Premature Ejaculation
Premature ejaculation (PE) occurs when a man experiences orgasm and expels
semen soon after sexual penetration and with minimal penile stimulation. It has
also been called early ejaculation, rapid ejaculation, rapid
climax, premature climax, and (historically) ejaculation
praecox. There is no uniform cut-off defining "premature," but a consensus
of experts at the International Society for Sexual Medicine endorsed a
definition including "ejaculation which always or nearly always occurs prior to
or within about one minute." The international classification of
diseases (ICD-10) applies a cut-off of 15 seconds from the beginning of
intercourse.
Although
men with premature ejaculation describe feeling that they have less control over
ejaculating, it is not clear if that is true, and many or most average men also
report that they wish they could last longer. Men's typical ejaculatory latency
is approximately 4–8 minutes.
Men with PE
often report emotional and relationship distress, and some avoid pursuing sexual
relationships because of PE-related embarrassment. Compared with men, women
consider PE less of a problem, but several studies show that the condition also
causes female partners distress.
Premature ejaculation is most
prevalent sexual dysfunction in men; however, because of the variability in time
required to ejaculate and in partners’ desired duration of sex, exact prevalence
rates of PE are difficult to determine. In the “Sex in America” surveys (1999
and 2008), University of Chicago researchers found that between adolescence and
age 59, approximately 30% of men reported having experienced PE at least once
during the previous 12 months, whereas about 10 percent reported erectile
dysfunction (ED). After age 60, ED becomes men’s most prevalent sex problem,
however premature ejaculation remains a significant concern affecting 28 percent
of men age 65–74, and 22 percent of age 75–85. Other studies report PE
prevalence ranging from 3 percent to 41 percent of men over 18, but the great
majority estimate a prevalence of 20 to 30 percent—making PE men’s most common
sex problem.
There is a common misconception
that younger men are more likely to suffer premature ejaculation and that its
frequency decreases with age. Prevalence studies have indicated, however, that
rates of PE are constant across age groups.
Mechanism
of ejaculation
Main
article: Ejaculation
The physical process of
ejaculation requires two actions: emission and expulsion.
The emission is the first phase.
It involves deposition fluid from the ampullary vas deferens, seminal vesicles,
and prostate gland into the posterior urethra. The second phase is the expulsion
phase. It involves closure of bladder neck, followed by the rhythmic
contractions of the urethra by pelvic-perineal and bulbospongiosus muscle, and
intermittent relaxation of external urethral sphincters.
Sympathetic motor neurons control
the emission phase of ejaculation reflex, and expulsion phase is executed by
somatic and autonomic motor neurons. These motor neurons are located in the
thoracolumbar and lumbosacral spinal cord and are activated in a coordinated
manner when sufficient sensory input to reach the ejaculatory threshold has
entered the central nervous system.
Intromission
time
The 1948 Kinsey Report suggested
that three quarters of men ejaculate within two minutes of penetration in over
half of their sexual encounters.
Current evidence supports an
average intravaginal ejaculation latency time (IELT) of six and a half
minutes in 18–30 year olds. If the disorder is defined as an IELT percentile
below 2.5, then premature ejaculation could be suggested by an IELT of less than
about 2 minutes. Nevertheless, it is possible that men with abnormally low IELTs
could be "happy" with their performance and do not report a lack of control.
Likewise, those with higher IELTs may consider themselves premature ejaculators,
suffer from detrimental side effects normally associated with premature
ejaculation, and even benefit from treatment.
Diagnostic
issues
When deciding the appropriate
treatment, it is important for physician to distinguish PE as a "complaint"
versus PE as a "syndrome". About 20 years ago, PE was classified into "lifelong
PE" and "acquired PE". Recently, a new classification of PE was proposed based
on controlled clinical and epidemiological stopwatch studies and it included 2
other PE syndromes: "natural variable PE" and "premature-like ejaculatory
dysfunction". Only individuals with lifelong PE with IELT shorter than 1–1.5
minutes should require medication as a first option, along with or without
therapy. For those who fall into one of the other categories, treatment should
consist of patient reassurance, behavior therapy, and/or psychoeducation to
explain irregular early ejaculation is a normal variation.
Several possible
subclassifications have been discussed, but none is in universal usage.
Primary premature ejaculation refers to lifelong experience of the
problem (since puberty), and secondary premature ejaculation reference to
the problem beginning later in life. It has also been subdivided into global
premature ejaculation, when it occurs with all partners and contexts, and
situational premature ejaculation, when it occurs in some situations or
with specific partners.
Causes
The causes of premature
ejaculation are unclear. Many theories have been suggested, including that PE
was the result of masturbating quickly during adolescence to avoid being caught
by an adult, of performance anxiety, of an unresolved Oedipal conflict, of
passive-aggressiveness, and having too little sex—but there is little evidence
to support any of these theories.
Several physiological mechanisms
have been hypothesized to contribute to causing premature ejaculation including
serotonin receptors, a genetic predisposition, elevated penile sensitivity, and
nerve conduction atypicalities.
The nucleus paragigantocellularis
of the brain has been identified as involved in ejaculatory control. Scientists
have long suspected a genetic link to certain forms of premature
ejaculation. In one study, ninety-one percent of men who have had premature
ejaculation for their entire lives also had a first-relative with lifelong
premature ejaculation. Other researchers have noted that men who have premature
ejaculation have a faster neurological response in the pelvic
muscles.
PE may be caused by prostatitis
or as a drug side effect.
Treatments
Several treatments have been
tested for treating premature ejaculation. A combination of medication and
non-medication treatments is often the most effective method.
Self-treatment
Many men attempt to treat
themselves for premature ejaculation by trying to distract themselves, such as
by trying to focus their attention away from the sexual stimulation. There is
little evidence to indicate that it is effective, however. Other self-treatments
include thrusting more slowly, withdrawing the penis altogether, purposefully
ejaculating before sexual intercourse, and using more than one condom. Some men
report these to have been helpful.
By the 21st century, most men
with premature ejaculation could cure themselves, either solo or with a partner,
using self-help resources, and only those with unusually severe problems had to
consult sex therapists, who cured 75 to 80 percent.
Psychoanalysis
Freudian theory postulated that
rapid ejaculation was a symptom of underlying neurosis. The man suffers
unconscious hostility toward women, so he ejaculates rapidly, which satisfies
him but frustrates his lover, who is unlikely to experience orgasm that quickly.
Freudians claimed that premature ejaculation could be cured using
psychoanalysis. But even years of psychoanalysis accomplished little, if
anything, in curing premature ejaculation.
There is no evidence that men
with premature ejaculation harbor unusual hostility toward women,
however.
Sex
therapy
Several techniques have been
developed and applied by sex therapists, including Kegel exercises (to
strengthen the muscles of the pelvic floor) and Masters and Johnson's
"stop-start technique" (to desensitize the man's responses) and "squeeze
technique" (to reduce excessive arousal)
To treat premature ejaculation,
Masters and Johnson developed the “squeeze technique.” Men were instructed to
pay close attention to their arousal pattern and learn to recognize how they
felt shortly before their “point of no return,” the moment ejaculation felt
imminent and inevitable. Sensing the point of no return, they were to signal the
partner, who squeezed the head of the penis between thumb and index finger,
suppressing the ejaculatory reflex and allowing the man to last
longer.
The squeeze technique worked, but
many couples found it cumbersome. From the 1970s to the 1990s, sex therapists
refined the Masters and Johnson approach, largely abandoning the squeeze
technique and basing the program on a simpler and more effective technique,
“stop-start.” During intercourse, as the man senses he’s approaching his point
of no return, both lovers stop moving and remain still until the man’s feelings
of ejaculatory inevitability subside, at which point, they are free to resume
active intercourse.
In addition to the stop-start
technique, other sexual adjustments help men develop and maintain ejaculatory
control, among them: masturbation exercises, deep breathing, and whole-body
massage. Sex therapists estimate that the refined last-longer program teaches
effective ejaculatory control to 90 percent of men. The authors of one study
concluded that sex therapy “has a remarkable therapeutic effect on premature
ejaculation.”
Medications
Drugs that increase serotonin
signalling in the brain slow ejaculation and have been used successfully to
treat PI. These include selective serotonin reuptake inhibitors (SSRIs), such as
paroxetine (Paxil), sertraline (Zoloft), and fluoxetine (Prozac), as well as
clomipramine (Anafranil). Ejaculatory delay typically begins within a week of
beginning medication. The treatments increase the ejaculatory delay to 6–20
times greater than before medication. Although men often report satisfaction
with treatment by medication, many men discontinue it within a
year.
Dapoxetine (Priligy) is a
short-acting SSRI marketed for the treatment of premature ejaculation.
Dapoxetine is the only drug with regulatory approval for such an indication.
Currently, it is approved in several European countries, including Finland,
Sweden, Portugal, Austria and Germany. Dapoxetine is currently waiting for U.S.
Food and Drug Administration (FDA) approval after concluding the
Phase III study, which included participants from 25 other countries,
including the United States. In this diverse population, dapoxetine
significantly improved all aspects of PE and was generally well
tolerated.
Paroxetine (Paxil) appears to be
the most effective drug treatment. In a 6-week long randomized, double-blind
study, the ejaculatory latency of men with PE increased from an average 20
seconds to 2-1/2 minutes, whereas there as no change at all in the placebo
group.
Tramadol (Ultram or Tramal) is an
FDA-approved atypical oral analgesic generally used to treat mild pain. Tramadol
also has few side effects, low abuse potential, and increases ejaculatory
latency to 4-20 times in more than 90% of men tested.
Clomipramine (Anafranil) is
sometimes prescribed to treat PE. One side effect of the drug can help delay
ejaculatory response. The side effect is described by the Mayo Clinic as
"Increased sexual ability, desire, drive, or
performance.
Desensitizing topical medications
that are applied to the tip and shaft of the penis can also be used. These are
applied "as needed," 10–15 minutes before sexual activity and have fewer
potential systemic side effects as compared to pills. Use of topicals has is
sometimes disliked due to the reduction of sensation in the penis as well as for
the partner (due to the medication rubbing onto the partner). These effects can
be lesser with topical anesthetic sprays
History
Ejaculatory control issues have
been documented for more than 1,500 years. The Kamasutra, the 4th century Indian
sex handbook, declares: “Women love the man whose sexual energy lasts a long
time, but they resent a man whose energy ends quickly because he stops before
they reach a climax.
Nineteenth-century authorities
considered rapid ejaculation a sign of masculine vigor.
Non-human mammals ejaculate
quickly during intercourse, prompting biologists to declare that rapid
ejaculation had evolved into men’s genetic makeup to increase their chances
of passing their genes.
semen soon after sexual penetration and with minimal penile stimulation. It has
also been called early ejaculation, rapid ejaculation, rapid
climax, premature climax, and (historically) ejaculation
praecox. There is no uniform cut-off defining "premature," but a consensus
of experts at the International Society for Sexual Medicine endorsed a
definition including "ejaculation which always or nearly always occurs prior to
or within about one minute." The international classification of
diseases (ICD-10) applies a cut-off of 15 seconds from the beginning of
intercourse.
Although
men with premature ejaculation describe feeling that they have less control over
ejaculating, it is not clear if that is true, and many or most average men also
report that they wish they could last longer. Men's typical ejaculatory latency
is approximately 4–8 minutes.
Men with PE
often report emotional and relationship distress, and some avoid pursuing sexual
relationships because of PE-related embarrassment. Compared with men, women
consider PE less of a problem, but several studies show that the condition also
causes female partners distress.
Premature ejaculation is most
prevalent sexual dysfunction in men; however, because of the variability in time
required to ejaculate and in partners’ desired duration of sex, exact prevalence
rates of PE are difficult to determine. In the “Sex in America” surveys (1999
and 2008), University of Chicago researchers found that between adolescence and
age 59, approximately 30% of men reported having experienced PE at least once
during the previous 12 months, whereas about 10 percent reported erectile
dysfunction (ED). After age 60, ED becomes men’s most prevalent sex problem,
however premature ejaculation remains a significant concern affecting 28 percent
of men age 65–74, and 22 percent of age 75–85. Other studies report PE
prevalence ranging from 3 percent to 41 percent of men over 18, but the great
majority estimate a prevalence of 20 to 30 percent—making PE men’s most common
sex problem.
There is a common misconception
that younger men are more likely to suffer premature ejaculation and that its
frequency decreases with age. Prevalence studies have indicated, however, that
rates of PE are constant across age groups.
Mechanism
of ejaculation
Main
article: Ejaculation
The physical process of
ejaculation requires two actions: emission and expulsion.
The emission is the first phase.
It involves deposition fluid from the ampullary vas deferens, seminal vesicles,
and prostate gland into the posterior urethra. The second phase is the expulsion
phase. It involves closure of bladder neck, followed by the rhythmic
contractions of the urethra by pelvic-perineal and bulbospongiosus muscle, and
intermittent relaxation of external urethral sphincters.
Sympathetic motor neurons control
the emission phase of ejaculation reflex, and expulsion phase is executed by
somatic and autonomic motor neurons. These motor neurons are located in the
thoracolumbar and lumbosacral spinal cord and are activated in a coordinated
manner when sufficient sensory input to reach the ejaculatory threshold has
entered the central nervous system.
Intromission
time
The 1948 Kinsey Report suggested
that three quarters of men ejaculate within two minutes of penetration in over
half of their sexual encounters.
Current evidence supports an
average intravaginal ejaculation latency time (IELT) of six and a half
minutes in 18–30 year olds. If the disorder is defined as an IELT percentile
below 2.5, then premature ejaculation could be suggested by an IELT of less than
about 2 minutes. Nevertheless, it is possible that men with abnormally low IELTs
could be "happy" with their performance and do not report a lack of control.
Likewise, those with higher IELTs may consider themselves premature ejaculators,
suffer from detrimental side effects normally associated with premature
ejaculation, and even benefit from treatment.
Diagnostic
issues
When deciding the appropriate
treatment, it is important for physician to distinguish PE as a "complaint"
versus PE as a "syndrome". About 20 years ago, PE was classified into "lifelong
PE" and "acquired PE". Recently, a new classification of PE was proposed based
on controlled clinical and epidemiological stopwatch studies and it included 2
other PE syndromes: "natural variable PE" and "premature-like ejaculatory
dysfunction". Only individuals with lifelong PE with IELT shorter than 1–1.5
minutes should require medication as a first option, along with or without
therapy. For those who fall into one of the other categories, treatment should
consist of patient reassurance, behavior therapy, and/or psychoeducation to
explain irregular early ejaculation is a normal variation.
Several possible
subclassifications have been discussed, but none is in universal usage.
Primary premature ejaculation refers to lifelong experience of the
problem (since puberty), and secondary premature ejaculation reference to
the problem beginning later in life. It has also been subdivided into global
premature ejaculation, when it occurs with all partners and contexts, and
situational premature ejaculation, when it occurs in some situations or
with specific partners.
Causes
The causes of premature
ejaculation are unclear. Many theories have been suggested, including that PE
was the result of masturbating quickly during adolescence to avoid being caught
by an adult, of performance anxiety, of an unresolved Oedipal conflict, of
passive-aggressiveness, and having too little sex—but there is little evidence
to support any of these theories.
Several physiological mechanisms
have been hypothesized to contribute to causing premature ejaculation including
serotonin receptors, a genetic predisposition, elevated penile sensitivity, and
nerve conduction atypicalities.
The nucleus paragigantocellularis
of the brain has been identified as involved in ejaculatory control. Scientists
have long suspected a genetic link to certain forms of premature
ejaculation. In one study, ninety-one percent of men who have had premature
ejaculation for their entire lives also had a first-relative with lifelong
premature ejaculation. Other researchers have noted that men who have premature
ejaculation have a faster neurological response in the pelvic
muscles.
PE may be caused by prostatitis
or as a drug side effect.
Treatments
Several treatments have been
tested for treating premature ejaculation. A combination of medication and
non-medication treatments is often the most effective method.
Self-treatment
Many men attempt to treat
themselves for premature ejaculation by trying to distract themselves, such as
by trying to focus their attention away from the sexual stimulation. There is
little evidence to indicate that it is effective, however. Other self-treatments
include thrusting more slowly, withdrawing the penis altogether, purposefully
ejaculating before sexual intercourse, and using more than one condom. Some men
report these to have been helpful.
By the 21st century, most men
with premature ejaculation could cure themselves, either solo or with a partner,
using self-help resources, and only those with unusually severe problems had to
consult sex therapists, who cured 75 to 80 percent.
Psychoanalysis
Freudian theory postulated that
rapid ejaculation was a symptom of underlying neurosis. The man suffers
unconscious hostility toward women, so he ejaculates rapidly, which satisfies
him but frustrates his lover, who is unlikely to experience orgasm that quickly.
Freudians claimed that premature ejaculation could be cured using
psychoanalysis. But even years of psychoanalysis accomplished little, if
anything, in curing premature ejaculation.
There is no evidence that men
with premature ejaculation harbor unusual hostility toward women,
however.
Sex
therapy
Several techniques have been
developed and applied by sex therapists, including Kegel exercises (to
strengthen the muscles of the pelvic floor) and Masters and Johnson's
"stop-start technique" (to desensitize the man's responses) and "squeeze
technique" (to reduce excessive arousal)
To treat premature ejaculation,
Masters and Johnson developed the “squeeze technique.” Men were instructed to
pay close attention to their arousal pattern and learn to recognize how they
felt shortly before their “point of no return,” the moment ejaculation felt
imminent and inevitable. Sensing the point of no return, they were to signal the
partner, who squeezed the head of the penis between thumb and index finger,
suppressing the ejaculatory reflex and allowing the man to last
longer.
The squeeze technique worked, but
many couples found it cumbersome. From the 1970s to the 1990s, sex therapists
refined the Masters and Johnson approach, largely abandoning the squeeze
technique and basing the program on a simpler and more effective technique,
“stop-start.” During intercourse, as the man senses he’s approaching his point
of no return, both lovers stop moving and remain still until the man’s feelings
of ejaculatory inevitability subside, at which point, they are free to resume
active intercourse.
In addition to the stop-start
technique, other sexual adjustments help men develop and maintain ejaculatory
control, among them: masturbation exercises, deep breathing, and whole-body
massage. Sex therapists estimate that the refined last-longer program teaches
effective ejaculatory control to 90 percent of men. The authors of one study
concluded that sex therapy “has a remarkable therapeutic effect on premature
ejaculation.”
Medications
Drugs that increase serotonin
signalling in the brain slow ejaculation and have been used successfully to
treat PI. These include selective serotonin reuptake inhibitors (SSRIs), such as
paroxetine (Paxil), sertraline (Zoloft), and fluoxetine (Prozac), as well as
clomipramine (Anafranil). Ejaculatory delay typically begins within a week of
beginning medication. The treatments increase the ejaculatory delay to 6–20
times greater than before medication. Although men often report satisfaction
with treatment by medication, many men discontinue it within a
year.
Dapoxetine (Priligy) is a
short-acting SSRI marketed for the treatment of premature ejaculation.
Dapoxetine is the only drug with regulatory approval for such an indication.
Currently, it is approved in several European countries, including Finland,
Sweden, Portugal, Austria and Germany. Dapoxetine is currently waiting for U.S.
Food and Drug Administration (FDA) approval after concluding the
Phase III study, which included participants from 25 other countries,
including the United States. In this diverse population, dapoxetine
significantly improved all aspects of PE and was generally well
tolerated.
Paroxetine (Paxil) appears to be
the most effective drug treatment. In a 6-week long randomized, double-blind
study, the ejaculatory latency of men with PE increased from an average 20
seconds to 2-1/2 minutes, whereas there as no change at all in the placebo
group.
Tramadol (Ultram or Tramal) is an
FDA-approved atypical oral analgesic generally used to treat mild pain. Tramadol
also has few side effects, low abuse potential, and increases ejaculatory
latency to 4-20 times in more than 90% of men tested.
Clomipramine (Anafranil) is
sometimes prescribed to treat PE. One side effect of the drug can help delay
ejaculatory response. The side effect is described by the Mayo Clinic as
"Increased sexual ability, desire, drive, or
performance.
Desensitizing topical medications
that are applied to the tip and shaft of the penis can also be used. These are
applied "as needed," 10–15 minutes before sexual activity and have fewer
potential systemic side effects as compared to pills. Use of topicals has is
sometimes disliked due to the reduction of sensation in the penis as well as for
the partner (due to the medication rubbing onto the partner). These effects can
be lesser with topical anesthetic sprays
History
Ejaculatory control issues have
been documented for more than 1,500 years. The Kamasutra, the 4th century Indian
sex handbook, declares: “Women love the man whose sexual energy lasts a long
time, but they resent a man whose energy ends quickly because he stops before
they reach a climax.
Nineteenth-century authorities
considered rapid ejaculation a sign of masculine vigor.
Non-human mammals ejaculate
quickly during intercourse, prompting biologists to declare that rapid
ejaculation had evolved into men’s genetic makeup to increase their chances
of passing their genes.
