Premature ejaculation

Most professionals who treat premature ejaculation define this condition as the occurrence of ejaculation prior to the wishes of both sexual partners. This broad definition thus avoids specifying a precise duration for sexual relations and reaching a climax, which is variable and depends on many factors specific to the individuals engaging in intimate relations. An occasional instance of premature ejaculation might not be cause for concern, but, if the problem occurs with more than 50% of attempted sexual relations, a dysfunctional pattern usually exists for which treatment may be appropriate.

To clarify, a male may reach climax after 8 minutes of sexual intercourse, but this is not premature ejaculation if his partner regularly climaxes in 5 minutes and both are satisfied with the timing. Another male might delay his ejaculation for a maximum of 20 minutes, yet he may consider this premature if his partner, even with foreplay, requires 35 minutes of stimulation before reaching climax. If intercourse is the method of sexual stimulation for the second example and the male climaxes after 20 minutes of intercourse and then loses his erection, satisfying his partner (at least with intercourse), who needs 35 minutes to climax, is impossible.

Because many females are unable to reach climax at all with vaginal intercourse (no matter how prolonged), this situation may actually represent delayed orgasm for the female partner rather than premature ejaculation for the male; the problem can be either or both, depending on the point of view. This highlights the importance of obtaining a thorough sexual history from the patient (and preferably from the couple).

The human sexual response can be divided into 3 phases: desire (libido), excitement (arousal), and orgasm. The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) classifies sexual disorders into 4 categories: (1) primary, (2) general medical condition·related, (3) substance-induced, and (4) not otherwise specified. Each of the 4 DSM-IV categories has disorders in all 3 sexual phases.

Premature ejaculation may be primary or secondary. Primary applies to individuals who have had the condition since they became capable of functioning sexually (ie, postpuberty). Secondary indicates that the condition began in an individual who previously experienced an acceptable level of ejaculatory control, and, for unknown reasons, he began experiencing premature ejaculation later in life. With secondary premature ejaculation, the problem does not relate to a general medical disorder, and it is usually not related to substance inducement, although, rarely, hyperexcitability might relate to a psychotropic drug and resolves when the drug is withdrawn. Premature ejaculation fits best into the category of not otherwise specified because no one really knows what causes it, although psychological factors are suggested in most cases.

Pathophysiology: Premature ejaculation is believed to be a psychological problem and does not represent any known organic disease involving the male reproductive tract or any known lesions in the brain or nervous system. The organ systems directly affected by premature ejaculation include the male reproductive tract (ie, penis, prostate, seminal vesicles, testicles, and their appendages), the portions of the central and peripheral nervous system controlling the male reproductive tract, and the reproductive organ systems of the sexual partner (for the purpose of this discussion, the partner is assumed to be female) that may not be stimulated sufficiently to achieve orgasm. If the premature ejaculation occurs so early that it happens before commencement of sexual intercourse and the couple is attempting pregnancy, then pregnancy is impossible to achieve unless artificial insemination is used. Perhaps the most affected organ system is the psyche of the partners. Both partners are likely to be dissatisfied emotionally and
physically by this problem.

Premature ejaculation has historically been considered a psychological disorder. One theory is that males are conditioned by societal pressures to reach climax in a short time because of fear of discovery when masturbating as teenagers or during early sexual experiences “in the back seat of the car” or with a prostitute. This pattern of rapid attainment of sexual release is difficult to change in marital or long-term relationships. The fact that female arousal and orgasm require more time than male arousal is being increasingly recognized, and this may result in increased recognition and definition of premature ejaculation as a problem.

Some have questioned whether premature ejaculation is purely psychological. A number of investigators have found differences in nerve conduction/latency times and hormonal differences in men who experience premature ejaculation compared with individuals who do not. The theory is that some men have hyperexcitability or oversensitivity of their genitalia, thus preventing down-regulation of their sympathetic pathways and delay of orgasm.

One might find some logical sense, from an evolutionary point of view, that males who can ejaculate rapidly would be more likely to succeed in fertilizing a female than males who require prolonged stimulation to reach climax. (This applies to prehistoric evolutionary development; little, if any, human evolution has occurred over the last 5000 y.) The genes of a person who ejaculates rapidly (but not so rapidly that ejaculation occurs before intromission) would be more likely to be passed on to succeeding generations. The male who does not complete the fertilizing process quickly might be pushed away or killed by a competing male because of his obvious vulnerability during intercourse.

Frequency:

In the US: The prevalence rate of premature ejaculation in American males is estimated to range from 30-70%. The National Health and Social Life Survey (NHSLS) indicates a prevalence of 30%, which is fairly steady through all adult age categories. (In contrast, erectile dysfunction [ED] rises in prevalence with increasing age). However, various surveys have shown that many men do not report premature ejaculation to their physician. This may be because of embarrassment or a feeling that no treatment is available for the problem. Some men might not even perceive premature ejaculation as a medical problem. Such survey data suggest that the percentage of men who experience premature ejaculation at some point in their lives is almost certainly more than the 30% reported in the NHSLS.

Internationally: Estimates for European countries and India mirror the prevalence in the United States. The prevalence in other parts of Asia, Africa, Australia, and elsewhere is unknown.

Mortality/Morbidity: No known direct morbidity or mortality results from premature ejaculation. Indirectly, premature ejaculation may alter self-esteem, cause marital dysfunction, and may be a factor in depression with its obvious consequences.

Race: Although no reproducible data exist on major differences between racial groups with respect to the incidence or prevalence of premature ejaculation, a few recent surveys suggest that some racial variation may exist with respect to this condition. One recent telephone survey (Carson and associates) found in interviews of 1320 men without ED that 21% of non-Hispanic African Americans reported premature ejaculation, while 29% of Hispanics and 16% of non-Hispanic whites reported premature ejaculation. An analysis by Laumann et al of the NHSLS found that premature ejaculation was more prevalent among African American men (34%) and white men (29%) than among Hispanic men (27%). However, drawing firm conclusions from these data is difficult in view of the small number of such studies and lack of suitable controls.

Sex: Premature ejaculation is a condition that only affects males.

Age: Premature ejaculation can occur at virtually any age in an adult man’s life. As a reported condition, it is most common in younger men (aged 18-30 y) but may also occur in conjunction with secondary impotence in men aged 45-65 years.

History of the patient’s premature ejaculation

The is helpful because it ultimately guides the treatment that is best suited to the patient (and his partner). One needs to focus on whether premature ejaculation is lifelong (ie, primary) or acquired (ie, secondary) and assess the severity of the problem.

For completeness, a general medical history should be taken to screen for other medical conditions that might be relevant. For example, if the patient has angina and this causes fear of a myocardial infarction during sexual activity, he might present with premature ejaculation when the actual underlying problem is his cardiac disease and his mental insecurity regarding his cardiac disease. Resolution of the cardiac problem usually solves the premature ejaculation, with no specific therapy for the premature ejaculation. For the purpose of this discussion, the patient is assumed to be healthy, and sexual dysfunction is the only significant problem.

If the patient has always experienced premature ejaculation from the time he began coitus, then he has primary premature ejaculation. If he had successful coital relationships in the past, yet began experiencing premature ejaculation with the current relationship, then he has secondary premature ejaculation. In most cases, secondary premature ejaculation is easier to treat and has a better prognosis.

Primary premature ejaculation

In addition to the general medical history, inquire about any prior psychological difficulties because males with primary premature ejaculation have a higher incidence of associated psychiatric conditions than that found in the general population.

The history should include questions about the patient’s early sexual experiences. Did he experience a traumatic sexual episode as a child or teenager? An example might be discovery by a parent during masturbation, with subsequent feelings of guilt. Alternatively, the patient may have been punished or threatened with punishment for masturbation.

Inquire about the patient’s family relationships while he was growing up. How did he relate to his mother, father, brother(s), sister(s)? Does his family have a history of incest or sexual assault? Males can be sexually assaulted by other males and, in rare instances, by females, including siblings.

What were peer relationships like? Did he have other male friends, any female friends? How does he regard himself with respect to peers (eg, inferior, superior, athletic, frail, more intelligent, less intelligent)?

Does the patient have any difficulties with work (or school, if still a student)?

What is the patient’s general attitude toward sex (ie, whether it is regarded as dirty), and what is the patient’s sexual preference, fantasy, and arousal pattern?

Did the patient have a strict religious upbringing? If so, what was the teaching about sex?

If the premature ejaculation began with an initial nonmarital relationship, does he feel guilt about this?

If the first coital experience was within a marital relationship that involved premature ejaculation from the start, inquire about premarital, noncoital sexual play between the partners.

Ask about the sexual attitude and response of the female partner; if she is having a problem, such as dyspareunia, it could relate to the male’s problem or may have preceded it.

What is the nonsexual part of the relationship like? Does the couple fight or are they going through a power struggle?

If the sexual partner is not present, inquire as to why (ie, whether the partner is not supportive or is blaming him).

Clues from these and similar questions usually point toward causation factors that may be addressed specifically with therapy.

Secondary premature ejaculation

In addition to a general medical history, the history should include details about prior relationships in which premature ejaculation was not a problem for this individual and any prior relationships in which transient episodes of premature ejaculation occurred.

In the current relationship, was premature ejaculation always a problem or did it start after an initial time frame when coitus was satisfactory to both partners?

Inquire specifically as to the quality of the relationship with respect to nonsexual factors. Do the partners get along on most issues, or is conflict present? Who is dominant in the relationship, or is the relationship generally equal?

Is the female partner in the office with the male patient? If not, ask why. Possibly, she regards the problem as only his problem and not a problem of the couple, which may be an important clue.

Does he have an impotence problem? If erectile dysfunction (ED) is present, did this begin after the problem with premature ejaculation or before? If ED is not present, what is the general timing for the male (ie, commencement of intromission to climax)?

Can actual coitus be achieved, or does premature ejaculation prevent this?

Is the patient experiencing premature ejaculation with self-stimulation (ie, masturbation), with nonintercourse stimulation by the partner, or just with coitus?

What is the time required for the female partner to reach climax? Can she reach climax with intercourse, or does she require direct clitoral stimulation (oral or manual) to be able to climax?

If ED is present but began after the premature ejaculation, then treatment of both conditions may be required; sometimes, the ED resolves when the patient gains confidence in controlling his ejaculation. If the ED started initially, then the premature ejaculation may be a secondary sexual dysfunction, which resolves when the patient is confident in being able to maintain his erection.

Clarification of these and other factors usually proves very helpful when arriving at a treatment plan.

Physical: Physical examination findings are normal in males when premature ejaculation is the only presenting condition.

Causes: The cause of premature ejaculation is considered psychological, although no one really knows.

Primary premature ejaculation

In primary premature ejaculation, in which the male has never experienced sexual relations without also experiencing premature ejaculation, a deep-seated emotional disturbance may be present and the causes may be multiple.

Sometimes, the behavior is a conditioned response resulting from teen masturbation practices, but, sometimes, the patient has deep anxiety about sex that relates to one or more traumatic experiences encountered during development. Examples may include family incest, sexual assault, conflict with one or both parents, or other serious disturbances.

In most cases, a primary care physician or a urologist should consult with a psychiatrist, psychologist, or other professional in cases of primary premature ejaculation.

Secondary premature ejaculation

With regard to secondary premature ejaculation, some type of performance anxiety is often a major factor.

Performance pressure (ie, fear of failure to satisfy the partner) can arise from various precipitating events. ED is a common precipitating event. If the male is afraid his erection will not last, because of either actual instances of previous ED or imagined failure of his erection, this may precipitate premature ejaculation. The patient may have used the phrase, “Honey, you excited me so much I just could not hold back,” which might be a way for him to avoid admitting to the humiliation of being unable to keep his erection throughout intercourse. If he climaxes quickly, he then has an excuse to justify his inability to maintain his erection.

However, a careful history is needed because the situation may be complex.

Perhaps ED is not a part of the problem.

Possibly, his partner has belittled him with comments such as “You must not be much of a man, since you cannot stay hard until I am satisfied.” In addition, she actually may have difficulty achieving climax through intercourse and may require direct clitoral stimulation to reach a climax. If she does not communicate this to him (and she may conceal it because of feelings about her own inadequacy), then he will always fail to provide coital satisfaction for her.

Because most physicians are not trained sex therapists, sorting out conflicts in the relationship and then referring couples for counseling to professionals with experience and training in that area is important. If a physician has some training or experience in the treatment of premature ejaculation and is comfortable managing the problem, then the physician may choose to begin treatment (eg, counseling, medication, both). If the patient does not respond favorably or if the physician is not comfortable with the treatment of premature ejaculation, then referral to a sex therapist, psychologist, or psychiatrist is the next step.

Medical Care: Medical treatment for premature ejaculation includes several options. Any serious primary medical condition (eg, angina) should be treated; for the purpose of the following discussion, the male is assumed to be healthy and premature ejaculation is assumed to be his only problem. In addition, any accompanying erection problem can be treated with various methods with excellent success (see Erectile Dysfunction) and thus, only passing reference is made to treatment of erectile dysfunction (ED) that may accompany the premature ejaculation problem.

Including the female partner as much as possible in the treatment and counseling sessions is important to achieve the best outcome.

The first step for treatment of premature ejaculation is to relieve any underlying performance pressure on the male.

Assuming that premature ejaculation occurs when intercourse is attempted, instruct the couple that intercourse should not be attempted until premature ejaculation is treated. The male may use manual stimulation, oral sex, or other means to satisfy the female partner in the meantime.

If the male always experiences ejaculation with initial sexual excitement or early foreplay, this is a serious problem and probably indicates primary premature ejaculation (the history should reveal this), which then most likely requires treatment in conjunction with a mental health care professional. These more difficult cases should be screened out.

The couple should then be instructed on sexual therapy, such as the stop-start or squeeze-pause technique popularized by Masters and Johnson.

The female partner should slowly begin stimulation of the male and should stop as soon as he senses a feeling of excessive excitement that may lead to ejaculatory inevitability.

Then, she should administer a firm compression of the penis just behind the glans, pressing mainly under the penis. This should be uncomfortable but not painful.

Stimulation then should begin again after the male has a feeling that the ejaculation is no longer imminent.

The process should be repeated and practiced at least 10 or more times.

Gradually, most males find this technique helps decrease the impending inevitable need to ejaculate.

After a period of practicing this method, the couple can sit facing each other, with the woman’s legs crossing on top of the male’s legs. She can stimulate him by manipulating his penis close to, then with friction against, her vulval area. Each time he senses excessive excitement, she can apply the squeeze and stop all stimulation until he calms down enough for the process to be repeated.

Finally, coitus may be attempted, with the female partner in the superior position so that she may withdraw immediately and again apply a squeeze to remove his urge to climax.

Most couples find this technique to be highly successful. It can also help the female partner to be more aroused and can shorten her time to climax because it constitutes a form of extended foreplay in many cases.

Another therapeutic modality is the use of desensitizing cream for the male.

In Korea and other areas of the Far East, SS Cream (a combination of 9 ingredients, mainly herbal) has been shown to desensitize the penis, decrease the vibratory threshold, and help men with premature ejaculation to significantly delay their ejaculatory response.

Unfortunately, SS Cream is not yet approved by the US Food and Drug Administration (FDA), but simple combinations of lidocaine cream or related topical anesthetic agents can be used with similar effects and they are safe as long as the patient has no history of allergy to the substance.

If the male is relatively young and he can achieve another erection in a few minutes following an episode of premature ejaculation, he may find that his control is much better the second time.

Some therapists advise young men to masturbate (or have their partner stimulate them rapidly to climax) 1-2 hours before sexual relations are planned.

The interval for achieving a second climax often includes a much longer period of latency, and the male can usually exert better control in this setting.

In an older man, such a strategy may be less effective because the older man may have difficulty achieving a second erection after his first rapid sexual release. If this occurs, it can damage his confidence and may result in secondary impotence.

The most effective pharmacologic modality found to aid men with premature ejaculation is a drug from the selective serotonin reuptake inhibitors (SSRIs) class, drugs which are used normally as antidepressants in the clinical setting.

Some tricyclic antidepressants with SSRI-like activity also achieve the same result.

Many of these agents have been found to have, as a side effect, a tendency to cause both male and female patients to experience a significant delay in reaching orgasm.

For this reason, medications with SSRI side effects have been used in men who experience premature ejaculation.

Surgical Care: No recommended surgical treatment exists for premature ejaculation.

Consultations:

Consultation with a sex therapist, psychologist, or psychiatrist may prove helpful if the primary care physician or urologist cannot provide successful treatment or does not have the time to explore psychological issues and implement behavioral techniques (eg, squeeze-pause). If the primary care physician or urologist is not experienced in treating premature ejaculation or is uncomfortable with treatment, then early referral should take place (to a sex therapist, psychologist, or psychiatrist). Some physicians are comfortable implementing medication therapy but not behavioral therapy. The patient should be offered all treatment options as with any medical condition, and the physician should proceed with referral for those option(s) considered to require more specialized help than the physician can provide.

For men who may be experiencing a severe emotional disturbance that is an underlying factor to premature ejaculation, referral to a mental health professional is most appropriate. Diagnosis and treatment of the various psychological factors that manifest partly as premature ejaculation are beyond the scope of this discussion.

Consider anorgasmia or severely delayed orgasm in the female partner, in which the word delayed is a relative term because the average time to climax for a female varies but averages 12-25 min according to many studies. If a female partner requires 3 hours to reach climax, this is well outside the norm. In extreme cases of delayed or difficult orgasm in the female partner, nearly all men would be considered to have premature ejaculation. The partner’s sexual response must be considered.

Consider a rare adverse effect from a psychotropic drug. If the premature ejaculation problem started in association with some time relationship to commencing the drug and premature ejaculation ceases when the drug is withdrawn, one should strongly consider that the two are related.

Some men may confuse premature ejaculation with what is colloquially referred to as “pre-come,· ie, pre-ejaculate, the lubricating fluids produced by Cowper glands and other glands during the excitement phase of sexual stimulation. A detailed sexual history should clarify this matter and should enable reassurance of the male as to what is actually happening.

Erectile dysfunction (ED) may be a clinical symptom of some men who are actually experiencing premature ejaculation. Differentiating between the 2 problems is important.

Medical Care: Medical treatment for premature ejaculation includes several options. Any serious primary medical condition (eg, angina) should be treated; for the purpose of the following discussion, the male is assumed to be healthy and premature ejaculation is assumed to be his only problem. In addition, any accompanying erection problem can be treated with various methods with excellent success (see Erectile Dysfunction) and thus, only passing reference is made to treatment of erectile dysfunction (ED) that may accompany the premature ejaculation problem.

Including the female partner as much as possible in the treatment and counseling sessions is important to achieve the best outcome.

The first step for treatment of premature ejaculation is to relieve any underlying performance pressure on the male.

Assuming that premature ejaculation occurs when intercourse is attempted, instruct the couple that intercourse should not be attempted until premature ejaculation is treated. The male may use manual stimulation, oral sex, or other means to satisfy the female partner in the meantime.

If the male always experiences ejaculation with initial sexual excitement or early foreplay, this is a serious problem and probably indicates primary premature ejaculation (the history should reveal this), which then most likely requires treatment in conjunction with a mental health care professional. These more difficult cases should be screened out.

The couple should then be instructed on sexual therapy, such as the stop-start or squeeze-pause technique popularized by Masters and Johnson.

The female partner should slowly begin stimulation of the male and should stop as soon as he senses a feeling of excessive excitement that may lead to ejaculatory inevitability.

Then, she should administer a firm compression of the penis just behind the glans, pressing mainly under the penis. This should be uncomfortable but not painful.

Stimulation then should begin again after the male has a feeling that the ejaculation is no longer imminent.

The process should be repeated and practiced at least 10 or more times.

Gradually, most males find this technique helps decrease the impending inevitable need to ejaculate.

After a period of practicing this method, the couple can sit facing each other, with the woman’s legs crossing on top of the male’s legs. She can stimulate him by manipulating his penis close to, then with friction against, her vulval area. Each time he senses excessive excitement, she can apply the squeeze and stop all stimulation until he calms down enough for the process to be repeated.

Finally, coitus may be attempted, with the female partner in the superior position so that she may withdraw immediately and again apply a squeeze to remove his urge to climax.

Most couples find this technique to be highly successful. It can also help the female partner to be more aroused and can shorten her time to climax because it constitutes a form of extended foreplay in many cases.

Another therapeutic modality is the use of desensitizing cream for the male.

In Korea and other areas of the Far East, SS Cream (a combination of 9 ingredients, mainly herbal) has been shown to desensitize the penis, decrease the vibratory threshold, and help men with premature ejaculation to significantly delay their ejaculatory response.

Unfortunately, SS Cream is not yet approved by the US Food and Drug Administration (FDA), but simple combinations of lidocaine cream or related topical anesthetic agents can be used with similar effects and they are safe as long as the patient has no history of allergy to the substance.

If the male is relatively young and he can achieve another erection in a few minutes following an episode of premature ejaculation, he may find that his control is much better the second time.

Some therapists advise young men to masturbate (or have their partner stimulate them rapidly to climax) 1-2 hours before sexual relations are planned.

The interval for achieving a second climax often includes a much longer period of latency, and the male can usually exert better control in this setting.

In an older man, such a strategy may be less effective because the older man may have difficulty achieving a second erection after his first rapid sexual release. If this occurs, it can damage his confidence and may result in secondary impotence.

The most effective pharmacologic modality found to aid men with premature ejaculation is a drug from the selective serotonin reuptake inhibitors (SSRIs) class, drugs which are used normally as antidepressants in the clinical setting.

Some tricyclic antidepressants with SSRI-like activity also achieve the same result.

Many of these agents have been found to have, as a side effect, a tendency to cause both male and female patients to experience a significant delay in reaching orgasm.

For this reason, medications with SSRI side effects have been used in men who experience premature ejaculation.

Surgical Care: No recommended surgical treatment exists for premature ejaculation.

Consultations:

Consultation with a sex therapist, psychologist, or psychiatrist may prove helpful if the primary care physician or urologist cannot provide successful treatment or does not have the time to explore psychological issues and implement behavioral techniques (eg, squeeze-pause). If the primary care physician or urologist is not experienced in treating premature ejaculation or is uncomfortable with treatment, then early referral should take place (to a sex therapist, psychologist, or psychiatrist). Some physicians are comfortable implementing medication therapy but not behavioral therapy. The patient should be offered all treatment options as with any medical condition, and the physician should proceed with referral for those option(s) considered to require more specialized help than the physician can provide.

For men who may be experiencing a severe emotional disturbance that is an underlying factor to premature ejaculation, referral to a mental health professional is most appropriate. Diagnosis and treatment of the various psychological factors that manifest partly as premature ejaculation are beyond the scope of this discussion.