Premature ejaculation

Premature ejaculation (PE), also known as rapid ejaculation, rapid climax, premature climax or early ejaculation , is a condition affecting 25%-40% of men in the U.S. It is characterized by a lack of voluntary control over ejaculation. Masters and Johnson stated that a man suffers from premature ejaculation if he ejaculates before his sex partner achieves orgasm in more than fifty percent of their sexual encounters. Other sex researchers have defined premature ejaculation as occurring if the man ejaculates within two minutes of penetration; however, a survey by Alfred Kinsey in the 1950s demonstrated that three quarters of men ejaculate within two minutes of penetration in over half of their sexual encounters. Self reported surveys report up to 75% of men ejaculate within 10 minutes of penetration . Today, most sex therapists understand premature ejaculation as occurring when a lack of ejaculatory control interferes with sexual or emotional well-being in one or both partners.

The term "premature ejaculation" is not well defined in medical circles and is sometimes considered to be more of a marketing tool than a medical condition. By widely advertising PE/ED as a problem, an industry has been created to solve what in the past might not have been a great concern. The psychological effects of PE and ED have also been considered similar to the effects on young women of the thin model paradigm.

Most men experience premature ejaculation at least once in their lives. Often adolescents and young men experience premature ejaculation during their first sexual encounters, but eventually learn ejaculatory control.Because there is great variability in both how long it takes men to ejaculate and how long both partners want sex to last, researchers have begun to form a quantitative definition of premature ejaculation. Current evidence supports an average intravaginal ejaculation latency time of six and a half minutes in 18-30 year olds. If the disorder is defined as an IELT percentile below 2.5, then premature ejaculation could be suggested by an IELT of less than about one and a half minutes. Nevertheless, it is well accepted that men with IELTs below 1.5 minutes could be "happy" with their performance and do not report a lack of control and therefore do not suffer from PE. On the other hand, a man with 2 minutes IELT may have the perception of poor control over his ejaculation, distressed about his condition, has interpersonal difficulties and therefore be diagnosed with PE.

Possible psychological and environmental factors

Psychological factors commonly contribute to premature ejaculation. While men sometimes underestimate the relationship between sexual performance and emotional well-being, premature ejaculation can be caused by temporary depression, stress over financial matters, unrealistic expectations about performance, a history of sexual repression, or an overall lack of confidence. Interpersonal dynamics strongly contribute to sexual function, and premature ejaculation can be caused by a lack of communication between partners, hurt feelings, or unresolved conflicts that interfere with the ability to achieve emotional intimacy. Neurological premature ejaculation can also lead to other forms of sexual dysfunction, or intensify the existing problem, by creating performance anxiety. In a less pathological context, premature ejaculation could also be simply caused by extreme arousal.

According to the theories developed by Wilhelm Reich, premature ejaculation may be a consequence of a stasis of sexual energy in the pelvic musculature which prevents the diffusion of such energy to other parts of the body.

One study of young married couples (Tullberg, 1999) reported that the husband's IELT seems to be affected by the phases of the wife's menstrual cycle, the IELT tending to be shortest during the fertile phase. Other studies suggest that young men with older female partners reach the ejaculatory threshold sooner, on average, than those whose partners are their own age or younger.

Possible physical factors

Science of mechanism of ejaculation

The physical process of ejaculation requires two sequential actions: emission and expulsion

The emission phase is the first phase. It involves deposition of seminal fluid from the ampullary vas deferens, seminal vesicles and prostate gland into posterior urethra. The second phase is the expulsion phase. It involves closure of bladder neck, followed by the rhythmic contractions of the urethra by pelvic-perineal and bulbospongiosus muscle, and intermittent relaxation of external urethral sphincters.

It is believed that the neurotransmitter serotonin (5HT) plays a central role in modulating ejaculation. Several animal studies have demonstrated its inhibitory effect on ejaculation. Therefore, it is perceived that low level of serotonin in the synaptic cleft in these specific areas in the brain could cause premature ejaculation. This theory is further supported by the proven effectiveness of selective serotonin reuptake inhibitors (SSRIs), which increase serotonin level in the synapse, in treating PE.

Sympathetic motor neurons control the emission phase of ejaculation reflex and expulsion phase is executed by somatic and autonomic motor neurons. These motor neurons are located in the thoracolumbar and lumbosacral spinal cord and are activated in a coordinated manner when sufficient sensory input to reach the ejaculatory threshold has entered the central nervous system.

Several areas in the brain, and especially the nucleus paragigantocellularis, have been identified to be involved in ejaculatory control. Scientists have long suspected a genetic link to certain forms of premature ejaculation. In one study, ninety-one percent of men who suffered from lifelong premature ejaculation also had a first-relative with lifelong premature ejaculation. Other researchers have noted that men who suffer from premature ejaculation have a faster neurological response in the pelvic muscles. Simple exercises commonly suggested by sex therapists can significantly improve ejaculatory control for men with premature ejaculation caused by neurological factors. Often, these men may benefit from anti-anxiety medication or SSRIs, such as sertraline or paroxetine, as these slow down ejaculation times. Some men prefer using anaesthetic creams, however, these creams may also deaden sensations in the man's partner, and are not generally recommended by sex therapists.

Diagnosis

Diagnostic criteria for Premature Ejaculation DSM-IV-TR (American Psychiatric Association)

A. Persistent or recurrent ejaculation with minimal sexual stimulation before, on, or shortly after penetration and before the person wishes it. The clinician must take into account factors that affect duration of the excitement phase, such as age, novelty of the sexual partner or situation, and recent frequency of sexual activity.

B. The disturbance causes marked distress or interpersonal difficulty.

C. The premature ejaculation is not due exclusively to the direct effects of a substance (e.g., withdrawal from opioids).

Differential diagnosis

Premature ejaculation should be distinguished from erectile dysfunction related to the development of a general medical condition. Some individuals with erectile dysfunction may omit their usual strategies for delaying orgasm. Others require prolonged noncoital stimulation to develop a degree of erection sufficient for intromission. In such individuals, sexual arousal may be so high that ejaculation occurs immediately. Occasional problems with premature ejaculation that are not persistent or recurrent or are not accompanied by marked distress or interpersonal difficulty do not qualify for the diagnosis of premature ejaculation. The clinician should also take into account the individual's age, overall sexual experience, recent sexual activity, and the novelty of the partner. When problems with premature ejaculation are due exclusively to substance use (e.g., opioid withdrawal), a substance-induced sexual dysfunction can be diagnosed.

Ejaculation disorder types

• Premature ejaculation - Ejaculation occurs very early
• Delayed ejaculation - Ejaculation takes a long time
• Retrograde ejaculation - Semen flows from the prostate gland into the bladder rather than exiting out of the penis.
• Inhibited orgasm in males

Treatment

In mundane cases, treatments are focused on gradually training and improving mental habituation to sex and physical development of stimulation control. In clinical cases, various medications are being tested to help slow down the speed of the arousal response.

Masters and Johnson recommended a start and stop technique to increase the time till ejaculation. This requires a great deal of couple cooperation and communication and may be difficult for some.

Another method is that of control not prevention. Performing routines such as Kegel exercises which as above mention relate to gaining the voluntary control of the PC Muscle and thus give a person more control over this muscle. When ejaculating the control of this muscle is said to be lost and thus learning to keep control of it can be of aid to some.

Medications

Serotonergic medications, such as SSRIs can delay ejaculation. SSRIs are commonly used as anti-depressants. Examples include Prozac, Zoloft, Celexa, Effexor, and Lexapro. Clinical trials indicate that Paroxetine gives the largest increase in intravaginal ejaculation latency time.Clomipramine often helps with serious cases which are related to the central nervous system (as opposed to psychological factors). The drug has the added benefit of also improving erection quality in some patients.

William Francis Ganong, cited dietary 5-HTP as an alternative source to raising serotonin levels. Many supplements are available that contain 5-HTP.

Medical grade topical anesthetics are a common ingredient in many over-the-counter products such as condoms and non-aerosol sprays.

Magnesium deficiency, very common in the Western world and especially in the United States, has been associated with premature ejaculation. See: Seminal plasma magnesium and premature ejaculation: a case-control study.

Nikoobakht MR, Aloosh M, Hasani M.

Urol J. 2005 Spring;2(2):102-5.

PMID: 17629880 [PubMed - in process]

2:

Seminal plasma magnesium and premature ejaculation: a case-control study.

Aloosh M, Hassani M, Nikoobakht M.

BJU Int. 2006 Aug;98(2):402-4.

PMID: 16879686 [PubMed - indexed for MEDLINE]

3:

Proposals or findings for a new approach about how to define and diagnose premature ejaculation.

Wang W, Kumar P, Minhas S, Ralph D.

Eur Urol. 2005 Sep;48(3):418-23. Review.

PMID: 15967566 [PubMed - indexed for MEDLINE]

4:

Magnesium in human semen: possible role in premature ejaculation.

Omu AE, Al-Bader AA, Dashti H, Oriowo MA.

Arch Androl. 2001 Jan-Feb;46(1):59-66.

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