Ejaculatory Disorders & Low Sexual Desire

See also erectile dysfunction and Peyronie’s disease — a 2023 AJGP article classifies all four together as “male sexual dysfunction.”

Classification

Male sexual dysfunction is classified into four groups, which frequently overlap and should be assessed together:

1. Low sexual desire (hypoactive sexual desire disorder).
2. Erectile dysfunction.
3. Peyronie’s disease.
4. Ejaculatory/orgasmic disorders — premature ejaculation, delayed ejaculation, anejaculation, retrograde ejaculation.

Assessment

• History: onset, severity, presence of morning erections (helps distinguish organic from purely psychogenic causes), medication use, and psychosocial factors (relationship stress, anxiety, depression).
• Examination: body habitus, cardiovascular and neurological screen, genital palpation for testicular size and penile plaques.
• Investigations: fasting glucose or HbA1c, lipid profile, and morning hormone levels (testosterone) — the same baseline panel used for erectile dysfunction.

As with ED, lifestyle modification, management of reversible risk factors, and optimising existing medical conditions are first-line, before pharmacotherapy.

Premature ejaculation

First-line: behavioural techniques — the stop-start technique (stopping genital stimulation until the urge to ejaculate subsides) or the squeeze technique — combined with psychosexual counselling.

Pharmacological options: topical anaesthetics (lignocaine gel), and dapoxetine (starting dose 30mg, maximum 60mg) — currently the only medication specifically approved for premature ejaculation.

Delayed ejaculation

Multimodal management: behavioural techniques, sexual counselling focused on arousal and intimacy, and penile vibratory stimulation devices. Various antidepressants and bupropion have been used off-label, though the evidence base is still limited and warrants further study.

Low sexual desire

Testosterone therapy is the primary intervention where hypogonadism is confirmed (see male hypogonadism for the diagnostic workup). Options include:

• Topical gel: 1% gel, 50mg sachets daily, escalating to two sachets if needed.
• Intramuscular: testosterone esters 250mg/mL every 2 weeks, or testosterone undecanoate 1000mg/4mL every 3 months.

Also address any underlying endocrine cause, and treat concurrent depression or anxiety, which commonly contribute to and are worsened by low desire.