Premature ejaculation

Definition

Premature ejaculation (PE) refers to the persistent or recurrent discharge of semen with minimal sexual stimulation before, on, or shortly after penetration, before the person wishes it, and earlier than he expects it. In making the diagnosis of PE, the clinician must take into account factors that affect the length of time that the man feels sexually excited. These factors include the age of the patient and his partner, the newness of the sexual partner, and the location and recent frequency of sexual activity.

Causes

Premature ejaculation (PE) is a common complaint. The available evidence supports the notion that control and modulation of sexual excitement is learned behavior. If someone has learned it incorrectly or inadequately, they can relearn it. PE is only rarely caused by a physical or structural problem; in these cases it is usually associated with other physical symptoms, usually pain. In rare cases, PE may be associated with a neurological condition; infection of the prostate gland; or urethritis (inflammation of the duct that carries urine and semen to the outside of the body). With the rising prevalence of substance abuse, an increasing number of cases of PE are being diagnosed in patients withdrawing from drugs, especially opioids.

PE may be of lifelong duration or develop in later life, especially if a difficult interpersonal relationship is one of its causes. Although PE is commonly associated with psychological symptoms, especially performance anxiety and guilt, these symptoms are its consequences rather than its causes. Once PE is firmly established, however, the accompanying psychological factors, especially in combination with sexual overstimulation, may form a self-perpetuating cycle that makes the disorder worse.

Premature ejaculation is common in adolescents where it may be made worse by feelings of sinfulness concerning sexual activity, fear of discovery, fear of making the partner pregnant, or fear of contracting a sexually transmitted disease (STD). All of these may be made worse by performance anxiety. Adults may have similar concerns as well as interpersonal factors related to the sexual partner.

Symptoms

In PE, ejaculation occurs earlier than the patient and/or the couple would like, thus preventing full satisfaction from intercourse, especially on the part of the sexual partner, who frequently fails to attain orgasm. PE is almost invariably accompanied by marked emotional upset and interpersonal difficulties that may add frustration to an already tense situation, which makes the loss of sexual fulfillment even worse. It is also important to differentiate male orgasm from ejaculation. Some men are able to distinguish between the two events and enjoy the pleasurable sensations associated with orgasm apart from the emission of semen, which usually ends the moment of orgasm. In these cases, the partner is capable of achieving orgasm and sexual satisfaction.

Diagnosis

The physical examination of a patient who is having problems with PE usually results in normal findings. Abnormal findings are unusual. The best source of information for diagnosing the nature of the problem is the patient's sexual history. On taking the patient's history, the clinician should concentrate on the sexual history, making sure that both partners have adequate and accurate sexual information. Ideally, the sexual partner should participate in the history and is often able to contribute valuable information that the patient himself may be unaware of or unwilling to relate. The female partner should also be examined by a gynecologist in order to ascertain her sexual capabilities and to eliminate the possibility that the size or structure of her genitals is part of the reason for the male's premature ejaculation.

Treatment

Preferably, therapy for PE should be conducted under the supervision of a health professional trained in sexual dysfunction. Both partners must participate responsibly in the therapeutic program. Treatment of PE requires patience, dedication and commitment by both partners, and the therapist must convey this message to both. The first part of therapy requires both partners to avoid intercourse for a period of several weeks. This period of abstinence is helpful in relieving any troublesome performance anxiety on the part of the man that may interfere with therapy.

Behavioral techniques, taught either individually, conjointly, or in groups, are effective in the therapy of PE. A preliminary stage of all treatment is termed "sensate focus" and involves the man's concentration on the process of sexual arousal and orgasm. He should learn each step in the process, most particularly the moment prior to the "point of no return." The sexual partner participates in the process, maintaining an awareness of the patient's sensations and how close he is to ejaculating. At this point, two techniques are commonly used:

• • The "stop and start" technique. This approach involves sexual stimulation until the man recognizes that he is about to ejaculate. At this time, the stimulation is discontinued for about thirty seconds and then resumed. This sequence of events is repeated until ejaculation is desired by both partners, with stimulation continuing until ejaculation occurs.
• • The "squeeze" technique. This approach involves sexual stimulation, usually by the sexual partner, until the man recognizes that he is about to ejaculate. At this time stimulation ceases. The patient or his partner gently squeezes the end of the penis at the junction of the glans penis (tip of the penis) with the shaft. The squeezing is continued for several seconds. Sexual stimulation is withheld for about 30 seconds and then resumed. This sequence of events is repeated by the patient alone or with the assistance of his partner until ejaculation is desired. At this point stimulation is continued until the man ejaculates.

The patient and his partner should be advised against trying any of the many unproven remedies that are available either over the counter or popularized on the Internet. Certain prescription medications, especially antidepressants that produce delayed ejaculation as a side effect, may be useful as therapeutic adjuncts. Recently, the use of a class of drugs known as selective serotonin receptor inhibitors (SSRIs) has shown promise in the treatment of premature ejaculation. The SSRIs prolong the time it takes the man to ejaculate by as much as 30 minutes. The SSRIs most commonly used to treat PE are sertraline (Zoloft) and fluoxetine (Prozac), which are currently approved by the Food and Drug Administration (FDA) for use in treating depression and panic attacks. It is important to emphasize that the use of these drugs to treat premature ejaculation is still considered experimental, as the FDA has not approved them for this specific use as of 2002.

Potential complications

Premature ejaculation that takes place before the man's penis enters the woman's vagina will interfere with conception, if the couple is planning a pregnancy. Continued lack of ejaculatory control may lead to sexual dissatisfaction for either or both members of the couple. It may become a source of marital tension, disturbed interpersonal relationships, and eventual separation or divorce.

Failure to respond to treatment for PE and the complications that may result from it should encourage the patient to seek further help from a health provider trained and experienced in treating the problem.

Prognosis

In most cases (some observers claim a 95% success rate), the patient is able to control ejaculation through education and practice of the techniques outlined. In chronic cases that do not respond to treatment, the PE may be related to a serious psychological or psychiatric condition, including depression or anxiety. Patients in this category may benefit from psychotherapy .

See also Male orgasmic disorder

Resources

BOOKS

Lue, Tom F., F. Goldstein. "Impotence and Infertility." In Atlas of Clinical Urology. Volume 1. New York: Current Medicine, 1999.

Masters. William, and Virginia Johnson. Masters and Johnson on Sex and Human Loving. New York: Little, Brown,1986.

Steidle, Christopher P., M.D. The Impotence Source Book. Los Angeles: Howell House, 1998.

Ralph Myerson, M.D.

Premature Ejaculation

Definition

Premature ejaculation occurs when male sexual climax (orgasm) occurs before a man wishes it or too quickly during intercourse to satisfy his partner.

Description

Premature ejaculation is the most commonly reported sexual complaint of men and couples. The highest number of complaints is among teenage, young adult, and sexually inexperienced males. Increased risk is associated with sexual inexperience and lack of knowledge of normal male sexual responses.

Causes and symptoms

There are several reasons why a man may ejaculate prematurely. For some men, the cause is due to an innate reflex or psychological predisposition of the nervous system. Sometimes it can be caused by certain drugs, such as non-prescription cold medications. Psychological factors, such as stress, fear, or guilt can also play a role. Examples of psychological factors include guilt that the sexual activity is wrong or sinful, fear of getting caught, or stress from problems at work or home.

In general, symptoms are when a male reaches climax in less than two minutes or when it occurs before the male or couple want it to occur.

Diagnosis

There are no tests used to diagnose premature ejaculation. It is usually determined by the male involved based on his belief that he reached orgasm too quickly. General guidelines for premature ejaculation is if it occurs in two minutes or less, or prior to about 15 thrusts during sexual intercourse.

Treatment

In 1966, William H. Masters and Virginia E. Johnson published Human Sexual Response, in which they broke the first ground in approaching this topic from a new perspective. Their method was devised by Dr. James Seman and has been modified subsequently by Dr. Helen Singer Kaplan and others.

A competent and orthodox sex therapist will spend much more time focusing on the personal than the sexual relationship between the two people who come for treatment. Without emotional intimacy, sexual relations are superficial and sexual problems such as premature ejaculation are not always overcome.

With that foremost in mind, a careful plan is outlined that requires dedication, patience, and commitment by both partners. It necessarily begins by prohibiting intercourse for an extended period of time—at least a week, often a month. This is very important to the man because "performance anxiety" is the greatest enemy of performance. If he knows he cannot have intercourse he is able to relax and focus on the exercises. The first stage is called "sensate focus" and involves his concentration on the process of sexual arousal and climax. He should learn to recognize each step in the process, most particularly the moment just before the "point of no return." Ideally, this stage of treatment requires the man's partner to be devoted to his sensations. In order to regain equality, he should in turn spend separate time stimulating and pleasing his mate, without intercourse.

At this point the techniques diverge. The original "squeeze technique" requires that the partner become expert at squeezing the head of the penis at intervals to prevent orgasm. The modified procedure, described by Dr. Ruth Westheimer, calls upon the man to instruct the partner when to stop stimulating him to give him a chance to draw back. A series of stages follows, each offering greater stimulation as the couple gains greater control over his arousal. This whole process has been called "outercourse." After a period of weeks, they will have together retrained his response and gained satisfactory control over it. In addition, they will each have learned much about the other's unique sexuality and ways to increase each other's pleasure.

With either technique, the emphasis is on the mutual goal of satisfactory sexual relations for both partners.

However, the 1990s ushered in a new era in the treatment of premature ejaculation when physicians discovered that certain antidepression drugs had a side effect of delaying ejaculation. Clinical studies have shown that a class of antidepressants called selective seratonin reuptake inhibitors (SSRIs) can be very effective in prolonging the time to ejaculation. The individual drugs and the average amount of time they delay ejaculation are fluoxetine (Prozac), one to two minutes with doses of 20-40 milligrams per day (mg/day) and eight minutes with 60 mg/day; paroxetine (Paxil), three to 10 minutes with doses of 20-40 mg/day; and sertraline (Zoloft), two to five minutes with doses of 50-200 mg/day.

Alternative treatment

There are several alternative products, usually found in health food and nutrition stores, designed to be sprayed or rubbed on the penis to delay ejaculation. Although the products promise results, there are no valid clinical studies to support the claims. A device called a testicular restraint, sold through erotic mailorder magazines, sometimes helps men delay ejaculation. The Velcro-like device restrains the testicles from their natural tendency to move during sex. Testicular movement can cause premature ejaculation.

Prognosis

The "squeeze technique" has elicited a 95% success rate, whereby the patient is able to control ejaculation. Treatment with SSRIs is effective in 85-90% of cases. However, the effectiveness begins to decrease after five weeks of daily administration. Although more studies are needed, this suggests the SSRIs are more effective when used on an as-needed basis.

Prevention

The best prevention is obtaining adequate information on normal sexual responses of males before having sex. It is also helpful to have sex in a comfortable, relaxed, private setting, free of guilt, stress, and fear.

Resources

PERIODICALS

"Lengthen Your Fuse." Men's Health November 1999: 56.

Rowland, David L., and Arthur L. Burnett. "Pharmacotherapy inthe Treatment of Male Sexual Dysfunction." The Journal of Sex Research August2000: 226+.

ORGANIZATIONS

American Association for Marriage and Family Therapy. 1133 15th St. NW, Suite 300, Washington, DC 20005-2710. (202) 452-0109. 〈http://www.aamft.org.〉.

American Association of Sex Educators, Counselors, and Therapists. P.O. Box 5488, Richmond, VA 23220. 〈http://www.aasect.org.〉.

Sexuality Information and Education Council of the U.S. 130 W. 42nd St., Ste. 350, New York, NY 10036. (212) 819-9770. 〈http://www.siecus.org.〉.