AUA Summit - Premature Ejaculation: Causes & Treatment

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What is Premature Ejaculation?

Some people think premature ejaculation (PE) is a disease or a problem that cannot be fixed. Others may think certain men are born with better control than others. These ideas are simply not true.

PE is when a man climaxes and ejaculates (releases semen) sooner than he would like during sex. It is a common sexual issue. In the United States, about 1 in 3 men aged 18 to 59 years old have problems with PE.PE can be primary or acquired, and accrues over time.

Many men feel stressed if they experience PE for any period of time. Men with PE and their partners can feel unhappy or embarrassed about their sexual relations. Treatment is available and these feelings can change.

If PE causes you (or your loved one) to worry or to feel stressed, then you should ask your health care provider for help. Remember that you are not alone, and your provider knows what to do. Together, you can find the underlying cause and find treatment.

How Does Ejaculation Work?

Ejaculation is the sudden, pleasurable release of semen through the penis. It is controlled by your brain (your central nervous system).When you are sexually stimulated, signals are sent up your spinal cord to your brain. When you reach a certain level of excitement, your brain tells your reproductive organs to “go!” This causes semen to be ejected through the penis (ejaculation).

Ejaculation has two phases: emission and expulsion.

  • Phase 1: Emission
    Emission is when sperm moves from the testicles to the prostate. There it mixes with seminal fluid to make semen. The vasa deferentia are the tubes that help move the sperm from the testicles through to the prostate to the base of the penis. (When you are talking about just one 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. Often, ejaculation and orgasm (climax) happen at the same time. Some men climax without ejaculating. In most cases, erections go away after this phase.

What is Premature Ejaculation?

Premature ejaculation (PE) is when ejaculation happens sooner than a man or his partner would like during sex, within a defined period of time, usually less than 2 to 3 minutes.

Occasional PE is also known as rapid ejaculation, premature climax or early ejaculation.PE might not be a cause for worry. But, 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.

Premature Ejaculation and Erectile Dysfunction (ED)

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

Causes

The exact cause of PE is not known, but there are many reasons why a man may have PE. There may be biological, chemical or emotional reasons. Below are some more specific causes.

Serotonin

Serotonin is a natural substance in your body made by nerves. It helps to control the way the brain manages mood, emotion, sleep and sexual desire. 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 with PE and may include:

  • Depression
  • Anxiety
  • Stress
  • Guilt
  • Unrealistic expectations about sex
  • Lack of confidence
  • History of sexual repression (blocked or bottled-up sexual feelings)
  • 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. Yet, ED can be more common with age, which may be linked to lower serum testosterone levels. For some older men, erections may not be as firm or as large. Erections may not last as long as 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 less connection with your sexual partner. You might feel angry, ashamed or upset, and turn away from your sexual partner. Premature ejaculation may not only affect you, it may also affect your partner.PE can cause partners to feel less connected or 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 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 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 that worries the man or his sexual partner(s), PE may be present.

When PE gets in the way of your sexual pleasure, you should see a 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 the PE happen?
  • Has the PE been present lifelong, or started recently?
  • 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 (sexual exercises) and drugs are the main treatments for PE. You and your doctor can work together to decide the best choice for you. Many people try more than one treatment 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 and might now work for all people.

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 three times. You ejaculate on the fourth time. You repeat this method three times a week until you have gained more control.

Medical Therapy

No drugs have been approved in the United States to treat PE. Still, there are a number of drugs, numbing creams and numbing sprays that slow ejaculation in men with PE and are used off label.

  • Drugs
    Doctors noticed that men and women on antidepressants have delayed orgasms. Drugs such as clomipramine, fluoxetine, paroxetine, sertraline 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 two to six 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 five to ten minutes before sex. Wearing a condom can also help dull sensation. Condoms may also prevent the medicine from numbing the vagina and it protects from disease and pregnancy.

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 June 2023.


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