How Long Should Sex Last? Understanding Ejaculatory Disorders

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2:42Welcome back to the mail room. Jordan Runtah in the house. How you doing, man? You sound a little stuffy, maybe. Talk to me about what's going on in your life right now, man. Man, I went up to visit my folks for Memorial Day. I grew up on a lake in central Massachusetts. Seems like the perfect place to do some grilling, hanging out by the dock. But I got here, and the place was yellow, just pollen everywhere. And I've got nuclear-grade allergies right now. Sorry, everybody. Spring has sprung. No, man, I think, you know, you're like half a register from Barry White. We should lay down some tracks.

3:20No, it's all good. You wear it well. But allergies suck. I've been blessed to not have those. But yeah, bummer. Yeah. Do you do Allegra and all that stuff? I'm on everything right now. No, just the whole cocktail, seeing what works. Yeah. God bless you. How was your holiday? It was good. You know, just did my run, got in the sunshine, worked on my citrus grove. I mean, all kinds of just fun California things to do. What is your citrus grove? Wait, what is your citrus grove? So I, you know, we moved back to California and I grew up here, you know, pretty much. And I was gone for almost 20 years.

3:52And I said, if we're moving back, I really, I got to have an orange tree. I got to have a lemon tree. We actually grew a lemon tree in Colorado that I would take out every winter. I would bring in rather than in the summer, I would take it out and it would grow it on the deck. I mean, I was so citrus fixated because to me, that's like the sign of just, you know, it's live and it's so good and fresh citrus. And I remember the first summer took two to three years of growing this lemon tree, about four or five feet. You know, it was a big ass planter and we had it on rollers so I could roll it in and out in the Colorado sun, which is amazing and it's incredible.

4:25But obviously the winners, we had to bring it inside into our little solarium. And I was growing this lemon and I was so excited. It had this beautiful lemon. It was green. It was just starting to get a little bit yellow. And then a squirrel ate it and it was the worst. The thing that was so bad about it, because I love my nature and our wildlife, but it just, it hated it. It cut it, it bit it out, and it tried to eat it. It was like, this sucks. And so this lemon that I've been nurturing for months to have my first lemon off my Colorado lemon tree, this goddamn squirrel ate it. So I was so pissed.

5:00Didn't get to enjoy it. And then finally, you know, got the call to come back to UCLA, and I said, we're having trees. And so it started off with, like, one lime tree, and then I got a couple Meyer lemon trees. And now I've got navels and pomegranates, which I know are not citrus, but they're in my little grove. I've got grapefruit trees. I've got a couple of Eureka lemons, a couple of tangerines, kumquats, kalmandin, you know, those little delicious kumquat-like varieties are fantastic. Yeah, so I have about 13 or 14 trees that I love to tend to as sort of my outdoor therapy and getting a little bit of the sunshine.

5:34So, yeah, and I'm not allergic to any of those things. So sucks to be you, man. I was going to say, my hometown is the birthplace of Johnny Appleseed, so we're an apple. No way. Yeah. All right, what's your favorite apple variety? Is it Cosmic Crisp? Gotta go Fuji. Oh, really? Okay, yeah. I got turned on to the Cosmic Crisp, which are absolutely fantastic, but yeah, Fugees are great. Yeah, they're kind of a West Coast thing. I think they're grown in Washington, but they're pretty delicious. So that's what I got going on. You are a man of many talents. I don't know about that. Musicians. surgeon, wood major, and grove master.

6:13Grove master, yes. I did spend time when I was a kid. I had a really good friend whose dad had a citrus farm and avocado farm. So I did learn a few things when I was growing up and we spent the weekends down there in San Diego. So maybe I had that, but bottom line is it's great to have your own fresh citrus. So cool. Amen. So that's my deal. Hey, should we do something like medical or do you want to just talk about citrus? And well, we did start out with allergies, for example. I love vitamin C. Vitamin C, scurvy. That's where you get limeys from. No offense to my British listeners, by the way.

6:42I won't call you limeys anymore. I promise that's sort of a 17th or 18th century insult. But it's a supplement that works. Vitamin C is a supplement that works. So you heard it here. Not all supplements are bad. Yeah, I don't know. I was thinking about talking about ejaculatory disorders because when we started this gig a while back, one of our first guests was Natalie Feingold-Goldberg, who is a sex therapist. And we brought up premature ejaculation, brought up delayed ejaculation, touched on a little bit, but it's something that's so common in my practice that I thought maybe we actually do a little Q &A with what's on your mind, as well as a little physiology for our, and anatomy, I guess, for that matter, for our listeners out there, just because I think it is something that you can't talk about enough.

7:24And it just always comes up and it can be vexing for my guys, as well as the partners they're with. So let's talk Welcome to the mailroom. Let's talk about it. Yeah. So talk to me about, well, you tell me what you know about premature ejaculation, delayed ejaculation. What's the difference between ejaculation and orgasm, for example? Okay. Ejaculation actually is the release of sperm. Boom. Sperm. The money shot. And orgasm is something more internal. Orgasm is the euphoric feeling of when one expels a load of semen. Yeah. So that's the difference between ejaculation and orgasm. So there are guys, the most common are men after prostate cancer surgery, where we take out their ejaculation organs, which are the seminal vesicles and the prostate where the fluid is made, but they still have orgasms.

8:15In fact, sometimes they have more intense orgasms afterwards because they don't have that fluid to expel. So the same muscles are just squeezing joy and euphoric feelings up in the brain. And so orgasm is that sensation. and ejaculation is the fluid. So actually, I think that's a reasonable place to start. So I think about ejaculation and orgasm in physiologic anatomic terms. So there is a nerve that is on the tip of the penis in the area we call the frenulum, which is if you're standing up, looking down at your penis and you see the head right on the opposite side of that head. So at the six o 'clock position, that's an incredibly sensitive part of the penis.

8:58And it's also we call an ejaculatory reflex arc, which comes about midway into your spinal cord around T10 to T12, somewhere in there. And it is what causes us to have a orgasm through stimulation, which would be either hand, mouth, vibrator, orifice, anus, vagina, however, pillows, whatever. You know, there's a lot of different ways that guys can generate an orgasm and an ejaculation. And it does stimulate that T12 reflex arc. And so even in guys with spinal cord injuries, interestingly enough, if their injury is above that area, they can actually still have an ejaculation and potentially an orgasm because that arc is intact.

9:44So that's the beginning of this. The deeper center for orgasm actually is in the tiny sympathetic nerve fibers that surround the prostate. And so there are guys that talk about having prostate orgasms, and that's a real thing too, because you can stimulate the nerve fibers right at the level of the prostate, usually through rectal massage. Rarely can guys do it through the perineum because it's a little bit too much skin in the way. But essentially, that's the other way to have an orgasm is through prostatic massage. and now we go up to the brain and there's about five different hormones that are necessary for a guy to be able to have an orgasm and ejaculation just guess one you have five different ones so just give me one i feel like you're one of my medical students now dopamine yeah okay that's yeah damn dopamine good yeah i mean that's that's number one dopamine is that feel-good hormone so that's one serotonin yeah number two why are you googling this come on open book yep dopamine serotonin oxytocin oxytocin wow there's two more i mean the big one that like you know everybody and everybody and everybody's on it the big t man testosterone oh Oh, duh.

11:03And then the last one is prolactin. So you got the three hard ones. Yeah, yeah. So any disorder in any of those or any drugs that we take can cause disorders in ejaculation based on how they perturb any of those levels from testosterone to dopamine to everything in between. So in order to have a good intact orgasmic response, and by the way, those are pretty much the same in women as men. All those hormones are conserved across gender. And so even testosterone. So women that have hypoarousal disorder, where it's very difficult for them to get aroused or have orgasms, often have low testosterone.

11:37So you got to have hormones and you got to have nerves. And those are really the two different ways that we think about orgasm. And so when we think about disorders of orgasm and ejaculation, we think about them as a spectrum of timing. And what I mean by that is there are men that have incredibly shortened ejaculatory responses where they, what we often refer to as premature ejaculation or rapid ejaculation, where briefly after stimulation, sometimes even prior to penetrative intercourse, a man will ejaculate. And that is almost always a reflex issue. And when I try to unshame this and a guy comes into me, because again, this is something guys get judged with, they get compared to other partners with.

12:24It's an incredibly shameful thing for guys to go through. And it doesn't have to be. The reason for that is that when I went to medical school and I did my rotations, one of the rotations that we did is in neurology where we all walked around with their reflex hammers, Maxwell's silver hammer for Beatles fans out there. which I think he used for very different purposes, but it probably started off as a reflex hammer. And it was this little rubber mallet that you would hit right under the kneecap. And that was a great way to test our reflexes. I'm sure if you're at any high school physical, everybody remembers sitting down in the doctor's office with their knees hanging over the bed and she or he hit your reflex and you kicked your knee out.

13:04And we graded that from zero to two, I believe, or two plus where a guy could be hyper reflexic. So those knees, that knee reflex, and the same thing we can do in the elbow is very important for our ability to know how well we're doing neurologically. And if a guy has diminished reflex or hyperreflexia, there could be a neurologic condition. Well, I kind of look at ejaculation the same way because I just said that that reflex arc at the tip of the penis is very important for determining how much stimulation you need to form an ejaculation. Some guys, the wind blows funny, boom, you know, they ejaculate.

13:42Some guys, they can have penetrative sex for minutes upon hours and not be able to ejaculate. And a lot of that is delayed reflex. So that's the way I look at this. I talk about physiology and, you know, I'm good friends with and colleagues with Natalie Feingold-Kolberg, who we had on a few episodes ago, 20-odd. and we talk about that, that a lot of my sex therapists, you know, they want me to correct the physiology so that they can deal with the psychological manifestations of the physiologic or anatomic abnormalities. So whether it's about the size of a guy's penis or whether it's about how quickly they ejaculate, there are things I can do anatomically and physiologically to improve those.

14:21So then my therapist job is a little bit more, I don't know, synergistic. We work together better that way. Okay. So that's the anatomy, the physiology of an ejaculation in six short minutes, I'm just guessing on the time. So what can go wrong? So a guy can either come too fast or he can not come at all. And what can we do to treat all of those? And so I think what I would love for you to do, because I just feel like I talk all the time, Jordan, I want you to put on your journalist hat and pretend like I'm not Ringo Starr. But, you know, as a Rolling Stone journalist extraordinaire, you know, in your former life, interview me.

14:59Tell me what you want to know about ejaculation, the good, the bad and the ugly. What are the most common issues that you see in your practice? I think the majority of guys, and I think this bears out in the literature and surveys, is that most men are more concerned with premature ejaculation. It is something that especially happens, we think, in younger people. And often it starts off with less experienced men because all of this is new to them and their nerves. And so it's something that is prevalent. And there are all kinds of treatments out there, including a lot of off-label things that we use.

15:34In fact, there's actually no FDA approved drug for premature ejaculation. So whatever I write for, if I'm writing a prescription, it's not going to be FDA approved. But yeah, I would say premature ejaculation is the most common one. So the first thing I want to do is rule out any other things going on. You know, I do a full evaluation. Often I will even check hormones because I just don't want to miss anything. But most of the time, the guy with premature ejaculation is perfectly healthy. otherwise it doesn't really indicate any other underlying hormonal pathology or any neurologic dysfunction and it's just a matter of how do we diminish that trigger how do we diminish that t12 reflex arc or that pathway at the frenulum and so for me the common treatment for this is is to do something to diminish the sensitivity not to the point where the guy is numb or not to the point where he could spread any treatment i give to him to his partner especially having a penis and vagina panasex or PNV sex.

16:32But there are really good over-the-counter topical creams and sprays. You can get them online. You can get them at CVS, Target, I think, anywhere that, and I don't endorse any of these, but they're pretty easy to find in Google, is to help decrease that sensitivity so that when a man's having direct stimulation of that area, they don't have that quick trigger. And so I think that's first line. Anybody, it's safe, it's effective. And most of time guys don't complain that it gets to the point where they can't have any sensitivity at all. It's just enough so they can have incredibly meaningful sex and last longer than they would without it at all.

17:08So that's my, that's my first line therapy. Now, do you see, have you noticed in your practice that younger men these days are having more issues with ejaculation than men previously? You know, I think it's what it is, is just becoming much more prevalent and much more talked about. And, you know, one thing we also didn't talk about, which was huge in the zeitgeist is ejaculate volume and this idea of load maxing and shooting ropes. And again, that goes back to what it all goes back to. It seems like when we talk about sex on this podcast is what are your expectations based on what you see on the internet or in pornography?

17:42And so it goes back to the athleticism of some of our adult entertainers that are able to ejaculate volumes of semen and be able to hold their ejaculation through what seems like interminable sexual relations. and that to the average guy, especially some that's not so sexually experienced, thinks that that is what they aspire for. And again, as we talk about so often in the show, most people, especially, well, I should say, most people that have vaginas are not orgasming through penetrative intercourse. And so sometimes too much can actually be too much. And so this is not the goal as to how long are you able to hold out before you orgasm.

18:22But if you do have a partner that does orgasm through vaginal intercourse and you can time it, then this idea of simultaneous climax is a pretty great aspirational thing, but functionally it doesn't really happen that often and is something more in romance novels and in fireworks on scene. So again, don't aspire for something that probably doesn't exist that often in nature.

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21:37Backing it up a little bit, you talked about too soon, too late, for lack of a better term. In real numbers, what is a realistic, what is the normal amount of time? And I hate using the word normal, but... Yeah, I love it. No, actually, there are clinical definitions of what we consider premature ejaculation. And really, the best definition I have is that any time that a patient or his partner is not satisfied with the length of time prior to ejaculation and orgasm, that is what I would consider not long enough because there are some guys that, again, have such severe, I think, is reasonable to say premature ejaculation, rapid ejaculation, that they're having an orgasm prior to even having penetrative sex.

22:22And so that's on one end of the spectrum. The typically agreed upon term is, you know, somewhere under a couple minutes. It's, you know, the average sexual expanse from insertion. Again, this is based on penis and vagina sex for the most part, because that's what we have standardized questionnaires for. Unfortunately, we don't have great other alternative methods of having sex from anal and oral intercourse. But it is this two minute to five minutes is kind of a normal time from insertion to orgasm. And so that means anything greater than that. If again, it's causing discomfort to either the patient or the partner, then that could be delayed ejaculation.

22:59And so really the sweet spot depends on the couple. You know, for some it's the partner comes first and then it's just a matter of the man or the person with the penis that is able to finish whenever at their leisure because the other person has already achieved orgasm. Then premature ejaculation, delayed ejaculation becomes less of an issue. And there are some men who struggle to orgasm during partnered sex, even though when they're alone, that is not a problem. other than performance anxiety or any kind of other psychological issues. Are there some physiological reasons for that? Yeah, I mean, there are.

23:35I mean, I think that I kind of not joke about it, but I do want people to kind of think about the fact that if a man has been used to the feeling of his own hand and grip strength for a long period of time and spends a lot of time in masturbation, then that's a feeling and that's a neurologic condition response that when he goes to have penetrative intercourse with a partner, it may not feel the same way to those nerves and so there can be a desensitization to that i'm not here to judge on you know what the appropriate amount or the ratio of of single versus partnered sex should be because i don't think anybody has an answer to that except for if it becomes a problem where it's pathologic and somebody's having more partnered or more solo sex than partnered sex and the partner's like hey what's going on then that becomes a problem but but for sure it's not as simple as just a psychological issue saying i can't orgasm with my partner, but I can by myself, but it can be definitely a relationship issue that needs to be explored.

24:32And really the therapy for that depends. Sometimes it is sex therapy. Sometimes it is not having solo sex and manual sex for a period of time, and then having engaging in normal penetrative intercourse with a partner that can help some guys through this. But yes, a condition response is for sure. I mean, again, it's a neurologic issue. And if you desensitize the penis or you get used to only one sensation to orgasm it's the same thing with positions i mean there's some men that can only orgasm in one position versus another position and it's that same condition response some of that isn't pathologic as long as you're okay with it in other words as long as you and your partner are okay and you're both sexually satisfied then everything else is just judgment and we don't judge here man i guess dumbtail with that there's a phrase that's become very buzzy I've seen on the internet lately.

25:22I was curious if it's crossed your path in your practice. Death grip syndrome. Does that mean anything to you? Well, I can only imagine, but obviously we have different feeds. I mostly get updates on my sabermetrics on my Dodgers and my inbasket. But okay, Jordan, again, I'm not judging. I've not had any death grip syndrome feet. But it sounds like, yeah, guys are probably using way too much manual grip strength in order to induce an orgasm. So they're used to that incredible level of grip strength, or just the right amount of stimulation, which again, goes back to the whole deal is if you're only doing it one way, then that can condition that response so that that's the only way you're ever going to orgasm and your partners don't stand a chance.

26:08And I think that is much more common than And we think, and one that probably does take a lot of retraining and maybe a little bit of sex therapy, but mostly probably neurologic reconditioning so that they can have a better sex life and not induce death grip syndrome in order to have that same ejaculatory response. That's sad. I mean, I haven't heard of death grip syndrome, but boy, now I can't unthink it or unsee it probably. And I'll go back to my office today and have three guys that have death grip syndrome in my clinic because of you now. Death grip. Weren't they one of the big four in post-punk?