Premature ejaculation

Premature ejaculation
Specialty	Psychiatry, psychology

Premature ejaculation (PE), also known as, rapid ejaculation, rapid climax, premature climax or early ejaculation, is the most common sexual problem in men, affecting 25%-40% of men. It is characterized by a lack of voluntary control over ejaculation. Masters and Johnson stated that a man suffers from premature ejaculation if he ejaculates before his sex partner achieves orgasm in more than fifty percent of their sexual encounters. Other sex researchers have defined premature ejaculation as occurring if the man ejaculates within two minutes of penetration; however, a survey by Alfred Kinsey in the 1950s demonstrated that three quarters of men ejaculate within two minutes of penetration in over half of their sexual encounters. Today, most sex therapists understand premature ejaculation as occurring when a lack of ejaculatory control interferes with sexual or emotional well-being in one or both partners.

Most men experience premature ejaculation at least once in their lives. Often adolescents and young men experience premature ejaculation during their first sexual encounters, but eventually learn ejaculatory control. Because there is great variability in both how long it takes men to ejaculate and how long both partners want sex to last, researchers have begun to form a quantitative definition of premature ejaculation. 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 one and a half minutes. Nevertheless, it is well accepted that men with IELTs below 1.5 minutes could be "happy" with their performance and do not report a lack of control and therefore do not suffer from PE. On the other hand, a man with 2 minutes IELT could present with perception of poor control over his ejaculation, distressed about his condition, has interpersonal difficulties and therefore be diagnosed with PE.

Possible Psychological and Environmental Factors

Psychological factors commonly contribute to premature ejaculation. While men sometimes underestimate the relationship between sexual performance and emotional well-being, premature ejaculation can be caused by temporary depression, stress over financial matters, unrealistic expectations about performance, a history of sexual repression, or an overall lack of confidence. Interpersonal dynamics strongly contribute to sexual function, and premature ejaculation can be caused by a lack of communication between partners, hurt feelings, or unresolved conflicts that interfere with the ability to achieve emotional intimacy. Neurological premature ejaculation can also lead to other forms of sexual dysfunction, or intensify the existing problem, by creating performance anxiety. In a less pathological context, premature ejaculation could also be simply caused by extreme arousal.

Recent research has also investigated the role of factors involving the female partner. One study of young married couples (Tullberg, 1999) reported that the husband's IELT seems to be affected by the phases of the wife's menstrual cycle, the IELT tending to be shortest during the fertile phase. Other studies suggest that young men with older female partners reach the ejaculatory threshold sooner, on average, than those whose partners are their own age or younger .

Science of Mechanism of Ejaculation

The physical process of ejaculation requires two sequential actions: emission and expulsion.

Mechanism of Ejaculation

The emission phase is the first one to happen and it involves deposition of seminal fluid from ampullary vasa deferens, seminal vesicles & prostate gland into posterior urethra. Second phase is the expulsion of semen which involves closure of bladder neck followed by the rhythmic contractions of urethra by pelvic-perineal and bulbospongiosus muscle and intermittent relaxation of external Sphincter urethrae. Today it is believed that the neurotransmitor serotonin (5HT) has a central role in modulating ejaculation. Several animal studies have demonstrated its inhibitory effect on ejaculation modulated through the PGI system in the brain. Therefore, it is perceived that low level of serotonin in the synaptic cleft in these specific areas in the brain could cause premature ejaculation. This theory is further supported by the proven effectiveness of SSRIs, which increase serotonin level in the synapse, in treating PE.

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.

Several areas in the brain, and especially the nucleus paragigantocellularis, have been identified to be 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 suffered from lifelong premature ejaculation also had a first-relative with lifelong premature ejaculation. Other researchers have noted that men who suffer from premature ejaculation have a faster neurological response in the pelvic muscles. Simple exercises commonly suggested by sex therapists can significantly improve ejaculatory control for men with premature ejaculation caused by neurological factors. Often, these men may benefit from anti-anxiety medication or selective serotonin reuptake inhibitors (SSRIs), such as sertraline or paroxetine, as these slow down ejaculation times[1]. Some men prefer using anaesthetic creams, however, these creams may also deaden sensations in the man's partner, and are not generally recommended by sex therapists.

Treatment

Depending on severity, premature ejaculation symptoms can be significantly reduced. In mundane cases, treatments are focused on gradually training and improving mental habituation to sex and physical development of stimulation control. In clinical cases, various medications are being tested to help slow down the speed of the arousal response.

Behavior modification

Most sex therapists and sex educators prescribe a series of exercises to enable the man to gain ejaculatory control. These are considered the first line of treatment, and are usually recommended to be tried before other methods.

One of the most common exercises is the “Start-Stop” technique in which during sex when he feels that he is getting too close to orgasm, he stops and does not move, to avoid more stimulation. He may withdraw his penis, or stay inside and request that his partner also not move. He waits seconds or minutes until his arousal lessens, and then resumes sex. He may stop and then re-start as many times as necessary.

Another technique is the "Squeeze Technique", in which during sex (or masturbation if he wants to practice it) when he feels the urge to ejaculate, he would withdraw his penis and squeeze at the tip of the shaft below the glans of his penis near the frenulum of his penis, until the feeling subsides. To be more specific, the proper hand position for this technique is for him to place his thumb on the frenulum, and his index and middle fingers above and below the coronal ridge (which is on the other side of the head of his penis), and then squeeze his penis from front to back. He may consult a sex therapist for more directions to this technique.

The male's partner plays an essential role in enabling him to overcome premature ejaculation. Without understanding and emotional support, the male is unlikely to obtain the level of relaxation required for sexual satisfaction. Both the male and his partner should communicate their feelings openly and with sensitivity. The partner may also be integrated into the exercises to keep her involved. She can learn to deliver the squeeze technique, and she can encourage the stop-start technique.

Both partners should also be aware of the sexual positions that make the male most likely to ejaculate quickly. They should avoid those positions if they want to prolong sex. Some men ejaculate quickly in any position, however, so the other methods would be more effective.

In cases where the chief concern is reaching simultaneous orgasm, it is also possible to simply work around the premature ejaculation problem by changing positions frequently (which studies have shown delays male orgasm by a factor of 2-3), using lubrication to reduce friction (friction stimulates the male but is not as important in female orgasm), or switching to cunnilingus for awhile when close to ejaculation, and then switching back when ejaculation is no longer imminent.

Medications

SSRI antidepressants have been shown to delay ejaculation in men treated for different psychiatry disorders. SSRIs are considered the most effective treatment currently available for PE. These include paroxetine, fluoxetine, sertraline and more. The use of these drugs, that require chronic therapy, is limited by the neuropsychiatric side effects. New SSRI drugs specifically targeted to treat premature ejaculation (e.g. dapoxetine) can be taken on an as needed basis and have been recently shown positive results in large phase III studies. Nevertheless dapoxetine is not yet approved by any regulatory authority around the world. There is speculation that some of the associated effects are caused by lowered libido and blood pressure as well as lowered anxiety levels. Other pharmaceutical products known to delay male orgasm are; opioids, cocaine, and diphenhydramine.

Local anesthetic creams (like lidocaine, prilocaine and combinations) have shown to be effective in clinical trials and are being used for the treatment of PE. Their use is limited by its own anesthetic effect that reduce sensation on the penis and vagina.

Devices

External latex rigid sheathes fastened to the body have been developed that cover all part of the penis during penetration so that the penis is protected from all the stimulation of the vagina. These help to gain control and to provide satisfaction to the partner. Masters and Johnson recommended the use of the Lateral coital position to help alleviate premature ejaculation.

Alternative therapies

Many alternative therapies are available for the treatment of PE. Caution should be exercised when researching alternative sources of advice however, most treatments have not actually been shown to be effective. Some web sites even advocate the dangerous and antiquated method of pulling the testes downwards when aroused. This is actually a good way to slightly strain the interior of the testes and is associated with reports of injury and weakened/deteriorated erection. For some reason this advice is still widespread on the Internet.

It is very important to remember that the response rates from well conducted placebo controlled trials demonstrate that placebo has the ability to DOUBLE (Pryor et al Lancet Sept 2006) ejaculatory latency times in men with PE. Alternative therapies would need to show a magnitude of effect above and beyond this doubling to be deemed effective. The majority of information presented in the alternative treatments have failed to provide this level of evidence.

Hypnosis has also proven very effective in the treatment of premature ejaculation. It is believed by some that ejaculation is a subconscious habit and by giving the mind hypnotic suggestions to last longer, the problem can be greatly alleviated if not completely cured. Most men report dramatic improvement after only a few sessions of hypnosis. A good example of this can be heard at http://premature-ejaculation-selfhelp.com

The prostate gland plays a very important part in regulating arousal. Pressure in between the engorged prostate and the erection causes most of the pleasurable sensations and it may be emptied manually before sex by prostate massage. This causes the erection to be strong but less sensitive, and increases a patient's awareness of his physiology. Regarding the prostate gland playing an important role in regulating arousal. This is no scientific evidence to support this theory.

There is a trend toward the use of nutritional supplements when treating men who suffer from PE. Effective supplements must contain 5HTP which is a precursor to serotonin. A highly respected physiologist and author of numerous medical physiology textbooks, Dr. William Ganong, noted that serum serotonin levels could be increased through dietary means. 5-HTP is identified by Dr. Ganong as the supplemental source that can increase the serum level of serotonin thus helping to inhibit the ejaculatory reflex.

There are a number of nutritional remedies available primarily on the Internet. The best of these such as Detain X capitalize on Dr. Ganong's invaluable research and the importance of dietary 5 HTP as an essential factor for raising the all-important serotonin levels.

Another alternative type of treatment is the smoking of cannabis. Cannabis was widely used in ancient India as a general aphrodisiac and to delay ejaculation [2] and is still today one of the more successful (and currently illegal) methods of treatment for PE.

Diagnosis

Diagnostic criteria for Premature Ejaculation DSM-IV-TR (American Psychiatric Association)

A. Persistent or recurrent ejaculation with minimal sexual stimulation before, on, or shortly after penetration and before the person wishes it. The clinician must take into account factors that affect duration of the excitement phase, such as age, novelty of the sexual partner or situation, and recent frequency of sexual activity.

B. The disturbance causes marked distress or interpersonal difficulty.

C. The premature ejaculation is not due exclusively to the direct effects of a substance (e.g., withdrawal from opioids).

Differential diagnosis

Premature ejaculation should be distinguished from erectile dysfunction related to the development of a general medical condition. Some individuals with erectile dysfunction may omit their usual strategies for delaying orgasm. Others require prolonged noncoital stimulation to develop a degree of erection sufficient for intromission. In such individuals, sexual arousal may be so high that ejaculation occurs immediately. Occasional problems with premature ejaculation that are not persistent or recurrent or are not accompanied by marked distress or interpersonal difficulty do not qualify for the diagnosis of premature ejaculation. The clinician should also take into account the individual's age, overall sexual experience, recent sexual activity, and the novelty of the partner. When problems with premature ejaculation are due exclusively to substance use (e.g., opioid withdrawal), a substance-induced sexual dysfunction can be diagnosed.

Ejaculation Disorder Types

• Premature ejaculation -Ejaculation occurs very early
• Retarded ejaculation -Ejaculation takes a long time
• Retrograde ejaculation -Semen flows from the prostate gland into the bladder rather than spurting out of the penis
• Inhibited orgasm in males

Associated conditions

• Neurological disorders, e.g., multiple sclerosis
• Prostatitis
• Psychological disorders
• Inter- and intrapersonal disorders

See also

• Delayed ejaculation
• Premature Ejaculation: Personal story and advice from an affected