Videos Presented by: Dr Andrew L. Siegel. He is a urological surgeon at Hackensack University Medical Center, and is the director of The Center of Continence Care.
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Premature ejaculation (PE) is a condition in which a man ejaculates earlier than he or his partner would like him to. Premature ejaculation is also known as rapid ejaculation, rapid climax, premature climax, or early ejaculation. Masters and Johnson defines PE as the condition in which a man 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. Self reported surveys report up to 75% of men ejaculate within 10 minutes of penetration. 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. PE affects 25%-40% of men in the United States.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 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 2 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 would not be defined as having PE. On the other hand, a man with 2 minutes IELT may have the 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 caused simply by extreme arousal.
According to the theories developed by Wilhelm Reich, premature ejaculation may be a consequence of a stasis of sexual energy in the pelvic musculature, which prevents the diffusion of such energy to other parts of the body.
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
Possible physical factors
Science of mechanism of ejaculation
The physical process of ejaculation requires two sequential actions: emission and expulsion.
The emission phase is the first phase. It involves deposition of seminal fluid from the ampullary vas deferens, seminal vesicles, and prostate gland into the posterior urethra. 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.
It is believed that the neurotransmitter serotonin (5HT) plays a central role in modulating ejaculation. Several animal studies have demonstrated its inhibitory effect on ejaculation. 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 selective serotonin reuptake inhibitors (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 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. 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 SSRIs, such as sertraline or paroxetine, as these slow down ejaculation times. 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.
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.
Other ejaculation disorder types
- Delayed ejaculation – Ejaculation takes a long time
- Retrograde ejaculation – Semen flows from the prostate gland into the bladder rather than exiting out of the penis.
- Inhibited orgasm in males
Medical treatment for premature ejaculation (rapid 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); thus, only passing reference is made to treatment of erectile dysfunction (ED) that may accompany the premature ejaculation problem.
Include the female partner as much as possible in the treatment and counseling sessions in order to achieve the best outcome.
1. Relieve any underlying performance pressure on the male.
Assuming that premature ejaculation occurs when intercourse is attempted, the couple should be instructed 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.
2. 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.
3. 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; SS stands for Super Secret) has been shown to desensitize the penis, decrease the vibratory threshold, and help men with premature ejaculation to significantly delay their ejaculatory response.[12, 13]
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.
4. If the male is relatively young and 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.
5. 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 yield the same result.
As a side effect, many of these agents have been found to cause a significant delay in reaching orgasm in both male and female patients.
For this reason, medications with SSRI side effects have been used in men who experience premature ejaculation.
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