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Last updated October 24, 2019. 6 minute read

Premature ejaculation (PE): what causes it?

Men who are usually satisfied with their ejaculation time and only have PE on occasion may be experiencing natural variable PE; this is a normal variation of sexual performance and not a sexual dysfunction. However, if PE is happening to you regularly or causing you significant distress, then you need to speak to your healthcare provider about your symptoms.

Dr Chimene Richa Md Written by Dr. Chimene Richa, MD
Reviewed by Dr. Mike Bohl, MD, MPH

Premature ejaculation (PE) is a form of sexual dysfunction, meaning that it can keep you and your partner from having a satisfying sex life. It is one of the most common male sexual disorders; according to the American Urologic Society (AUA), one in three men aged 18 to 59 have problems with PE (AUA, n.d.). Ejaculation happens when you climax during sexual activities and the penis releases semen. In PE, ejaculation occurs earlier than you or your partner would like. Men who are usually satisfied with their ejaculation time and only have PE on occasion may be experiencing natural variable PE; this is a normal variation of sexual performance and not a sexual dysfunction (ISSM, 2014). However, if PE is happening to you regularly or causing you significant distress, then you need to speak to your healthcare provider about your symptoms.

Vitals

  • One in three men aged 18 to 59 has premature ejaculation.
  • The causes of PE are not well defined but are thought to be a combination of psychological and biological factors.
  • Psychological factors include anxiety, depression, and stress.
  • Biological factors include serotonin or testosterone imbalances, chronic prostate inflammation, and thyroid problems.

Premature ejaculation is usually characterized as one of two types: lifelong and acquired. Lifelong PE is an issue with nearly all of your sexual encounters since your first. Acquired PE, on the other hand, affects men who had previously ordinary ejaculation experiences and then suddenly or gradually developed PE.

There was no proper definition for PE until the International Society for Sexual Medicine (ISSM), met in 2014. According to the 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 

You can learn more about premature ejaculation by clicking here.

To accurately diagnose and eventually treat PE, you need to have an honest discussion with your healthcare provider about your symptoms. The questions may be awkward and uncomfortable for many men, but they are essential to get at the root of your problem. Most of the time, your provider can diagnose PE with a physical exam and a discussion of your sexual difficulties. Some of the questions may include (AUA, n.d.):

  • What is the time between penetration and ejaculation (cumming)? 
  • Can you delay ejaculation? 
  • Do you feel bothered, annoyed, and frustrated by your premature ejaculation?
  • How often does PE happen to you?
  • How long have you had a problem with ejaculatory control?
  • Does this happen with just one particular person or every sexual partner?
  • Does PE happen every time you engage in sex?
  • What type of sexual activity (foreplay, masturbation, intercourse, etc.) do you engage in and how often?
  • How has PE affected your sex life?
  • Is there anything that makes your PE better or worse?

If your provider finds anything questionable on the physical exam, he or she may order lab testing.

What causes premature ejaculation?

The causes of premature ejaculation include a wide range of psychological and biological theories; the exact cause of PE is not known but is likely due to a combination of both medical and psychological factors.

Psychological factors that may contribute to PE include (McMahon, 2016):

  • Anxiety, including sexual performance anxiety
  • Depression
  • History of sexual abuse or sexual repression
  • Lack of self-esteem
  • Social phobias (fear of being judged by others)
  • Decreased sexual drive
  • Guilt (may cause you to rush your sexual activities leading to PE)
  • Relationship problems or stress

It is worth noting that anxiety and depression may also be caused by having PE; there have been many studies looking at the relations between anxiety, depression, and PE (McMahon, 2016).

Several biological factors have been proposed as possibly leading to PE. Some men have found that if they have an underlying medical condition, treating it may improve their PE. There have been no extensive studies looking at any of these factors (ISSM, 2014):

  • Neurotransmitters (substances produced by nerves in the brain) like serotonin, dopamine, and oxytocin: Increased serotonin delays ejaculation while low levels shorten the time to ejaculation, leading to PE. Serotonin imbalance is thought to cause a 2–5% of cases of lifelong PE (ISSM, 2014). Dopamine and oxytocin may also affect ejaculation, but they are less well studied; in animal studies, both appear to stimulate ejaculation (ISSM, 2014).
  • Increased sensitivity of the head of the penis (glans penis)
  • Inflammation of the prostate gland (prostatitis) or chronic pelvic pain syndrome: While 26–77% of men with these conditions also have PE, the relationship between the two is unclear. Inflammation may contribute to PE (ISSM, 2014).
  • Thyroid hormone imbalances: The role of thyroid hormones in ejaculation is not known, but most patients with thyroid hormone imbalances also have sexual dysfunction (McMahon,  2016). Checking thyroid levels routinely in men with PE is not necessary unless you have other symptoms that suggest thyroid involvement. 
  • Testosterone level abnormalities: Testosterone plays a significant role in male sexual health. Low levels of this hormone are sometimes associated with PE, but more studies are needed to define the relationship further.

PE is sometimes confused with erectile dysfunction (ED). In men with ED, the penis cannot get firm or stay firm enough for sex; it can sometimes be due to an underlying medical condition. Men with ED may rush sex to achieve climax before they lose their erection and ejaculate before they or their partner would like. Others may get PE because of the performance anxiety they have due to their ED (Serefoglu, 2014). Both PE and ED can exist together, further decreasing sexual satisfaction and affecting your sex life. Be sure to tell your provider if you have any issues getting and maintaining an erection. In some men, treating the ED can improve their PE.

Lastly, some men think that aging causes PE; this is not the case. Aging causes changes in erections and ejaculation, but is not a direct cause of PE (AUA, n.d.). Your erections may not be as firm and you may not last as long before ejaculation, but these are natural changes that occur as you age.

How to treat PE

After discussing your sexual difficulties with your provider, you can decide on a treatment plan that is right for you (and your partner). The AUA estimates that 95% of men will recover from PE with treatment (AUA, n.d.). Several therapies for PE exist and they are often combined; these include psychological, behavioral, and medical treatments.

Psychological therapy for men and couples, such as sex counseling, can address performance anxiety and improve sexual self-confidence as well as allow you to discuss personal and relationship issues that may be linked to your premature ejaculation. Relationship problems in men with PE are frequent, so you should be honest and consider having your partner involved in the treatment plan (McMahon, 2012). The main side effects of psychological therapy are cost and time investment. This treatment seems to be most beneficial when combined with medical therapies (Porst, 2019).

Behavioral therapy includes the stop-start method, the squeeze technique, pelvic floor exercises, and masturbation before sex.

  • Stop-start: You and your partner engage in your usual sexual activities until you feel almost ready to ejaculate. Stop sex until the urge to ejaculate has passed, then resume. This process can be repeated.
  • Squeeze technique: You and your partner have sex as usual until you feel almost ready to ejaculate. At this point, your partner squeezes your penis where the head meets the shaft until the urge to ejaculate decreases; repeat as necessary. 
  • Pelvic floor exercises (Kegel exercises):  These maneuvers can strengthen muscles that help in ejaculation. The pelvic floor muscles are the ones you use to prevent yourself from passing gas or stopping urination mid-stream. 
  • Masturbation before sex: Some men feel that masturbating before sex makes the penis less sensitive and allows for better ejaculation control.

Some common medications used to treat PE include:

  • Antidepressants: Specifically, selective serotonin reuptake inhibitors (SSRIs) and tricyclic antidepressants (TCAs) can delay ejaculation in some men (Porst, 2019). SSRIs include drugs like paroxetine, sertraline, and dapoxetine, and TCAs include clomipramine.
  • ED medications: Phosphodiesterase-5 inhibitors (PDE5i), like sildenafil, tadalafil, and vardenafil, are most useful for men with both ED and PE; their effectiveness is uncertain with regards to treating PE alone (Porst, 2019). 
  • Over-the-counter numbing sprays, creams, and wipes: These all use numbing medicines like lidocaine, benzocaine, or prilocaine to decrease penis sensation.

You can learn more about PE treatment by clicking here.

In conclusion

Premature ejaculation affects many men and the causes are not well defined. If you think you might have PE, talk to your healthcare provider (and your partner) about your symptoms and treatment options.