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Premature ejaculation (PE) is one of the most common male sexual disorders and has been recognized as a problem for over 100 years (ISSM, 2014). It is a form of sexual dysfunction, meaning that PE can keep you and your partner from experiencing satisfaction from sexual activities. According to the American Urologic Society (AUA), 33% of men aged 18 to 59 have problems with PE (AUA, n.d.). What is premature ejaculation? Ejaculation is a release of semen from the penis; premature ejaculation is when ejaculation happens before you or your partner would like. PE that occurs occasionally is also called rapid ejaculation, premature climax, or early ejaculation. Occasional PE is usually nothing to worry about; however, if it is happening regularly or causing you significant distress, then you need to speak to your healthcare provider about your symptoms.
According to the International Society for Sexual Medicine (ISSM), you may have PE if you (Serefoglu, 2014):
- Always or almost always ejaculate within one minute of penetration (for lifelong PE) or within three minutes of penetration (for acquired PE)
- Are unable to control or delay ejaculation during sexual activities all or nearly all of the time
- Are experiencing distress, frustration, and/or avoidance of sexual intimacy
There are two main types of premature ejaculation: lifelong and acquired. Lifelong premature ejaculation happens with all or almost all of your sexual activities—ever since your first sexual encounters. In acquired PE, a man who had previously healthy ejaculatory control suddenly or gradually develops PE. Men who usually have an average ejaculation time and experience PE on occasion may have natural variable PE; this is considered a normal variation of sexual performance rather than sexual dysfunction (ISSM, 2104).
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What causes premature ejaculation?
Though the exact cause of premature ejaculation is not known, it is thought to be due to a combination of psychological and biological factors.
Psychological factors that may play a role in PE include (AUA, n.d.):
- Anxiety, including worrying about PE
- History of sexual abuse or sexual repression
- Poor body image and/or lack of self-esteem
- Decreased sexual drive
- Guilt (may cause you to rush your sexual activities leading to PE)
- Unrealistic expectations about sexual performance
- Relationship problems
Several biological factors have also been hypothesized to lead to PE. None of these have been confirmed with extensive studies, but you should keep them in mind when thinking about the potential causes of your PE. In some cases, by treating the underlying condition, your PE may get better. One factor that may contribute to PE is serotonin, a substance produced by nerves in the brain. An increased amount of serotonin increases the time to ejaculation while low levels shorten it, leading to PE. Serotonin imbalance is thought to cause a small portion (2-5%) of cases of PE (ISSM, 2014).
Other biological factors that may play a role include (1):
- Hypersensitivity of the glans penis (the head of the penis)
- Prostatitis (inflammation of the prostate gland)
- Withdrawal/detoxification from prescribed or recreational drugs
- Chronic pelvic pain syndrome
- Thyroid hormone abnormalities
- Testosterone imbalance
Erectile dysfunction (ED) is sometimes confused with PE. In ED, your penis cannot get firm or stay firm enough for sex and may be due to an underlying medical condition. Sometimes men with ED rush through their sexual activities to finish before they lose their erection. Others may get PE because of the performance anxiety they have due to their ED. Both PE and ED can exist together, further decreasing sexual satisfaction and affecting your sex life (Serefoglu, 2014).
Aging causes changes in erections and ejaculation, but is not a direct cause of PE (AUA, n.d.). As you get older, your erections may not be as firm, and you may not last as long before ejaculation. These are natural changes that occur as you age, and older men may ejaculate earlier.
Signs and symptoms
According to the definition of PE, the main symptom is the inability to keep yourself from ejaculating within one minute of penetration in lifelong PE or three minutes in acquired PE. This difficulty controlling your ejaculation can also occur during masturbation or other forms of sexual activity.
Successful treatment of PE hinges on you and your provider having an open and honest discussion regarding your sexual difficulties. While these conversations may be awkward, they are vital to getting you the correct treatment and improving your sexual health. Your provider will ask you several questions to determine if you have PE and, if so, which type (lifelong or acquired). According to the AUA, 95% of men will recover from PE (AUA, n.d.). Several types of treatment for PE exist, and they are often combined; these include psychological, behavioral, and medical therapies.
Psychological therapy for men and couples, such as sex counseling, works by improving sexual self-confidence and performance anxiety as well as allowing you to address personal and/or relationship issues that may be linked to your premature ejaculation. Relationship problems are a common side effect of PE, so it is essential to be open and have your partner involved in the treatment plan (4). The main side effects are cost and time investment. Psychological therapy seems to be most beneficial when combined with medical treatment (Porst, 2019).
Studies suggest that behavioral therapy can be useful for PE. The three behavioral therapies most commonly discussed are the stop-start method, the squeeze technique, and pelvic floor exercises.
- Stop-start: In the stop-start method, you and your partner perform your usual sexual activities until you feel almost ready to ejaculate. Your partner then stops until the urge to ejaculate has passed, after which you resume your sexual activities. This process is then repeated.
- Squeeze technique: You and your partner initiate sex as usual until you feel almost ready to ejaculate. At this point, your partner squeezes the end of your penis, where the head meets the shaft until the urge to ejaculate diminishes; repeat as necessary.
- Pelvic floor exercises (Kegel exercises): These can help strengthen muscles used during ejaculation. The pelvic floor muscles appear to have increased activity during ejaculation, and it may be that strengthening these muscles can help you delay ejaculation (Pastore, 2014). The pelvic floor muscles are the ones that allow you to stop urinating mid-stream or what you would use to prevent yourself from passing gas.
Decreasing penis sensitivity can help delay ejaculation in some men; there are several ways to achieve this. Some men find that masturbating before intercourse partially desensitizes the penis and allows for better control of ejaculation. Alternatively, there are over-the-counter sprays, creams, and wipes. These all use topical anesthetics (numbing medicines) like lidocaine, benzocaine, or prilocaine to decrease penis sensation. The creams/sprays are applied to the head of the penis 10-20 minutes before sex and five minutes before sex if you are using the wipes. There are also “climax control” condoms; these differ from regular condoms because they decrease penis sensation with either a coating of a topical anesthetic or they may have thicker latex than usual.
When it comes to medical management, there are no FDA-approved medications for premature ejaculation. However, some drugs are used “off-label” in the United States, meaning that it is being used to treat a condition that it was not FDA-approved to treat. The most common medications used to treat PE include:
- Selective serotonin reuptake inhibitors (SSRIs): These drugs were initially FDA-approved for depression treatment, but studies have shown them to be effective in treating PE as well. Paroxetine and sertraline are longer-acting SSRIs that can be taken daily to treat premature ejaculation; they are effective and relatively low-cost (Porst, 2019). Dapoxetine is a short-acting SSRI that is currently in clinical trials in the U.S. for PE treatment. It can be taken one hour before sexual activity and has been shown to delay ejaculation (Porst, 2019).
- Tricyclic antidepressants (TCAs): This class includes medications like clomipramine and was also initially approved to treat depression. Studies do show a significant delay in ejaculation with TCAs when used either daily or on-demand (two to six hours before sex) (Porst, 2019).
- Phosphodiesterase-5 inhibitors (PDE5i): Usually used to treat erectile dysfunction, this type includes sildenafil, tadalafil, and vardenafil. They are most useful for men with both ED and PE; their effectiveness is uncertain with regards to treating PE alone (Porst, 2019).
- Alpha-1 adrenoceptor antagonists: Medications such as silodosin may help with premature ejaculation if taken one hour before sex, but more studies are needed (Porst, 2019).
- Modafinil, a drug used to help people with narcolepsy (a sleeping disorder) stay awake, showed a small benefit in one clinical trial, but more research is necessary (Tuken, 2016).
You can learn more about treatment for PE by clicking here.
If you are having difficulty controlling your ejaculations during sex, and it is putting a strain on you and your relationship, you may have premature ejaculation. Talk to your healthcare provider (and your partner) about your symptoms and treatment options.
- Premature ejaculation (PE) is defined as almost always ejaculating within one minute of penetration, being unable to control ejaculation during sex, and experiencing distress as a result.
- In the U.S., 33% of men aged 18–59 have problems with PE.
- PE is thought to be due to a combination of psychological and biological factors.
- Treatment for PE is usually a combination of psychological, behavioral, and medical therapies.