Premature Ejaculation (PE)
Premature ejaculation (PE), is also known as rapid ejaculation, premature climax, or early ejaculation. In the United States, PE affects about one in five men ages 18 to 59. Although the problem is often assumed to be psychological, biology also may play a role.
How does ejaculation occur?
Ejaculation, controlled by the central nervous system, happens when sexual stimulation and friction provide impulses that are delivered to the spinal cord and into the brain.
Ejaculation has two phases:
Phase I: Emission
The vas deferens (the tubes that store and transport sperm from the testes) contract to squeeze the sperm toward the base of the penis through the prostate gland. The seminal vesicles release secretions that combine with the sperm to make semen. The ejaculation is unstoppable at this stage.
Phase II: Ejaculation
The muscles at the base of the penis contract forcing semen out of the penis (ejaculation and orgasm) while the bladder neck contracts. Orgasm can occur without the delivery of semen (ejaculation) from the penis. Normally, erections are lost following ejaculation.
What is premature ejaculation?
Premature ejaculation (PE) is characterized by a lack of voluntary control over ejaculation. Many men occasionally ejaculate sooner than they or their partner would like during sexual activities. PE is a frustrating problem that can reduce the enjoyment of sex, harm relationships and affect quality of life. Occasional instances of PE might not be cause for concern. However, when the problem occurs frequently and causes distress to the man or his partner, treatment may be of benefit.
What causes premature ejaculation?
Although the exact cause of premature ejaculation (PE) is not known, new studies suggest that serotonin, a natural substance produced by nerves, is important. A breakdown of the actions of serotonin in the brain may be a cause. Studies have found that high amounts of serotonin in the brain slow the time to ejaculation while low amounts of serotonin can produce a condition like PE.
Psychological factors also commonly contribute to PE. Temporary depression, stress, unrealistic expectations about performance, a history of sexual repression, or an overall lack of confidence can cause PE. Interpersonal dynamics may contribute to sexual function. PE can be caused by a lack of communication between partners, hurt feelings, or unresolved conflicts that interfere with the ability to achieve emotional intimacy.
Can premature ejaculation develop later in life?
Premature ejaculation (PE) can occur at any age. Surprisingly, aging appears not to be a cause of PE. However, the aging process typically causes changes in erectile function and ejaculation. Erections may not be as firm or as large. Erections may be maintained for a shorter period before ejaculating. The feeling that an ejaculation is about to happen may be shorter. These factors can result in an older man having an ejaculation earlier than when he was younger.
Can both premature ejaculation and erectile dysfunction affect a man at the same time?
Sometimes premature ejaculation (PE) may be a problem in men who have erectile dysfunction (ED)—the inability to achieve and/or maintain an erection sufficient for satisfactory sexual performance. Some men do not understand that the loss of erection normally occurs after ejaculation and may wrongly complain to their doctor that they have ED when the actual problem is PE. It is recommended that the ED be treated first if you experience both ED and PE, since the PE may resolve on its own once the ED has been adequately treated.
When should a doctor be seen?
When premature ejaculation (PE) happens so frequently that it interferes with your sexual pleasure, it becomes a medical problem requiring the care of a doctor. To understand the problem, the doctor will need to ask questions about your sexual history such as the following:
- How often does the PE occur?
- How long have you had this problem?
- Is the problem specific to one partner? Or does it happen with every partner?
- Does PE occur with all or just some attempts at sexual relations?
- How much stimulation results in PE?
- What type of sexual activity (i.e., foreplay, masturbation, intercourse, use of visual clues, etc.) is engaged in and how often?
- How has PE affected sexual activity?
- What is the quality of your personal relationships?
- How does PE affect your quality of life?
- Are there any factors that make PE worse or better (i.e., drugs, alcohol, etc.)?
Usually, laboratory testing is not necessary unless the history and a physical examination reveal something more complicated.
How to talk to your partner about premature ejaculation?
Premature ejaculation (PE) affects not only you but also your partner and your sexual relationship. In an episode of PE, the intimacy shared with a partner suddenly comes to a quick end. You might feel angry, ashamed, and frustrated, and turn away from your partner. At the same time, your partner may be upset with the rapid emotional change, or the outcome of the sexual encounter.
Communication is not only important to successful diagnosis and treatment, but can also help a partner understand the feelings of the individual. Sometimes couple counseling or sex therapy may be useful. Together a couple might develop techniques (for example, the squeeze technique) that may prolong an erection. Most importantly, the couple should try to relax. Anxiety (especially performance anxiety) only makes this condition worse.
What treatments are available?
There are several treatment choices for premature ejaculation: psychological therapy, behavioral therapy and medications. Be sure to discuss these treatments with your doctor and together decide which of the following options is best for you:
- Psychological therapy addresses feelings a man may have about sexuality and sexual relationships.
- Behavioral therapy makes use of exercises to help a man develop tolerance to stimulation and, as a result, delay ejaculation.
- Medical therapy includes medications that are commonly used to treat depression. In addition, topical anesthetic creams may be used.
Psychological therapy can be used as the only treatment or can be used together with medical therapy or behavioral therapy. The focus of psychological therapy is to help you to identify and solve any difficulties in your relationships that may have added to the cause of premature ejaculation (PE). This therapy can also help couples to talk about problems with intimacy that occurred after PE began. Psychological therapy can also help a man learn to be less anxious about his sexual performance and have greater sexual confidence. Typically, a man will receive specific advice on how to enhance his and his partner's sexual satisfaction.
Behavioral therapy can play a key part in the usual treatment of premature ejaculation. Exercises are effective; however, they may not always provide a lasting solution to the problem. Also, they rely heavily on the cooperation of the partner, which in some cases, may be a problem.
With the squeeze method, an exercise developed by Masters and Johnson, the partner stimulates the man's penis until he is close to ejaculation. At the point when he is about to ejaculate, the partner squeezes the penis hard enough to make him partially lose his erection. The goal of this technique is to teach the man to become aware of the sensations leading up to orgasm, and then begin to control and delay his orgasm on his own.
With the stop-start method, the partner stimulates the man's penis until just before ejaculation. The partner should then stop all stimulation until the urge to ejaculate subsides. As the man regains control, he instructs the partner to begin stimulating his penis again. This procedure is repeated three times before allowing the man to ejaculate on the fourth time. The couple repeats this exercise three times a week, until the man has gained good control.
Although not approved by the U.S. Food and Drug Administration (FDA) for this purpose, drugs used for depression and anesthetic creams have been shown to delay ejaculation in men with premature ejaculation (PE).
Medications are a relatively new form of treatment for PE. Doctors first noticed that men and women who were taking drugs for the treatment of depression (antidepressants) also had delayed orgasms. Doctors then began to use these drugs "off-label" (this implies using a medication for a different illness than what it was originally manufactured for) to treat PE. These medications include antidepressants that affect serotonin such as fluoxetine, paroxetine, sertraline and clomipramine.
If one medication fails to work, a second one is usually recommended. If the second one fails, trying a third medication will not likely be beneficial. An alternative is to combine medication with behavioral therapy and/or creams.
For use in PE, the doses of antidepressants are usually lower than those recommended for the treatment of depression. Common side effects of antidepressants can include nausea, dry mouth, drowsiness and reduced desire for sexual activity.
These drugs can be taken either every day or only taken before sexual activity. Your doctor will decide how you should take the medication based on the frequency of intercourse. The best time for taking the antidepressant medications before sexual activity has not been established, but most doctors will recommend from two to six hours depending on the medication. Because PE can recur when the medication is not taken, you most likely will need to take it on a continuing basis.
Local anesthetic creams can be used to treat PE. These creams are applied to the head of the penis about 20 to 30 minutes before intercourse to lessen the sensitivity. Prior to sexual intercourse, a condom (if used) may be removed and the penis washed clean of any remaining cream. A loss of erection can occur if the anesthetic cream is left on the penis for a longer period of time than recommended. Also, the anesthetic cream should not be left on the exposed penis during vaginal intercourse since it may cause vaginal numbness.
See your urologist for evaluation and treatment for the biological aspects of premature ejaculation. For further information on the psychosocial causes or to find a therapist:
Society for Sex Therapy and Research
409 12th Street, S.W.
P.O. Box 96920
Washington, D.C. 20090-6920
American Association for Marriage and Family Therapy
112 South Alfred Street
Alexandria, VA 22314-3061
American Association of Sex Educators, Counselors, and Therapists
P.O. Box 5488
Richmond, VA 23220-0488
Download a copy of "The Management of Premature Ejaculation: A Patient's Guide".
Reviewed January 2011