Premature ejaculation

This article is about the condition. For the music group, see Premature Ejaculation (band).
Premature ejaculation
Classification and external resources
Specialty Urology
ICD-10 F52.4
ICD-9-CM 302.75
MedlinePlus 001524
eMedicine med/643
Patient UK 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.[6][7][8]

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.[9] 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[10] 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 fluid from the ampullary vas deferens, seminal vesicles, and prostate gland into the posterior urethra.[11] 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.[12]

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.[13][14]

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.[15]

Current evidence supports an average intravaginal ejaculation latency time (IELT) of six and a half minutes in 18- to 30-year-olds.[16][17] 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.[18] 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".[19] About 20 years ago, PE was classified into "lifelong PE" and "acquired PE".[20] Recently, a new classification of PE was proposed based on controlled clinical and epidemiological stopwatch studies,[19] 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.[21][22]

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.[23]

Treatments

Several treatments have been tested for treating premature ejaculation. A combination of medication and non-medication treatments is often the most effective method.[24]

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.[25][26]

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.[27] Freudians claimed that premature ejaculation could be cured using psychoanalysis. But even years of psychoanalysis accomplished little, if anything, in curing premature ejaculation.[27]

There is no evidence that men with premature ejaculation harbor unusual hostility toward women.[28]

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).[24]

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.[29][30][31]

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.[32][33][34][35][36] 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.[37][38][39][40][41] The authors of one study concluded that sex therapy "has a remarkable therapeutic effect on premature ejaculation".[26]

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.[42] It is generally well tolerated.[43] Tramadol, an atypical oral analgesic, appears to be effective.[44]

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.[45] 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).[46] Penis insensitivity and transference to the partner are practically eliminated when using topical anesthetic sprays based on absorption technology[47] 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.[48][49][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][10][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]

See also

References

  1. ↑ Sharlip, I. D., Hellstrom, W. J., & Broderick, G. A. (2008). The ISSM definition of premature ejaculation: A contemporary, evidence-based definition. Journal of Urology, 179(suppl), 340, abstract 988.
  2. 1 2 3 4 Althof, S. E. (2007). Treatment of rapid ejaculation: Psychotherapy, pharmacotherapy, and combined therapy (pp. 212–240). In S. R. Leiblum (Ed.), Principles and practice of sex therapy (4th ed.). NY: Guilford.
  3. 1 2 3 Strassberg, D. S., & Perelman, M. A. (2009). Sexual dysfunctions. In P. H. Blaney & T. Millon (Eds.), Oxford textbook of psychopathology (2nd ed.), (pp. 399–430). NY: Oxford University Press.
  4. 1 2 Barnes T., I. Eardley (2007). "Premature Ejaculation: The Scope of the Problem". Journal of Sex and Marital Therapy 33 (3): 151–170. doi:10.1080/00926230601098472. PMID 7365515.
  5. ↑ Byers, E.S. and G. Grenier (2003). "Premature or Rapid Ejaculation: Heterosexual Couples’ Perceptions of Men’s Ejaculatory Behavior". Archives of Sexual Behavior 32 (3): 261–70. doi:10.1023/A:1023417718557. PMID 12807298.
  6. ↑ Limoncin, E.; et al. (2013). "Premature Ejaculation Results in Female Sexual Distress: Standardization and Validation of a New Diagnostic Tool for Sexual Distress". Journal of Urology 189 (5): 1830–5. doi:10.1016/j.juro.2012.11.007. PMID 23142691.
  7. ↑ Graziottin, A. and S. Althof (2011). "What Does Premature Ejaculation Mean to the Man, the Woman, and the Couple?". Journal of Sexual Medicine 8: 304–9. doi:10.1111/j.1743-6109.2011.02426.x. PMID 21967392.
  8. ↑ Barnes T., I. Eardley (2007). "Premature Ejaculation: The Scope of the Problem". Journal of Sex and Marital Therapy 33 (3): 151–170. doi:10.1080/00926230601098472. PMID 7365515.
  9. ↑ Coolen LM, Olivier B, Peters HJ, Veening JG (1997). "Demonstration of ejaculation-induced neural activity in the male rat brain using 5-HT1A agonist 8-OH-DPAT". Physiol. Behav. 62 (4): 881–91. doi:10.1016/S0031-9384(97)00258-8. PMID 9284512.
  10. 1 2 Althof, S.E.; et al. (2010). "International Society for Sexual Medicine's Guidelines for the Diagnosis and Treatment of Premature Ejaculation". Journal of Sexual Medicine 7 (9): 2947–69. doi:10.1111/j.1743-6109.2010.01975.x. PMID 21050394.
  11. ↑ Böhlen D, Hugonnet CL, Mills RD, Weise ES, Schmid HP (2000). "Five meters of H(2)O: the pressure at the urinary bladder neck during human ejaculation". Prostate 44 (4): 339–41. doi:10.1002/1097-0045(20000901)44:4<339::AID-PROS12>3.0.CO;2-Z. PMID 10951500.
  12. ↑ Master VA, Turek PJ (2001). "Ejaculatory physiology and dysfunction". Urol. Clin. North Am. 28 (2): 363–75, x. doi:10.1016/S0094-0143(05)70145-2. PMID 11402588.
  13. ↑ deGroat WC, Booth AM (1980). "Physiology of male sexual function". Ann. Intern. Med. 92 (2 Pt 2): 329–31. doi:10.7326/0003-4819-92-2-329. PMID 7356224.
  14. ↑ Truitt WA, Coolen LM (2002). "Identification of a potential ejaculation generator in the spinal cord". Science 297 (5586): 1566–9. doi:10.1126/science.1073885. PMID 12202834.
  15. ↑ Kinsey, Alfred (1948), Sexual Behavior in the Human Male, Philadelphia: W. B. Saunders Co
  16. ↑ "Ejaculation delay: what's normal? [July 2005; 137-4]". Retrieved 2007-10-21.
  17. ↑ Waldinger MD, Quinn P, Dilleen M, Mundayat R, Schweitzer DH, Boolell M (2005). "A multinational population survey of intravaginal ejaculation latency time". The journal of sexual medicine 2 (4): 492–7. doi:10.1111/j.1743-6109.2005.00070.x. PMID 16422843.
  18. ↑ Waldinger MD, Zwinderman AH, Olivier B, Schweitzer DH (2005). "Proposal for a definition of lifelong premature ejaculation based on epidemiological stopwatch data". The journal of sexual medicine 2 (4): 498–507. doi:10.1111/j.1743-6109.2005.00069.x. PMID 16422844.
  19. 1 2 Waldinger, MD. "Changing paradigms from a historical DSM-III and DSM-IV view toward an evidence based definition of premature ejaculation. Part II: Proposals for DSM-V and ICD-11". Proposals for DSM-V and ICD-11. J Sex Med.
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  21. ↑ Waldinger, Marcel D. "New Insights in Premature Ejaculation". Psychiatric Times Vol. 24 No. 9. Psychiatric Times. Retrieved 1 August 2007.
  22. ↑ Serefoglu, EC; Yaman O; Cayan S; et al. (2011). "Prevalence of the complaint of ejaculating prematurely and the four premature ejaculation syndromes". J Sex Med 8 (2): 540–8. doi:10.1111/j.1743-6109.2010.02095.x. PMID 21054799.
  23. ↑ Godpodinoff M.L. Premature Ejaculation: Clinical Subgroups and Etiology Journal of Sex and Marital Therapy 1989; 15(2):130-134
  24. 1 2 LeVay, S., & Baldwin, J. (2009). Human sexuality (3rd. ed.) (pp. 532–534). Sunderland, MA: Sinauer.
  25. ↑ McCabe, M.P. (2001). "Evaluation of a Cognitive Behavior Therapy Program for People with Sexual Dysfunction". Journal of Sex and Marital Therapy 27 (3): 259–71. doi:10.1080/009262301750257119. PMID 11354931.
  26. 1 2 Chen, G.H.; et al. (2009). "A Clinical Study on Psycho-Behavioral Therapy for Premature Ejaculation". Zonghua Nan Ke Xua (Chinese journal) 15 (10): 929–31. PMID 20112744.
  27. 1 2 Kaplan, Helen S. (1989), PE: How to Overcome Premature Ejaculation, Brunner Mazel/New York Times, p. 28
  28. ↑ Kaplan, Helen S. (1974), The New Sex Therapy, Brunner Mazel/New York Times, p. 295
  29. ↑ Castleman, M. (2004), Great Sex, Rodale, Inc., pp. 137–138
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  31. ↑ Belliveau, F. and L. Richter (1970), Understanding Human Sexual Inadequacy, Hodder and Stoughton
  32. ↑ Castleman, M. (2004), Great Sex, Rodale, Inc., pp. 136–137
  33. ↑ Kaplan, Helen S. (1989), PE: How to Overcome Premature Ejaculation, Brunner Mazel/New York Times, pp. 48–58
  34. ↑ Metz, M. and B. McCarthy (2003), Coping With Premature Ejaculation, New Harbinger Publications, pp. 123–128
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  36. ↑ Birch. R.W. (2007), A Short Book About Lasting Longer, PEC Publishing, pp. 27–38
  37. ↑ Castleman, M. (2004), Great Sex, Rodale, Inc., pp. 122–141
  38. ↑ Kaplan, Helen S. (1989), PE: How to Overcome Premature Ejaculation, Brunner Mazel/New York Times, pp. 43–61
  39. ↑ Metz, M. and B. McCarthy (2003), Coping With Premature Ejaculation, New Harbinger Publications, pp. 105–133
  40. ↑ Silverberg, S. (2010) [1978], Lasting Longer: The Treatment Program for Premature Ejaculation, Physicians Medical Press, pp. 42–57
  41. ↑ Birch. R.W. (2007), A Short Book About Lasting Longer, PEC Publishing, pp. 16–44
  42. ↑ Hutchinson, K; Cruickshank, K; Wylie, K (May 1, 2012). "A benefit-risk assessment of dapoxetine in the treatment of premature ejaculation.". Drug safety : an international journal of medical toxicology and drug experience 35 (5): 359–72. doi:10.2165/11598150-000000000-00000. PMID 22452563.
  43. ↑ McMahon, CG; Althof, SE, Kaufman, JM, Buvat, J, Levine, SB, Aquilina, JW, Tesfaye, F, Rothman, M, Rivas, DA, Porst, H (February 2011). "Efficacy and safety of dapoxetine for the treatment of premature ejaculation: integrated analysis of results from five phase 3 trials.". The journal of sexual medicine 8 (2): 524–39. doi:10.1111/j.1743-6109.2010.02097.x. PMID 21059176.
  44. ↑ Wong, BL; Malde, S (Jan 2013). "The use of tramadol "on-demand" for premature ejaculation: a systematic review.". Urology 81 (1): 98–103. doi:10.1016/j.urology.2012.08.037. PMID 23102445.
  45. ↑ Porst H (2011). "An overview of pharmacotherapy in premature ejaculation". J Sex Med. 4: 335–41. doi:10.1111/j.1743-6109.2011.02451.x.
  46. ↑ MacCarty E.J., Dinsmore W.W. (2010). "Premature Ejaculation: Treatment Update". International Journal of STD AIDS 21: 77–81.
  47. ↑ Kang L. Jun HW, Mani N. (Jul 2001). "Preparation and characterization of two-phase melt systems of lidocaine". Int J Pharm 222 (1): 35–44. doi:10.1016/s0378-5173(01)00689-5.
  48. ↑ "Mayo Clinic Premature Ejaculation Treatments and Drugs". mayoclinic.org. Mayo Clinic.
  49. ↑ "WebMD Male Sexual Dysfunction Treatments". webmd.com. WebMD.
  50. ↑ name="Health Communities premature ejaculation treatment">"Health Communities: Treatment for Premature Ejaculation". healthcommunities.com. Remedy Health Media with partners: Cornell University and the Sexual Medicine Society of North America.
  51. 1 2 "Premature ejaculation". Mayo Clinic.com. Retrieved 2007-03-02.
  52. 1 2 Laumann, E.O.; et al. (1999). "Sexual Dysfunction in the United States: Prevalence and Predictors". Journal of the American Medical Association 281 (6): 537–44. doi:10.1001/jama.281.6.537. PMID 10022110.
  53. ↑ Schouten BW, Bohnen AM, Groeneveld FP, Dohle GR, Thomas S, Bosch JL (July 2010). "Erectile dysfunction in the community: trends over time in incidence, prevalence, GP consultation and medication use—the Krimpen study: trends in ED". J Sex Med 7 (7): 2547–53. doi:10.1111/j.1743-6109.2010.01849.x. PMID 20497307.
  54. ↑ Mathers, M.J.; et al. (2013). "Premature Ejaculation in Urological Routine Practice". Aktuelle Urology (German) 44 (1): 33–9. doi:10.1055/s-0032-1331727. PMID 23381878.
  55. ↑ Serefoglu E.C. and T.R. Saitz (2012). "New Insights on Premature Ejaculation: A Review of Definition, Classification Prevalence, and Treatment". Asian Journal of Andrology 14 (6): 822–9. doi:10.1038/aja.2012.108. PMID 23064688.
  56. ↑ Tang, W.S. and E.M. Khoo (2011). "Prevalence and Correlates of Premature Ejaculation in a Primary Care Setting: A Preliminary Cross-Sectional Study". Journal of Sexual Medicine 8 (7): 2071–8. doi:10.1111/j.1743-6109.2011.02280.x. PMID 21492404.
  57. ↑ Porst, H.; et al. (2007). "The Premature Ejaculation Prevalence and Attitudes (PEPA) Survey: Prevalence, Co-morbidities, and Professional Help-Seeking". European Urology 51 (3): 816–824. doi:10.1016/j.eururo.2006.07.004. PMID 16934919.
  58. ↑ Rowland, D.; et al. (204). "Self-Reported Premature Ejaculation and Aspects of Sexual Functioning and Satisfaction". Journal of Sexual Medicine 1 (2): 225–32. doi:10.1111/j.1743-6109.2004.04033.x. PMID 16429622.
  59. ↑ Birch, Robert (16 November 2007). "Did you orgasm?". Sexualhealth.com. Archived from the original on 16 July 2011. Retrieved 21 April 2010.
  60. ↑ Vatsyayana, M. (translators) Doniger, W. and Kakar, S. (2009), Kamasutra, Oxford University Press
  61. ↑ Kaplan, Helen S. (1974), The New Sex Therapy, Brunner Mazel/New York Times, p. 292

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