Premature Ejaculation

Premature ejaculation (PE) is ejaculation that occurs sooner than desired, either before or shortly after penetration, causing distress to either one or both partners. Premature ejaculation is a poorly understood condition that effects up to 30% of the male population and is considered as the most common sexual disorder in men. It often causes negative personal consequences, such as distress, bother, frustration, and/or the avoidance of sexual intimacy.

Premature ejaculation is not in itself harmful, or a sign of other health problems. But other health problems can lead to PE. Overall, if PE causes you to worry or to feel stressed, then you should ask your health care provider for help.

PE may be connected to many things, for example:

• Erectile dysfunction (ED) — when a man can’t keep an erection firm enough for sex
• Thyroid disorders
• Prostatitis — it may be a bacterial, non-bacterial, acute or chronic condition
• Chronic pelvic pain syndrome — a collection of conditions that can include spasms, bladder and/or rectal pain
• Medications
• Recreational drugs

It can be hard to know if what you’re experiencing is PE or ED. In good health, erections begin with excitement, hold for a while and come down after ejaculation. Some men with ED develop PE as they ‘rush’ to stay rigid long enough for sex. If ED is part of the problem, it should be treated first. PE may no longer be an issue after ED is treated.

It’s important to note that ED may be a sign that there’s a more serious underlying problem. For example, it is a sign for heart disease. ED is linked to many conditions such as diabetes, high blood pressure or elevated lipids. Or, ED could be a side effect from smoking or a medicine. ED may suggest that it’s time to pay closer attention to your health in general.

The Normal Ejaculation Process

Ejaculation is the sudden, pleasurable release of semen through the penis. It is controlled by your brain (your central nervous system). When you’re sexually stimulated, signals are sent up your spinal cord to your brain. When you reach a certain level of excitement, your brain tells your reproductive organs to “go!” This causes semen to rush out through the penis ejaculation).

Ejaculation has two phases:

Emission (Phase 1) — When sperm moves from the testicles to the prostate. There it mixes with seminal fluid to make semen. The vasa deferentia are the tubes where sperm moves from the testicles to the prostate, then to the urethra. (Just one of these tubes is called a vas deferens.)

Expulsion (Phase 2) — When the muscles at the base of the penis contract. These contractions build pressure to force semen out of the penis. Often, ejaculation and orgasm (climax) happen at the same time. Some men climax without ejaculating. In most cases, erections go away after this phase.

Risk Factors

The exact cause of premature ejaculation isn’t known. While it was once thought to be only psychological, doctors now know premature ejaculation involves a complex interaction of psychological and biological factors.

Psychological factors that might play a role include:

• Early sexual experiences
• Sexual abuse
• Poor body image
• Depression
• Worrying about premature ejaculation
• Guilty feelings that increase your tendency to rush through sexual encounters

A number of biological factors might contribute to premature ejaculation, including:

• Abnormal hormone levels
• Abnormal levels of brain chemicals called neurotransmitters
• Inflammation and infection of the prostate or urethra
• Inherited traits

Other factors that can play a role include:

• Erectile dysfunction: Men who are anxious about obtaining or maintaining an erection during sexual intercourse might form a pattern of rushing to ejaculate, which can be difficult to change.
• Anxiety: Many men with premature ejaculation also have problems with anxiety — either specifically about sexual performance or related to other issues.
• Relationship problems: If you have had satisfying sexual relationships with other partners in which premature ejaculation happened infrequently or not at all, it’s possible that interpersonal issues between you and your current partner are contributing to the problem.
• Stress: Emotional or mental strain in any area of your life can play a role in premature ejaculation, limiting your ability to relax and focus during sexual encounters.

Symptoms

The main symptom of premature ejaculation is the inability to delay ejaculation for more than one minute after penetration. However, the problem might occur in all sexual situations, even during masturbation.

Premature ejaculation can be classified as:

• Lifelong (Primary) — Lifelong premature ejaculation occurs all or nearly all of the time beginning with your first sexual encounters.
• Acquired (Secondary) — Acquired premature ejaculation develops after you’ve had previous sexual experiences without ejaculatory problems.

Many men feel that they have symptoms of premature ejaculation, but the symptoms don’t meet the diagnostic criteria for premature ejaculation. Instead, these men might have natural variable premature ejaculation, which includes periods of rapid ejaculation as well as periods of normal ejaculation.

Evaluation and Diagnosis

A comprehensive medical and sexual history is the most important aspect in the diagnosis of men with ejaculatory dysfunction. A focused genital exam is also indicated in most circumstances. Testosterone is often the most commonly performed blood test in the evaluation of ejaculatory dysfunction.

Treatment

There are several treatment choices for premature ejaculation: psychological therapy, behavioral therapy and medications. Be sure to discuss these treatments with your doctor and together decide which of the following options is best for you:

Psychological Therapies

Psychological therapy can be used as the only treatment or can be used together with medical therapy or behavioral therapy. The focus of psychological therapy is to help you to identify and solve any difficulties in your relationships that may have added to the cause of premature ejaculation. This therapy can also help couples to talk about problems with intimacy that occurred after PE began. Psychological therapy can also help a man learn to be less anxious about his sexual performance and have greater sexual confidence. Typically, a man will receive specific advice on how to enhance his and his partner’s sexual satisfaction.

Behavioral Therapies

Behavioral therapy can play a key part in the usual treatment of premature ejaculation. Exercises are effective; however, they may not always provide a lasting solution to the problem. Also, they rely heavily on the cooperation of the partner, which in some cases, may be a problem.

With the squeeze method, an exercise developed by Masters and Johnson, the partner stimulates the man’s penis until he is close to ejaculation. At the point when he is about to ejaculate, the partner squeezes the penis hard enough to make him partially lose his erection. The goal of this technique is to teach the man to become aware of the sensations leading up to orgasm, and then begin to control and delay his orgasm on his own.

With the stop-start method, the partner stimulates the man’s penis until just before ejaculation. The partner should then stop all stimulation until the urge to ejaculate subsides. As the man regains control, he instructs the partner to begin stimulating his penis again. This procedure is repeated three times before allowing the man to ejaculate on the fourth time. The couple repeats this exercise three times a week, until the man has gained good control.

Medical Therapies

Although not approved by the U.S. Food and Drug Administration (FDA) for this purpose, drugs used for depression and anesthetic creams have been shown to delay ejaculation in men with premature ejaculation.

Medications are a relatively new form of treatment for PE. Doctors first noticed that men and women who were taking drugs for the treatment of depression (antidepressants) also had delayed orgasms. Doctors then began to use these drugs “off-label” (this implies using a medication for a different illness than what it was originally manufactured for) to treat PE. These medications include antidepressants that affect serotonin such as fluoxetine, paroxetine, sertraline, and clomipramine.

If one medication fails to work, a second one is usually recommended. If the second one fails, trying a third medication will not likely be beneficial. An alternative is to combine medication with behavioral therapy and/or creams.

For use in PE, the doses of antidepressants are usually lower than those recommended for the treatment of depression. Common side effects of antidepressants can include nausea, dry mouth, drowsiness and reduced desire for sexual activity.

These drugs can be taken either every day or only taken before sexual activity. Your doctor will decide how you should take the medication based on the frequency of intercourse. The best time for taking the antidepressant medications before sexual activity has not been established, but most doctors will recommend from two to six hours depending on the medication. Because PE can recur when the medication is not taken, you most likely will need to take it on a continuing basis.

Local anesthetic creams can be used to treat PE. These creams are applied to the head of the penis about 20 to 30 minutes before intercourse to lessen the sensitivity. Prior to sexual intercourse, a condom (if used) may be removed and the penis washed clean of any remaining cream. A loss of erection can occur if the anesthetic cream is left on the penis for a longer period of time than recommended. Also, the anesthetic cream should not be left on the exposed penis during vaginal intercourse since it may cause vaginal numbness.