ABSTRACTIntroduction

Delayed ejaculation (DE) is a poorly understood and uncommon male sexual dysfunction. The etiology of DE includes psychological and biological factors, which are usually combined. Herein, we report a case of acquired and situational DE due to improper male condom size.

Aims

To identify and correct the possible cause of acquired and situational DE.

Methods

A male patient presented with new-onset DE for 6 months. His physical and mental examination was unremarkable. Laboratory results were all normal. He was diagnosed with acquired, situational DE and received sessions of sexual counseling. However, his DE persisted until he accidentally used a larger condom. He then reported normal orgasm.

Main outcome measures

Resolution of acquired and situational DE.

Results

His DE was improved after using a more proper condom size.

Conclusion

Most patients are believed to have psychological problems and proper condom use is under-recognized. To the best of our knowledge, this is the first report of DE caused by this etiology.

Wainipitapong S, Wiwattarangkul T, Bumphenkiatikul T. Delayed Ejaculation Due to Improper Male Condom Size: A Case Report. Sex Med 2021;9:100373.

Key WordsDelayed ejaculation (DE) is a poorly understood and uncommon male sexual dysfunction, characterized by a marked delay, or even absence, in ejaculation. The etiology of DE includes psychological and biological factors, which are usually combined.1Delayed ejaculation: pathophysiology, diagnosis, and treatment. DE can before according to onset (lifelong or acquired subtype) or circumstance (generalized or situational subtype). Each subtype requires different approaches and treatments.2American Psychiatric Association
Diagnostic and Statistical Manual of Mental Disorders: DSM-5. Herein, we report a case of acquired and situational DE due to improper male condom size.CASE REPORT

A 22-year-old Thai male presented with DE for 6 months. He reported that he had normal ejaculation until he had broken up with his girlfriend before the onset of DE. He then had protected intercourse with multiple partners and noted ejaculation problems. His desire and erection were intact. He had no pain or other difficulties except that he could not reach orgasm during vaginal intercourse. His ejaculation remained normal in masturbation and oral sex. He denied a history of drug abuse, underlying diseases, or any psychological problems apart from distress caused by DE. The physical and mental examination was unremarkable. Laboratory results were all normal except his level of serum testosterone at 729 ng/dL (171.1-716.3 ng/dL) which was slightly increased and could not explain his symptom. He was diagnosed with acquired, situational DE and received sessions of sexual counseling. However, his DE persisted until he accidentally used a larger condom. When using a condom 58 millimeters (mm) in width instead of his regular 56 mm size, his DE partially improved. Since commonly used condom sizes in Thailand range from 49 to 56 mm, larger sizes are rarely sold.

He was reassessed for a comprehensive history taking and physical examination. Before his DE, he had only one regular partner, so he did not think it was necessary to use a condom. His stretched penile length was 17.3 centimeters (cm) and 15.2 cm in circumference, while his flaccid penile length was 7.1 cm and identified as normal in the initial examination. He was suggested to use a larger condom and his DE was significantly improved with a condom size of 62 mm in width. He then reported normal orgasm and realized that the size does matter.

DISCUSSIONAll sexual dysfunctions can disturb individual sexual satisfaction as well as the quality of life. Delayed ejaculation (DE) is one of these dysfunctions that has received less academic attention. According to the Diagnostic and Statistical Manual of Mental Disorders; 5th edition, DE symptoms include a marked delay, infrequency, or absence of ejaculation on all or almost all partnered sexual activities. The symptoms should not be explained by other mental or medical conditions, and persist for more than 6 months, and cause significant distress.2American Psychiatric Association
Diagnostic and Statistical Manual of Mental Disorders: DSM-5. Another DE diagnostic criterion proposed by the International Society of Sexual Medicine focuses on long intravaginal ejaculation latency time.3Reexamining the definitions of PE and DE.Our patient was diagnosed with DE according to both criteria. He reported a recent breakup with his girlfriend before the symptoms. Complete history taking and physical examination demonstrated no signs and symptoms of medical etiologies. Slightly high testosterone level, which could be found as a variation, was not responsible for DE.4Alwaal A Breyer BN Lue TF. Normal male sexual function: emphasis on orgasm and ejaculation. We initially diagnosed the patient with a psychogenic, acquired, situational DE after excluding probable biological factors, such as congenital anatomical anomalies, neurological or endocrinological diseases, inflammation, or history of using DE-inducing medication.The critical point was his history of condom use which at the time was not recognized as important. The patient-reported a history of DE during vaginal intercourse but did not mention his condom use. He had never used any protection during the relationship with his previous partner because he had a single regular partner. This is in line with a previous study that demonstrated that having intercourse with a regular partner is the leading cause of not using a condom.5Bjekić M Sipetić-Grujičić S Vlajinac H et al.Reasons for not using condoms among heterosexual men in Belgrade, Serbia. He then started to use condoms for sexually transmitted disease prevention after the breakup since he had multiple partners afterward. He could not detect that his condom was too small and tight. His desire and erectile function were intact. He had no pain and misunderstood that the condom size he used was the most proper since it was the largest size generally available in Thailand.Condoms are considered to have no side effects other than allergic reactions and sexual dissatisfaction. However, one qualitative study reported that decreased sensitivity during intercourse is believed to inhibit male orgasm and prolong the sexual encounter.6Davis KC Schraufnagel TJ Kajumulo KF et al.A qualitative examination of men's condom use attitudes and resistance: “it's just a part of the game. Since genital stimulation is an important part of the ejaculation process, decreasing penile sensations by condom use could explain a delay in ejaculation. The penile vibrotactile threshold is confirmed to be higher in a penis with a condom which indicates the decreasing penile sensitivity.7Hill BJ Janssen E Kvam P et al.The effect of condoms on penile vibrotactile sensitivity thresholds in young, heterosexual men. The same study also found that the vibrotactile sensitivity threshold in an erected penis was higher compared to a flaccid penis. The condoms use in this study were standard condoms, therefore, data of variation in condom size, thickness, and texture are still lacking. We believed that the threshold could be further heightened in a condom that is too tight by affecting penile innervation, resulting in DE as presented in our patient.Compared to those using appropriate condom sizes, the prevalence of orgasm difficulty among ill-fitting condom users is higher (95% CI 1.39–2.62, P-value .001).8Crosby RA Yarber WL Graham CA et al.Does it fit okay? Problems with condom use as a function of self-reported poor fit. Tight condoms could also cause erection difficulty, pain, condom breakage as well as slippage since condoms that are too small are not able to cover the length of the penis.9Crosby RA Graham CA Yarber WL et al.If the condom fits, wear it: a qualitative study of young African-American men.In Thailand, a variety of condoms with different textures and thicknesses are available. However, the available condom size has been limited with a range from 49 to 56 mm in width. Hence, men with a need for a larger condom size such as our patient might experience sexual dysfunctions, which are underreported. Sexual issues are a forbidden topic in Thailand and other Asian countries. Clinicians should be aware of this hidden issue of improper fit between a condom and penile size since this might be the key to patients’ proper treatment.CONCLUSION

Most patients are believed to have psychological problems and proper condom use is under-recognized. An inappropriate condom size can cause DE. This issue should be included in history taking, especially in patients with the acquired and situational subtype of DE. To the best of our knowledge, this is the first report of DE caused by this etiology.

Statement of Authorship

Sorawit Wainipitapong: Conception and design of the study, Acquisition of data, Analysis and interpretation of data, Drafting the article, Revising it critically for important intellectual content, Final approval of the completed article; Teeravut Wiwattarangkul: Conception and design of the study, Acquisition of data, Analysis and interpretation of data, Drafting the article; Thanapob Bumphenkiatikul: Revising it critically for important intellectual content, Final approval of the completed article.

ACKNOWLEDGMENT

We thank Dr. Yanin Thipakorn for her kind advice in grammatical reviews.

REFERENCES

Delayed ejaculation: pathophysiology, diagnosis, and treatment.

World J Mens Health. 36: 22-40American Psychiatric Association

Diagnostic and Statistical Manual of Mental Disorders: DSM-5.

5th edition. American Psychiatric Association, Arlington, VAhttps://doi.org/10.1176/appi.books.9780890425596

Reexamining the definitions of PE and DE.

J Sex Marital Ther. 43: 633-644Alwaal A Breyer BN Lue TF.

Normal male sexual function: emphasis on orgasm and ejaculation.

Fertil Steril. 104: 1051-1060Bjekić M Sipetić-Grujičić S Vlajinac H et al.

Reasons for not using condoms among heterosexual men in Belgrade, Serbia.

Acta Dermatovenerol Croat ADC. 26: 58-60Davis KC Schraufnagel TJ Kajumulo KF et al.

A qualitative examination of men's condom use attitudes and resistance: “it's just a part of the game.

Arch Sex Behav. 43: 631-643Hill BJ Janssen E Kvam P et al.

The effect of condoms on penile vibrotactile sensitivity thresholds in young, heterosexual men.

J Sex Med. 11: 102-106Crosby RA Yarber WL Graham CA et al.

Does it fit okay? Problems with condom use as a function of self-reported poor fit.

Sex Transm Infect. 86: 36-38Crosby RA Graham CA Yarber WL et al.

If the condom fits, wear it: a qualitative study of young African-American men.

Sex Transm Infect. 80: 306-309

Department of Disease Control. Condom. Bangkok: Ministry of Public Health of Thailand; 2016. Available at: https://ddc.moph.go.th/disease_detail.php?d=43. Accessed February 23, 2021.

Article InfoPublication History

Published online: May 30, 2021

Accepted: March 29, 2021

Received: March 18, 2021

Footnotes

Patient informed consent: Written informed consent was obtained from the patient. This report was approved by the Institutional Review Board of the Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.

Conflict of Interest: The authors report no conflicts of interest.

Funding: None.

Identification

DOI: https://doi.org/10.1016/j.esxm.2021.100373

Copyright

Copyright © 2021 The Authors. Published by Elsevier Inc. on behalf of the International Society for Sexual Medicine.

User License Creative Commons Attribution – NonCommercial – NoDerivs (CC BY-NC-ND 4.0) | How you can reuse Permitted For non-commercial purposes: Read, print & download Redistribute or republish the final article Text & data mine Translate the article (private use only, not for distribution) Reuse portions or extracts from the article in other worksNot PermittedSell or re-use for commercial purposes Distribute translations or adaptations of the article
Elsevier's open access license policy ScienceDirectAccess this article on ScienceDirect Related Articles