AUA Summit - Premature Ejaculation: Causes & Treatment

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What is Premature Ejaculation?

Ejaculation is the expulsion of semen from the body. Premature ejaculation (PE) is when ejaculation happens sooner than a man or his partner would like during sex. PE is also known as rapid ejaculation, premature climax or early ejaculation. PE might not be a cause for worry. It can be frustrating if it makes sex less enjoyable and impacts relationships. If it happens often and causes problems, your health care provider can help.

In the U.S., about 1 in 3 men 18 to 59 years old have problems with PE. The problem is often thought to be psychological, but biology may also play a role.

How Does Ejaculation Work?

Ejaculation is controlled by the central nervous system. When men are sexually stimulated, signals are sent to your spinal cord and brain. When men reach a certain level of excitement, signals are then sent from your brain to your reproductive organs. This causes semen to be ejected through the penis (ejaculation).

Ejaculation has 2 phases: emission and expulsion.

Phase 1: Emission

Emission is when sperm moves from the testicles to the prostate and mixes with seminal fluid to make semen. The vasa deferentia are tubes that help move the sperm from the testicles through the prostate to the base of the penis. (When you are talking about just 1 of these tubes, it is called a vas deferens).

Phase 2: Expulsion

Expulsion is when the muscles at the base of the penis contract. This forces semen out of the penis. Mostly, ejaculation and orgasm (climax) happen at the same time. Some men climax without ejaculating. In most cases, erections go away after this step.

Premature Ejaculation and Erectile Dysfunction (ED)

Sometimes PE is a problem for men who have erection problems (erectile dysfunction or ED). This is when men are not able to get or keep an erection that's firm enough for sex. Since an erection goes away after ejaculation, it can be tough to know if the problem is PE or ED. ED should be treated first. Premature ejaculation may not be a problem once the ED is treated.

Causes

Serotonin

Though the exact cause of PE is not known, serotonin may play a role. Serotonin is a natural substance in your body made by nerves. High amounts of serotonin in the brain increase the time to ejaculation. Low amounts can shorten the time to ejaculation, and lead to PE.

Psychological Issues

Psychological, or mental health, issues can be involved in PE and may include:

  • depression
  • stress
  • guilt
  • unrealistic expectations about sexual performance
  • history of sexual repression
  • lack of confidence
  • relationship problems

Taking care of emotional problems often helps.

Other Issues

PE and Age

PE can happen at any age. Aging is not a direct cause of PE, though aging does cause changes in erections and ejaculation. For older men, erections may not be as firm or as large. Erections may not last as long before ejaculation occurs. The feeling that ejaculation is about to happen may be shorter. These changes can lead to an older man ejaculating earlier.

PE and Your Partner

With PE, you may feel you lose some of the closeness shared with a sexual partner. You might feel angry, ashamed or upset, and turn away from your partner. Premature ejaculation may not only affect you, it may also affects your partner. PE can cause partners to feel less connected or feel hurt.

Talking about the problem is an important step. Couples counseling or sex therapy can be helpful. Exercises, such as the squeeze technique, may be helpful for you and your partner to prolong an erection (see the treatment section of this article for details). Most importantly, a couple should learn ways to relax. Worry (such as performance anxiety) can make PE worse.

Diagnosis

It is typical for men to be able to have at least some control of if and when they ejaculate during partnered sex and masturbation. If a man does not feel that he has control of when ejaculation occurs, and if there is worry by the man or his sexual partner(s), PE may be present.

When PE gets in the way of your sexual pleasure, you should see your health care provider. The diagnosis is determined by whether ejaculation occurs early, late, or not at all. Most often, your health care provider will diagnose PE after a physical exam and talking with you. Some questions he or she may ask are:

  • How often does PE happen?
  • How long have you had this problem?
  • Does this happen with just one partner, or all partners?
  • Does PE happen with each attempt at sex?
  • What type of sexual activity (i.e., foreplay, masturbation, intercourse, use of visual cues, etc.) do you take part in and how often?
  • How has PE changed your sexual activity?
  • How are your personal relationships?
  • Is there anything that makes PE worse or better (i.e., drugs, alcohol, etc.)?

Lab testing is only needed if your health care provider finds something during your physical exam.

Treatment

Psychological therapy, behavioral therapy and drugs are the main treatments for PE. You can talk with your health care provider to decide the best choice for you. More than one type of treatment may be used at the same time.

Psychological Therapy

Psychological therapy is a way to work through the feelings and emotions that may lead to problems with sexual relationships. The goal of this type of therapy is to learn the source of problems and find solutions that may help PE. It can also help couples learn to grow closer. Psychological therapy can help you become less nervous about sexual performance. It can also give you greater sexual confidence and understanding to help your partner's satisfaction. This type of therapy can be used as the only treatment, or it may be used along with medical or behavioral therapy.

Behavioral Therapy

Behavioral therapy uses exercises to help build tolerance to delay ejaculation. The goal is to help you train your body away from PE. Some choices are the squeeze method and the stop-start method. Exercises work well, but they may not be a lasting answer.

    • The Squeeze Method
      With this method, you or your partner stimulates your penis until you are close to ejaculation. When you are close, you or your partner firmly squeezes your penis so your erection partly goes away. The goal is for you to become aware of the sensations leading to climax. The squeeze method may help you better control and delay climax on your own.
    • The Stop-Start Method
      In this method, you or your partner stimulates your penis until just before ejaculation. When you are about to climax, you or your partner stops until the urge to climax lets up. As you regain control, you and your partner start stimulating your penis again. This process is repeated 3 times. You ejaculate on the fourth time. You repeat this method 3 times a week until you have gained more control.

Medical Therapy

No drugs have been approved in the U.S. to treat PE. Still, there are a number of drugs, numbing creams and numbing sprays that may slow ejaculation in men with PE.

Drugs

Doctors noticed that men and women on antidepressants have delayed orgasms. Drugs such as fluoxetine, paroxetine, sertraline, clomipramine and tramadol affect serotonin levels. Some doctors use these drugs "off-label" (for a different reason than the drug's original use) to treat PE. If one drug does not work, your doctor may suggest you try a different drug.

For others, α1-Adrenoceptor antagonists are another option for drug therapy. These drugs may induce ejaculatory dysfunction such as retrograde ejaculation and/or failure of emission.

Drugs for PE can be taken each day or only before sex. Your health care provider will suggest when you should take a drug based on your activity level. The best time to take the drug is not clear. Most doctors suggest from 2 to 6 hours before sex. PE can return if you stop taking these drugs. Most men with PE need to take these drugs on an ongoing basis.

Numbing Creams or Sprays

Numbing creams and sprays may be put on the head of the penis about 20 to 30 minutes before sex. If you leave the numbing cream/spray on your penis for longer than suggested, your erection may go away. Also, the numbing cream/spray should not be left on the exposed penis during vaginal sex because it may cause vaginal numbness. Wash the cream off your penis 5 to 10 minutes before sex. Wearing a condom can also help dull sensation.

After Treatment

With the techniques listed here, about 95 out of 100 men will recover from PE. There is no way to promise recovery, but learning how to relax may help. If the problem stays, keep working with your health care provider to find solutions.

Updated July 16, 2020


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