Premature Ejaculation Causes and Treatment

What is Premature Ejaculation (P.E.)?

Premature ejaculation occurs when a man experiences climax during intercourse sooner than he or his partner desire. Also known as rapid ejaculation, premature ejaculation is the most common type of sexual problem affecting men younger than 40 years.

The average time from the initiation of intercourse to ejaculation is generally about five minutes. Some men ejaculate even before intercourse begins or immediately after penetration. However, what constitutes premature ejaculation varies considerably depending on the man and what he and his partner find sexually satisfying.

According to the Diagnostic and Statistical Manual of Mental Disorders Fourth Edition (DSM-IV), the criteria for premature ejaculation are:

• Persistent and recurrent ejaculation with minimal sexual stimulation before, on, or shortly after penetration before the person desires it
• Marked interpersonal difficulty or distress
• Not exclusively due to direct effects

Who Experiences Premature Ejaculation?

According to the National Health and Social Life Survey (NHSLS), premature ejaculation affects 30 percent of American males. However, other surveys have shown that many men to not report premature ejaculation to their doctor, and some do not believe it is a medical problem that can be resolved. Therefore it is likely the 30 percent figure is low. (Benson)

Premature ejaculation can occur at any age during an adult man’s lifetime. However, it is most common in men aged 18 to 30, although it can also occur along with secondary impotence in men aged 46 to 65.

Several surveys have indicated there may be some racial differences with respect to premature ejaculation. A telephone survey conducted in 2003 of 1,320 men without erectile dysfunction reported that 21 percent of African American men reported P.E. compared with 29 percent of Hispanics and 16 percent of non-Hispanic whites. An analysis of the NHSLS found that 34 percent of African American men, 29 percent of white men, and 27 percent of Hispanic men experienced premature ejaculation. (Giuliano 2008)

Types of P.E.

Premature ejaculation can be primary (lifelong) or secondary (acquired). According to the International Society for Sexual Medicine, primary P.E. is characterized by

• Ejaculation that always or nearly always occurs within one minute of vaginal penetration
• An inability to delay ejaculation on nearly all or all vaginal penetrations
• Negative personal characteristics, such as stress, frustration, or avoidance of sexual

Men who have secondary premature ejaculation generally have the same symptoms as the primary type, except the critical difference is that their ejaculatory difficulties develop after they have had previous, satisfying sexual relationships without ejaculatory problems.

Risk Factors of Premature Ejaculation

Several factors can increase a man’s risk of developing premature ejaculation. They include:

• Erectile dysfunction. Men who occasionally or consistently have difficulty attaining or maintaining an erection are at increased risk of experiencing P.E., likely because of the fear of losing their erection, which causes them to rush through sexual relations.
• Stress and/or anxiety. Emotional stress and anxiety can make it difficult to relax and/or focus during sexual relations and thus has a role in premature ejaculation.
• Health problems. The presence of health problems, such as heart disease or arthritis, may cause men to unknowingly rush to ejaculate.
• Use of medications. Rarely, use of certain medications, especially psychotropics, can influence the activity of chemical messengers in the brain and contribute to premature ejaculation.

Causes of Premature Ejaculation

Viewed from an evolutionary perspective, in primitive times it was likely beneficial for males to ejaculate quickly so they could successfully fertilize a female before being challenged by other males. From a societal perspective, one theory is that men are expected to reach orgasm quickly because they are afraid to get caught masturbating or having sex during their teen years.

At one time, P.E. was believed to be caused by psychological issues, but research has shown that it is more complex and likely has both biological and psychological causes. Possible causes of premature ejaculation include:

• Feelings of guilt that make men tend to rush through sexual intercourse
• Presence of or worries about erectile dysfunction
• Anxiety regarding sexual performance or other issues
• Relationship problems with one’s sexual partner
• Abnormal hormone levels. Higher levels of testosterone have been found in men who experience premature ejaculation than in men without premature ejaculation. (Corona 2008)
• Abnormal levels of neurotransmitters
• Thyroid problems
• Abnormal reflex activity of the ejaculatory system
• Inflammation and infection of the prostate or urethra
• Heredity/genetics
• Nervous system damage as the result of trauma or surgery (rare)
• Withdrawal from certain medications used to treat mental health issues (rare)

Diagnosis

Men who are suffering from premature ejaculation should consult a urologist or other knowledgeable health professional. In men who experience P.E. and who have no other medical problems, there are no conventional laboratory tests that can have an effect on treatment. Physicians can make a diagnosis by taking a detailed history of a man’s health and sex life, as well as performing a physical examination. Men who are experiencing erectile dysfunction along with P.E. are often asked to undergo a blood test to determine their testosterone and prolactin levels to see if they may be a factor, and referral to a urologist may be made. If depression or other medical problems are present, then a physician should order the appropriate laboratory tests.

Premature Ejaculation Treatment

Treatments for premature ejaculation can include sexual therapy, psychotherapy, and medication. For some men, a combination of therapies provides the best solution. Experts recommend that men include their female partner in treatment and counseling sessions to achieve the best outcome. Consultation with a sex therapist, or with a psychologist or psychiatrist is recommended if the primary care doctor or urologist cannot or does not have the time to implement behavioral therapy or is not experienced in treating P.E.

See also

Can the Mind Control Premature Ejaculation?

Sexual Therapy

Sexual therapy, which can be provided by a certified sex therapist or other mental health professional (e.g., psychiatrist, psychologist) with expertise in sexual issues, may involve a variety of techniques, ranging from implementing relaxation techniques to different methods to delay ejaculation. For example, one approach is to ask men to masturbate an hour or two before intercourse to help them delay ejaculation during sexual relations. Another technique is for a man and his partner to engage in other forms of sexual intimacy while avoiding intercourse in an attempt to remove anxiety and pressure about sexual performance from the picture.

Sexual therapy may also include use of two similar techniques–the squeeze technique and the stop-and-start technique—which a man can do with his partner to help him to learn how to control delaying ejaculation. To perform the squeeze technique, which was made popular by Masters and Johnson:

• A man and his partner begin sexual activity, including penile stimulation, until he feels nearly ready to ejaculate
• The man’s partner gently squeezes the end of the penis where the head meets the shaft. The partner should keep squeezing until the urge to ejaculate goes away
• After the squeeze is released, about 30 seconds should pass before foreplay is resumed.
• When the urge to ejaculate returns, the squeeze technique should be repeated. The cycle can be repeated until the man wants to ejaculate.

Once a man has practiced this technique long enough to delay ejaculation, he can practice the next phase, which involves the couple sitting facing each other with the woman’s legs crossing on top of the man’s legs. The woman can stimulate the penis close to and then against her vulval region until the man is intensely excited. Then the female should apply the squeeze technique and repeat the cycle until the man wants to ejaculate.

The final phase involves an attempt at sexual intercourse, with the woman on top so she can withdraw quickly and apply the squeeze technique. This approach is highly successful for many couples, and it also can help females become more aroused because foreplay is extended. Masters and Johnson claim that more than 85 percent of men who have premature ejaculation can be treated successfully using the squeeze approach alone, and that success can be reached within 3 months of starting therapy. (Masters)

The stop-and-start method is similar to the squeeze technique, except when a man feels the urge to ejaculate, his partner simply stops stimulation and waits for 30 seconds before resuming. Both of these techniques can help men reach a point where they can enter their partner without ejaculating and delay ejaculation for longer periods of time. Men can also practice these techniques on their own.

Cognitive Behavioral Therapy

Cognitive behavioral therapy, also referred to as talk therapy, involves talking with a mental health professional about relationships, performance anxiety, stress, and experiences. This approach can be most beneficial when a man and his partner both participate in the sessions. A qualified mental health professional can help men find effective ways to cope with their stress, fears, and anxiety. Such therapy is frequently used along with medication.

Medications

Certain medications, including antidepressants, topical anesthetic creams, and phosphodiesterase type-5 inhibitors are sometimes used to treat premature ejaculation. Thus far, no drugs have been approved by the Food and Drug Administration to treat P.E., and so when taken for this purpose, it is considered off-label use. A drug called dapoxetine (Priligy), a selective serotonin reuptake inhibitor (SSRI) marketed for the treatment of premature ejaculation, has been approved for premature ejaculation in several European countries. In the United States, it is currently in Phase III of the FDA approval process.

Antidepressants can be helpful because one of the side effects of some antidepressants is delayed orgasm, which is likely due to their ability to inhibit serotonin. Other side effects may include nausea, dry mouth, decreased libido, and drowsiness, so men need to discuss the pros and cons of taking an antidepressant to treat premature ejaculation. Some things to know about antidepressants and premature ejaculation:

• SSRIs, such as citalopram (Celexa), fluoxetine (Prozac), paroxetine (Paxil), and sertraline (Zoloft) may delay ejaculation. It may take 10 to 21 days for these drugs to be effective. (Kim 1998)
• The tricyclic antidepressant clomipramine (Anafranil) has been shown to help men who have P.E. (Girgis 1982)
• Your healthcare provider can determine how often you will need to take an antidepressant to help prevent premature ejaculation. Taking a low dose a few hours before sexual intercourse may be sufficient.

Topical anesthetic creams that contain prilocaine and/or lidocaine can be applied shortly before intercourse to dull sensation on the penis and thus delay ejaculation. In one study, 11 healthy married men with premature ejaculation and without erectile problems applied lidocaine-prilocaine cream 30 minutes before sexual contact and covered the penis with a condom. Nine of the men said the result was excellent (5) or better (4), while two men said there was no change after using the cream. (Berkovitch 1995) The cream should be wiped off when the penis has lost enough feeling to help achieve delayed ejaculation. Use of topical anesthetic creams can cause some side effects, including reduced sexual pleasure for men, reduced genital sensitivity and sexual pleasure in a man’s female partner, and, in rare cases, an allergic reaction to the cream.

Phosphodiesterase type-5 inhibitors, which include sildenafil (Viagra), tadalafil (Cialis), and vardenafil (Levitra) are typically used to treat erectile dysfunction, but they may have a role in treating ejaculatory disorders as well. A review of nine studies that examined the efficacy of PDE5is in the treatment of premature ejaculation, alone or along with the antidepressant class selective serotonin reuptake inhibitors, was conducted by a team of Italian researchers. All the studies showed some significant improvements in the time before ejaculation after penetration (intravaginal ejaculatory latency time) and sexual satisfaction scores, although not all the findings were clinically significant. The reviewers concluded that well-designed multicenter studies are necessary to better understand the efficacy, safety, and mechanisms of action of PDE5 in treating premature ejaculation. (Aversa 2011)

Some studies have indicated that use of PDE5 inhibitors along with SSRIs provide better results when treating P.E. than use of SSRIs alone, although the reason for this is not known. However, one explanation may be that PDE5 inhibitors improve erection durability and/or firmness while the antidepressant relieves some anxiety. (Abdel-Hamid 2004)

Tramadol is an opioid analgesic that inhibits serotonin and norepinephrine reuptake and has shown some ability to improve premature ejaculation. A study of 57 men with premature ejaculation were randomly assigned to take 50 mg tramadol or placebo about 2 hours before planned sexual activity for 8 weeks. The average intravaginal ejaculatory latency time (IELT) after tramadol increased from 19 seconds to approximately 243 seconds, while in the placebo group it increased from 21 seconds to 34 seconds. (Safarinejad 2006) In another study, 60 men with lifelong P.E. (defined as ejaculation occurring less than 2 minutes in 80% of episodes) took either 25 mg of tramadol or placebo 1 to 2 hours prior to intercourse for 8 weeks. Before tramadol treatment, average IELT was 1.17 minutes, which increased significantly to an average of 7.37 minutes after treatment. (Salem 2008)

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References

Abdel-Hamid IA. Phosphodiesterase 5 inhibitors in rapid ejaculation: potential use and possible mechanisms of action. Drug 2004; 64(1):13-26.

Aversa A et al. Is there a role for phosphodiesterase type-5 inhibitors in the treatment of premature ejaculation? Intl J Impotence Res 2011; 23: 17-23
Benson A. Premature ejaculation. Emedicine: http://emedicine.medscape.com/article/435884-overview

Berkovitch M, Keresteci AG, Koren G. Efficacy of prilocaine-lidocaine cream in the treatment of P.E. J Uro. Oct 1995; 154(4):1360-61.

Corona G et al. Different testosterone levels are associated with ejaculatory dysfunction. J Sex Med 2008 Aug; 8:1991-98

Girgis SM et al. A double-blind trial of clomipramine in P.E. Andrologia Jul-Aug 1982; 14(4):364-68.

Giuliano F et al. Premature ejaculation: results from a five-country European observational study. Eur Urol 2008 May; 53(5): 1048-57

Kim SC, Seo KK. Efficacy and safety of fluoxetine, sertraline and clomipramine in patients with premature ejaculation: a double-blind, placebo controlled study. J Urol Feb 1998; 159(2):425-27.

Masters WH, Johnson VE. Premature ejaculation. In: Human Sexual Inadequacy. Boston, Mass: Little Brown & Company; 1970:92-115.
Mayo Clinic: http://www.mayoclinic.com/health/premature-ejaculation/DS00578

Safarinejad MR, Hosseini SY. Safety and efficacy of tramadol in the treatment of premature ejaculation: a double-blind, placebo-controlled, fixed-dose, randomized study. J Clin Psychopharmacol. Feb 2006; 26(1):27-31.

Salem EA et al. Tramadol HCL has promise in on-demand use to treat premature ejaculation. J Sex Med Jan 2008; 5(1):188-93.

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