Premature ejaculation

Premature ejaculation (PE) occurs when a man experiences orgasm and expels semen soon after sexual activity and with minimal penile stimulation. It has also been called early ejaculation, rapid ejaculation, rapid climax, premature climax, and (historically) ejaculatio 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".^[1] The International Classification of Diseases (ICD-10) applies a cut-off of 15 seconds from the beginning of sexual intercourse.^[2]

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.^[3]

Men with PE often report emotional and relationship distress, and some avoid pursuing sexual relationships because of PE-related embarrassment.^[4] Compared with men, women consider PE less of a problem,^[5] but several studies show that the condition also causes female partners distress.^[4][6][7]

Cause

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.^[3]

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.^[2]

The nucleus paragigantocellularis of the brain has been identified as having involvement in ejaculatory control.^[8] Scientists have long suspected a genetic link to certain forms of premature ejaculation. In one study, 91 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^[9] or as a drug side effect.

Mechanism

The physical process of ejaculation requires two actions: emission and expulsion. The emission is the first phase. It involves deposition of fluid from the ampullary vas deferens, seminal vesicles, and prostate gland into the posterior urethra.^[10] 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.^[11]

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.^[12][13]

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.^[14]

Current evidence supports an average intravaginal ejaculation latency time (IELT) of six and a half minutes in 18- to 30-year-olds.^[15][16] 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 two minutes.^[17] 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.

Diagnosis

When deciding the appropriate treatment, it is important for physician to distinguish PE as a "complaint" versus PE as a "syndrome".^[18] About 20 years ago, PE was classified into "lifelong PE" and "acquired PE".^[19] Recently, a new classification of PE was proposed based on controlled clinical and epidemiological stopwatch studies,^[18] 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 that irregular early ejaculation is a normal variation.^[20][21]

Several possible sub-classifications 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.^[22]

Treatments

Several treatments have been tested for treating premature ejaculation. A combination of medication and non-medication treatments is often the most effective method.^[23]

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, and it tends to detract from the sexual fulfilment of both partners. Other self-treatments include during the act thrusting more slowly, withdrawing the penis altogether, purposefully ejaculating before sexual intercourse, and using more than one condom. Using more than one condom is not recommended as the friction will often lead to breakage. Some men report these to have been helpful.^[3]

By the 21st century, most men with premature ejaculation could cure themselves, either on their own 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.^[24][25]

Psychoanalysis

Freudian theory postulated that rapid ejaculation was a symptom of underlying neurosis. It stated that 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.^[26] Freudians claimed that premature ejaculation could be cured using psychoanalysis. But even years of psychoanalysis accomplished little, if anything, in curing premature ejaculation.^[26]

There is no evidence that men with premature ejaculation harbor unusual hostility toward women.^[27]

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).^[23]

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 it, they were to signal their partner, who squeezed the head of the penis between thumb and index finger, suppressing the ejaculatory reflex and allowing the man to last longer.^[28][29][30]

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 focused on a simpler and more effective technique called the "stop-start" technique. During intercourse, as the man senses he is approaching climax, both partners stop moving and remain still until the man's feelings of ejaculatory inevitability subside, at which point, they are free to resume active intercourse.^{[31][32][33][34][35]} To help the man increase awareness of his sexual experience, he is encouraged to create an excitement scale of 1-100. Successful completion of this scale will include paying attention to his heart rate, when (and if) he squeezes his inner thighs, and sensations in all parts of his body. By creating this scale, he will be more able to pace himself as he uses the "stop-start" technique.

In addition to the stop-start technique, other sexual adjustments help men develop and maintain ejaculatory control, among them: focus exercises, mind/body coordination exercises, 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.^{[36][37][38][39][40]} The authors of one study concluded that sex therapy "has a remarkable therapeutic effect on premature ejaculation".^[25]

Medications

Drugs that increase serotonin signalling in the brain slow ejaculation and have been used successfully to treat PE. These include selective serotonin reuptake inhibitors (SSRIs), such as paroxetine or dapoxetine, as well as clomipramine. Ejaculatory delay typically begins within a week of beginning medication. The treatments increase the ejaculatory delay to 6–20 times greater than before medication. Men often report satisfaction with treatment by medication, and many discontinue it within a year.^[2] However, SSRIs can cause various types of sexual dysfunction such as anorgasmia, erectile dysfunction, and diminished libido.

Dapoxetine is a short-acting SSRI which appears to work when taken as needed for PE.^[41] It is generally well tolerated.^[42] Tramadol, an atypical oral analgesic, appears to be effective.^[43]

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.^[44] Use of topicals 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).^[45] Penis insensitivity and transference to the partner are practically eliminated when using topical anesthetic sprays based on absorption technology^[46] which enable the active ingredient to penetrate through the surface skin of the penis (stratum corneum) to the sensory nerves which reside in the dermis.

Several notable medical institutions suggest Promescent as a viable topical medication.^[47][48][49] Promescent is an ejaculation-delaying topical agent that appears to be effective in increasing the time to ejaculation and the overall quality of the sexual experience in men with subjective premature ejaculation. Further clinical trials that include the partner perspective would be beneficial and a larger population of patients with lifelong premature ejaculation, acquired premature ejaculation, natural variable premature ejaculation, and in male volunteers with normal intravaginal ejaculatory latency times would enhance the understanding of the differential effects of this product on all men looking to delay their ejaculation.^[50]

In 2005, researchers at the Australian Centre for Sexual Health in Sydney measured the ability of sildenafil citrate (a treatment primarily used to medicate erectile dysfunction) to treat subjects experiencing premature ejaculation. Even though it did not significantly lengthen ejaculatory latency, sildenafil reportedly 'increased confidence, the perception of ejaculatory control, and overall sexual satisfaction' in those studied, and aided in the achievement of a second erection following premature ejaculation.^[51]

Epidemiology

Premature ejaculation is a prevalent sexual dysfunction in men;^[52] 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).^[53] Although ED is men's most prevalent sex problem after age 60, and may be more prevalent than PE overall according to some estimates,^[54] premature ejaculation remains a significant issue that, according to the survey, affects 28 percent of men age 65–74, and 22 percent of men age 75–85.^[53] 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 a very common sex problem.^{[4][9][52][55][56][57][58][59]}

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.^[2]

History

Other 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.^[60]

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."^[61]

Sex researcher Alfred Kinsey did not consider rapid ejaculation a problem, but viewed it as a sign of "masculine vigor" that could not always be cured.^[62] The belief that it should be considered a disease rather than a normal variation has also been disputed by some modern researchers.^[63]

See also

• Anorgasmia
• Delayed ejaculation
• Orgasm control
• Pre-ejaculate
• Retrograde ejaculation

References

External links

• Media related to premature ejaculation at Wikimedia Commons