Premature ejaculation
Premature ejaculation is a male sexual dysfunction that occurs when a male expels semen soon after beginning sexual activity, and with minimal penile stimulation. It has also been called early ejaculation, rapid ejaculation, rapid climax, premature climax and 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. The International Classification of Diseases applies a cut-off of 15 seconds from the beginning of sexual intercourse.
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. The opposite condition is delayed ejaculation.
Men with PE often report emotional and relationship distress, and some avoid pursuing sexual relationships because of PE-related embarrassment. Compared with males, females consider PE less of a problem, but several studies show that the condition also causes female partners distress.
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.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. 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. PE may be caused by prostatitis 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.
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. 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.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.
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.Evidence supports an average intravaginal ejaculation latency time of six and a half minutes in 18- to 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 two minutes. Still, it is possible for some men with abnormally low IELTs to be satisfied with their performance and not report a lack of control. 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.
Diagnosis
The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition 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. These factors are identified by talking with the person, not through any diagnostic test. 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.The 2007 ICD-10 defined PE as ejaculating without control, and within around 15 seconds.
Treatments
Several treatments have been tested for treating premature ejaculation. A combination of medication and non-medication treatments is often the most effective method.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 fulfillment 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.Sex therapy
Several techniques have been developed and applied by sex therapists, including Kegel exercises and Masters and Johnson's "stop-start technique" and "squeeze technique".To treat premature ejaculation, Masters and Johnson developed the "squeeze technique", based on the Semans technique developed by James Semans in 1956. 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.
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.
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 showcases the effectiveness of this approach. 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. 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. Access to functional-sexological therapy can be limited due to a shortage of qualified professionals. A study published in the Journal of Sex & Marital Therapy found that many individuals experience difficulties in seeking treatment for sexual concerns, largely due to a lack of awareness about available services and the scarcity of trained sex therapists, making these services appear inaccessible to those in need.
Medications
, a selective serotonin reuptake inhibitor, has been approved for the treatment of premature ejaculation in several countries. Other SSRIs are used off-label to treat PE, including fluoxetine, paroxetine, sertraline, citalopram, escitalopram and clomipramine. The opioid tramadol, an atypical oral analgesic is also used. Results have found PDE5 inhibitors to be effective in combination treatment with SSRIs. The full effects of these medications typically emerge after 2-3 weeks, with results indicating about ejaculatory delay of up to 4 times greater than before medication if the medication is combined with psychotherapy. Premature ejaculation can return upon discontinuation, and the side effects of these SSRIs can also include anorgasmia, erectile dysfunction, and diminished libido.Topical anesthetics such as lidocaine and benzocaine, commonly known as delay sprays, that are applied to the tip and shaft of the penis have also been developed to essentially numb the intended area. These topical anesthetics are applied 10–15 minutes before sexual activity and have fewer potential side effects as compared to SSRIs. However, this is sometimes disliked due to the reduction of sensation in the penis as well as for the partner. In North America, the most popular delay spray, , is approved by the FDA and Health Canada. Another research was conducted in 21 men who were randomized 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. After 2 months, men in the treatment group had significant improvement in IELT with a mean increase of 231.5 ± 166.9 seconds which was significantly greater than men on placebo.