Premature Ejaculation

How does ejaculation occur?
Sexual stimulation (physical) causes nerves in the penis to send chemical messages to the spinal cord and the brain. Similarly, the brain releases chemicals with mental stimulation.  These chemicals help relay messages of stimulation throughout the brain, while nerve signals from the brain carry these messages to the rest of the body through the spinal cord to the male reproductive organs. When a man reaches a certain level of excitement during this process, chemical and nerve messages sent to the pelvis cause ejaculation. While not completely understood, it is believed that the chemical serotonin plays a major role in this process.

Ejaculation is the process by which semen is released from the penis. Ejaculation involves mainly two phases. The first process through which the components of semen are released from the male reproductive organs (prostate, seminal vesicle, vas deferens) is called emission. During this process semen is deposited into the urethra (urine channel). The second phase (ejaculation proper, evacuation, or expulsion) is a reflex that causes rhythmic contractions of the muscles around the urethra, which propels the semen through the urethra and from the penis.

What are the components of semen?
Semen is the fluid releases from the penis upon ejaculation. Semen is made up of two parts: 1) sperm from the vas deferens and 2) seminal fluid which contains fluid from mainly the prostate gland and seminal vesicles.

Each time a male ejaculates, normally between 50- to 500-million sperm are released. However, they make up only about 2-5% of the volume of semen. The bulk of the semen is composed of the ejaculate fluid portion of semen. Men produce between 1 ml and 5 milliliters of semen during each ejaculation.

What is premature ejaculation (PE)?
Premature ejaculation is rapid ejaculation in response to minimal stimulation before, at the time of, or shortly after sexual stimulation, but before the man wishes it, and over which the man feels he has little or no control. It is important to recognize that premature ejaculation is a subjective diagnosis and takes into consideration the satisfaction of both the patient and their partner.

How common is PE?
PE is the most common sexual dysfunction reported by men but is still under-diagnosed and under-treated. Estimating the prevalence of PE is difficult since many men do not want to talk about it, while others may not even perceive that they have PE. Recent research indicates that 25-30% of men struggle with PE. PE can happen at any age and its prevalence is consistent across all ages.

PE may be either life-long or acquired. Primary PE refers to men who have experienced this sexual problem since first having sex. Secondary PE refers to men who had ejaculatory control at some point but began experiencing PE later in life, sometimes even after years of satisfying sex, without explanation.

PE can have a broad impact on many aspects of a man's life. Men experiencing PE can suffer anxiety, embarrassment, inadequacy, depression, anger and guilt. PE can cause both personal stress, and stress to a relationship. In one study, men with PE were less satisfied with sexual intercourse and their sexual relationship and suffered more problems with sexual anxiety and arousal compared to non-sufferers.

Some men with PE have trouble staying in relationships or may be scared to begin new ones. Partners sometimes experience frustration and anger. Also, many couples do not discuss the problem and there can be a breakdown of intimacy between them.

Unfortunately, the cause of PE is generally unknown. Historically PE was seen as a psychological disorder, but researchers now suggest that most cases are multi-factorial with a contribution from both psychological and physical factors.

Many researchers believe that premature ejaculation, at least in some men, may be due to a chemical imbalance or changes in receptor sensitivity in the brain or spinal cord.

Many men with PE also experience erectile dysfunction (ED). One proposed relationship between ED and PE is that poorly maintained erections may lead to behavioral changes in which PE may develop. In other words, men with ED may learn to ejaculate quickly to reach climax before their erection subsides. Or, men with ED may require additional stimulation to maintain the erection, which then leads to PE.  The exact relationship between these two conditions remains unknown.

Although there are no specific diagnosis or treatment guidelines for PE, the diagnosis of PE is based mainly on a detailed sexual history that establishes:

• The patients' perception of his control over ejaculation. Is it poor, fair or good?
• The time frame within which he ejaculates. Less than a minute? More than 2 minutes?
  • The majority of men who self-identify themselves as having PE will ejaculate in less than 2 minutes.
  • The majority of men who self-identify as NOT having PE will ejaculate in longer than 2 minutes.
  • PE is considered to be the occurrence of ejaculation prior to the wishes of both sexual partners, (which can vary widely from couple to couple); no clear time cut-offs have been set as to the appropriate duration for sexual contact before reaching orgasm, although the FDA in its assessment of drugs for PE uses 2 minutes as the guideline. Patient self-report time to ejaculation (known as ejaculatory latency time) has been shown to be surprisingly accurate.
• That the short ejaculatory latency time is a source of distress for him or for his partner.
• That the short ejaculatory latency time is interfering with the satisfaction of sexual relations for him or the couple.
• If this condition has been life-long or if it has occurred more recently. Life-long PE is known as primary PE and recently acquired PE is known as secondary PE. If the onset of the problem is more recent, are there precipitating factors?
• Frequency of PE. An occasional instance of PE might not be cause for concern, but if the problem happens more than 50% of the time, a pattern usually exists for which treatment may be appropriate.

While a physical examination is often conducted (involving an abdominal and genital examination and possibly a prostate examination) it generally aids little in the diagnosis of PE.

Some men may not know if they have ED or PE. ED is a man's inability to attain or sustain an erection for the duration of sexual intercourse. Whereas PE is when a man and/or his partner perceives that he reaches orgasm and ejaculates too quickly and with little control.

In other words, PE is ejaculation before a man and his partner wants it to happen. There are men however who develop PE as a result of poor erection sustaining capability. In this situation, they condition themselves to reach orgasm/ejaculation quicker so they can do so before they lose their erection. The treatment of this begins by treating the erection problem first. With treatment many men can resolve the PE problem. Differentiating between the two conditions is a very important step for patients and physicians. An experienced physician should be able to define the real problem relatively easily.

It is also important to recognize that, after ejaculation, it is normal for erections to subside. The “refractory time,” or time between orgasm and when a man can achieve an erection again, varies from person to person and can increase with age. Some men with PE may think they have ED due to their inability to quickly regain an erection. However, this is the body’s normal response after ejaculation.

What types of treatment are available for PE?

• Medications
• Physical & Psychological Treatment

What kind of doctor takes care of PE?
Many different types of specialists are interested in sexual medicine and PE. The first resource would be the members of this society as they are all committed to excellence in sexual medicine and have a significant part of their practices devoted to this area. But if not possible, generally a urologist or a mental health professional (sex therapist, psychologist, psychiatrist) would be the primary specialists to go to for the treatment of PE.

Remember that psychologists cannot prescribe medications, so if a patient is interested in trying prescription medication, a physician will have to be further consulted (urologist, psychiatrist or even a family physician). Of note, the average family physician may not be familiar with the treatment of PE, but simply asking him/her is a good way to find this out. If he/she is not comfortable with the treatment of PE, then they can refer you to a local expert.

What medications are currently available for PE?
There are no FDA approved medications indicated for the treatment of PE, although, there currently are a number of treatments types used to manage PE.

The risks and benefits of all of the below treatment options should be discussed between the caregiver and the patient, as patient and partner satisfaction is the primary goal in the treatment of PE.

• Desensitization treatments: these are aimed at reducing the sensitivity of the penis immediately before sexual relations. It is noteworthy to mention that there is no evidence that men with PE have any difference in penis sensitivity than men without PE. Although these techniques work for some men with mild PE, they can cause a reduction in sensitivity so that sexual satisfaction during intimacy is also reduced. Little research has been done on these techniques and their true benefit. Techniques that are employed by some men include:
  • Using condoms: the use of a single condom may reduce sensitivity enough to make a difference in ejaculatory control for some men. Using multiple condoms, however, reduces sensitivity, potentially to the point where the sensation during relations is less than satisfactory for men.
  • Using desensitization ointments, creams or foams: local anesthetics like lidocaine/prilocaine creams can be applied to the head of the penis (the glans) 30 minutes before sex. Many of these treatments are best applied and then washed off 5-10 minutes before sexual relations to prevent transfer to the partner. Some of these treatments can be combined with condoms.
  • Masturbating prior to intercourse: many men with PE, even those with primary (life-long) PE, have much better ejaculatory control if they have sexual relations a second time within a short period of time after the initial encounter. Some men use masturbation in the hours before anticipated intimacy as a means to improve ejaculatory control.
• Non-FDA approved treatment options: a number of over the counter and prescription medications have been used for PE:
  • Herbal therapies: there are currently no studies that show the effectiveness of herbal products (also known as nutraceuticals). Many of these products contain androgens (testosterone, DHEA and androstenedione) that may be inappropriate for some men to use. Furthermore, some herbal products used for male sexual health contain the active ingredients in Viagra and Cialis, which is of concern to men taking nitroglycerin-containing medications, since taking these together can be deadly.
  • PDE-5 inhibitors: medications such as Viagra®, Levitra® and Cialis® have been used by some men for PE. Studies suggest that they may help some men suffering from PE. Scientists are not sure why these medications would work in men with PE. However, it is generally believed that these medications can help men with PE who also have ED.
  • Antidepressant medications: Antidepressants have been used for the treatment of PE. Prozac®, Paxil® and Zoloft® have been used with some success for this condition. Although no antidepressants have been specifically used to treat PE, on-demand or continuous treatment with some of these medications has been shown to help many men with PE. The drawbacks of these medications include the need for daily use in many men (when men stop using them they may return to having rapid ejaculation), the stigma that they are anti-depressant drugs (for example, airline pilots are not permitted to take these medications and fly) and side effects (drowsiness, nausea, dizziness, dry mouth and a range of sexual problems, such as decreased or increased sexual interest, ejaculation or orgasm problems, and impotence).

What types of psychological treatments are available?
Distraction techniques: distracting mental exercises during sex can be used to help PE (such as thinking of mundane things like baseball, work, etc.). These techniques are probably most useful for men with occasional PE or men who experience PE in the initial stages of a new sexual relationship. For men with long-standing PE, the consistent use of these techniques usually interferes with spontaneity and satisfaction.

Psychological Therapy: these treatments have been utilized for decades and are associated with success in many people. However, it is questionable for how long these treatments work. For example, for a man who has derived benefit from the techniques described, how long-lasting are the beneficial effects? It is estimated that 25% of men helped by such techniques retain the benefit for 2 years after starting the treatments.

PE can be both due to, and the cause of, psychological stress or other mental health and personal issues. Psychological treatments often involve counseling or sexual therapy that can include talking about relationships and experiences with a mental health professional and/or learning practical tools. By investigating relationships and individual issues that may be causing or compounding PE, mental health professionals can help find effective ways of coping with and solving problems that may be causing PE. For many couples affected by PE, working with a therapist together may produce the best results.

Some psychological therapies also focus on helping the individual find ways in which they can control ejaculation. Healthcare practitioners may provide instruction about distraction techniques, and "stop-start" and "squeeze" techniques that allow the patient to develop a sense of ejaculatory control.

The stop-start method works to help the individual identify ways of controlling their sexual stimulation and ejaculatory response. This method requires the man to engage in sexual stimulation, either with or without his partner, until he realizes that he is about to ejaculate. At this point he stops for about thirty seconds, reducing his urge to ejaculate, and then begins the sexual stimulation again. These steps are repeated until ejaculation is desired. In the final step of the sequence, stimulation is continued until a climax is achieved.

The squeeze method also involves sexual stimulation until just prior to the "point of no return". Once the man senses that he is about to ejaculate, his partner stops sexual stimulation and tip or the base of the penis is gently squeezed for several seconds. Further stimulation is withheld for 30 seconds and then resumed. The couple may choose to repeat the sequence as many times as they like, or continue stimulation until ejaculation is desired. These exercises likely work best with the participation of partner.

How do I find a psychologist experienced in treating PE?
Talking with a primary care provider is a good place to start. He/she will be able to recommend psychologists experienced in treating PE. There are all kinds of psychologists, so seeing a sex psychologist (as opposed to an addiction, family therapy or depression specialist) is recommended. You can also use resources such as this website, AASECT (www.aasect.org) and SSTAR (www.sstarnet.org) to help find a sex psychologist near you. 

Can I live with PE and still satisfy my partner?
It can be possible to still have a satisfactory sex life even with PE. The experience of sex and intimacy does not begin with penetration and end with male ejaculation. For men in heterosexual relationships, it is worth noting that recent research suggests most women do not experience orgasm from penetration alone. Foreplay including clitoral stimulation by mutual masturbation, oral sex and the use of sexual devices can improve the experience of sexual activity for both your partner and you. Similar concepts can be applied to men in non-heterosexual relationships as well. It is important for men to keep these considerations in mind if they might not want to seek treatment, or if they have exhausted several treatment options. 

Condition overview written by Petar Bajic, MD