Ejaculation/Orgasm Disorders

Three disorders of ejaculation/orgasm are most common in primary care: Premature

Ejaculation [PE], Delayed Ejaculation/ Orgasm [DE/O], and Retrograde Ejaculation

[RE]. Three others are found infrequently: Anejaculation, Painful Ejaculation, and

Anorgasmic Ejaculation. The six conditions are discussed in order of frequency.


Premature Ejaculation

Time and time again premature ejaculators of many years’ standing not only lose confidence in their

own sexual performance but also, unable to respond positively while questioning their own masculinity,

terminate their sexual functioning with secondary impotence. This stage of functional involution is, of

course, the crowning blow to husband and wife as individuals and usually to the marital relationship.

Masters & Johnson, 19701


The Problem

A couple in their late 20s and married for three years was concerned about the

man’s ejaculation. For religious reasons, they had not attempted intercourse before

marriage. Since they were married, he regularly ejaculated before attempts at vaginal

entry. As a result, their union had not been “consummated.” Her sexual desire

diminished considerably over the three years of their marriage. Apart from embarrassment

and diminished sexual pleasure that they both experienced, they wanted

to have children and for her to become pregnant in the “natural way.” Ejaculating

quickly was not a new problem for him. Since the first time he attempted intercourse

at the age of 14, he was unable to accomplish vaginal entry except on one

occasion, and, then, he ejaculated in a matter of seconds. Since the “squeeze technique”

described by Masters & Johnson1 was tried and found not helpful, the couple

felt desperate and anticipated separation and divorce if another way to help them

could not be found.


A couple in their mid-50s and married for 25 years was seen because of erectile and

ejaculation problems. Sexual difficulties began about five years before and were

gradually becoming worse. The husband was aware of the association between

sexual dysfunctions and diabetes (a disease with which he lived in the previous 20

years) but until recently had not volunteered information to his physician about his

sexual difficulties. He believed that the onset of his (generalized) erectile problems

preceded his ejaculation difficulty by about one year. He described ejaculating rapidly

after a frantic process of gaining vaginal entry and before any softening of his

erection made continued containment impossible.



Patients often use the word “come” to describe an ejaculation/orgasm and “Premature

Ejaculation” when this process happens too quickly. When the term, Premature Ejaculation

(PE), is used by health professionals, some consider it to be pejorative and value

laden. Preferring a more descriptive term, McCarthy has suggested Early Ejaculation as

an alternative2 (p. 144). Others have also used the term, Rapid Ejaculation.3,4 These

terms indicate that speed of ejaculation is on a continuum from slow to fast rather

than a normal/abnormal dichotomy. For reasons of consistency with DSM-IV5 and

DSM-IV-PC6 nomenclature, as well as the inclusion of the concept of control in the

definition (see immediately below), the term, Premature Ejaculation, will be used in this




Definition problems abound in attempts to clarify PE. Does one use a time element?

(Critics say that no one carries a stopwatch to bed.) Or is it better to specify the number

of movements or thrusts? (One might legitimately ask: just what is the “correct”

number?) Should one follow the Masters and Johnson suggestion that the woman be

“satisfied” 50% of the time when intercourse occurs?1 (p. 92) (On the presumption that

“satisfaction” means “orgasm,” of what relevance is the Masters and Johnson definition

to a man who is having intercourse with a woman who comes to orgasm only with

direct clitoral stimulation and not with intercourse?)

Usually no one debates the issue of the definition of prematurity when a heterosexual

man ejaculates before, during, or immediately after vaginal entry. Definition

problems arise with lengthening of the amount of time after penetration. It is

conceivable that two syndromes exist: (1) ejaculation before, during, or immediately

after vaginal entry and (2) ejaculation after vaginal entry but with little or

no control over the timing. It may be that the former has “premature ejaculation”

and the latter is simply quite fast and would be reasonably described as having

“rapid ejaculation.”

Grenier and Byers suggest a different way of considering the definition of PE: there

should be two criteria for the diagnosis. One is based on the extent of voluntary control

experienced by the man and the other is based on “latency,” or the amount of time

from vaginal entry to ejaculation.3

Does PE apply to men who are sexually active with other men? The literature is

unclear on this subject. Masters and Johnson found that PE “rarely represents a serious

problem to interacting male homosexuals . . . [since] . . . neither man is dependent

upon the other’s ejaculatory control to achieve sexual satisfaction”7 (p. 239). However,

another study declared that 19% of a convenience sample of 197 gay men reported

“ejaculating too soon/too quickly.”8

If the definition of PE includes only the speed of ejaculation, the definition

doubtless applies to men sexually active with other men. However, if the definition

also includes control, the answer is not so clear. It might depend on the kind of

sexual practices between the two men. For example, some men might ejaculate rapidly

and out of control during anal intercourse but rapidly and in control with

mutual masturbation.



DSM-IV-PC summarizes the criteria for the diagnosis of PE as follows: “Persistent or

recurrent ejaculation with minimal stimulation before, on, or shortly after penetration

and before the person wishes it, causing marked distress or interpersonal difficulty.”6

(This statement introduces a subjective element by using the phrase “wishes it”). The

clinician is further instructed to “ . . . take into account factors that affect the duration

of the sexual excitement phase, such as age, novelty of the sexual partner or situation,




and frequency of sexual activity.” As with other sexual dysfunctions, clinicians are also

asked to specify if the problem is lifelong or acquired, or situational or generalized.

The assessment of premature ejaculation is outlined in Figure 10-1



The majority of men who ask for assistance describe a lifelong pattern of ejaculating

quickly and without any control in attempts at intercourse. This process usually contrasts

with ejaculation with masturbation, the timing of which is described as entirely

in their control.

History reveals increasing concern about ejaculation in intercourse after an initial

period in which the man seemed unaware of possible dissatisfaction of previous sexual

partners (“no one ever said anything”). His sexual activities tend to focus on intercourse.

On a time scale, the man often ejaculates within seconds after vaginal entry.

While ejaculation is pleasurable, the total sexual experience is anything but, since it is

filled with worry and trepidation about ‘the same thing taking place that occurred the

last time.’ Various attempts at controlling ejaculation (including distracting oneself by

nonsexual thoughts or masturbating before a sexual encounter) have been tried and

found wanting. The patient is apologetic to his partner and privately self-deprecatory.

The current partner is often angry because her sexual arousal is repeatedly interrupted.

Her interest in sexual activities may decline. Sometimes a woman in this situation

believes that the man deliberately chooses not to control the timing of his ejaculation.

Resulting intra- and interpersonal tensions can be substantial.

Some men describe difficulties with the timing of ejaculation of relatively recent

onset and after a lengthy period in which this was not considered to be a problem by

him or his partner(s). The distinction between this acquired form and its lifelong counterpart

is important from etiological and therapeutic viewpoints.



Some information about “normal” latency was provided by Kinsey and his colleagues

in their survey of men in the general population9 (pp. 579-581). While they did not

seem to consider PE to be a disorder, curiosity about speed of ejaculation

(rather than definition of the problem) resulted in them asking

about ejaculation latency (that is, the estimated average time for ejaculation

to occur after vaginal entry). The time was two minutes for about

three fourths of the men studied.

Laumann and his colleagues asked those who were surveyed: “during

the last 12 months has there ever been a period of several months

or more when you came to a climax too quickly?”10 pp.368-375)

Twenty-nine percent of the men answered “yes”—the most common

sexual complaint, by far, of the men surveyed. Positive answers were

greatest in men who were under the age of 40 and over the age of 54, married and

divorced (compared to those who had never married), less educated (i.e., received less

than high school education), black, in poor health, and unhappy.

PE has varied from 15% to 46% of presenting complaints at sexual problem clinics

in a review of studies completed between 1970 and 1988.11 Furthermore, for unknown

reasons, PE may be decreasing over time as the principal sexual concern of men who

appear at the clinics.


Question: “During the last 12 months

has there ever been a period of several

months or more when you came to a

climax too quickly?” Twenty-nine percent

of the men surveyed answered,

“Yes.” (This is, by far, the most common

sexual complaint of the men surveyed.)

The acquired form of PE (sometimes referred to as “secondary”) is characterized by:

(1) an older man, (2) a briefer interval of time existing between beginning of the difficulty

and seeking professional assistance, and (3) erectile difficulties preceding the




The variety of psychologically and biologically based etiological hypotheses for PE

have been thoroughly reviewed3 and include the following:

1. Psychodynamic theories (excessive narcissism or a virulent dislike of women)

2. Early experience (conditioning based on haste and nervousness)

3. Anxiety (causing activation of the sympathetic nervous system or distraction

from worry resulting in lack of awareness of sensations premonitory to ejaculation)

4. Low frequency of sexual activity

5. Not using techniques that other men have learned to control the timing of ejaculation

6. Not considering rapidity of ejaculation to be a disorder, since it is a superior trait

from an evolutionary viewpoint

7. Easier arousal

8. Greater sensitivity to penile stimulation

9. Malfunctioning of the normal ejaculatory reflex3

Theories about PE represent etiological speculations concerning men

who are otherwise healthy. However, PE has also been reported in

association with trauma to the sympathetic nervous system during surgery

for aortic aneurysm, pelvic fracture, prostatitis, urethritis4 and

neurological diseases such as multiple sclerosis2 (p. 148).

While the presence of anxiety often seems to be associated with PE,

the direction of the relationship (cause or effect) is unclear. What is

striking, however, is the fact that many men (perhaps most) who ejaculate unpredictably

with a partner are able to control the timing of their ejaculation when masturbating.

(A few men who appear to be otherwise healthy ejaculate spontaneously and

without control in the presence of any kind of sexual stimulation.)

Assuming a relationship between anxiety and ejaculatory control, anxiety

is helpful as an explanation for the occurrence of PE only in relation

to intercourse (since men are considerably less anxious when masturbating13).

One of the more compelling hypotheses for PE is that it “may be,

at least in part, the result of a physiologically determined hypersensitivity

to sexual stimulation,” that is, PE may be a reflection of a

lower ejaculatory threshold. In a study that adds support to this

idea, speed of ejaculation was compared in premature and nonpremature

ejaculating men when masturbating. Assessment of latency to ejaculation

showed that when at home the men with PE ejaculated in about half the time as

their counterparts (three minutes versus six minutes).11 The authors of this study

suggest a diathesis-stress model in which “some individuals with a particularly strong


Many men (perhaps most) who ejaculate

unpredictably with a partner are

able to control the timing of their ejaculation

when masturbating.

Speed of ejaculation was compared in

premature and nonpremature ejaculating

men when masturbating. Assessment

of latency to ejaculation showed that

when at home the men with PE ejaculated

in about half the time as their

conterparts (three minutes versus six


somatic vulnerability may require little, if any, anxiety in order to manifest their low

orgastic threshold.”

Investigation into the etiology of the acquired form of PE suggests separation into

two groups: (1) one in which the patients had a “demonstrable organic cause” (e.g.,

erectile dysfunction as a result of diabetes) and (2) one in which the men were involved

in disturbed relationships.12




The history is the key to the diagnosis of PE in a man who is otherwise healthy. While

history can be obtained from the man alone, the effect of this syndrome on both sexual

partners is best gauged by talking directly with each. Issues to inquire about and suggested

descriptive questions (asked of heterosexual men, although easily adapted to

gay men as well) include:

1. Duration of ejaculatory difficulty (see Chapter 4, “lifelong versus acquired”)

Suggested Question: Has ejaculating quickly always been a problem

for you or was there a period of time when this did not


2. Subjective feeling before ejaculation (see Chapter 4, “generalized versus situational”)

Suggested Question: “If you compare your ejaculation when having

intercourse to masturbating, how much warning do you

have that ejaculation is about to occur in each situation?”

3. Timing of ejaculation (see Chapter 4, “description”)

Suggested Question: “Do you ejaculate before, during, or after

vaginal entry?”

4. Speed of ejaculation (see Chapter 4, “description”)

Question if Answer is “After”: “On the basis of time, how long does it

take you to ejaculate after entry?”

Additional Question: “On the basis of numbers of movements or

thrusts, how many occur before you ejaculate?”

5. Methods used to control ejaculation (see Chapter 4, “description”)

Suggested Question: “Have you tried to control the timing of

your ejaculation?”

If the Answer is “Yes,” Follow-up Suggested Question: “What methods have

you used to do this?”

Additional Question: “For Example, Many Men Stop Moving (or use

condoms, anesthetic creams or oils, or think of something

nonsexual) in an Attempt to Prevent Themselves From Getting

Close. Is That Something You’ve Tried to Do?”

6. Subjective feeling of orgasm (see Chapter 4, “description”)

Suggested Question: “Although orgasm is difficult to describe,

can you explain what it feels like when you ejaculate?”

Additional Possible Question: “Is it a pleasant or unpleasant experience

for you?”

7. Description of emission (see Chapter 4, “description”)

Suggested Question: “Men usually experience repeated or rhythmic

contractions when they ejaculate so that the semen comes

out in spurts. Do you notice these contractions when you


Additional Suggested Question: “When ejaculation occurs, does the

semen come out in spurts or does it dribble out?”

(Comment: There is less force to ejaculation when there is some obstruction [e.g.,

prostatic hypertrophy or urethral stricture] neurological disorder, and in the aging

process14 [pp. 257-259].)

8. Psychological accompaniment (see Chapter 4, “patient and partner’s reaction to


Suggested Question: “When you have trouble with ejaculation,

what’s going through your mind?”

Additional Question: “What does your wife (partner) think?”


Physical and laboratory examinations

In otherwise healthy men, these investigations add little useful information.



Given the substantial frequency of lifelong Premature Ejaculation in

the community, the focus on history-taking as the principal diagnostic

technique, the etiological concentration on the present rather than the

past, and the usefulness of some brief approaches, treatment of this

disorder is well within the purview of primary care.

Masters and Johnson described a talk-oriented treatment method for PE that provides

an “overall failure rate” of 2.7%1 (pp. 92-115 and 367). Perhaps as a result of the

reported benefits, little else was suggested therapeutically for some time after. Others

also reported positive effects after treatment but when long-term follow-up studies


Given the prevalence of lifelong Premature

Ejaculation, the focus on historytaking

as the principal diagnostic technique,

the etiological concentration on

the present rather than the past, and

the usefulness of some brief approaches,

treatment of this disorder is well within

the purview of primary care.

were done considerably less robust results were found. A three-year follow-up study

(for example) reported dramatic changes at the end of treatment for PE in the duration

of intercourse. However, pretreatment levels returned after three years.15 (Interestingly,

significant improvements in the duration of foreplay reported at the end of treatment

were found in this study to have persisted at follow-up.)

Counseling and medications are presently the mainstays of treatment for lifelong

PE. Obviously, drug prescription is available only to physicians. However, cooperative

relationships between all professionals in the health care system increasingly reflect

changes toward improvement in the quality of patient care.



Evidence for the utility of drug treatment of PE is increasing. In case reports and single

blind studies, psychotropic drugs are noted to interfere with ejaculation as a side

effect.16 Some investigators reason that this observation could be turned to advantage,

suggesting that a side effect is not necessarily an adverse effect. The antidepressants

paroxetine,17 sertraline,18 and clomipramine4 have undergone double-blind testing for

their usefulness in the treatment of PE (often in smaller doses than that used in the

treatment of depression). (Paroxetine [Paxil] and sertraline [Zoloft] are selective serotonin

reuptake inhibitors [SSRIs], and clomipramine [Anafranil] is a chemical hybrid of

a tricyclic and SSRI).

Waldinger and his colleagues conducted a double-blind, randomized, placebo-controlled

study of paroxetine (40 mg/day for five of the six weeks of the study [higher

than what is usually prescribed in treating depression]) in the treatment of PE in 17

men.17 Patients and partners were questioned separately. The improvement was

described as dramatic and began in the first days of treatment (suggesting that the

effect was not a result of diminished psychopathology). No anticholinergic side effects

(a possible problem with clomipramine, depending on the dose) or effect on erection

function was reported.

Mendels and his colleagues randomly assigned 52 heterosexual males to an eight

week study of either sertraline or a placebo administered in a double-blind fashion.18

The drug was given daily and the dose varied from 50 to 200 mg, depending on the

beneficial response and adverse experiences of the patient. Sertraline was judged to be

significantly better than placebo in (1) prolongation of time to ejaculation and (2)

number of successful attempts at intercourse.

Althof and his colleagues completed a double-blind placebo-controlled crossover

trial of clomipramine in a group of 15 otherwise healthy men with lifelong PE who

were also married or cohabiting with a woman for at least six months.4 Partners participated

in the study. Results of the study are as follows:

1. Mean ejaculatory latency increased almost threefold at a dose of 25 mg/day and

over five-fold at the other studied dose of 50 mg/day

2. Both partners reported statistically significant greater levels of sexual satisfaction

3. Some of the women who reported never previously experiencing orgasm with

intercourse became coitally orgasmic

4. Over half of the 10 women who previously reported orgasm during intercourse

indicated that it now happened more frequently

5. The men reported greater emotional and relationship satisfaction

However, when the drug was discontinued, sexual function returned to the level that

existed before the study.

The use of clomipramine on an “as needed” basis was examined19 in another study.

Using a double-blind, placebo-controlled, crossover design, eight men with PE, six

men with PE and erectile dysfunction, and eight control men were studied. Partners

did not participate in the study. Subjects took 26 mg of clomipramine or placebo 12

to 24 hours before anticipated sexual activity. In contrast to the marked beneficial

effect in the men with “primary” (i.e., lifelong) PE, the authors report that the drug was

not useful in men who had PE and erectile dysfunction. This result affirms the importance

of subclassification.


A 28-year-old man and his 32-year-old wife were seen because of his difficulty with

regular ejaculation before vaginal entry. This pattern of ejaculation had existed

since the beginning of his attempts at intercourse as a teenager. His wife was

becoming sexually disinterested and questioned her commitment to the relationship,

particularly because “the biological clock was ticking” and she wanted to

begin a family. The couple had undergone a Masters and Johnson-type of treatment

program about one year earlier and found that the initial gains were shortlived.

1 A one-visit assessment was conducted with them together, and clomipramine

was prescribed. The couple was seen again two weeks later, when substantial

improvement was reported in the following:

• His ejaculation latency

• Their sexual relationship

• Other aspects of their life as a couple

Much to the wife’s pleasure, she became pregnant within two months of the first

visit. The man was seen for a third time alone because the wife was unable to

accompany him for the visit. He reported continued improvement in sexual and

nonsexual areas of their life. Telephone contact was periodically maintained for the

purpose of medication refills.


In a review of pharmacologic studies into the treatment of PE, Althof asks the following

serious questions.4

1. Should drugs be the first line of treatment?

2. How should drugs be used? (daily? the day of intercourse? a duration of weeks?

months? lifetime?)

3. What are the indications and contraindications? (Used only in the lifelong form?

The acquired form? Prescribed only for men who do not ejaculate before, during,

or immediately after entry but want to “last longer?”)

4. What should be the relationship between drug treatment and psychotherapy?

Althof concludes that all of these questions require empirical research and are therefore

difficult to answer at the present time. Some of these questions are considered

below, and the information given is based more on clinical judgment and experience

than research data.

Should drugs be the first line of treatment? Drugs may well be used immediately, as follows:

• A man who persistently ejaculates in an uncontrolled manner with any

form of sexual stimulation and particularly before vaginal entry

• A couple when talk-oriented treatment methods are not helpful

• Many single men without partners

• When talking to a couple is unproductive even if a couple relationship

exists (e.g., in the case of a couple raised in a culture where gender roles

dictate that the woman is subservient to the man and both subscribe to

this philosophy—a situation that is functionally the same as talking

with the man by himself)

How should drugs be used? Daily and ad hoc (e.g., clomipramine four hours before intercourse

is expected to occur) administration methods have been found helpful.

What are the contraindications? There are two reasons why drug treatment should not

be used in men who have the acquired form of PE based on relationship discord. First,

PE in this situation is clearly symptomatic and it makes little sense to treat the symptom

and not the “disease” (i.e., the relationship discord). Second, the

problem of PE may well be reversed with attention given to the disrupted

relationship. Furthermore, in acquired PE associated with erectile

problems, clomipramine treatment has been shown to be ineffective.

17 On the subject of contraindications, Althof also counseled that

considerable caution be exercised in response to requests from men

who want “boundless intercourse or designer orgasmic capabilities.”4

What should be the relationship between drug therapy and psychotherapy?

Althof states that there should not be an either/or attitude to the use of

these treatment methods and that both may be desirable or necessary.4

“The two treatment approaches are not to be compared solely in terms

of economics or ejaculatory latency. Psychotherapy educates, clarifies,

and often addresses other issues not perceived when the diagnosis was

originally made.” Indeed, if the physician’s approach to medications is such that psychotherapy

is not used in conjunction, then, by experience so far, the man is implicitly

being told that he must take this medication for, perhaps, a lifetime. The implications

of such a treatment decision are substantial, especially given that many of the men

presenting with the lifelong and situational form of PE are young and in the early

stages of their sexual experience.



The talking part of the treatment of someone with PE includes at least four components:


If the physician’s approach to medications

is such that psychotherapy is not

used in conjunction, the man patient is

implicitly being told that he must take

this medication for (perhaps) a lifetime.

The implications of such a treatment

decision are substantial, especially since

many men presenting with the lifelong

and situational form of PE are young

and in the early stages of their sexual


• Information

• Specific techniques

• Adaptation

• Attention to psychological issues

Some are easily incorporated into primary care practice.



PE-related self-help books seem to be particularly useful in providing two elements

of counseling20-22:

• Information (in this instance about men and sexual issues)

• Specific advice (in this example about controlling ejaculation)

The extent to which these two elements are therapeutically helpful is unclear, since

men who benefit greatly from such books would not be likely to seek assistance from

health professionals. Judging by the reaction of patients to whom such books are suggested,

many find the content to be at least informative and reassuring and some follow

the specific treatment methods suggested. Apart from specific issues around ejaculation

control, Zilbergeld, in particular, interests male readers when discussing the

powerful and influential sexual “myths” that so often determine how men think and

behave sexually—in their own eyes and in those of their sexual partners.20,22 This is

“sex education” as it should be, that is, the description of body parts and their function

and the discussion of sex-related aspects of human relationships. Kaplan’s book includes

information about PE and specific techniques for ejaculatory control (see immediately




A second element in counseling, more applicable to couples, is directed at specific

techniques to control the speed of ejaculation. Two approaches were described in the

past: “stop-start”23 and the “squeeze technique”1 (pp. 102-104). The stop-start technique

is more popular among sex therapists because it is easier for health professionals

to explain and for patients to use. The stop-start approach involves an exercise in

“communication” and comprises at least four steps:

1. Both partners initially agree not to attempt intercourse on at least several occasions

(this is essential)

2. The woman stimulates the man’s erect penis until he is close to ejaculation at

which point he signals her to stop

3. This happens three or four times on any one sexual occasion before he eventually


4. The couple then integrates this into intercourse experiences with frequent




An additional facet of counseling, also more directed to couples, is incorporated

into the concept of adaptation. Even if little change develops in the timing or speed of

ejaculation as a result of talking forms of treatment, a considerable shift may occur in

the sexual experiences of the couple such that the timing of the man’s ejaculation

becomes a lesser or even nonissue. For example, if the usual “order” of sexual events is

such that the man ejaculates before his partner is stimulated, this process can be altered

so that attention is given to the woman’s satisfaction and (possibly) orgasm, before or

after vaginal entry occurs. The notion of adaptation is consistent with some results

found at follow-up, namely that treatment of PE may change aspects of foreplay rather

than ejaculatory control.12



Ignoring concurrent psychological issues in the counseling process decreases the

potential for a good outcome.


A couple in their late 30s, married for 15 years, was referred because the man

regularly ejaculated immediately after vaginal entry, a pattern that existed throughout

all of his life. In the process of initially talking with both (together and separately)

it became clear that she was angry and “at the end of (her) rope.” She was

seriously considering separation for sexual and nonsexual reasons. Sexually, her

level of interest was similar to her husband’s (i.e., substantial) but her sexual arousal

was interrupted continually by his ejaculation. She was orgasmic with direct clitoral

stimulation before intercourse but this was irregular and unpredictable. Her

animosity toward her husband about nonsexual concerns related to his inclination

to continually avoid talking about contentious issues (including their sexual troubles).

It was evident that simply delaying his ejaculation by using pharmacotherapy

would not circumvent the discord between the two. Thus deliberate decision was

made to treat this couple using traditional counseling methods.


Psychological issues may be particularly important in the solo male. A man might ask

for solo treatment for several reasons:

1. He may not have a partner

2. Confidentiality and trust issues may prevent the involvement of a new partner

3. A partner may be unwilling or unable to participate in the process (this is less

frequent than many men report)

In such circumstances, it is usually best to explain that although much can be accomplished

diagnostically in seeing him alone, the absence of a sexual partner is often

therapeutically limiting. Some aspects of the multifaceted treatment approach described

above can be applied to the solo male, including the provision of information and

learning specific techniques such as stop-start while masturbating.

When the limitations of solo (versus couple) treatment are discussed, clinicians frequently

meet with a “catch-22” response in which the man says that the very existence

of this problem prevents establishment of a relationship. He is, in effect, saying that

speed of ejaculation is a determining force in relationships between men and women—

a suggestion that (to say the least) not everyone supports. The fact that a partner is not

present to possibly refute this argument puts the health professional in the difficult

position of presenting a different point of view to the patient and potentially disrupting

the professional relationship in the process. Psychotherapy might be helpful to the

extent that the man is prepared to examine all aspects of a failed relationship, sexual

and otherwise.


Indications for Referral for Consultation or Continuing Care by a Specialist

1. Consultation with a physician is required when pharmacotherapy is considered

and the health professional is trained in a different discipline.

2. In the acquired form of PE associated with relationship discord, the ejaculation

issue is likely symptomatic and treatment would involve relationship therapy—

a process that is best undertaken on a continuing care basis by those in the

health care system with clinical experience in this area, that is, mental health


3. In the acquired form of PE associated with an erectile disorder, managing both

problems may be complex. Therefore referral to a sex-specialist for continuing

care may be necessary.

4. Care of the solo man, beyond the use of drugs, often presents a dilemma.

Men who are unwilling to use pharmacotherapy or who continue to have

inter- or intrapersonal difficulty despite slower ejaculation are best seen for

continuing care by a mental health professional who is comfortable with sexual


5. Unsuccessful treatment at the primary care level should result in referral to a

sex-specialist, at least for consultation, and possibly for continuing care.



Premature Ejaculation (PE) in heterosexual men is difficult to define precisely except

in situations where ejaculation occurs persistently before, during, or immediately

after vaginal entry. Control over the process of ejaculation appears to be a significant

element in the definition, as well as the duration of time between vaginal entry

and ejaculation. Most men with this disorder describe a lifelong pattern. “Coming

to a climax too quickly” was the most common sexual complaint registered by

men in a substantial survey of sexual behavior. An unreplicated study suggests an

appealing hypothesis for the etiology of the lifelong form of PE, namely, that it is

partly related to a “physiologically determined hypersensitivity to sexual stimulation.”

The acquired form seems to be the result of relationship discord or medical

illness. The focus of investigation into the lifelong form of PE is particularly on

history-taking (rather than physical examination or laboratory studies). Counseling

and medications are the mainstays of treatment of this disorder. The latter has

demonstrated great value, although many details concerning drug treatment have

yet to be elaborated.

Long term follow-up studies of counseling alone show modest results. The potential

value of combining the two treatment forms has not been investigated. Intuitively,

medications may be considered a short-term intervention, and psychotherapy may be

included toward the long-term goal of permanent change. Referral for consultation

with a physician is required when drug therapy is undertaken by a health professional

from another discipline. Referral for continuing care is particularly reasonable in the

acquired form of PE and when slowing of ejaculation in a man seen alone has resulted

in limited success in allowing him to develop intimate relationships.


Delayed Ejaculation/Orgasm


This syndrome has been variously called:

• Ejaculatory Incompetence1

• Retarded Ejaculation24

• Male Orgasm Disorder5,6

An evident problem with the terms is the confusion about whether this is a disorder of

ejaculation, of orgasm, or both. These two phenomena are separate from a neurophysiological

viewpoint although usually tightly interwoven. The separateness is evident

in the normal development of preadolescent boys who are able to come to orgasm

but who cannot ejaculate because the mechanism is not fully developed. The term,

Delayed Ejaculation/Orgasm (DE/O), is preferred because it is entirely descriptive and

DE/O refers to a delay in both ejaculation and orgasm.



Defining DE/O presents problems similar to PE, namely, the question of how much

time constitutes a delay? In one form, the definition of time is not a problem, since

the man can ejaculate without difficulty when alone (without any delay), but usually

not at all when with a partner. When ejaculation is truly delayed, it is slow in all

situations—regardless of the sexual activity and the nature of the partnership. In fact,

ejaculation/orgasm may be so delayed that the person stops trying. In either case

(delayed or absent) the definition is usually provided by the patient as he, for example,

compares his present experience to that of the past or receives complaints from

a sexual partner who may become vaginally uncomfortable because of a lengthy

period of intercourse.



In DSM-IV-PC, orgasm difficulties for men and women are classified similarly6 (p.

117). “Male Orgasmic Disorder” is defined as: persistent or recurrent delay in, or

absence of, orgasm after a normal sexual excitement phase. This can be present in all

situations, or present only in specific settings, and causes marked distress or interpersonal

difficulty. Additional clinical information is provided: “In diagnosing Orgasmic

Disorder, the clinician should also take into account the person’s age and sexual experience.
. . . In the most common form of Male Orgasmic Disorder, a male cannot

reach orgasm during intercourse, although he can ejaculate with a partner’s manual or

oral stimulation. Some males. . . . can reach coital orgasm but only after very prolonged

and intense noncoital stimulation. Some can ejaculate only from masturbation.

When a man has hidden his lack of coital orgasm from his sexual partner, the

couple may present with infertility of unknown cause.” Determining the subclassification

as lifelong or acquired, generalized or situational can be crucial to determining

etiology and treatment.

The assessment of Delayed Ejaculation/Orgasm is outlined in Figure 10-2.



DE/O presents clinically in one of two forms:

• Situational

• Generalized

When situational, the problem is usually lifelong rather than acquired. When generalized,

it is much more likely to be acquired.

In the situational form, the history is usually one of ejaculation without difficulty

when alone but inability to ejaculate with partners generally or during a specific sexual




activity, typically intercourse. The request for assistance often can be traced to the

partner and characteristically results from vaginal discomfort, concerns about reproduction,

or both. Sometimes the man describes a method of masturbation that is difficult

to transfer to sexual activity with a partner (e.g., rubbing his penis against a firm

surface rather than using his hand).


Two gay men in their 20s were seen because one was unable to ejaculate in the

presence of the other while having no such difficulty when masturbating alone.

Strains in their relationship became apparent when the sexually functional partner

let it be known that he considered his partner’s inability to ejaculate to be a form

of rejection. History revealed that the man with DE/O experienced this pattern of

ejaculation in previous brief sexual relationships as well as the three he considered

long-term. Treatment using the approach described by Masters and Johnson was

unsuccessful at reversing the pattern1 (pp. 129-133). One-year follow-up revealed

that the relationship had dissolved.


In the generalized form (lifelong or acquired), history reveals that the man is experiencing

substantial delay or absence of ejaculation/orgasm in all circumstances. Typically,

the history is brief and clearly indicates that this is acquired and dates from the

onset of the use of a particular medication (see “Etiology” below in this chapter). Occasionally

this may be life long. Cultural or religious beliefs may also be a critical factor.

On some occasions, the history reveals a hybrid form, that is, one that has characteristics

of both syndromes. Ejaculation is possible but only during masturbation.

When ejaculation does occur in such circumstances, vigorous and lengthy penile

stimulation is usually required—much more so than can be provided by vaginal



A 35-year-old single man described an inability to ejaculate with a partner in spite

of intercourse lasting up to one hour. Women partners initially enjoyed the experience

and would find themselves repeatedly orgasmic. However, this attitude

was soon replaced by one of impatience as the pleasure was superseded

by the vaginal discomfort accompanying the long duration of

intercourse. He described being able to ejaculate only with masturbation

in a process that required about 15 minutes and great physical exertion

in which he “worked” so hard he would sweat. He forcefully rubbed

his penis against a hard surface while fantasizing about himself dressed

as a woman.


In the Lauman study,10 8% of men

reported being “unable to orgasm.”

(The investigators did not apparently

distinguish between ejaculation/orgasm

that was delayed and that which was

entirely absent.)


In the Laumann study, 8% of men reported being “unable to orgasm”10(pp. 370-374).

(The investigators did not apparently distinguish between ejaculation/orgasm that was

delayed and that which was entirely absent.) The age category in which this syndrome

was reported with greatest frequency was the 50 to 54 year old group (14%). Inability

to come to orgasm was also reported more commonly in “Asian/Pacific Islander” men

(19%), as well as those who were poorly educated (13%—less than high school), and

financially poor (16%). As with other dysfunctions, the percentages of affected men

increased with diminished health (18% of those whose health was “fair”) and happiness

(23% of men who were “unhappy most times”).

“Male Orgasm Disorder” accounted for 3% to 8% of cases presenting for treatment

in a review of clinical studies.11



In the situational and hybrid forms, it is evident that specific sexual and/or psychosocial

factors are central to etiological speculations25 (pp.179-185); 1(p. 126). Theories


1. That some men are highly reactive genitally

2. That some men are fearful of dangers associated with ejaculation

3. An inhibition reflex

4. Religious orthodoxy

5. Male fear of pregnancy

6. Sexual interest in other men

7. A psychologically traumatic event

In the acquired and generalized form, there is often a history of recent

use of a medication that is known to interfere with ejaculation/orgasm (see Appendix

V) or the presence of a neurological disorder such as multiple sclerosis.

“All of the drugs approved for the treatment of depression or the treatment of

obsessive-compulsive disorder in the United States, with the exception of nefazodone

and bupropion, have been reported to be associated with ejaculatory or

orgasmic difficulty.”26 Prevalence figures for any one of the drugs varies as a result

of different sources (manufacturer or published report) or variations in methodology

(spontaneous reports or direct inquiry). Ejaculatory problems (delay or inhibition)

have been reported in patients taking the following drugs:

• Imipramine (30%)

• Phenelzine (40%)

• Clomipramine (96%)

• Fluoxetine (24% to 75%)

• Sertraline (16%)

• Paroxetine (13%)

• Venlafaxine (12%)

Some antihypertensive drugs also interfere with ejaculation/orgasm. One of the problems

in investigating the extent of this problem is that hypertension can cause sexual


All drugs approved for treatment of

depression or obsessive-compulsive disorder

in the United States with the

exception of nefazodone and bupropion

are reported to be associated wih ejaculatory

or orgasmic difficulty.26

difficulties apart from the drugs used in its treatment. “Ejaculatory dysfunction” was not

found at all in two studies that included normotensives, but was associated with 7% to

17% of untreated, and 26% to 30% of treated patients27 (p. 204). Antihypertensive

drugs that can cause sexual difficulties were reviewed27: and, in relation to delayed

ejaculation, specifically included the following:

• Reserpine (p. 216)

• Methyldopa (p. 219)

• Guanethidine (p. 224)

• Alpha1 blockers (p. 235)

• Alpha2 agonists (p. 237)

• Calcium channel blockers (p. 245)

Notably missing from this list were the following:

• Diuretics (p. 210)

• Beta-blockers (p. 227)

• ACE inhibitors (p. 242)




1. Duration (see Chapter 4, “lifelong versus acquired”)

Suggested Question: “Has ejaculation difficulty been a problem all

your life or is it a problem that developed recently?”

2. Ejaculation with a partner (see Chapter 4, “generalized versus situational”)

Suggested Question: “Do you ejaculate at all now when you are

with a partner?”

Additional Question if the Answer is “No”: “Have you ever ejaculated with

a partner?”

Additional Question if the Answer to Either Previous Question is “Yes”: “What kind

of sexual activity resulted in your ejaculation (e.g., intercourse

or oral stimulation)?”

3. Ejaculation with masturbation (see Chapter 4, “generalized versus situational”)

Suggested Question: “Do you ejaculate now when you masturbate?”

Additional Question if the Answer is “No”: “Have you ever ejaculated

when you masturbated?”

4. Feeling prior to ejaculation/orgasm (see Chapter 4, “description”)

Suggested Question: “Do you sometimes feel that you are close to

ejaculation/ orgasm but then the feeling disappears?”

Additional Question: “When with a partner, Do you ever pretend

that you have come to orgasm?”

Physical and Laboratory Examinations

In an otherwise healthy man, no particular physical or laboratory examinations are




In the care of men with the situational form of DE/O, reported series are few. Masters

and Johnson described their treatment format and their five-year follow-up of 17 men

and reported a treatment failure rate of 17.6%1 (pp. 116-136, p.357). Another threeyear

follow-up study in the United States described the treatment of five men15 who

reported themselves as:

Three men Improved

One man The same

One man Worse

A one to six year follow-up study conducted in the United Kingdom

described two cases of “ejaculatory failure” and reported that in one

there was no change, and in the other, the problem was resolved

although still experienced.28 No other case studies involving large

numbers of patients have been published.

On the basis of impression rather than data, the occasional man with DE/O asks for

care in his teens, and soon after intercourse experiences have begun. Such men may be

amenable to the reassurance and provision of information that often comes with history-

taking alone. The health professional might be justifiably optimistic about the

result in such circumstances. Unfortunately, in most instances, men with DE/O do not

ask for treatment until years later when they are pressured into it by a sexual partner.

By that time, many sexual experiences have taken place (either alone or with partners)

with a particular method of ejaculation, a pattern that may have become crystallized

and difficult to change.

In the generalized form of DE/O, and when there is reason to suspect the use of a

medication in the etiology, the following treatment “strategies” are suggested:

1. Maintain dosage of the medication and wait for tolerance to develop

2. Reducing the dosage

3. Change the regimen (e.g., the use of a “drug holiday”)29

4. Change to an alternative medication (e.g., when the sexual side effects of sertraline

and nefazodone were compared in the treatment of depression, nefazodone

was said to have no inhibitory effects on ejaculation)30

5. Administer a second medication to counter the sexual side-effect of the first (see

immediately below)26


Men with DE/O usually do not ask for

treatment until they are pressured into

it by a sexual partner. By then, many

sexual experiences may have taken

place, resulting in a firmly established

pattern of ejaculation that may be difficult

to change.

Two potential problems exist when using other medications at the same time: the clinician

must ensure that the second medication does not counteract the therapeutic impact

of the first, and sexual spontaneity inevitably diminishes somewhat when planning

precedes the sexual event (although often an exaggerated patient concern).

Segraves described seven medications that have been used in an effort to control

the sexual side-effects of antidepressants (mostly SSRIs): bethanechol, cyproheptadine,

yohimbine, amantadine, bupropion, dextroamphetamine, and penoline.26 Methylphenidate

has been suggested31 also, as well as intermittent nefazodone32 (Box 10-1 and

Table 10-1).

Since outcome research has not subclassified patients, one can only provide clinical

impressions about the generalized and lifelong form of DE/O. Given that biological

factors likely explain the etiology, helping the patient adapt through the provision of

information seems the optimal approach.


Box 10-1
Strategies in Treating Delayed Ejaculation/Orgasm due to Antidepressant Drugs

1. Wait for tolerance to develop

2. Decrease dosage

3. Change regimen (e.g., “drug holiday”)

4. Use alternate drugs

5. Use additional drugs (“antidotes”)


Indications for Referral for Consultation or Continuing Care by a Specialist

1. Situational DE/O: If this pattern of ejaculation has existed for some years, referral

for sex therapy for the purpose of continuing care may be most beneficial

2. Acquired and generalized DE/O: where medications seem etiologically significant

but the symptom has not altered with the strategies outlined in Box 10-1, it

is reasonable to ask for advice (consultation) from a physician who has expertise

in the use of the particular class of drugs.

3. Lifelong and generalized DE/O: if the provision of information and reassurance

about the likely positive outcome proves insufficient, referral to a sex therapist

for continuing care is the next logical step



Delayed Ejaculation usually represents a disorder (delay or absence) of both ejaculation

and orgasm, hence the use of the abbreviation, “DE/O.” The disorder appears in

two forms:

• Situational, in that the man can come to ejaculation/orgasm without

problem when alone but has great difficulty when a partner is present

• Generalized in the sense that the man has difficulty under all circumstances

(with a partner or when alone with masturbation)

While unusual, the problem of delayed ejaculation is by no means rare (8% of men in

one community survey indicated inability “to orgasm”). Etiologies are as follows:

1. The situational form includes significant psychosocial factors

2. The lifelong and generalized form includes biological factors that have not yet

been defined

3. The acquired and generalized form can usually be explained by the use of medications

(especially medications used in Psychiatry and in the control of hypertension)

or the onset of a neurological disorder

The effects of treatment in the situational form seem better when the duration of the

problem is brief. Several approaches are suggested for the generalized and acquired

form where the etiology is related to medications. Treatment for the lifelong and generalized

form can generally be undertaken initially on a primary care level through the

provision of information and reassurance. Men with the acquired and generalized form

who have never ejaculated in the waking state require care from a specialist.


Retrograde Ejaculation


Retrograde ejaculation (RE) “is the propulsion of seminal fluid from the posterior urethra

into the bladder”.33 What is usually referred to as “ejaculation” actually comprises

three separate events34 (p. 423):

• First, “emission”

• Second, closure of the “bladder neck”

• Third, “ejaculation”

Emission involves the deposition of seminal fluid from the vas deferens, the seminal

vesicles, and prostate gland into the posterior urethra. Ejaculation refers to the expulsion

of semen from the penis, which, in turn, requires simultaneous closure of the

muscular valve at the junction between the urethra and bladder (the bladder “neck”).

This blockage prevents the semen from traveling backward into the bladder instead of

going forward out the end of a man’s penis. The expulsion of semen (true ejaculation)

also involves intermittent relaxation of the “external sphincter”; there are three to seven

contractions about 0.8 seconds apart (see Figure 10-3).

The final portion of this process comprises rhythmic contractions of the bulbospongiosus

and ischiocavernosus muscles, resulting in forward movement of seminal fluid

through the anterior urethra and emerging from the penile meatus. Orgasm is considered

a cerebral event that occurs together with emission or ejaculation and associated

with unknown physiological mechanisms35 (p. 155).

Emission and bladder neck closure appear to be predominantly under the control of

the sympathetic portion of the autonomic nervous system, and the expulsion of semen

is predominately under the influence of the somatic nervous system35 (pp. 165-166).

“Any interference (anatomical, traumatic, neurogenic or drug-induced) with (the integrity

of these systems) may result in abnormal function of the internal sphincter of the

urethra, and favor retrograde ejaculation (RE) as the path of least resistance”.36




One way of considering etiological factors in RE is to separate them into (1) ones that

disrupt the anatomy of the sphincter at the bladder neck and (2) ones that interfere

with this sphincter’s function37 (p. 383). The best example of an anatomical disruption

of this sphincter is a transurethral prostatectomy (TURP). Examples of factors that

interfere with function of this sphincter include the following:

1. Retroperitoneal lymph node dissection (RPLND) or total lymphadenectomy in

the treatment of some testicular cancers

2. Diabetes

3. Abdominopelvic surgery

4. Spinal cord injury

Some medications can induce a pharmacologic “sympathectomy” resulting in failure of

emission and/or bladder neck closure (see Appendix V). These drugs34 (p. 427) include

the following antipsychotics (e.g., chlorpromazine and Haldol), antidepressants (e.g.,

amitriptyline and SSRIs), antihypertensives (e.g., guanethidine, diuretics and prazosin),

and others (including alcohol).



RE seems to be common as a complication of TURP but the actual frequency is not

entirely clear. In one study of men before and after surgery, 24% who had no presurgical

difficulty with ejaculation answered “yes” to the following question after surgery:

“Do you have difficulty with getting the sperm out?”38 However, 37% of the

men who had no presurgical difficulty also said that they had no ejaculatory problem


Given the frequency with which RE seems to occur as a result of

TURP, the aging of the population (assuming TURP continues to be

medically popular as a treatment of benign prostatic hypertrophy)

might well result in an increase in the prevalence of RE.

RE seems to be infrequent as a cause of infertility in men (up to

2%)37 (p. 383).



History reveals that the patient reports not ejaculating while (in the

majority of cases) continuing to experience orgasm (“dry orgasm”). The

definitive diagnosis is made by laboratory examination of the man’s

urine immediatly after orgasm, and finding spermatozoa in the sample.



Most men who develop RE as a consequence of TURP accept this situation and do not

ask for treatment. When care is required (usually because of infertility), RE is best

managed by physicians. The focus of infertility treatment is on attempting to induce

antegrade ejaculation by increasing sympathetic tone at the bladder neck or diminishing

parasympathetic activity.33 Alpha-adrenergic agents are commonly used to enhance


Most men who develop RE as a consequence

of TURP accept this situation and

do not ask for treatment. When care is

required (usually because of infertility),

RE is best managed by physicians. The

focus of infertility treatment is on

attempting to induce antegrade ejaculation

by increasing sympathetic tone at

the bladder neck or diminishing parasympathetic


sympathetic tone. In a detailed study of one patient who stopped ejaculating as a result

of lymphadenectomy, four such drugs were used39 and all seemed equally efficacious:

1. Dextroamphetamine sulphate, 5 mg four times daily

2. Ephedrine, 25 mg four times daily

3. Phenylpropanolamine, 75 mg twice daily

4. Pseudoephedrine, 60 mg four times daily

The study concluded that long-term treatment was consistently more effective than a

single dose. Elliott (personal communication, 1997) found that in patients who have

RE as a result of a spinal injury the effects of pseudoephedrine, in particular, can diminish

if used continuously for more than four days, and that it may be more useful to use

it on an “as needed” basis Anticholinergics have also been used successfully (brompheniramine

8 mg twice daily) and imipramine (25 to 50 mg daily). Surgery has also been


When antegrade ejaculation can not be restored the treatment of infertility involves

inseminating the woman with sperm cells taken from the urine by the process of centrifugation.

In one group of eight patients with RE, the combination of alkalinization

of the urine, immediate removal of sperm cells from the urine, and the implementation

of artificial insemination techniques resulted in a “fecundity rate” of 45%40 (p. 440).

When psychological concerns exist, they often relate to surprise and apprehension

if, for example, a patient who has undergone a TURP was not forewarned about not

seeing semen when he ejaculates. Psychological concerns may also be about other

accompanying factors such as the possible presence of erectile or orgasmic difficulties

and infertility. These other issues can have powerful repercussions.


Indications for Referral for Consultation or Continuing Care by a Specialist

As an isolated issue, RE does not appear to be a cause of further sexual difficulties. To

the extent that sexual concerns are related to information, primary care treatment is

usually sufficient. Consultation with a sexual medicine specialist may be useful in

instances when RE is associated with other sexual difficulties. When infertility concerns

result from RE (generally younger men of reproductive age who have experienced

retroperitoneal lymph node dissection or total lymphadenectomy for the treatment of

testicular cancer), continuing care should be undertaken by an expert physician.



Retrograde ejaculation (RE) is usually reported by a man as an orgasm without the

associated emergence of semen (“dry orgasm”). Semen travels “backward” into the

bladder and the definitive diagnosis can be made by the finding of spermatozoa in the

urine. The most common cause of RE is the TURP procedure for benign prostatic

hypertrophy. For most men, information is the only treatment needed. When fertility

is a concern, medical treatment focus is on the attempt to enhance sympathetic tone

at the bladder neck by using alpha-adrenergic agents or diminishing parasympathetic

activity. Specialist care is required only in those instances where there are associated

sexual difficulties or concerns about infertility.


Infrequent Ejaculation/Orgasm Disorders

Infrequent ejaculation/orgasm disorders include painful ejaculation, anejaculation and

anorgasmic ejaculation. The assessment of infrequent ejaculation/orgasm disorders is

outlined in Figure 10-4.

Reports of genital pain associated with ejaculation are uncommon. The following

four causes are known:

1. Some of the tricyclic antidepressants (amoxapine [related to loxapine], imipramine,

desipramine, clomipramine)41,42

2. Seminal vesicle calculi43

3. Urological surgery

4. Vacuum erection devices (VEDs)

The first two explanations may not be immediately apparent. When associated with

tricyclic antidepressants, ejaculatory pain is dose-related so that it diminishes when the

dose is decreased and disappears when the medication is discontinued.42

The absence of ejaculation, or anejaculation (antegrade or retrograde), occurs as a

result of peripheral sympathetic neuropathy44 (pp. 404-6). It occurs in men with spinal




cord injury, men who had retroperitoneal lymph node dissection (RPLND) for testicular

cancer, and in neuropathies such as those seen in multiple sclerosis and diabetes.

Diagnosis is based on the absence of seminal fluid in postejaculatory urine to eliminate

the possibility of RE. Emission/ejaculation and subsequent pregnancy can result from

the use of specialized procedures such as vibratory stimulation or electroejaculation.45

Ejaculation without orgasm is quite unusual judging from the literature and clinical

experience. The etiology is unknown.


A 47-year-old man was seen with the complaint of ejaculating without the sensation

of orgasm. He vividly recalled the powerful feeling of orgasm in the past and

hoped that it would return. The sensation of orgasm tapered during the past three

years so that it was virtually absent at the present time—regardless if he ejaculated

with masturbation or with a partner. He had previously been married for 12 years

and had experienced premature ejaculation throughout all of the marriage. In four

of the seven years after his divorce, his sexual experiences with other women were

described with relish, particularly since he was then free of any ejaculatory difficulty.

His general health was unimpaired, his sexual desire was as strong as ever,

and he never experienced any erectile difficulties. When seen one year after his

initial consultation, the problem had not changed.



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