgasm. It is important in the history to ascertain whether the com- plaint concerns delayed ejaculation or the sensation of orgasm, or both. Ejaculation occurs in the genitals, whereas the experience of orgasm is believed to be primarily subjective.
Ejaculation and orgasm usually occur together but not always. For example, a man with a normal ejaculatory pattern may complain of decreased pleasure (i.e., anhedonic ejacula- tion). Such a complaint would not be coded as delayed ejaculation but could be coded as other specified sexual dysfunction or unspecified sexual dysfunction.
There is some evidence to suggest that delayed ejaculation may be more common in severe forms of major depressive disorder.
Diagnostic Criteria 302.72 (F52.21)
A. At least one of the three following symptoms must be experienced on almost all or all (approximately 75%—100%) occasions of sexual activity (in identified situational con- texts or, if generalized, in all contexts): 1. Marked difficulty in obtaining an erection during sexual activity.
2. Marked difficulty in maintaining an erection until the completion of sexual activity.
3. Marked decrease in erectile rigidity.
B. The symptoms in Criterion A have persisted for a minimum duration of approximately 6 months.
C. The symptoms in Criterion A cause clinically significant distress in the individual.
D. The sexual dysfunction is not better explained by a nonsexual mental disorder or as a consequence of severe relationship distress or other significant stressors and is not at- tributable to the effects of a substance/medication or another medical condition.
Specify whether:
Lifelong: The disturbance has been present since the individual became sexually ac- tive.
Acquired: The disturbance began after a period of relatively normal sexual function.
Specify whether:
Generalized: Not limited to certain types of stimulation, situations, or partners.
Situational: Only occurs with certain types of stimulation, situations, or partners.
Specify current severity:
Mild: Evidence of mild distress over the symptoms in Criterion A.
Moderate: Evidence of moderate distress over the symptoms in Criterion A.
Severe: Evidence of severe or extreme distress over the symptoms in Criterion A.