When men think about their sexual woes, erectile dysfunction (ED) usually comes to mind. But some face a different obstacle they may not think to discuss with a doctor—and that doctors themselves may not think to ask about. Despite being able to have erections, a man can have trouble reaching a satisfying climax. Unlike ED, inhibited ejaculation lacks FDA-approved remedies that doctors can offer.

"It's a tough problem because there just isn't a lot out there," says Dr. Michael O'Leary, a professor of surgery at Harvard Medical School and a urologist at Brigham and Women's Hospital.

Tough, but not always insurmountable. The possible causes of inhibited ejaculation are many. It may be a side effect of medication or spring from psychological or relationship issues. Discussing it with your doctor is the key first step to a solution.

Root causes

Most men ejaculate within four to 10 minutes of starting sexual intercourse. But if you try to reach climax for an extended period of time and give up in frustration or fatigue, chances are you are experiencing inhibited ejaculation.

Anything that disrupts nerve function in the pelvic region could potentially interfere with ejaculation and other aspects of male sexual function. First, rule out the simple things—like the effects of alcohol.

Also, with aging it may take somewhat longer to reach ejaculation, which may be less forceful, have a lower volume, and be accompanied by a less intense orgasm.

Medical causes

There are some strictly medical causes of inhibited ejaculation that your doctor may be able to help with. Most commonly, prescription medications can interfere with ejaculation. For instance, certain drugs for high blood pressure, such hydrochlorothiazide (HydroDiuril, others) and methyldopa (Aldomet, others), can cause inhibited ejaculation. Ask your doctor or pharmacist if you are taking anything that could affect sexual response.

However, Dr. O'Leary says, by far the most common cause of medication-induced delayed ejaculation is the use of selective serotonin reuptake inhibitor (SSRI) antidepressants. Men who cannot switch from an SSRI to another medication may benefit from taking an ED drug, such as sildenafil (Viagra), vardenafil (Levitra), or tadalafil (Cialis).

To counteract inhibited ejaculation caused by SSRIs, some doctors may prescribe drugs "off label" that the FDA has already approved for other uses. These include the Parkinson's disease drug amantadine (Symmetrel) and the antihistamine cyproheptadine (Periactin).

Anything that disrupts nerve function in the pelvic region could potentially interfere with ejaculation or erectile function.

New medication option?

Physicians may consider a new option for off-label prescribing: cabergoline (Dostinex, generic). In a small pilot study presented at the 2012 American Urological Association meeting, 50 of the 72 participants (69%) said their orgasms improved after taking 0.5 milligrams of cabergoline twice a week for an average of 10 months. Of the 50 men who said things got better, half (26) said their orgasm returned to normal.

The cabergoline finding is limited to a single clinic, over a relatively short period of time, in one group of men taking a single medication, and in a trial lacking basic controls for placebo effects. It's possible that the men involved in the study might have recovered their ability to experience orgasms over time for reasons unrelated to taking cabergoline.

On the other hand, treatments for inhibited ejaculation are lacking to such a degree that any news is good news. Dr. O'Leary, for instance, says cabergoline is now a possible option for his patients. "It's a drug we're familiar with for a relatively rare condition," he says. "It's worth a try and unlikely to be harmful."

Counseling

Frequently, delayed or absent ejaculation traces to something other than side effects of medication, says David L. Rowland, PhD, professor of psychology at Valparaiso University and author of a textbook for health professionals, Sexual Dysfunction in Men. "Although some men suffer from inhibited ejaculation due to a medical issue," Rowland says, "just as many do not have a clear medical or health related problem that could explain it."

In that case, the condition may be related more to a man's relationship with his partner, to lack of communication about sexual needs, to not feeling sufficiently aroused, or unfulfilled sexual expectations. "For these men, having a fuller understanding about the problem and discussing it with an expert counselor represent possible strategies to help with the problem," Rowland says.

It's best to find someone with experience treating sexual issues. Therapy is frequently successful for motivated couples prepared for a frank discussion.