Disorders of ejaculation include premature ejaculation, delayed ejaculation, retrograde ejaculation, and hematospermia. Lifelong premature ejaculation is defined as ejaculation always or nearly always within 1 minute of vaginal penetration that has been present since the first sexual encounter. Acquired premature ejaculation typically begins after a period of normal function, with ejaculation occurring within 3 minutes of penetration. Treatment options include medications and behavioral techniques. Selective serotonin reuptake inhibitors and tricyclic antidepressants are first-line drugs. Delayed ejaculation applies to a range of issues, from delay to complete absence of ejaculation. Guidelines suggest use of an ejaculatory latency time greater than 25 to 30 minutes for diagnosis. Etiologies include psychological and organic factors, such as adverse effects of medications. Treatment focuses on causal medication discontinuation, psychological interventions, and use of off-label drug therapy. Retrograde ejaculation occurs when semen enters the bladder due to an anatomic, neurogenic, or pharmacologic cause. Treatment options include sympathomimetic medications and surgical correction of anatomic abnormalities. Hematospermia, or blood in the semen, is generally benign and self-limited. However, underlying malignancy is possible and should be considered based on patient age and risk factors. Treatment ranges from reassurance to management of the underlying cause.

Case 3. DJ is a 55-year-old man with a history of diabetes, hypertension, and erectile dysfunction. He presents to your office for evaluation of rapid ejaculation within 1 minute of vaginal penetration with his new sexual partner and associated emotional distress.