Premature ejaculation

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Classification according to ICD-10
F52.4 Ejaculatio praecox
ICD-10 online (WHO version 2019)

Of premature ejaculation ( lat. Eiaculatio praecox "early Eject"; also premature ejaculation ) is a sexual disorder of the man , wherein the ejaculation (ejaculation) takes place at an early stage, partly directly after the insertion of the erect penis into the vagina, without this would be associated with a lustful orgasm . Premature ejaculation can have negative consequences for both partners, as sexual intercourse can usually not be continued directly due to the refractory phase and the decrease in erection after ejaculation, which in turn can lead to reduced sexual satisfaction, suffering and relationship conflicts in the long term.

It is the most common sexual dysfunction in men under the age of 60 ( prevalence : up to 30%). The largest international study to date on premature ejaculation comes to the conclusion that around 20% of men are affected.

features

Ejaculatio praecox is a sexual dysfunction characterized by premature ejaculation during sexual intercourse or other stimulation. There are different definitions with different strict criteria, v. a. in terms of time to ejaculation. However, most definitions include three criteria:

The ejaculatio praecox is characterized in that

  • the time from penetration of the penis into the vagina to ejaculation is perceived as too short,
  • the person concerned cannot control the ejaculation sufficiently (e.g. to achieve coitus interruptus , to delay one's own orgasm or because postcoital fatigue in men can mean that the woman is not stimulated to orgasm)
  • and that this results in considerable personal suffering, which is characterized by fear, frustration, problems in the partnership or the renunciation of sex.

The current guideline on the diagnosis and treatment of premature ejaculation from 2010 also contains the evidence-based definition of the lifelong form of premature ejaculation, which was developed in 2007 by the International Society of Sexual Medicine together with experts. According to this, ejaculatio praecox is a male sexual dysfunction with the following characteristics:

  • Ejaculation always or almost always occurs before or within about a minute of inserting the limb into the vagina
  • the inability to delay ejaculation with any or almost any vaginal penetration
  • negative personal consequences, such as suffering, anger, frustration and / or avoidance of sexual intimacy.

In the most severe form of premature ejaculation, ejaculation occurs before the penis is inserted. One then speaks of ejaculatio ante portas . In healthy men, ejaculation occurs on average 5.4 minutes after penetration of the penis into the partner.

The personal feelings of the person affected are always particularly important in the diagnosis.

Clinical classification

In general, ejaculatio praecox is one of the male ejaculation disorders. However, according to various sex medicine experts, this classification is controversial, as it is not a question of impaired ejaculation, but rather premature one. However, studies have repeatedly shown that ejaculation praecox can have a significant negative impact on the partnership. Like delayed orgasm and anorgasmia, it is assigned to orgasm disorders in the more recent literature. In the ICD classification of the World Health Organization (WHO) it is listed under number F52.4, the DSM classification lists it under number 302.75. The classification is created by experts and is used to facilitate diagnosis and healing.

history

The first description of the ejaculatio praecox was made by Karl Abraham under the title About Ejaculatio praecox in 1917 in the international journal for psychoanalysis . Research on ejaculatio praecox was carried out in the 1920s by Bernhard Schapiro, Arthur Kronfeld's successor at the Institute for Sexology in Berlin. With the Hamburg company Promonta, he developed the preparation praejaculin for the treatment of premature ejaculation. However, ejaculatio praecox did not move into the public eye until the 1970s and early 1980s, when a large number of studies, descriptions, diagnostic and causal models, and therapy proposals were published.

Epidemiology

Ejaculatio praecox is one of the most common sexual dysfunctions in men. Depending on the definition or study design, between 3 and 30 percent of men are affected by premature ejaculation. However, not even 10 percent of those affected go to the doctor.

The discrepancy between the number of men affected and the number of men seeking help can probably be explained primarily by the reluctance of those affected to reveal such an intimate problem. Many also do not know that the specialist in urology and sexual medicine is the right contact. Some sufferers may also have worked with their partner to find a way to make premature ejaculation less of a problem. There are couples for whom rapid ejaculation is not perceived as a problem, as well as those for whom the women even find the speed to be pleasant, as they themselves have very little interest in sexual encounters. On the other hand, there are also couples for whom the ejaculatio praecox is a great burden for the partnership and also causes sexual dysfunction in the partner, such as B. listlessness or difficulty having an orgasm.

Anthropological explanation

There are doubts whether a physiological reaction that affects 20 to 30% of humanity should even be classified as a disorder (more often than, for example, left-handedness , see there ). In the animal kingdom it comes in various types of Harem education, in which a dominant male ( silverback etc.) a harem of females controlled ( polygyny in herd animals with male lead animal so as apes, seals). The copulation process of these lead animals sometimes takes longer (observed in chimpanzees by Jane Goodall ). Other males are then forced to populate the terrain alone or in hordes of bachelors, whereby the formation of cohorts (group formation) is more likely to lead to success in the hunt. If such a sexually agile (young) male from the bachelor gang wants to mate a female guarded in this way, this will only lead to success if the mating process takes place as quickly as possible (also observed in chimpanzees). A quick ejaculation would therefore be a relic of such social behavior of primitive men - herd . Since both variants (harem guard and fast lover) led to offspring, they would have been evolutionarily preserved . The fact that premature ejaculation can partly be inherited speaks in favor of an evolutionary adaptation .

Causes and forms

The causes of ejaculatio praecox are not yet fully understood. In the last 20 years, however, great strides have been made in the field of causal research. It is now assumed that premature ejaculation can partly have physical or neurobiological causes. Before that, it was suspected that ejaculatio praecox had purely psychological causes. However, this view is now considered out of date.

A distinction is made between the lifelong (primary) and the acquired (secondary) form of ejaculatio praecox. In the lifelong form, premature ejaculation has occurred since sexual activity began. Control can also be limited during masturbation. Current studies suspect a partly genetic, altered serotonin balance as the cause. The acquired form, on the other hand, is usually the result of an underlying disease, such as B. erectile dysfunction, prostate inflammation, thyroid disease or psychological complaints. It only occurs over time. So there was a period of normal ejaculation.

Stress and problems in the couple relationship represent a further complex of the causal models. With many affected persons, quarrels and stress in the partnership can be determined, whereby these can also be the cause of the acquired form of the dysfunction. These conflicts can also have a negative impact on the lifelong form of the sexual disorder. This means that the premature ejaculation is getting worse.

Diagnosis

overview

Quantitative and qualitative criteria are used for the medical diagnosis. So it is not only important for the doctor to inquire about the time until ejaculation, but also how the person concerned and his partner deal with the premature ejaculation. In the conversation, the doctor also depends on finding out whether the person affected is the lifelong or the acquired form of ejaculatio praecox. In the event that premature ejaculation occurred in the person concerned only after years with normal ejaculation (acquired form), the doctor must clarify whether there are organic causes.

Quantitative and qualitative diagnosis

The quantitative and measurable characteristics include the time that elapses between the insertion of the penis into the vagina and ejaculation (so-called IELT, intravaginal ejaculation latency). For men who are affected by the lifelong form, for example, this is usually less than a minute. On average, affected men (lifelong and acquired form) ejaculate after 1.8 minutes.

Additional qualitative features are important for the diagnosis of ejaculatio praecox: If the person concerned cannot control the ejaculation and if the person concerned is suffering from it, then this is a sign of ejaculatio praecox.

However, it is also assumed that this condition persists and does not only occur during longer periods of abstinence or a new partner. However, permanent does not mean that premature ejaculation has to have existed since the first sexual experience - this only applies to the lifelong form. In the acquired form of ejaculatio precox, there was a time when ejaculation was normal. Only over time did regular and therefore permanent premature ejaculation occur.

History and differential diagnosis

The anamnesis is based on specific questions:

  • What is the time between penis penetration and ejaculation?
  • Can You Control Your Ejaculation?
  • Are you stressed if you come too early to have sex?
  • When did you first experience premature ejaculation?
  • Have you already experienced premature ejaculation during your first sexual contact?
  • Is it stressful for your partner if you are early in sex?
  • Does Your Partner Avoid Sex?
  • Is premature ejaculation affecting your relationship?

In addition to the questioning, a medical examination also plays an important role in the anamnesis. On the one hand, medical reasons that actually exist can be determined or ruled out in this way, and on the other hand they offer the examined man the security that his complaints will be taken seriously. The patient usually develops a somatic explanation himself , which must be excluded for a therapy to be successful.

A differential diagnosis is needed to rule out other reasons for the premature ejaculation. In the acquired form of ejaculatio praecox, it must be investigated whether organic causes, an erectile dysfunction, prostate inflammation or thyroid problems are the cause of the premature ejaculation. In addition, the following must be distinguished from ejaculatio praecox:

  • The ejaculatio diurana spontana, i.e. the spontaneous ejaculation while awake without any particular irritation. This is particularly common in adolescents during puberty .
  • Pre-ejaculative secretion, i.e. the discharge of secretion from the penis before the actual ejaculation occurs.
  • Spermatorrhea , the uncontrolled discharge of semen from the penis. This can especially occur in older men.
  • Ejaculations induced solely by the man's imagination.

therapy

overview

Premature ejaculation can be treated through sexual and couple therapy measures as well as through drug therapy options.

The partner should be included in the treatment, because seriously dealing with the sexual dysfunction and approaching the problem together have a positive effect on the treatment in many cases. However, the involvement of the partner is not essential for the success of the treatment.

In some sex therapy directions, techniques are often used that are intended to help affected men to perceive and influence ejaculation up to the point of time known as the point of no return . The squeeze and stop-start methods according to Masters and Johnson are particularly well known . In practice, however, these are not proven or popular methods. Especially with the lifelong form of premature ejaculation, both techniques do not help permanently.

Medicines can be used independently of sex or couples therapy. As resources are local anesthetics , drugs with ejakulationshemmenden side effects or approved for the treatment of premature ejaculation drug dapoxetine available. If other procedures are ineffective, there is the possibility of a surgical-surgical intervention.

Squeeze technique

With the squeeze technique , the man should first perceive his arousal more consciously through sensuality training . Then he learns to perceive the time of the unwanted ejaculation more precisely and to influence it in a further step. Ideally, this method is used in couples therapy, which means that the woman helps the man with the experience. With all these techniques, the woman must of course not serve as a tool; on the contrary, the man should pay special attention to the fulfillment of her sexual desires.

In a first step, the man is stimulated by the woman in a petting so that an erection occurs. The penis is now gently caressed and massaged until the man has the feeling that ejaculation is imminent. By pressing for several seconds, the penis is now "squeezed" by the woman or the man with his fingers (below the glans, between the top and bottom), which reduces the urge to ejaculate. After about 20 seconds, stimulation is repeated. Overall, the stimulation and squeeze technique should alternate over a period of around 20 minutes.

Once the man has learned to use the squeeze technique to gain control over the timing of ejaculation, this should be continued by passive insertion of the penis into the woman's vagina. For this purpose, the woman crouches over the man and inserts the erect penis into her vagina without causing increased arousal by moving the pelvis. If there is also a need to ejaculate here, the woman uses the squeeze technique again on the man's advice. Then she reinserts the penis and the process starts all over again and can be continued with pelvic movements as the progress increases. If he is unable to control his ejaculation here either, sexual intercourse should be carried out in a lateral position in a final phase, as this is where the best possible reaction to the excitement is available.

Stop-start technology

For many men, the stop-start technique is more suitable than squeezing, as it is much more similar to “normal” stimulation during sexual intercourse. Here, too, you should learn to perceive your own excitement better. In a first step, the man masturbates alone (i.e. without the partner under pressure to succeed) and stops masturbation shortly before the critical threshold, the "point of no return". He repeats this stopping and starting process over a period of around 15 minutes. As soon as he feels reasonably safe, he can integrate sexual intercourse in a second stage: If the urge to ejaculate is increased, the man should then indicate to the woman that further stimulation should not be carried out (stop signal) until he is clear again lower levels of arousal. As a bridge between the two stages, it is often recommended to vary the masturbation technique before the point of no return (e.g. take another hand, different rhythm, etc.) and thus maintain the stimulation for an even longer period of time. Only then should you move on to real sexual intercourse. As a rule, this two-stage approach enables very good results to be achieved.

Pelvic floor training

By exercising and tensing the pelvic floor muscles , men can also prevent premature ejaculation. Other methods for men are noted under Sexual Response Cycle # Multiple orgasms .

Local anesthetic sprays and condoms

Condoms to delay the ejaculation are provided with a local anesthetic on the inside

Local anesthetics (local anesthetics) such as lidocaine , benzocaine and prilocaine , in the form of so-called delay gels, sprays and ointments, reduce the excitability of the penis (especially the penile foreskin and glans ). Some of these products are sold over the counter by various manufacturers through drugstores and pharmacies. With benzocaine and prilocaine, some patients reported up to 4 times the ejaculation delay. The effect often sets in a minute after application, so that appropriate sexual intercourse was possible. Lidocaine, it takes about 20-30 minutes to the anesthesia used what lovemaking can severely affect. In Europe, a combination preparation consisting of the rapidly anesthetic prilocaine and subsequently effective lidocaine for the treatment of lifelong premature ejaculation is approved, which is sprayed onto the glans 5 minutes before sexual intercourse. The drug requires a prescription.

If the preparations are not removed by washing them off beforehand, the partner's genitals can be desensitized in the course of sexual intercourse. To avoid this, some manufacturers offer special condoms that have a light local anesthetic on the inside. Thus, only the man is desensitized without affecting the partner's ability to feel.

Oral medication

Prescription psychotropic drugs that have a direct effect on brain activity, such as clomipramine or selective serotonin reuptake inhibitors (SSRIs) such as citalopram , paroxetine , sertraline and fluoxetine can be used to treat premature ejaculation, but are not approved for this. One therefore speaks of off-label use . Originally, a reduced libido and excitability were noticed as side effects in this group of substances, which were successfully used in the therapy of ejaculatio praecox. They can cause side effects (e.g. nausea and headache) and have a long half-life. In addition, they can not only be used when needed, but must be taken daily over a longer period of time.

An orally effective drug specially approved for the treatment of ejaculatio praecox contains the active ingredient dapoxetine , a short-acting serotonin reuptake inhibitor. The prescription drug has been available in Germany since June 2009 under the trade name Priligy (approx. EUR 30/3 tablets of 30 mg dapoxetine) and is taken approx. One to three hours before sex if necessary. It has been shown that dapoxetine can significantly increase the time to ejaculation. Control over ejaculation and patient satisfaction also improved. The level of suffering and partnership problems decreased. Dapoxetine works with both lifelong and acquired forms of premature ejaculation.

Other drugs that have been shown to inhibit the possibility of ejaculation as a side effect are alpha blockers such as phenoxybenzamine , beta blockers and tricyclic antidepressants such as clomipramine . Clomipramine increases the time to ejaculation by 1.4 times, but it must be taken two to six hours before the expected sexual intercourse. In addition, these drugs require a prescription, but are not approved for the treatment of premature ejaculation.

With all forms of treatment, however, the ejaculatio praecox does not heal; the problem persists after the medication is discontinued. In rare cases, discontinuation of SSRIs can lead to post-SSRI sexual dysfunction , which can manifest itself in ejaculation disorders, loss of libido, genital numbness, orgasm disorders and erectile dysfunction.

Surgical treatment

Two different operations are available for the permanent treatment of premature ejaculation: the selective dorsal neurectomy (SDN) and the augmentation with hyaluronic acid gel . Both treatments were developed in South Korea and are quite common in that country. 72.9% of Korean urologists consider SDN to be a safe and efficient treatment. Preliminary studies have shown that both are relatively safe and effective, [44] but due to the lack of large, multicenter, randomized controlled trials with long-term follow-up , the International Society for Sexual Medicine has not yet been able to select them dorsal neurectomy and augmentation as treatment options to make a clear recommendation. The role of surgery in treating premature ejaculation is in the experimental stage pending further studies.

literature

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Individual evidence

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  2. ↑ a b c d e f g h i j k S. Althof u. a .: International Society for Sexual Medicine's Guidelines for the Diagnosis and Treatment of Premature Ejaculation . In: Journal of Sexual Medicine . tape 7 , no. 9 , September 2010, p. 2947-2969 , doi : 10.1111 / j.1743-6109.2010.01975.x .
  3. ↑ a b H. Porst u. a .: The Premature Ejaculation Prevalence and Attitudes (PEPA) Survey: Prevalence, Comorbidities, and Professional Help-Seeking . In: European Urology . tape 51 , no. 3 , March 2007, p. 585-872 .
  4. ^ F. Giuliano et al. a .: Premature Ejaculation: Results from a Five-Country European Observational Study . In: European Urology . tape 53 , no. 5 , May 2008, pp. 1048-1057 .
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  6. ↑ Götz Borgwardt: Bernhard Schapiro (1888–1966): Talmudic scholar - doctor - pioneer of the hormone treatment of cryptorchidism. In: Würzburg medical history reports. 23, 2004, p. 402 f.
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  9. ↑ a b c Jane Goodall: The Chimpanzees of Gombe: Patterns of Behavior. Boston 1986.
  10. ↑ Norbert Bischof: The Riddle Oedipus. The biological roots of the primal conflict between intimacy and autonomy. Munich / Zurich 1985 PDF file
  11. ↑ Erik Ernst Schwabach: The revolutionization of women. Der Neue Geistverlag, 1928.
  12. ↑ Alison Jolly: Lucy's Legacy. Sex and Intelligence in Human Evolution . Harvard University Press, Cambridge (Massachusetts), London (England), 1999, ISBN 0-674-00069-2 .
  13. ↑ Premature ejaculation can be inherited , at focus.de
  14. ↑ Patrick Jern, Pekka Santtila, Katarina Witting, Katarina Alanko, Nicole Harlaar, Ada Johansson, Bettina Von Der Pahlen, Markus Varjonen, Nina Vikström, Monica Ålgars, Kenneth Sandnabba: Premature and Delayed Ejaculation: Genetic and Environmental Effects in a Population-Based Sample of Finnish Twins , The Journal of Sexual Medicine, Volume 4, Issue 6, pp. 1739-1749.
  15. ↑ PKC Janssen u. a .: Serotonin Transporter Promoter Region (5-HTTLPR) Polymorphism is Associated with the Intravaginal Ejaculation Latency Time in Dutch Men with Lifelong Premature Ejaculation . In: Journal of Sexual Medicine . tape 6 , no. 1 , January 2009, p. 276-284 , doi : 10.1111 / j.1743-6109.2008.01033.x .
  16. ^ MD Waldinger: Premature Ejaculation . In: Drugs . tape 67 , no. 4 , March 2007, p. 547-568 , doi : 10.2165 / 00003495-200767040-00005 .
  17. ↑ Dieme 2003, Pfreunder 2005.
  18. ↑ CG McMahon et al. a .: Efficacy and Safety of Dapoxetine for the Treatment of Premature Ejaculation: Integrated Analysis of Results from Five Phase 3 Trials . In: The Journal of Sexual Medicine . tape 8 , no. 2 , February 2011, p. 524-539 , doi : 10.1111 / j.1743-6109.2010.02097.x .
  19. ^ MD Waldinger: Pharmacotherapy for premature ejaculation. In: Expert Opinion on Pharmacotherapy. 16 (17), 2015, pp. 2615-2624. PMID 26579971
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  21. ↑ Netherlands Pharmacovigilance Center Lareb: SSRIs and Persistent Sexual Dysfunction. ( Memento from April 2, 2015 in the Internet Archive ) 2012.
  22. ↑ You, HS (2000). The partial neurectomy of the dorsal nerve of the penis for patient with premature ejaculation. Korean Journal of Andrology, 18 (2), 143-148.
  23. ^ Zhang, GX, Yu, LP, Bai, WJ, & Wang, XF (2012). Selective resection of dorsal nerves of penis for premature ejaculation. International journal of andrology, 35 (6), 873-879. PMID 22882515 doi : 10.1111 / j.1365-2605.2012.01296.x
  24. ↑ Kim, JJ, Kwak, TI, Jeon, BG, Cheon, J., & Moon, DG (2004). Effects of glans penis augmentation using hyaluronic acid gel for premature ejaculation. International journal of impotence research, 16 (6), 547 PMID 15057258
  25. ↑ Kwak, TI, Jin, MH, Kim, JJ, & Moon, DG (2008). Long-term effects of glans penis augmentation using injectable hyaluronic acid gel for premature ejaculation. International journal of impotence research, 20 (4), 425. PMID 18548080 doi : 10.1038 / ijir.2008.26
  26. ↑ Yang, DY, Ko, K., Lee, WK, Park, HJ, Lee, SW, Moon, KH, ... & Min, K. (2013). Urologist's practice patterns including surgical treatment in the management of premature ejaculation: A Korean nationwide survey. The world journal of men's health, 31 (3), 226-231 PMID 4459656
  27. ^ Moon, DG (2016). Is there a place for surgical treatment of premature ejaculation ?. Translational andrology and urology, 5 (4), 502 PMID 27652223 doi : 10.21037 / tau.2016.05.06
  28. ↑ Anaissie, J., Yafi, FA, & Hellstrom, WJ (2016). Surgery is not indicated for the treatment of premature ejaculation. Translational andrology and urology, 5 (4), 607. doi : 10.21037 / tau.2016.03.10
  29. ↑ Serefoglu, EC, & Saitz, TR (2012). New insights on premature ejaculation: a review of definition, classification, prevalence and treatment. Asian journal of andrology, 14 (6), 822 doi : 10.1038 / aja.2012.108
This version was added to the list of articles worth reading on February 26, 2007 .