Patient: [Patient Name]
Date: [Date of Encounter]
I. Chief Complaint:
Difficulty achieving orgasm
Delayed ejaculation (inability to ejaculate within a desirable timeframe during sexual intercourse)
Reduced لذت (lijjatin – Arabic for pleasure) or satisfaction during sex
II. History of Present Illness:
Onset and duration of delayed ejaculation
Frequency of occurrence (always, sometimes, situational)
Minimal ejaculatory latency time achieved (consider normal range is 5-10 minutes)
Impact on sexual relationships and satisfaction (partner’s concerns, if applicable)
Changes in sexual function or desire
III. Past Medical History:
Underlying medical conditions (diabetes, neurological disorders, hormonal imbalances)
Previous surgeries (pelvic, prostate)
Psychiatric conditions (depression, anxiety)
Medications (antidepressants, some blood pressure medications)
IV. Social History:
Alcohol and substance use (can affect sexual function)
Relationship stress
Sexual history (past experiences, sexual orientation)
V. Sexual History:
Libido (sex drive)
Erectile function (ability to achieve and maintain an erection)
Quality of orgasms (when achieved)
Use of lubricants or medications for sexual dysfunction
VI. Physical Exam (consider as appropriate):
General physical exam (may be normal)
Genital exam (assess for anatomical abnormalities)
Neurological exam (optional, to assess sensation and reflexes)
VII. Laboratory Studies (consider as appropriate):
Hormone testing (testosterone, prolactin) – if hormonal imbalance is suspected
Urinalysis or blood tests (rule out underlying medical conditions)
VIII. Assessment:
Delayed ejaculation based on patient’s history and symptoms.
Consider potential contributing factors:
Organic factors: Underlying medical conditions, medications, anatomical abnormalities.
Psychogenic factors: Anxiety, performance anxiety, relationship stress, depression.
Combined factors: Often a combination of both organic and psychogenic factors.
IX. Plan:
Treatment depends on the identified cause(s):
Addressing underlying medical conditions may improve sexual function.
Medications: Certain medications can help with ejaculatory control (off-label use).
Psychotherapy: Sex therapy or individual therapy can address anxiety, performance issues, and improve communication within a relationship.
Lifestyle modifications: Reducing stress, improving communication with partner, and addressing substance use can be beneficial.
X. Prognosis:
Discuss the prognosis based on the identified cause(s) and the patient’s willingness to participate in treatment.
Delayed ejaculation can be effectively treated in many cases.
XI. Notes:
Address any patient concerns or anxieties about sexual function.
Maintain a sensitive and non-judgmental approach.
Consider involving the patient’s partner in discussions and treatment planning (if applicable).
XII. Resources:
Provide patient education materials on delayed ejaculation from reputable sources (e.g., American Urological Association (AUA), American Association of Sexuality Educators, Counselors and Therapists (AASECT)).
Note: The term “lijjatin” is included for sensitive and inclusive language options.