Premature ejaculation

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Premature ejaculation
Specialty Psychiatry, sexual medicine

Premature ejaculation (PE) is a male sexual dysfunction that occurs when a male expels semen (and most likely experiences orgasm) soon after beginning 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 of around one minute after penetration. [1] The International Classification of Diseases (ICD-10) applies a cut-off of 15 seconds from the beginning of sexual intercourse. [1]

Contents

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. In males, typical intravaginal ejaculation latency time is approximately 4–8 minutes. [2] The opposite condition is delayed ejaculation. [3]

Men with PE often report emotional and relationship distress, and some avoid pursuing sexual relationships because of PE-related embarrassment. [4] Compared with males, females consider PE less of a problem, [5] but several studies show that the condition also causes female partners distress. [4] [6] [7]

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, performance anxiety, passive-aggressive behavior or having too little sex; but there is little evidence to support any of these theories. [2]

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. [8] Scientists have long suspected a genetic link to certain forms of premature ejaculation. However, studies have been inconclusive in isolating the gene responsible for lifelong PE.

The nucleus paragigantocellularis of the brain has been identified as having involvement in ejaculatory control. [9] PE may be caused by prostatitis [10] or as a medication side effect.

PE has been classified into four subtypes - lifelong, acquired, variable and subjective PE. The pathophysiology of lifelong PE is mediated by a complex interplay of central and peripheral serotonergic, dopaminergic, oxytocinergic, endocrinological, genetic and epigenetic factors. Acquired PE may occur due to psychological problems - such as sexual performance anxiety, and psychological or relationship problems - and/or co-morbidity, including erectile dysfunction, prostatitis and hyperthyroidism. [11]

Mechanism

The physical process of ejaculation requires two actions: emission and expulsion. The emission is the first phase. It involves deposition of fluid from the ampullary vas deferens, seminal vesicles and prostate gland into the posterior urethra. [12] 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 the external male urethral sphincter. [13]

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. [14] [15]

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. [16]

Current evidence supports an average intravaginal ejaculation latency time (IELT) of six and a half minutes in 18- to 30-year-olds. [17] [18] 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. [19] Still, it is possible for some men with abnormally low IELTs to be satisfied with their performance and not report a lack of control. [20] Likewise, those with higher IELTs may consider themselves premature ejaculators, and suffer from quality of life issues normally associated with premature ejaculation, and even benefit from non-pharmaceutical treatment. [21]

Diagnosis

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) defines premature ejaculation as "A persistent or recurrent pattern of ejaculation occurring during partnered sexual activity within approximately 1 minute following vaginal penetration and before the person wishes it," with the additional requirements that the condition occurs for a duration longer than 6 months, causes clinically significant distress, and cannot be better explained by relationship distress, another mental disorder, or the use of medications. [1] These factors are identified by talking with the person, not through any diagnostic test. [1] The DSM-5 allows for specifiers whether the condition is lifelong or acquired, applying in general or only to certain situations, and severity based on the time under one minute, however these subtypes have been criticised as lacking validity due to insufficient evidence. [22]

The 2007 ICD-10 defined PE as ejaculating without control, and within around 15 seconds. [1]

Treatments

Several treatments have been tested for treating premature ejaculation. A combination of medication and non-medication treatments is often the most effective method. [23]

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 and it tends to detract from the sexual fulfilment of both partners. Other self-treatments include thrusting more slowly, withdrawing the penis altogether, purposefully ejaculating before sexual intercourse, and using more than one condom. Some men report these to have been helpful. [2]

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 male's responses) and "squeeze technique" (to reduce excessive arousal). [23] : 27 

To treat premature ejaculation, Masters and Johnson developed the "squeeze technique", based on the Semans technique developed by James Semans in 1956. [24] 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 male to last longer. [25] [26] [27]

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 male gets the sensation of approaching climax, both partners stop moving and remain still until the male's feelings of ejaculatory inevitability subside, at which point, they are free to resume active intercourse. [25] [28] [29] [30] [31]

The functional-sexological approach to treating premature ejaculation, as developed by François de Carufel & Gilles Trudel, offers a novel method focusing on sexual function improvement without interrupting sexual activity. This treatment, distinct from traditional behavioral techniques like the squeeze and stop-start methods, has demonstrated significant improvements in the duration of intercourse, sexual satisfaction, and overall sexual function. A pivotal study by De Carufel & Trudel (2006) showcases the effectiveness of this approach. [32] Moreover, the Cochrane review on psychosocial interventions for premature ejaculation recognizes the De Carufel study as having a low risk of bias, highlighting its methodological robustness among psychosocial intervention studies. [33] This acknowledgment points to the functional-sexological treatment as a promising avenue for individuals and couples grappling with premature ejaculation, suggesting a shift towards more contemporary and empirically supported treatments in the field. [34]

Medications

Dapoxetine, a selective serotonin reuptake inhibitor (SSRI), has been approved for the treatment of premature ejaculation in several countries. [35] [36] [37] Other SSRIs are used off-label to treat PE, including fluoxetine, paroxetine, sertraline, citalopram, escitalopram and clomipramine. [35] The opioid tramadol, an atypical oral analgesic is also used. [35] [38] Results have found PDE5 inhibitors to be effective in combination treatment with SSRIs. [35] The full effects of these medications typically emerge after 2-3 weeks, with results indicating about ejaculatory delay varying between 6–20 times greater than before medication. [35] Premature ejaculation can return upon discontinuation, [35] and the side effects of these SSRIs can also include anorgasmia, erectile dysfunction, and diminished libido. [35]

Topical anesthetics such as lidocaine and benzocaine that are applied to the tip and shaft of the penis have also been used. They are applied 10–15 minutes before sexual activity and have fewer potential side effects as compared to SSRIs. [39] However, this 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). [40] Another research was conducted in 21 men who were randomized (15 treatment, 6 placebo) and had complete follow-up data. Baseline mean ± standard deviation IELT was 74.3 ± 31.8 vs 84.9 ± 29.8 seconds among the treatment and placebo groups, respectively (p=0.39). After 2 months, men in the treatment group had significant improvement in IELT with a mean increase of 231.5 ± 166.9 seconds (95% confidence interval of 139-323 seconds) which was significantly greater than men on placebo (94.2 ± 67.1 seconds, p= 0.043). [41]

Surgical treatments

Two different surgeries, both developed in South Korea, are available to permanently treat premature ejaculation: selective dorsal neurectomy (SDN) [42] and glans penis augmentation using a hyaluronan gel. [43] [44] Circumcision has shown no effect on PE. [45] The International Society for Sexual Medicine guidelines do not recommend either surgical treatment due to the risk of permanent loss of sexual function and insufficient reliable data [45] [46] [22] and on the basis of violating the medical principle of non-maleficence as the surgery can lead to complications, of which some might not yet be known. [45] The most common complication of surgery is the recurrence of PE, reported to occur in about 10% of surgeries. [45] Other sources consider SDN as a safe and efficient treatment [47] and these surgeries are popular in Asian countries. [22] [46]

Epidemiology

Premature ejaculation is a prevalent sexual dysfunction in males; [48] 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). [49] In males, although ED is the most prevalent sex problem after age 60, and may be more prevalent than PE overall according to some estimates, [50] 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. [49] 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] [48] [51] [22] [52] [53] [54]

There is a common misconception that younger men are more likely to develop premature ejaculation and that its frequency decreases with age. [55] [56] Prevalence studies have indicated, however, that rates of PE are relatively constant across age groups. [8]

History

Naturalism

Male mammals ejaculate quickly during intercourse, prompting some biologists to speculate that rapid ejaculation had evolved into genetic makeup of human males to increase their chances of passing their genes. [57] [58]

Ejaculatory control issues have been documented for more than 1,500 years. The Kamasutra , the 4th century BCE Indian marriage handbook, declares that “if a male be long-timed, the female loves him the more, but if he be short timed, she is dissatisfied with him.” [59] [60]

Waldinger summarizes professional perspectives from early in the twentieth century. [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] The belief that it should be considered a disease rather than a normal variation, has also been disputed by some modern researchers. [63]

Medicalization

In the 19th century, a symptom called spermatorrhoea invented by William Acton in 1857, meaning excessive or involuntary semen discharge, was developed and at the time used as a medical justification of celibacy. [64] [65] Spermatorrhoea was later sub-classified into other symptom clusters based partially on how it affected semen. [65] Treatment for spermatorrhoea at the time included catheterisation, cauterisation, circumcision, and sticking needles through the perineum into the prostate. [65] In the 19th and early 20th centuries, the cultural stigma towards researching sexuality which drove its unpopularity among doctors and in publications. [64] The first recognition the symptoms described in spermatorrhoea as a disorder in itself is believed to be in 1883, termed ejaculatio praecox. [65] The origin of the modern version of ejaculatio praecox, called premature ejaculation, is thought to have begun with Alfred Adler before major developments of psycohanalytic theory. [66]

Through the mid 20th century, Sigmund Freud published widely accepted and virtually unchallenged theories that rapid ejaculation was due to neurosis, that penetrative sex was the only right way to achieve female orgasm, and that a man's erection was essential to female orgasm. [67] [68] It stated that males who ejaculate prematurely have unconscious hostility toward females, so they ejaculate rapidly, which satisfies them but frustrates their partners, who are unlikely to experience orgasm that quickly. [69] Freudians claimed that premature ejaculation could be cured using psychoanalysis. But even years of psychoanalysis accomplished little, if anything, in curing premature ejaculation. [69] In 1974, there was no evidence found to suggest that men with premature ejaculation harbor unusual hostility toward females. This so-called coital imperative has later been argued as a medically recognised disorder that did not actually serve the satisfaction of women but rather contributed to the pressure on and pathologisation of men in obtaining a so-called optimal time to ejaculation. [68] [70]

See also

Related Research Articles

Erectile dysfunction (ED), also referred to as impotence, is a form of sexual dysfunction in males characterized by the persistent or recurring inability to achieve or maintain a penile erection with sufficient rigidity and duration for satisfactory sexual activity. It is the most common sexual problem in males and can cause psychological distress due to its impact on self-image and sexual relationships.

<span class="mw-page-title-main">Peyronie's disease</span> Abnormal growth of scar tissue within the penis

Peyronie's disease is a connective tissue disorder involving the growth of fibrous plaques in the soft tissue of the penis. Specifically, scar tissue forms in the tunica albuginea, the thick sheath of tissue surrounding the corpora cavernosa, causing pain, abnormal curvature, erectile dysfunction, indentation, loss of girth and shortening.

<span class="mw-page-title-main">Female ejaculation</span> Expulsion of fluid during orgasm

Female ejaculation is characterized as an expulsion of fluid from the Skene's gland at the lower end of the urethra during or before an orgasm. It is also known colloquially as squirting or gushing, although research indicates that female ejaculation and squirting are different phenomena, squirting being attributed to a sudden expulsion of liquid that partly comes from the bladder and contains urine.

<span class="mw-page-title-main">Ejaculatory duct</span> Male anatomical structures

The ejaculatory ducts are paired structures in the male reproductive system. Each ejaculatory duct is formed by the union of the vas deferens with the duct of the seminal vesicle. They pass through the prostate, and open into the urethra above the seminal colliculus. During ejaculation, semen passes through the prostate gland, enters the urethra and exits the body via the urinary meatus.

Sexual dysfunction is difficulty experienced by an individual or partners during any stage of normal sexual activity, including physical pleasure, desire, preference, arousal, or orgasm. The World Health Organization defines sexual dysfunction as a "person's inability to participate in a sexual relationship as they would wish". This definition is broad and is subject to many interpretations. A diagnosis of sexual dysfunction under the DSM-5 requires a person to feel extreme distress and interpersonal strain for a minimum of six months. Sexual dysfunction can have a profound impact on an individual's perceived quality of sexual life. The term sexual disorder may not only refer to physical sexual dysfunction, but to paraphilias as well; this is sometimes termed disorder of sexual preference.

<span class="mw-page-title-main">Frenulum breve</span> Medical condition

Frenulum breve, or short frenulum, is a condition in which the frenulum of the penis, which is an elastic band of tissue under the glans penis that connects to the foreskin and helps contract it over the glans, is too short and thus restricts the movement of the foreskin. The frenulum should normally be sufficiently long and supple to allow for the full retraction of the foreskin so that it lies smoothly back on the shaft of the erect penis.

The human sexual response cycle is a four-stage model of physiological responses to sexual stimulation, which, in order of their occurrence, are the excitement, plateau, orgasmic, and resolution phases. This physiological response model was first formulated by William H. Masters and Virginia E. Johnson, in their 1966 book Human Sexual Response. Since that time, other models regarding human sexual response have been formulated by several scholars who have criticized certain inaccuracies in the human sexual response cycle model.

Sexual medicine or psychosexual medicine as defined by Masters and Johnsons in their classic Textbook of Sexual Medicine, is "that branch of medicine that focuses on the evaluation and treatment of sexual disorders, which have a high prevalence rate." Examples of disorders treated with sexual medicine are erectile dysfunction, hypogonadism, and prostate cancer. Sexual medicine often uses a multidisciplinary approach involving physicians, mental health professionals, social workers, and sex therapists. Sexual medicine physicians often approach treatment with medicine and surgery, while sex therapists often focus on behavioral treatments.

Hypospermia is a condition in which a man has an unusually low ejaculate volume, less than 1.5 mL. It is the opposite of hyperspermia, which is a semen volume of more than 5.5 mL. It should not be confused with oligospermia, which means low sperm count. Normal ejaculate when a man is not drained from prior sex and is suitably aroused is around 1.5–6 mL, although this varies greatly with mood, physical condition, and sexual activity. Of this, around 1% by volume is sperm cells. The U.S.-based National Institutes of Health defines hypospermia as a semen volume lower than 2 mL on at least two semen analyses.

Anejaculation is the pathological inability to ejaculate despite an erection in males, with (orgasmic) or without (anorgasmic) orgasm.

Sex and drugs refers to the influence of substances on sexual function and experience. Sex and drugs date back to ancient humans and have been interlocked throughout human history. Sexual performance is known as the execution of the act of sex and the quality of sexual activity. This includes elements such as libido, sexual function, sensation . Drugs are termed as any chemical substance that produces a physiological and or psychological change in an organism. Drugs categorized as psychoactive drugs, antihypertensive drugs, antihistamines, cancer treatment, and hormone medication have a significant impact on sexual performance. Various drugs result in different effects, both positive and negative. Negative effects may include low libido, erection issues, vaginal dryness and anorgasmia. Positive effects usually address these issues, overall enhancing sexual performance and contributing to a more enjoyable sexual experience. It is crucial to know that the impact of drugs on sexual performance varies among individuals, especially among different genders.

Delayed ejaculation (DE) is a man's inability or persistent difficulty in achieving orgasm, despite typical sexual desire and sexual stimulation. Generally, a man can reach orgasm within a few minutes of active thrusting during sexual intercourse, whereas a man with delayed ejaculation either does not have orgasms at all or cannot have an orgasm until after prolonged intercourse which might last for 30–45 minutes or more. Delayed ejaculation is closely related to anorgasmia.

<span class="mw-page-title-main">Human penis</span> Human male external reproductive organ

In human anatomy, the penis is an external male sex organ that serves as a passage for urine during urination and semen during ejaculation. The main parts are the root, body, the epithelium of the penis including the shaft skin, and the foreskin covering the glans. The body of the penis is made up of three columns of tissue: two corpora cavernosa on the dorsal side and corpus spongiosum between them on the ventral side. The urethra passes through the prostate gland, where it is joined by the ejaculatory ducts, and then through the penis. The urethra goes across the corpus spongiosum and ends at the tip of the glans as the opening, the urinary meatus.

Odynorgasmia, or painful ejaculation, also referred to as dysejaculation, dysorgasmia, and orgasmalgia, is a physical syndrome described by pain or burning sensation of the urethra or perineum during or following ejaculation. Causes include: infections associated with urethritis, prostatitis, epididymitis; use of anti-depressants; cancer of the prostate or of other related structures; calculi or cysts obstructing related structures; trauma to the region.

Intravaginal ejaculation latency time (IELT) is the time it takes to ejaculate during vaginal penetration. Average IELT varies between people and tends to decrease with age.

<span class="mw-page-title-main">Ejaculation</span> Semen discharge from the male reproductive tract

Ejaculation is the discharge of semen from the testicles through the penis and out the urethra. It is the final stage and natural objective of male sexual stimulation, and an essential component of natural conception. After forming an erection, many men emit pre-ejaculatory fluid during stimulation prior to ejaculating. Ejaculation involves involuntary contractions of the pelvic floor and is normally linked with orgasm. It is a normal part of male human sexual development.

Postorgasmic illness syndrome (POIS) is a syndrome in which human males have chronic physical and cognitive symptoms following ejaculation. The symptoms usually onset within seconds, minutes, or hours, and last for up to a week. The cause and prevalence are unknown; it is considered a rare disease.

<span class="mw-page-title-main">Dapoxetine</span> Medication used to treat premature ejaculation

Dapoxetine, marketed as Priligy, among others, is a selective serotonin reuptake inhibitor (SSRI) used for the treatment of premature ejaculation (PE) in men 18–64 years old. Dapoxetine works by inhibiting the serotonin transporter, increasing serotonin's action at the postsynaptic cleft, and as a consequence promoting ejaculatory delay. As a member of the selective serotonin reuptake inhibitor (SSRI) family, dapoxetine was initially created as an antidepressant. However, unlike other SSRIs, dapoxetine is absorbed and eliminated rapidly in the body. Its fast-acting property makes it suitable for the treatment of PE, but not as an antidepressant.

Ejaculation disorders are the most common sexual dysfunction in men. Common ejaculatory disorders include: premature ejaculation, retrograde ejaculation, delayed ejaculation, anejaculation, inhibited ejaculation, and anorgasmia.

Dysorgasmia is the experience of a painful orgasm, usually in the abdomen. The condition may be experienced during or after orgasm, sometimes as late as several hours after the orgasm occurred. Both men and women can experience orgasmic pain. The term is sometimes used interchangeably with painful ejaculation when experienced by a man, but ejaculatory pain is only a subtype of male dysorgasmia as men can experience pain without ejaculating. The phenomenon is poorly understood and underresearched. Dysorgasmia can come as a side effect of surgical interventions such as prostatectomy.

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