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Premature ejaculation (PE) is one of the most common male sexual dysfunctions; it can keep you and your partner from having a satisfying sex life. According to the American Urologic Society (AUA), one in three men aged 18 to 59 have problems with PE (AUA, n.d.). Premature ejaculation is when ejaculation happens before you, or your partner would like. Occasional PE is usually not a problem, but if it is happening regularly or causing stress to you and/or your partner, then it is time to speak to your healthcare provider about your symptoms.
- One in three men aged 18 to 59 have problems with premature ejaculation.
- Treatment is usually a combination of psychological, behavioral, and medical therapies.
- There is no FDA-approved medical treatment for PE, but many drugs are used “off-label” effectively.
- Psychological and/or behavioral therapies can be used to treat PE, often in combination with medical therapy.
- Selective serotonin reuptake inhibitors (SSRIs), tricyclic antidepressants (TCAs), and phosphodiesterase-5 inhibitors (PDE5i) are often used to treat PE.
- Zinc and magnesium may play a role in male sexual health.
Experts divide PE into two groups: lifelong and acquired. Lifelong PE happens to you with nearly all of your sexual encounters, ever since you became sexually active. Acquired PE can occur suddenly or gradually to a man after previously normal ejaculation control.
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
To successfully treat your PE, you need to have an honest discussion with your healthcare provider about your sexual problems. You may feel uncomfortable having these conversations, but they are vital to starting you on the right treatment and improving your sexual health. According to the AUA, 95% of men will recover from PE with treatment (AUA, n.d.). In treating PE, your healthcare provider may combine treatment options; these include psychological, behavioral, and medical therapies. Studies that look at the effectiveness of the various treatments typically measure the intravaginal ejaculation latency time (IELT) of the therapy; a higher time corresponds to a successful delay in ejaculation.
Psychological therapy for PE
Psychological therapy, or sex counseling, for men and couples can help improve sexual self-confidence and performance anxiety. It gives you a chance to work on personal and/or relationship issues that may result from or contribute to premature ejaculation. Relationship dysfunction is the second most common reported negative effect of PE, so having your partner involved in the treatment plan can be beneficial (McMahon, 2012). There are no real side effects other than the cost and time investment, and psychological therapy seems to have the most impact when combined with medical treatments (Porst, 2019). Psychological therapy is not a “quick fix,” and it can take weeks to see results.
Behavioral therapy for PE
Behavioral therapy comes in many forms; just as with psychological therapy, behavioral therapy can be combined with medical treatment to enhance its effectiveness. The three most commonly discussed are the stop-start method, the squeeze technique, and pelvic floor exercises. The ultimate goal of the first two methods is to make you more aware of mid-range levels of excitement and the sensations leading up to climax so that you can better control and delay ejaculation on your own. The goal of pelvic floor exercises is to strengthen the muscles activated during ejaculation.
- 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. Repeat this process three times, and then on the fourth, allow yourself to ejaculate. The AUA recommends that this method be repeated three times a week until you have regained control (AUA, n.d.).
- 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. A few studies have shown that pelvic floor muscles have increased activity during ejaculation, and strengthening these muscles can potentially delay ejaculation. They also function to support the bowel and bladder (Pastore, 2014).
How do you find your pelvic floor muscles? The next time you are urinating, stop mid-stream; those muscles you are contracting to keep your urine in are the pelvic floor muscles. They are the same muscles you would use to keep yourself from passing gas. Once you have identified the muscles, you can work on strengthening them by tightening the muscles, holding for three to five seconds, and then relaxing for three to five seconds. Repeat this ten times three times a day (morning, afternoon, evening); you can perform these steps while sitting, standing, or lying down. Take care to avoid using your abdomen, buttock, or thigh muscles during the exercises. It may take weeks to months to see results.
Decreasing penis sensitivity to treat PE
Decreasing penis sensitivity can help some men regain control of ejaculation, and you can accomplish this via several different methods.
- Masturbation before sex: Some men find that masturbating before intercourse partially desensitizes the penis and allows for better control of ejaculation.
- Topical anesthetic creams: Applying a topical anesthetic (numbing medication) to the penis has been used since the 1940s (5). The numbing medications used are most often lidocaine, benzocaine, or prilocaine, and these are used “off-label” (see below for a discussion of “off-label” drugs). You apply the cream to the head of the penis approximately 10–20 minutes before sex. However, if you use too much or leave it on for too long, you can get numbness of your penis, and you may lose your erection (5). Be sure to wipe it off before penetration to prevent the transfer to your partner.
- Topical anesthetic sprays: You can also apply topical anesthetics using a spray rather than a cream. One anesthetic spray, Lidocaine/Prilocaine (brand name Fortacin), has been approved by the European Union for the treatment of PE. It uses a unique formulation that prevents the numbing medicine from being absorbed into the skin of the shaft of the penis. Only the penis head (glans penis) is affected, thereby preventing numbness and loss of erection (5). Neither this nor the other topical anesthetic sprays are FDA-approved for the treatment of PE in the United States.
- Anesthetic wipes: Wipes are a discrete way of applying a topical anesthetic. Apply the wipe to the head of your penis and wait for 5–10 minutes. Wipe the area with a damp tissue immediately before sex.
Medical therapy for PE
Unfortunately, no FDA-approved medications exist for premature ejaculation at this time. There are, however, some medications that are used “off-label”; this means that providers are using the drug to treat a condition that it is not FDA-approved to treat. Several medications can work to treat PE when used off-label.
- Serotonin reuptake inhibitors (SSRIs): Studies are ongoing to figure out the exact cause of PE, but one factor that may be involved is serotonin. Serotonin is a substance produced by nerves in the brain; increased serotonin lengthens the time to ejaculation while low levels shorten it, leading to PE. SSRIs can improve the serotonin imbalance and have been shown to help PE, even though they were initially FDA-approved for the treatment of depression. Paroxetine, sertraline, fluoxetine, and citalopram are all long-acting SSRIs that can be taken daily to treat premature ejaculation; studies have shown a two to eight-fold increase in IELT while using these medications (Porst, 2019). Reported side effects include fatigue, nausea, diarrhea, sweating, erectile dysfunction (ED), and delayed/absent ejaculation. They may also negatively affect fertility, so you need to have a thorough discussion of risks and benefits with your provider before starting these medications (Porst, 2019).
- Tricyclic antidepressants (TCAs), such as clomipramine, were initially FDA-approved to treat depression and show a significant delay in ejaculation when used either daily or on-demand (two to six hours before sex). Side effects include fatigue, dizziness, dry mouth, nausea, and erectile dysfunction (Porst, 2019).
- Phosphodiesterase-5 inhibitors (PDE5i), like sildenafil, tadalafil, and vardenafil, are usually used to treat erectile dysfunction. They are effective for men with both erectile dysfunction and PE, but their usefulness is debated with regards to treating PE alone (Porst, 2019).
- Tramadol is a pain medication that also affects serotonin and can delay ejaculation (5). It also has the potential for addiction and abuse (Porst, 2019).
In addition to the medications above, several drugs are being looked at as potential treatments for PE, including:
- Dapoxetine, a short-acting SSRI, can be taken one hour before sexual activity and was able to delay ejaculation in clinical trials. However, these same trials also showed that within six months of starting dapoxetine, nearly all of the men who used it had stopped taking it, citing cost, the need to use it before each sexual encounter, and side effects of nausea, dizziness, headache, and diarrhea (Porst, 2019). This drug is currently in clinical trials in the U.S. but has been approved for PE treatment in other countries.
- Alpha-1 adrenoceptor antagonists, like terazosin, doxazosin, alfuzosin, tamsulosin, and silodosin, were initially FDA-approved for the treatment of high blood pressure and prostate enlargement. Small studies show that they may help with premature ejaculation if taken one hour before sex, but more research is necessary (Porst, 2019).
- Modafinil is a drug used to help people with narcolepsy (a sleeping disorder) stay awake; one clinical trial showed a small improvement ejaculation delay, but more data is needed (Tuken, 2016).
Natural remedies for PE
Both zinc and magnesium may play a role in male sexual health. Zinc may affect testosterone levels in men, and men with premature ejaculation have been shown to have less magnesium in their semen (Prasad, 1996 and Nikoobakht, 2005). While their roles in PE are not well understood, increasing your intake of both minerals may improve your PE. The best way to increase your zinc and magnesium intake is through diet, although supplementation is an option, with guidance from your healthcare provider. You can increase your zinc and magnesium by any of the following methods:
- Eating foods rich in zinc, including shellfish, lean beef, seeds, fortified cereals, dark chocolate, beans, and nuts
- Eating foods rich in magnesium, including leafy vegetables, nuts, beans, and whole-grain cereal
- Taking zinc supplements (recommended daily dose for zinc is 11 mg per day)
- Taking magnesium supplements (recommended daily dose for magnesium supplements is 350 mg/day for healthy adults)
Too much magnesium can be dangerous, so be sure to talk to your healthcare provider about your diet and mineral needs.
One study reported that a proprietary blend of zinc, folic acid, biotin, and Rhodiola rosea (golden root) improved premature ejaculation and quality of sex life among men who used it (Cai, 2016).
Premature ejaculation is very common, but it is treatable. Talk to your healthcare provider about problems with your sexual health so that you can get started on the right treatment. Consider engaging with your partner as well so that you can take a team approach to find the therapy that will work best for you.