Abstract
Background
Among causes of male sexual dysfunction, the prevalence of delayed ejaculation (DE) is lower than that of premature ejaculation or erectile dysfunction (ED), and its epidemiology remains poorly characterized, particularly in Asian populations.
Aim
To estimate DE prevalence and identify associated factors of DE in a nationwide sample of Japanese men.
Methods
A cross-sectional, internet-based survey conducted by the Clinical Research Promotion Committee of the Japanese Society for Sexual Medicine between May 29 and June 24, 2023, targeted Japanese men aged 20-79 years through a general population panel. Among 6228 valid responses, 5331 men who reported sexual activity were included in the analysis. DE-related distress was used to define the condition. Data on demographics, medical comorbidities, lifestyle factors, and sexual function were collected. Participants were also asked whether they desired treatment for DE and whether they had consulted a physician regarding this condition. Associated factors were identified through multivariate logistic regression analysis.
Outcomes
Prevalence of DE, associated demographic and clinical factors, treatment-seeking desire, and actual help-seeking behavior among sexually active Japanese men.
Results
The prevalence of DE was 5.16%. Of the affected individuals, 58.18% desired treatment, but only 11.88% actually sought it. Multivariate analysis revealed that psychotropic drug use (odds ratio [OR] = 2.41), pelvic trauma (OR = 2.39), low partnership satisfaction (OR = 2.27), ED (OR = 2.04), neurological diseases (OR = 2.02), obesity (OR = 1.51), high frequency of masturbation (OR = 1.24), and high frequency of sexual intercourse (OR = 1.17) were significantly associated with DE (all P < .05). Conversely, having children showed an independent association with a lower likelihood of DE (OR = 0.57, P < .001).
Clinical Implications
These findings highlight that DE is associated with multiple psychological, sexual, and physical health factors and that treatment-seeking behavior remains low despite substantial distress.
Strengths and Limitations
This large, nationwide epidemiological study on DE in Japan is the first with a robust sample size and multivariate analysis. However, the reliance on self-reported data and internet-based sampling may introduce reporting bias and limit generalizability.
Conclusion
DE affects approximately 5% of sexually active Japanese men and shares many risk factors with ED. Although more than half of those with DE desire treatment, only a minority seek care. Greater clinical awareness and patient education are warranted.
Keywords: Associated factors, cross-sectional studies, ejaculatory dysfunction, internet, prevalence
Introduction
Delayed ejaculation (DE) considered either a consistent and bothersome inability to achieve ejaculation or excessive or increased ejaculation latency despite adequate sexual stimulation and desire to ejaculate.1 DE can be categorized into lifelong DE (LDE) or acquired DE (ADE), with the former presenting consistently from a man’s first sexual experiences, and the latter developing later in life.1
DE is a complex and relatively underexplored male sexual dysfunction, with clinical significance that extends beyond sexual dissatisfaction to encompass psychological distress, interpersonal difficulties, and implications for reproductive health. The prevalence of DE is estimated to range from approximately 1.2% to 6.3% among community-dwelling men.2–4 Specifically, the prevalence of LDE is around 1%, and ADE may affect up to 4% of sexually active men; however, the evidence supporting these estimates remains limited.4 Although less frequently reported than erectile dysfunction (ED) or premature ejaculation (PE), DE remains a condition of substantial clinical concern. However, these estimates are likely conservative due to diagnostic ambiguity, cultural stigma, and lack of large-scale population-based data—particularly from non-Western settings.5 Notably, the Global Study of Sexual Attitudes and Behaviors found that help-seeking behavior was infrequent, highlighting a substantial gap between sexual health needs and clinical engagement.6–9 The pathogenesis of DE is recognized as multifactorial. Biologically, DE has been associated with selective serotonin reuptake inhibitors (SSRIs) use, other psychotropic agents, neurological conditions, and endocrine dysfunction.4,10,11 Psychological factors, including performance anxiety and maladaptive masturbation practices—such as high-frequency, idiosyncratic techniques that are not easily replicated during partnered intercourse—have been identified as potential contributors to the development and persistence of DE.12 Sociocultural and economic factors may also impede the recognition and treatment of DE, with studies from Denmark, Brazil, and the Republic of Korea reporting that stigma, aging-related normalization, and limited sexual health literacy often prevent men from seeking help.7,8,13 Despite increased interest in male sexual dysfunctions, DE remains particularly under-researched in Asia. In Japan, large-scale studies have been conducted on ED and PE. A recent nationwide survey reported that the prevalence of ED as indicated by an Erection Hardness Score (EHS) ≤ 2 was 30.9%, corresponding to approximately 14 million men in Japan.14 Notably, the prevalence of ED was unexpectedly high even among younger men, with 26.6% affected in the 20-24-year age group. This study highlights a decline in sexual function across age groups, particularly among younger generations.14 Also, a recent nationwide survey reported that 23.39% of Japanese men experienced distress related to PE.15 According to the International Society for Sexual Medicine definition, the prevalences of lifelong and acquired PE were 0.54% and 3.47%, respectively, and ED was the most consistently associated factor. Despite the high level of distress, only 4.81% of affected individuals sought medical care.15 However, no epidemiological data on DE in Japan have been published to date. This study addresses this knowledge gap by presenting results of the first nationwide, internet-based survey on DE among sexually active men in Japan, under the auspices of the Clinical Research Promotion Committee of the Japanese Society for Sexual Medicine (JSSM). This study aimed to determine the prevalence of DE and test the hypothesis that DE is significantly associated with specific sociodemographic, clinical, and psychosocial characteristics. To examine this hypothesis, we asked: What is the prevalence of DE among sexually active Japanese men, and what factors are independently associated with its presence?
Methods
Study design
To comprehensively study male sexual dysfunction, a nationwide internet-based, cross-sectional survey of men aged 20 to 79 years was performed to evaluate DE prevalence and its associated factors in Japan. During the four-week period between May 29 and June 24, 2023, 37 485 men were invited to participate. The inclusion criterion required that participants engaged in sexual intercourse, with only valid responses being analyzed. The Regional Ethics Committee of Juntendo University, Tokyo, Japan, approved this study (approval number: E22-0452). All subjects provided informed consent at the time of enrollment.
Survey instruments
To estimate the prevalence of DE, participants were asked a direct yes/no question regarding whether they experienced distress related to DE. While no universally established diagnostic criteria for DE, LDE, or ADE currently exist, classifications were made based on self-reported responses to questions aligned with descriptions outlined in the American Urological Association/Sexual Medicine Society of North America (AUA/SMSNA) Guideline.1 These pragmatic definitions were adopted to facilitate consistent self-reported assessments in the context of a large-scale, population-based survey.1 Demographic and clinical data, including ED (determined from the EHS), were collected.14 Factors including neurological disorders; a history of trauma, pelvic surgery, or cardiovascular diseases; and psychological factors were assessed via a structured yes/no questionnaire, as were lifestyle factors, psychotropic drug use, and dissatisfaction in sexual relationships with partners. Sexual relationship satisfaction was evaluated with the International Index of Erectile Function (IIEF), item 14, that asks, “How satisfied have you been with your sexual relationship with your partner?” This validated measure of satisfaction with a participant’s sexual relationship helps to assess how sexual dysfunction affects interpersonal dynamics.16 Sexual desire was evaluated using IIEF items 11 and 12. Item 11 (Desire frequency) asked, “How often have you felt sexual desire?” Item 12 (Desire level) asked, “How would you rate your level of sexual desire?” These validated items allowed for quantification of both the frequency and subjective intensity of sexual desire, contributing to a more comprehensive understanding of sexual function in relation to DE.16
Presence of differences in demographic and clinical characteristics were investigated by directly comparing the LDE and ADE groups. Participants were questioned on their desire for treatment of DE and if they had sought medical consultation for the problem. Subsequently, discrepancies between treatment desire and true help-seeking behavior were analyzed.
Statistical analysis
Factors associated with DE were identified with univariate and multivariate logistic regression analyses. Variables with statistical significance from univariate analysis were analyzed in the multivariate model. The odds ratio (OR), 95% CI, and P values are presented. DE was coded as 1 and others as 0. For all categorical predictors, a lower score indicates a worse state (eg, presence of dysfunction or dissatisfaction), and a higher score indicates a better state. χ2 tests analyzed associations between categorical variables, whereas the Mann–Whitney U test analyzed continuous variables between the LDE and ADE groups, with χ2 tests used for analysis of the categorical data. Age-related trends were assessed using separate logistic regression models for DE. Statistical significance was indicated by a P-value <.05. Statistical analyses were performed with SPSS Japanese version 28.0 (IBM Japan, Tokyo, Japan).
Results
Participants
In total, 37 485 men were asked to participate in the survey, of whom 6228 submitted valid responses, yielding a 16.61% response rate. This analysis included 5331 men confirmed to be sexually active and who reported prior sexual intercourse, ensuring that the sample was appropriately aligned with the study’s objectives. Table 1 summarizes the respondents’ demographic and clinical characteristics. Men within the 45-49-year age group were most common (11.25%), whereas men aged 75-79 years constituted the smallest proportion (5.80%). Among the participants, 67.36% were married, and 61.04% reported having children. Notably, individuals in their twenties (ages 20-29) were predominantly unmarried and childless. With respect to occupation, company employees accounted for 55.03% of the cohort, whereas smaller segments comprised students (1.99%) and unemployed individuals (15.46%). These characteristics reflect a demographically and socioeconomically varied sample, thus providing a robust foundation for evaluating DE prevalence and its associated factors in a representative adult male population (Table 1).
Table 1.
Demographic and clinical background data of the respondents by age range.
| Age ranges in years | |||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 20-24 | 25-29 | 30-34 | 35-39 | 40-44 | 45-49 | 50-54 | 55-59 | 60-64 | 65-69 | 70-74 | 75-79 | Total (%) | |
| Total % | 4.45 | 6.27 | 6.83 | 8.29 | 9.38 | 11.25 | 11.18 | 9.23 | 8.55 | 8.84 | 9.94 | 5.80 | 100 |
| Marital status | |||||||||||||
| No | 91.56 | 62.57 | 45.33 | 32.81 | 33.60 | 32.50 | 31.21 | 30.08 | 24.34 | 19.32 | 13.77 | 10.36 | 32.64 |
| Yes | 8.44 | 37.43 | 54.67 | 67.19 | 66.40 | 67.50 | 68.79 | 69.92 | 75.66 | 80.68 | 86.23 | 89.64 | 67.36 |
| Having children | |||||||||||||
| No | 94.51 | 76.05 | 58.52 | 43.67 | 42.00 | 39.67 | 39.93 | 33.54 | 27.85 | 22.08 | 14.34 | 11.33 | 38.96 |
| Yes | 5.49 | 23.95 | 41.48 | 56.33 | 58.00 | 60.33 | 60.07 | 66.46 | 72.15 | 77.92 | 85.66 | 88.67 | 61.04 |
| Occupation | |||||||||||||
| Civil servant | 4.22 | 9.88 | 7.14 | 8.82 | 5.40 | 8.00 | 5.20 | 8.54 | 5.04 | 4.03 | 0.57 | 0.00 | 5.65 |
| Executive | 0.84 | 0.60 | 0.55 | 1.13 | 2.20 | 3.50 | 3.19 | 3.66 | 6.14 | 7.01 | 3.77 | 2.91 | 3.19 |
| Employee (clerical) | 5.06 | 14.97 | 16.76 | 16.06 | 17.40 | 19.17 | 17.95 | 14.63 | 14.25 | 7.86 | 2.64 | 1.29 | 13.04 |
| Employee (technical) | 20.68 | 35.33 | 31.87 | 28.28 | 27.00 | 25.50 | 25.00 | 23.58 | 20.39 | 5.73 | 3.58 | 2.27 | 20.77 |
| Employee (other) | 13.92 | 27.84 | 26.37 | 33.94 | 31.80 | 24.83 | 26.68 | 24.39 | 19.96 | 11.25 | 4.15 | 1.94 | 21.22 |
| Self-employed | 0.84 | 2.69 | 3.02 | 2.94 | 4.80 | 7.17 | 8.05 | 10.37 | 10.31 | 10.83 | 10.75 | 9.39 | 7.22 |
| Freelance | 0.84 | 0.90 | 2.75 | 1.13 | 2.20 | 2.33 | 2.68 | 3.05 | 1.75 | 2.55 | 3.77 | 0.97 | 2.23 |
| Stay-at-home husband | 0.00 | 0.00 | 0.55 | 0.23 | 0.40 | 0.50 | 0.50 | 0.41 | 0.88 | 1.06 | 1.32 | 0.65 | 0.58 |
| Part-time job | 8.02 | 2.10 | 4.12 | 2.94 | 2.60 | 2.17 | 3.86 | 3.66 | 6.58 | 11.04 | 13.77 | 5.50 | 5.50 |
| Student | 43.04 | 0.60 | 0.27 | 0.00 | 0.20 | 0.00 | 0.00 | 0.00 | 0.00 | 0.00 | 0.00 | 0.00 | 1.99 |
| Other | 1.69 | 2.40 | 3.02 | 2.04 | 2.60 | 3.67 | 1.85 | 3.66 | 2.41 | 5.10 | 4.15 | 5.18 | 3.17 |
| Unemployed | 0.84 | 2.69 | 3.57 | 2.49 | 3.40 | 3.17 | 5.03 | 4.07 | 12.28 | 33.55 | 51.51 | 69.90 | 15.46 |
Values are presented as percentages (%), unless otherwise specified.
DE prevalence
The study population showed a DE prevalence of 5.16% (275/5331). Among these participants, 1.73% (n = 92) were classified as having LDE, whereas 3.43% (n = 183) met the criteria for ADE. As shown in Figure 1, the prevalence of DE decreased significantly with age (P for trend <.001).
Figure 1.
Prevalence of delayed ejaculation by age group in a nationwide sample of sexually active Japanese men. The distribution across age groups demonstrates a significant trend (P < .001), with higher prevalence observed in younger age brackets.
Associated factors
Table 2 lists the results of the logistic regression analyses. The multivariate model showed use of psychotropic drugs to be significantly associated with DE (OR: 2.412, 95% CI, 1.676-3.471, P < .001), followed by a history of pelvic trauma (OR = 2.388, 95% CI, 1.179-4.838, P = .016). Other factors associated independently with increased odds of DE included low partnership satisfaction (OR = 2.270, 95% CI, 1.566-3.291, P < .001), presence of ED (OR = 2.035, 95% CI, 1.533-2.701, P < .001), presence of neurological disease (OR = 2.018, 95% CI, 1.102-3.694, P = .023), obesity (OR = 1.513, 95% CI, 1.145-2.000, P = .004), high frequency of masturbation (OR = 1.236, 95% CI, 1.146-1.333, P < .001), and high frequency of sexual intercourse (OR = 1.171, 95% CI, 1.101-1.244, P < .001). In contrast, having children was associated with a significantly lower likelihood of DE (OR = 0.570, 95% CI, 0.439-0.740, P < .001).
Table 2.
Clinical characteristics of the men with delayed ejaculation (DE+) and without delayed ejaculation (DE-).
| Univariate analysis | Multivariate analysis | |||||||||
|---|---|---|---|---|---|---|---|---|---|---|
| 95% CI | 95% CI | |||||||||
| Factor | DE + (%) | DE − (%) | P-value | Odds ratio | Lower | Upper | P-value | Odds ratio | Lower | Upper |
| Use of psychotropic drugs | 18.91 | 6.35 | <.001 | 3.440 | 2.492 | 4.748 | <.001 | 2.412 | 1.676 | 3.471 |
| History of pelvic trauma | 5.45 | 1.21 | <.001 | 4.724 | 2.649 | 8.425 | .016 | 2.388 | 1.179 | 4.838 |
| Low partnership satisfaction | 81.45 | 71.58 | <.001 | 1.744 | 1.279 | 2.378 | <.001 | 2.270 | 1.566 | 3.291 |
| Presence of erectile dysfunction | 38.18 | 27.18 | <.001 | 1.655 | 1.288 | 2.127 | <.001 | 2.035 | 1.533 | 2.701 |
| Presence of neurological disease | 7.27 | 2.27 | <.001 | 3.370 | 2.062 | 5.507 | .023 | 2.018 | 1.102 | 3.694 |
| Obesity | 32.00 | 21.08 | <.001 | 1.761 | 1.355 | 2.289 | .004 | 1.513 | 1.145 | 2.000 |
| High frequency of masturbation, median | Twice/week | Once/week | <.001 | 1.244 | 1.158 | 1.336 | <.001 | 1.236 | 1.146 | 1.333 |
| High frequency of sexual intercourse, median | Once/2-3 months | Once/year | <.001 | 1.092 | 1.039 | 1.148 | <.001 | 1.171 | 1.101 | 1.244 |
| Having children | 42.91 | 62.03 | <.001 | 0.460 | 0.360 | 0.588 | <.001 | 0.570 | 0.439 | 0.740 |
| Presence of phimosis | 40.00 | 27.59 | <.001 | 1.750 | 1.364 | 2.244 | .077 | |||
| Presence of mental illness | 16.36 | 5.76 | <.001 | 3.204 | 2.279 | 4.504 | .244 | |||
| History of pelvic surgery | 4.73 | 1.29 | <0.001 | 3.810 | 2.074 | 7.000 | .494 | |||
| History of aortic aneurysm surgery | 2.91 | 0.59 | <.001 | 5.020 | 2.279 | 11.055 | .648 | |||
| Age (continuous variable), median | 46.00 years | 51.00 years | <.001 | 0.980 | 0.972 | 0.987 | .770 | |||
| Presence of chronic kidney disease | 4.36 | 1.38 | <.001 | 3.250 | 1.740 | 6.071 | .774 | |||
| Marital status | 54.91 | 68.04 | <.001 | 0.572 | 0.448 | 0.731 | .858 | |||
| Presence of lower urinary tract symptom | 12.73 | 7.36 | .001 | 1.836 | 1.268 | 2.658 | .074 | |||
| Presence of sleep apnea syndrome | 14.18 | 9.63 | .014 | 1.550 | 1.091 | 2.203 | .773 | |||
| Presence of cardiovascular disease | 6.55 | 3.68 | .017 | 1.834 | 1.112 | 3.023 | .928 | |||
| Presence of dyslipidemia | 15.27 | 10.80 | .022 | 1.489 | 1.059 | 2.093 | .358 | |||
| Presence of hypertension | 30.18 | 24.29 | .028 | 1.348 | 1.033 | 1.757 | .209 | |||
| Low level of sexual desire | 10.90 | 18.20 | .027 | 0.893 | 0.808 | 0.987 | .864 | |||
| Low partnership satisfaction | 12.00 | 8.62 | .054 | |||||||
| Diabetes | 12.00 | 8.62 | .054 | |||||||
| Drinking (including history) | 68.36 | 62.78 | .062 | |||||||
| Antihypertensive drugs | 22.18 | 17.74 | .062 | |||||||
| Job, most frequent | Employee (technical) | Employee (other) | .062 | |||||||
| Smoking (including history) | 41.45 | 46.82 | .083 | |||||||
| Desire frequency, median | Sometimes | Sometimes | .358 | |||||||
| Household income, median | ¥4 M-6 M/year | ¥4 M-6 M/year | .708 | |||||||
| Body mass index, median | 23.15 kg/m2 | 22.86 kg/m2 | .742 | |||||||
| Personal income, median | ¥4 M-6 M/year | ¥4 M-6 M/year | 0.977 | |||||||
Bold values indicate variables that remained statistically significant in the multivariate logistic regression analysis (P < .05).
When examining aspects of sexual desire, individuals with DE were significantly less likely to report low or very low levels of sexual desire compared to those without DE (P = .027). Several other factors—including phimosis, mental illness, history of pelvic or aortic aneurysm surgery, age, chronic kidney disease, marital status, lower urinary tract symptoms, sleep apnea syndrome, cardiovascular disease, dyslipidemia, and hypertension—were significantly associated with DE in univariate analyses but did not retain significance in the multivariate model (Table 2).
Treatment desire and help-seeking behavior
Among participants who reported distress related to DE, 58.18% indicated that they would like to receive treatment for their condition. However, only 11.88% had ever consulted a healthcare professional. This marked discrepancy between treatment desire and actual help-seeking behavior underscores a substantial unmet clinical need.
Direct comparisons between LDE and ADE
In this subgroup analysis, participants with LDE were significantly younger and reported higher masturbation frequency compared to those with ADE. In contrast, ADE was more frequently associated with the presence of ED, lower satisfaction with one’s sexual partner, and lower levels of subjective sexual desire. Additionally, occupational status differed significantly between the two groups (P = .029), with LDE participants more inclined to be students—likely reflecting the younger age distribution in this group (Table 3).
Table 3.
Clinical characteristics of the lifelong delayed ejaculation (LDE) and acquired delayed ejaculation (ADE) groups.
| LDE (%) | ADE (%) | P-value | |
|---|---|---|---|
| Age (continuous variable), median | 36.00 years | 50.00 years | <.001 |
| High frequency of masturbation, median | Twice/week | Once/week | .005 |
| Low level of sexual desire | 8.70 | 27.32 | .005 |
| Presence of erectile dysfunction | 27.17 | 43.72 | .008 |
| Low partnership satisfaction | 73.91 | 85.25 | .023 |
| Job, student | 66.67 | 33.33 | .036 |
| Desire frequency, median | Sometimes | Sometimes | .058 |
| Presence of phimosis | 47.83 | 36.07 | .060 |
| Presence of chronic kidney disease | 7.61 | 2.73 | .062 |
| Having children | 35.87 | 46.45 | .094 |
| Presence of hypertension | 23.91 | 33.33 | .108 |
| Marital status | 48.91 | 57.92 | .157 |
| Presence of lower urinary tract symptom | 9.78 | 14.21 | .200 |
| Body mass index, median | 22.58 kg/m2 | 23.51 kg/m2 | .228 |
| Presence of neurological disease | 9.78 | 6.01 | .256 |
| Presence of cardiovascular disease | 8.7 | 5.46 | .307 |
| History of aortic aneurysm surgery | 4.35 | 2.19 | .314 |
| High frequency of sexual intercourse, median | Once/2-3 months | Once/2-3 months | .352 |
| Antihypertensive drugs | 19.57 | 23.5 | .459 |
| Obesity | 33.7 | 31.15 | .669 |
| History of pelvic surgery | 5.43 | 4.37 | .695 |
| Presence of dyslipidemia | 14.13 | 15.85 | .709 |
| Drinking (including history) | 69.57 | 67.76 | .761 |
| Smoking (including history) | 40.22 | 42.07 | .768 |
| Use of psychotropic drugs | 19.57 | 18.58 | .844 |
| Household income, median | ¥6 M-8 M/year | ¥4 M-6 M/year | .861 |
| Personal income, median | ¥4 M-6 M/year | ¥4 M-6 M/year | .892 |
| Presence of mental illness | 16.3 | 16.39 | .985 |
| Sleep apnea syndrome | 14.13 | 14.21 | .986 |
| Diabetes | 11.96 | 12.02 | .987 |
| History of pelvic trauma | 5.43 | 5.46 | .992 |
Bold values indicate statistical significance (P < .05).
Discussion
This is the first nationwide, population-based investigation of DE among sexually active men in Japan conducted by the Clinical Research Promotion Committee of the JSSM. Despite its potential impact on psychological well-being, relational satisfaction, and fertility, DE remains one of the most infrequently studied and poorly understood male sexual dysfunctions.1,5 By identifying DE prevalence and its associated factors in a large representative cohort, this study contributes valuable epidemiological data to guide clinical understanding and management. The prevalence of DE in our cohort was 5.16%, aligning with prior global estimates ranging from 1.2% to 6.3%, depending on definition and methodology.2–4 This consistency strengthens the generalizability of the present findings. However, the sharp contrast between the high proportion of individuals desiring treatment (58.18%) and the small fraction who had actually sought medical help (11.88%) highlights an important gap between clinical need and service utilization. International studies have consistently shown that cultural and socioeconomic factors contribute to the under-recognition and under-treatment of DE. In particular, findings from Denmark, Brazil, and the Republic of Korea suggest that men often normalize DE as a consequence of aging or avoid seeking medical help due to stigma and low sexual health literacy.7,8,13 Despite the burden of DE, few affected individuals receive clinical evaluation or treatment. Moreover, there are no approved pharmacological therapies specific to DE, and most treatment strategies remain empirical or psychosexual in nature.1,5 Although previous international reviews have suggested aging to be a major risk factor for DE, several population-based studies have reported no significant association between DE and age.3,4,8 Despite this discrepancy, our study observed a significantly higher prevalence of DE among younger participants. This trend was evident in both the univariate analysis and age-stratified prevalence data (Figure 1, P < .001). One possible explanation is that younger men, particularly those engaged in intercourse with the intent of achieving pregnancy, may be more acutely distressed by DE.17 In contrast, older men may experience DE but consider it less problematic in the absence of reproductive goals. Furthermore, Japan is known for having one of the lowest frequencies of sexual intercourse globally,14 and it is conceivable that men without fertility-related concerns may be less likely to perceive DE as a source of distress. This observation is further supported by a national survey on ED in Japan, which revealed that 70.4% of men were classified as sexless (engaging in sexual intercourse less than once per month), with the highest rate—exceeding 60%—observed in the 20-24-year age group.14 These younger men also exhibited lower-than-expected scores for sexual desire, orgasm, and satisfaction. Such findings suggest a broader sociocultural context in which partnered sexual activity is declining among Japanese youth, potentially reducing the salience of DE symptoms and lowering treatment-seeking motivation.14
Multivariate analysis identified several independent factors significantly associated with DE. Notably, psychotropic drug use emerged as the strongest predictor, with an OR of 2.412. This finding is consistent with prior reports indicating that SSRIs and other psychotropic agents interfere with ejaculatory pathways by modulating serotonergic and noradrenergic neurotransmission.10 Clinicians should be aware of this relationship, especially in patients receiving psychiatric treatment who present with ejaculatory complaints.
Similarly, the history of pelvic trauma was also significantly associated with an increase in DE (OR = 2.388), likely due to disruption of neural or vascular pathways essential for ejaculatory control.18 Patient history-taking should therefore include detailed inquiry about prior pelvic injuries. Low partnership satisfaction was also strongly associated with DE (OR = 2.270). Prior literature has emphasized the critical role of relational dynamics in male sexual function.1,5 Dissatisfaction with a sexual partner may exacerbate performance anxiety, diminish sexual arousal, and ultimately impair ejaculatory processes.1 Addressing interpersonal factors through counseling or couples therapy may therefore be an important component of DE management.1,5 The presence of ED was another significant correlate (OR = 2.035), reinforcing the concept that DE and ED often coexist and may share underlying pathophysiological mechanisms such as impaired penile rigidity, reduced penile sensory feedback, or psychogenic distress.4,11 Management strategies for DE should include thorough assessment and treatment of concomitant ED.1,5 The presence of neurological diseases showed a significant association with DE (OR = 2.018). This supports existing literature suggesting that intact neural pathways are essential for the coordination of the sensory input and motor output necessary for ejaculation.4 Comprehensive neurological evaluation should be considered in patients with DE, particularly those with comorbid symptoms suggestive of neurogenic involvement.1,5
Obesity was also independently associated with DE in this study (OR = 1.513). This finding is consistent with previous literature indicating that obesity negatively impacts sexual function through mechanisms such as hormonal imbalance, vascular insufficiency, and systemic inflammation.19 Excess adiposity may impair neuroendocrine signaling related to ejaculation or reduce physical comfort and self-esteem during sexual activity, thereby contributing to ejaculatory dysfunction.19
Interestingly, high frequencies of both masturbation (OR = 1.236) and sexual intercourse (OR = 1.171) were positively associated with DE. While this may seem paradoxical, several interpretations are possible. Frequent masturbation may reflect a conditioned ejaculatory response to specific non-coital stimuli, such as rigid body positioning or audiovisual cues, which may not be replicable in partnered intercourse—thus leading to ejaculatory difficulty.12 This aligns with previous findings that high-frequency, idiosyncratic masturbation—often characterized by atypical techniques not replicable during partnered sex—can impair ejaculatory control during coitus.12 A notable clinical observation is that many men with DE maintain high frequencies of sexual intercourse not as a reflection of healthy sexual function but as an attempt to overcome ejaculatory delay. This compensatory behavior, often driven by anxiety or reproductive pressure, may paradoxically reinforce ejaculatory difficulties.12 This interpretation is further supported by the observed overlap between DE and ED in our cohort, both of which may share psychological and relational underpinnings such as anxiety or partner dissatisfaction.4,11,12
In contrast, having children was independently associated with a reduced likelihood of DE (OR = 0.570), possibly reflecting greater relationship stability, psychological confidence, or sexual self-efficacy among men who have successfully fathered children. Recent longitudinal data support this interpretation, indicating that fathers tend to show recovery in relationship satisfaction over time, suggesting adaptive interpersonal adjustment and emotional resilience that may contribute to healthier sexual function.20 Furthermore, infertility-related stress can negatively impact sexual satisfaction, further underscoring the importance of parenthood status in maintaining sexual health.17
Although a lower level of subjective sexual desire was significantly less common among the men with DE compared to those without DE in the univariate analysis, this association did not remain significant after adjustment for confounding factors in the multivariate model. This suggests that diminished sexual desire per se may not independently predict DE once other relevant variables are considered. Moreover, no significant difference was observed in the frequency of experiencing sexual desire between the DE and non-DE groups, further supporting the notion that DE is a condition distinct from hypoactive sexual desire disorder. These findings highlight the importance of carefully differentiating DE from disorders of sexual desire during clinical assessment. At the same time, several factors that demonstrated significant associations with DE in univariate analysis did not remain significant in the multivariate model. (Table 2) This discrepancy may be attributable to confounding and multicollinearity. Many of these conditions are interrelated and may exert their influence through stronger variables, such as ED, psychotropic drug use, or partnership dissatisfaction, which were retained as independent predictors. For example, cardiovascular and renal diseases often co-occur with ED, and low sexual desire or marital status may reflect broader psychosocial dynamics captured by relational satisfaction.14 These results highlight the complex interplay among demographic, clinical, and psychosocial domains in the etiology of DE, and the need for multivariable adjustment to isolate independent effects. Overall, they underscore the multifactorial nature of DE, with contributions from pharmacological, relational, neurological, and sexual health domains. A multidisciplinary, individualized approach is essential for the effective management of DE.1,5
One of the key contributions of this study is the comparative analysis between LDE and ADE. Our findings indicate that men with ADE are generally older and have more frequent comorbidities (eg, ED) than those with LDE. In contrast, compared to those men with ADE, the men with LDE showed a significant greater likelihood to report a high frequency of masturbation and less likelihood to report low levels of sexual desire. These patterns are consistent with existing literature suggesting that ADE may reflect cumulative health burdens and age-related changes in sexual function, whereas LDE may be more strongly influenced by psychosexual conditioning or maladaptive sexual learning.5,12
This study has several limitations. First, although our sample was representative of the general Japanese population regarding age and marital status, its internet-based nature may have introduced selection bias, favoring respondents with higher health literacy or digital access. Nevertheless, this remains a valid approach to the collection of large-scale epidemiological data following the COVID-19 era.21 In addition, the relatively low response rate (16.61 %) may have contributed to additional selection bias. Specifically, individuals with higher digital literacy, greater socioeconomic resources, or a stronger interest in sexual health topics may have been more likely to participate. This could limit the generalizability of our findings to subpopulations that are less health-conscious or have reduced access to digital technologies. Notably, similar methodological constraints were present in our prior nationwide survey on ED, yet the results were consistent with known trends and yielded clinically meaningful epidemiological insights.14 Second, the cross-sectional design limits causal inference regarding the association between DE and its associated factors. Longitudinal studies are needed to clarify the temporal relationships and potential causal pathways. Third, although validated instruments such as the Male Sexual Health Questionnaire for Ejaculatory Dysfunction Short Form (MSHQ-EjD) have been developed internationally to assess ejaculatory dysfunction—including aspects of delay, force, and volume—no officially validated Japanese version was available at the time of this study.22 Consequently, we relied on dichotomous (yes/no) self-reporting to identify DE. While this approach is consistent with previous large-scale epidemiological studies, it may underestimate milder or situational cases and lacks granularity in characterizing ejaculatory function.4 To clarify our methodological rationale, dichotomous yes/no questions were chosen to ensure simplicity and ease of understanding for participants in an anonymous, large-scale, internet-based survey. This format was particularly appropriate in the absence of a validated Japanese version of the MSHQ-EjD and has been successfully employed in prior epidemiological research to capture clinically meaningful distress associated with ejaculatory dysfunction in general populations.4,15 Fourth, although the American Psychiatric Association (APA) defines DE in three subtypes—lifelong, acquired, and situational—this study adopted the AUA/SMSNA classification, which delineates LDE and ADE.23 As a result, men with situational DE may have been misclassified or excluded, limiting comparability with APA-based diagnostic frameworks.
Nevertheless, this study helps clarify DE prevalence and its associated factors in Japan and the importance in clinical settings of addressing the psychological and physiological aspects of DE.
Notably, the Fifth International Consultation on Sexual Medicine (ICSM 2024) highlighted the scarcity of data related to ejaculation and orgasm disorders, particularly from non-Western populations, and underscored the need for more inclusive epidemiological research across diverse cohorts.24 Our findings contribute to addressing this gap by providing robust, population-based data on LDE and ADE among Japanese men.
Conclusion
This nationwide study is the first to report on DE prevalence and its associated factors among Japanese men. DE was found to affect approximately 5% of sexually active individuals and was linked to a range of psychological, sexual, and physical health factors. Despite a high desire for treatment, actual help-seeking behavior remained low, underscoring the need for increased clinical attention and public awareness. These findings support the development of more structured diagnostic criteria and targeted interventions for DE.
Acknowledgments
None.
Contributor Information
Masato Shirai, Department of Urology, Juntendo University Urayasu Hospital, Urayasu, Chiba 279-0021, Japan.
Akira Tsujimura, Department of Urology, Juntendo University Urayasu Hospital, Urayasu, Chiba 279-0021, Japan.
Shinichiro Fukuhara, Department of Urology, Osaka University Graduate School of Medicine, Suita, Osaka 565-0871, Japan.
Koji Chiba, Department of Urology, Kobe University Graduate School of Medicine, Kobe, Hyogo 650-0017, Japan.
Tsuyoshi Yoshizawa, Department of Urology, Nihon University School of Medicine, Itabashi-ku, Tokyo 173-8610, Japan.
Hikaru Tomoe, Department of Urology, Sayama Sougo Clinic, Sayama, Saitama 350-1305, Japan.
Kazunori Kimura, Department of Hospital Pharmacy, Graduate School of Pharmaceutical Sciences, Nagoya City University, Nagoya, Aichi 467-8603, Japan.
Eiji Kikuchi, Department of Urology, St. Marianna University School of Medicine, Kawasaki, Kanagawa 216-8511, Japan.
Eri Maeda, Department of Public Health, Faculty of Medicine, Hokkaido University, Sapporo, Hokkaido 060-8638, Japan.
Yoshikazu Sato, Department of Urology, Sanjukai Urological Hospital, Sapporo, Hokkaido 064-0807, Japan.
Atsushi Nagai, Management Department of Kawasaki Medical School Hospital, Kurashiki, Okayama 701-0192, Japan.
Koichi Nagao, Department of Urology, Faculty of Medicine, Toho University, Ota-ku, Tokyo 143-8540, Japan.
Haruaki Sasaki, Department of Urology, Showa Medical University Fujigaoka Hospital, Yokohama, Kanagawa 227-8501, Japan.
Author contributions
A.T. and H.S.: Conceptualization. M.S., S.F., K.C., T.Y., H.T., K.K., E.K., Y.S., A.N., and K.N.: Data curation. M.S. and H.S.: Formal analysis. A.T. and H.S. Funding acquisition. M.S., S.F., K.C., T.Y., H.T., K.K., E.K., Y.S., A.N., and K.N.: Investigation. A.T., M.S., and E.M.: Methodology. H.S.: Project administration. A.T.: Resources. A.T.: Software. A.N. and H.S.: Supervision. K.N.: Validation. M.S., A.T., and H.S.: Visualization. M.S.: Writing—original draft. A.T. and H.S.: Writing—review & editing.
Funding
None declared.
Conflicts of interest
None declared.
Ethics statement
The study protocol was reviewed and approved by the Institutional Review Board of Juntendo University, Tokyo, Japan (approval number: E22-0452). Informed consent was provided by all subjects when they were enrolled.
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