Premature Ejaculation

Premature ejaculation refers to the expulsion of semen (and reaching orgasm) with minimum penile stimulation during sexual intercourse before both sexual partners would otherwise wish. It can also be called rapid ejaculation, early ejaculation, immediate or early climax. It is the most common sexual problem of men less than 40 years of age, affecting around 30-70% of males in the United States at least once in their life. Several factors may be responsible for the dysfunction, but fortunately, the disorder can be treated successfully with combinations of medical, psychological therapies, and learning techniques. 

Premature ejaculation was once thought to be a psychological disorder, however, with the recent studies, multiple organic causes have been explored especially involving the nerves related to the process of ejaculation. The causes can be listed as:

Psychological

• Performance anxiety
• Depression
• History of sexual abuse
• Feelings of guilt related to a sexual experience in the past
• Stress
• Relationship problems
• Sexual attitude and response of the partner

Other causes

• Erectile dysfunction
• Hormonal imbalances: Testosterone, LH, FSH
• Chemical imbalances: Some neurotransmitters like dopamine, serotonin are involved in sexual excitation.
• Physical disorders affecting the sexual organs like the penis, seminal vesicles, prostate, testicles, etc
• Adverse effects of the medicines used for other diseases

Premature ejaculation can be classified into two types;

• Lifelong: In this type, a person has had this problem since the beginning of his sex life, even during masturbation.
• Acquired: In this type, a person has developed the problem later in life, and before it, he used to have a normal ejaculation. 

Some of the factors may increase your chances of having this disorder.

• Physical and mental stress in your life
• If you are suffering from any physical complaints like urethritis, prostatitis
• If you have had a problem with erection
• If you are using any psychotropic drug
• If you have started sexual relationships earlier in life
• If you are having a bad marital relationship with your current partner
• If you have a history of a traumatic event in childhood that may or may not is related to sex.

Premature ejaculation is known to be a very common problem throughout the world. It affects around 30-70% of males in the United States, with an estimated prevalence of 30%  that has remained static throughout all the age groups. It can affect any age group. No racial predilection has been noticed; however, some studies suggest higher prevalence in African American men than white Americans. 

Signs and symptoms of premature ejaculation are related to ejaculation mostly. If you face this problem occasionally, then it is not of great concern. However, suppose you experience premature ejaculation in almost all of the sexual intercourses or more than 50% of them. In that case, you might need to talk about it with your physician as it may lead to frustration and poor sex life for you and your partner.

There is no particular time limit cut-off to define premature ejaculation. It may be less than one minute for some people while it can be even more but still unsatisfactory for others. The normal ejaculatory latency time is 4-8 minutes.

Premature ejaculation may cause negative personal consequences, like distress, agitation, frustration, anger, poor performance at work, and/or the avoidance of sexual activity.

The DSM-5 (The Diagnostic and Statistical Manual of Mental Disorders) criteria for defining premature ejaculation are as follows:

• Experiencing premature ejaculation that is less than 1 minute or before the individual wishes for it in 75-100% of partnered sexual activity.
• Persistence of the above symptom for at least 6 months
• Suffering from a considerable amount of distress due to the above symptom.

Although discussing this issue can be subject to feelings of embarrassment for some people, it would be advisable to consult with your physician to improve the quality of your life. Your physician might take a detailed history asking a few questions like:

• Duration of your symptoms
• The circumstances which result in them
• The frequency of your symptoms
• If it happens with all the sexual attempts?
• If it happens with all the partners
• If you face a problem in maintaining an erection
• If it occurs during masturbation also?
• If you are using any drugs?
• If you are having any other symptoms or diseases related to sex organs

Then your physician will perform a physical examination with special emphasis on the genitals. No lab tests have been specified for the diagnosis of premature ejaculation. Your physician may advise some other tests to rule out other physical ailments affecting the function of ejaculation. If it accompanies impotence, free and total testosterone hormone levels may need to be investigated. Similarly, if it is accompanied by depression, other tests to determine the cause of depression, like thyroid hormones, would be carried out. 

Some other disorders should also be considered while making a diagnosis of premature ejaculation;

• Orgasm problems in the female partner
• The adverse effect from a psychotropic drug
• Presence of pre-ejaculate
• Erectile dysfunction

Premature ejaculation can be treated will excellent results by combining medical, behavioral, and psychological therapies. It is vital to treat the underlying medical conditions. Co-existing conditions related to genitalia like erectile dysfunction (impotence), infections (orchitis, prostatitis) should be treated. It is advisable to include the female partner in the treatment, as well issues related to the female partner should be addressed, like a delayed orgasm in the female partner.

Nonpharmacologic

Therapeutic strategies may include the following:

1. Behavioral techniques:

• Some tricks can be used to improve ejaculation time, like masturbating an hour or two before the actual sexual activity.
• Trying another erection shortly after an episode of premature ejaculation has shown improved control the second time.

2. Pelvic floor exercises: Performing pelvic floor exercises (kegel) can strengthen your muscles and improve control at ejaculation.

3. Sex therapy: Two sex techniques were proposed by Masters and Johnson; stop-start and squeeze-pause technique. In the stop-start method, the patient is asked to stop the activity the moment he starts feeling orgasm and restart after the feeling goes away. In the squeeze-pause technique, the partner is advised to squeeze the end of the penis on the feeling of ejaculation and keep pressing until the feeling goes away. By practice, the control will improve for ejaculation with both techniques.

4. Counseling: It would be beneficial to have counseling sessions for any underlying performance anxiety or depression, for relationship problems, for past traumatic events, etc.

5. Condoms: Using thick condoms or condoms with numbing agents can improve premature ejaculation. 

Pharmacologic therapy

May include:

1. Topical desensitizing agents: Some numbing medicines, for example, lidocaine and prilocaine, can be used for the male to apply 10-15 minutes before the sexual activity on the penis to improve the time for ejaculation. However, they can reduce sensitivity and pleasure.

2. Oral medications:

• Selective serotonin reuptake inhibitor (SSRI): Some antidepressant medications can be used like SSRIs: sertraline, fluoxetine, paroxetine, or dapoxetine. If these don’t work, a tricyclic antidepressant can be used.
• Phosphodiesterase type 5 (PDE5) inhibitor: Some medications used to treat erectile dysfunction can improve premature ejaculation, for example, sildenafil, tadalafil, etc.
• Tramadol: It’s a potent painkiller with a side effect of delayed ejaculation that can help with premature ejaculation. But its other side effects include nausea, dizziness, addiction, etc.
• No surgical procedures are recommended to treat this issue.

Premature ejaculation is quite a distressing problem. Fortunately, it can be treated with a combination of therapies. In some people, the problem can relapse. But the behavioral techniques can improve the results.

Premature ejaculation can be improved using the behavioral techniques discussed above. Remain stress-free using relaxation techniques. Ensure proper intake of healthy food and perform regular exercise to improve overall health and strength. Keep your relationship with your partner strong and consult a marriage counselor if needed. It would help if you thought about reaching out for help for other mental disorders like stress, performance anxiety, depression, etc.