Premature Ejaculation
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Premature ejaculation (PE) is a male
sexual dysfunction Sexual dysfunction is difficulty experienced by an individual or partners during any stage of normal sexual activity, including physical pleasure, desire, preference, arousal, or orgasm. The World Health Organization defines sexual dysfunction ...
that occurs when a male expels semen (and most likely experiences
orgasm Orgasm (from Greek , ; "excitement, swelling"), sexual climax, or simply climax, is the sudden release of accumulated sexual excitement during the sexual response cycle, characterized by intense sexual pleasure resulting in rhythmic, involu ...
) soon after beginning
sexual activity Human sexual activity, human sexual practice or human sexual behaviour is the manner in which humans experience and express their sexuality. People engage in a variety of sexual acts, ranging from activities done alone (e.g., masturbation) t ...
, and with minimal penile stimulation. It has also been called ''early ejaculation'', ''rapid ejaculation'', ''rapid climax'', ''premature climax'' and (historically) ''ejaculatio praecox.'' There is no uniform cut-off defining "premature", but a consensus of experts at the International Society for Sexual Medicine endorsed a definition of around one minute after penetration. The
International Classification of Diseases The International Classification of Diseases (ICD) is a globally used medical classification that is used in epidemiology, health management and clinical diagnosis. The ICD is maintained by the World Health Organization (WHO), which is the dir ...
(ICD-10) applies a cut-off of 15 seconds from the beginning of
sexual intercourse Sexual intercourse (also coitus or copulation) is a sexual activity typically involving the insertion of the Erection, erect male Human penis, penis inside the female vagina and followed by Pelvic thrust, thrusting motions for sexual pleasure ...
. Although men with premature ejaculation describe feeling that they have less control over ejaculating, it is not clear if that is true, and many or most average men also report that they wish they could last longer. In males, typical
intravaginal ejaculation latency time Intravaginal ejaculation latency time (IELT) is the time it takes to ejaculate during vaginal penetration. Average IELT varies between people and tends to decrease with age. Some medications such as selective serotonin reuptake inhibitors (SSR ...
is approximately 4–8 minutes. The opposite condition is delayed ejaculation. Men with PE often report emotional and relationship distress, and some avoid pursuing sexual relationships because of PE-related embarrassment. Compared with males, females consider PE less of a problem, but several studies show that the condition also causes female partners distress.


Cause

The causes of premature ejaculation are unclear. Many theories have been suggested, including that PE was the result of masturbating quickly during adolescence to avoid being caught, performance anxiety,
passive-aggressive behavior Passive-aggressive behavior is characterized by a pattern of passive hostility and an avoidance of direct communication. Inaction where some action is socially customary is a typical passive-aggressive strategy (showing up late for functions, s ...
or having too little sex; but there is little evidence to support any of these theories.Strassberg, D. S., & Perelman, M. A. (2009). Sexual dysfunctions. In P. H. Blaney & T. Millon (Eds.), ''Oxford textbook of psychopathology'' (2nd ed.), (pp. 399–430). NY: Oxford University Press. Several physiological mechanisms have been hypothesized to contribute to causing premature ejaculation, including
serotonin Serotonin (), also known as 5-hydroxytryptamine (5-HT), is a monoamine neurotransmitter with a wide range of functions in both the central nervous system (CNS) and also peripheral tissues. It is involved in mood, cognition, reward, learning, ...
receptors, a genetic predisposition, elevated penile sensitivity and nerve conduction atypicalities.Althof, S. E. (2007). "Treatment of rapid ejaculation: Psychotherapy, pharmacotherapy, and combined therapy", pp. 212–240 in S. R. Leiblum (Ed.), ''Principles and practice of sex therapy'' (4th ed.). NY: Guilford.
Scientist A scientist is a person who Scientific method, researches to advance knowledge in an Branches of science, area of the natural sciences. In classical antiquity, there was no real ancient analog of a modern scientist. Instead, philosophers engag ...
s have long suspected a genetic link to certain forms of premature ejaculation. However, studies have been inconclusive in isolating the gene responsible for lifelong PE. The nucleus paragigantocellularis of the brain has been identified as having involvement in ejaculatory control. PE may be caused by prostatitis or as a medication side effect. PE has been classified into four subtypes - lifelong, acquired, variable and subjective PE. The pathophysiology of lifelong PE is mediated by a complex interplay of central and peripheral serotonergic, dopaminergic, oxytocinergic, endocrinological, genetic and epigenetic factors. Acquired PE may occur due to psychological problems - such as sexual performance anxiety, and psychological or relationship problems - and/or co-morbidity, including
erectile dysfunction Erectile dysfunction (ED), also referred to as impotence, is a form of sexual dysfunction in males characterized by the persistent or recurring inability to achieve or maintain a Human penis, penile erection with sufficient rigidity and durat ...
, prostatitis and hyperthyroidism.


Mechanism

The physical process of ejaculation requires two actions: emission and expulsion. The emission is the first phase. It involves deposition of fluid from the ampullary
vas deferens The vas deferens (: vasa deferentia), ductus deferens (: ductūs deferentes), or sperm duct is part of the male reproductive system of many vertebrates. In mammals, spermatozoa are produced in the seminiferous tubules and flow into the epididyma ...
, seminal vesicles and
prostate gland The prostate is an male accessory gland, accessory gland of the male reproductive system and a muscle-driven mechanical switch between urination and ejaculation. It is found in all male mammals. It differs between species anatomically, chemica ...
into the posterior
urethra The urethra (: urethras or urethrae) is the tube that connects the urinary bladder to the urinary meatus, through which Placentalia, placental mammals Urination, urinate and Ejaculation, ejaculate. The external urethral sphincter is a striated ...
. The second phase is the expulsion phase. It involves closure of bladder neck, followed by the rhythmic contractions of the
urethra The urethra (: urethras or urethrae) is the tube that connects the urinary bladder to the urinary meatus, through which Placentalia, placental mammals Urination, urinate and Ejaculation, ejaculate. The external urethral sphincter is a striated ...
by pelvic-perineal and
bulbospongiosus muscle The bulbospongiosus muscles (in older texts bulbocavernosus and, for female muscle, constrictor cunni) are a subgroup of the superficial muscles of the perineum. They have a slightly different origin, insertion and function in males and females. ...
and intermittent relaxation of the external male urethral sphincter. 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 The spinal cord is a long, thin, tubular structure made up of nervous tissue that extends from the medulla oblongata in the lower brainstem to the lumbar region of the vertebral column (backbone) of vertebrate animals. The center of the spinal c ...
and are activated in a coordinated manner when sufficient sensory input to reach the ejaculatory threshold has entered the
central nervous system The central nervous system (CNS) is the part of the nervous system consisting primarily of the brain, spinal cord and retina. The CNS is so named because the brain integrates the received information and coordinates and influences the activity o ...
.


Intromission time

The 1948 Kinsey Report suggested that three-quarters of men ejaculate within two minutes of penetration in over half of their sexual encounters. Current evidence supports an average
intravaginal ejaculation latency time Intravaginal ejaculation latency time (IELT) is the time it takes to ejaculate during vaginal penetration. Average IELT varies between people and tends to decrease with age. Some medications such as selective serotonin reuptake inhibitors (SSR ...
(IELT) of six and a half minutes in 18- to 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 two minutes. Still, it is possible for some men with abnormally low IELTs to be satisfied with their performance and not report a lack of control. Likewise, those with higher IELTs may consider themselves premature ejaculators, and suffer from quality of life issues normally associated with premature ejaculation, and even benefit from non-pharmaceutical treatment.


Diagnosis

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (
DSM-5 The ''Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition'' (DSM-5), is the 2013 update to the '' Diagnostic and Statistical Manual of Mental Disorders'', the taxonomic and diagnostic tool published by the American Psychiat ...
) defines premature ejaculation as "A persistent or recurrent pattern of ejaculation occurring during partnered sexual activity within approximately 1 minute following vaginal penetration and before the person wishes it," with the additional requirements that the condition occurs for a duration longer than 6 months, causes clinically significant distress, and cannot be better explained by relationship distress, another mental disorder, or the use of medications. These factors are identified by talking with the person, not through any diagnostic test. The DSM-5 allows for specifiers whether the condition is lifelong or acquired, applying in general or only to certain situations, and severity based on the time under one minute, however these subtypes have been criticised as lacking validity due to insufficient evidence. The 2007
ICD-10 ICD-10 is the 10th revision of the International Classification of Diseases (ICD), a medical classification list by the World Health Organization (WHO). It contains codes for diseases, signs and symptoms, abnormal findings, complaints, social cir ...
defined PE as ejaculating without control, and within around 15 seconds.


Treatments

Several treatments have been tested for treating premature ejaculation. A combination of medication and non-medication treatments is often the most effective method.


Self-treatment

Many men attempt to treat themselves for premature ejaculation by trying to distract themselves, such as by trying to focus their attention away from the sexual stimulation. There is little evidence to indicate that it is effective and it tends to detract from the sexual fulfillment of both partners. Other self-treatments include thrusting more slowly, withdrawing the penis altogether, purposefully ejaculating before sexual intercourse, and using more than one condom. Some men report these to have been helpful.


Sex therapy

Several techniques have been developed and applied by sex therapists, including Kegel exercises (to strengthen the muscles of the pelvic floor) and Masters and Johnson's "stop-start technique" (to desensitize the male's responses) and "squeeze technique" (to reduce excessive arousal). To treat premature ejaculation, Masters and Johnson developed the "squeeze technique", based on the Semans technique developed by James Semans in 1956. Men were instructed to pay close attention to their arousal pattern and learn to recognize how they felt shortly before their "point of no return", the moment ejaculation felt imminent and inevitable. Sensing it, they were to signal their partner, who squeezed the head of the penis between thumb and index finger, suppressing the ejaculatory reflex and allowing the male to last longer. The squeeze technique worked, but many couples found it cumbersome. From the 1970s to the 1990s, sex therapists refined the Masters and Johnson approach, largely abandoning the squeeze technique and focused on a simpler and more effective technique called the "stop-start" technique. During intercourse, as the male gets the sensation of approaching climax, both partners stop moving and remain still until the male's feelings of ejaculatory inevitability subside, at which point, they are free to resume active intercourse. The functional-sexological approach to treating premature ejaculation, as developed by François de Carufel & Gilles Trudel, offers a novel method focusing on sexual function improvement without interrupting sexual activity. This treatment, distinct from traditional behavioral techniques like the squeeze and stop-start methods, has demonstrated significant improvements in the duration of intercourse, sexual satisfaction, and overall sexual function. A pivotal study by De Carufel & Trudel (2006) showcases the effectiveness of this approach. Moreover, the Cochrane review on psychosocial interventions for premature ejaculation recognizes the De Carufel study as having a low risk of bias, highlighting its methodological robustness among psychosocial intervention studies. This acknowledgment points to the functional-sexological treatment as a promising avenue for individuals and couples grappling with premature ejaculation, suggesting a shift towards more contemporary and empirically supported treatments in the field. Access to functional-sexological therapy can be limited due to a shortage of qualified professionals. A study published in the ''Journal of Sex & Marital Therapy'' found that many individuals experience difficulties in seeking treatment for sexual concerns, largely due to a lack of awareness about available services and the scarcity of trained sex therapists, making these services appear inaccessible to those in need.


Medications

Dapoxetine, a
selective serotonin reuptake inhibitor Selective serotonin reuptake inhibitors (SSRIs) are a class of drugs that are typically used as antidepressants in the treatment of major depressive disorder, anxiety disorders, and other psychological conditions. SSRIs primarily work by blo ...
(SSRI), has been approved for the treatment of premature ejaculation in several countries. Other SSRIs are used off-label to treat PE, including
fluoxetine Fluoxetine, sold under the brand name Prozac, among others, is an Antidepressant, antidepressant medication of the selective serotonin reuptake inhibitor (SSRI) class used for the treatment of major depressive disorder, Anxiety disorder, anx ...
,
paroxetine Paroxetine ( ), sold under the brand name Paxil among others, is an Antidepressant, antidepressant medication of the selective serotonin reuptake inhibitor (SSRI) class used to treat major depressive disorder, obsessive-compulsive disorder, o ...
,
sertraline Sertraline, sold under the brand name Zoloft among others, is an Antidepressant, antidepressant medication of the selective serotonin reuptake inhibitor (SSRI) class used to treat major depressive disorder, generalized anxiety disorder, socia ...
,
citalopram Citalopram, sold under the brand name Celexa among others, is an antidepressant of the selective serotonin reuptake inhibitor (SSRI) class. It is used to treat major depressive disorder, obsessive compulsive disorder, panic disorder, and soci ...
,
escitalopram Escitalopram ( ), sold under the brand names Lexapro and Cipralex, among others, is an antidepressant medication of the selective serotonin reuptake inhibitor (SSRI) class. It is mainly used to treat major depressive disorder, generalized ...
and clomipramine. The opioid tramadol, an atypical oral
analgesic An analgesic drug, also called simply an analgesic, antalgic, pain reliever, or painkiller, is any member of the group of drugs used for pain management. Analgesics are conceptually distinct from anesthetics, which temporarily reduce, and in s ...
is also used. Results have found
PDE5 inhibitor A phosphodiesterase type 5 inhibitor (PDE5 inhibitor) is a vasodilating medication, drug that works by blocking the degradative action of cGMP-specific phosphodiesterase type 5 (PDE5) on cyclic GMP in the smooth muscle cells lining the blood vess ...
s to be effective in combination treatment with SSRIs. The full effects of these medications typically emerge after 2-3 weeks, with results indicating about ejaculatory delay of up to 4 times greater than before medication if the medication is combined with psychotherapy. Premature ejaculation can return upon discontinuation, and the side effects of these SSRIs can also include anorgasmia,
erectile dysfunction Erectile dysfunction (ED), also referred to as impotence, is a form of sexual dysfunction in males characterized by the persistent or recurring inability to achieve or maintain a Human penis, penile erection with sufficient rigidity and durat ...
, and diminished
libido In psychology, libido (; ) is psychic drive or energy, usually conceived of as sexual in nature, but sometimes conceived of as including other forms of desire. The term ''libido'' was originally developed by Sigmund Freud, the pioneering origin ...
.
Topical anesthetic A topical anesthetic is a local anesthetic that is used to numb the surface of a body part. They can be used to numb any area of the skin as well as the front of the eyeball, the inside of the nose, ear or throat, the anus and the genital area. ...
s such as
lidocaine Lidocaine, also known as lignocaine and sold under the brand name Xylocaine among others, is a local anesthetic of the amino amide type. It is also used to treat ventricular tachycardia and ventricular fibrillation. When used for local anae ...
and
benzocaine Benzocaine, sold under the brand name Orajel amongst others, is a local anesthetic, belonging to the amino ester drug class, commonly used as a topical painkiller or in cough drops. It is the active ingredient in many over-the-counter ...
that are applied to the tip and shaft of the penis have also been used. They are applied 10–15 minutes before sexual activity and have fewer potential side effects as compared to SSRIs. However, this is sometimes disliked due to the reduction of sensation in the penis as well as for the partner (due to the medication rubbing onto the partner). Another research was conducted in 21 men who were randomized (15 treatment, 6 placebo) and had complete follow-up data. Baseline mean ± standard deviation IELT was 74.3 ± 31.8 vs 84.9 ± 29.8 seconds among the treatment and placebo groups, respectively (p=0.39). After 2 months, men in the treatment group had significant improvement in IELT with a mean increase of 231.5 ± 166.9 seconds (95% confidence interval of 139-323 seconds) which was significantly greater than men on placebo (94.2 ± 67.1 seconds, p= 0.043).


Surgical treatments

Two different surgeries, both developed in
South Korea South Korea, officially the Republic of Korea (ROK), is a country in East Asia. It constitutes the southern half of the Korea, Korean Peninsula and borders North Korea along the Korean Demilitarized Zone, with the Yellow Sea to the west and t ...
, are available to permanently treat premature ejaculation: selective dorsal neurectomy (SDN) and glans penis augmentation using a
hyaluronan Hyaluronic acid (; abbreviated HA; conjugate acid, conjugate base hyaluronate), also called hyaluronan, is an anion#Anions and cations, anionic, Sulfation, nonsulfated glycosaminoglycan distributed widely throughout connective tissue, connective ...
gel.
Circumcision Circumcision is a procedure that removes the foreskin from the human penis. In the most common form of the operation, the foreskin is extended with forceps, then a circumcision device may be placed, after which the foreskin is excised. T ...
has shown no effect on PE. The International Society for Sexual Medicine guidelines do not recommend either surgical treatment due to the risk of permanent loss of sexual function and insufficient reliable data and on the basis of violating the medical principle of non-maleficence as the surgery can lead to complications, of which some might not yet be known. The most common complication of surgery is the recurrence of PE, reported to occur in about 10% of surgeries. Other sources consider SDN as a safe and efficient treatment and these surgeries are popular in Asian countries.


Epidemiology

Premature ejaculation is a prevalent
sexual dysfunction Sexual dysfunction is difficulty experienced by an individual or partners during any stage of normal sexual activity, including physical pleasure, desire, preference, arousal, or orgasm. The World Health Organization defines sexual dysfunction ...
in males; however, because of the variability in time required to ejaculate and in partners' desired duration of sex, exact prevalence rates of PE are difficult to determine. In the "Sex in America" surveys (1999 and 2008),
University of Chicago The University of Chicago (UChicago, Chicago, or UChi) is a Private university, private research university in Chicago, Illinois, United States. Its main campus is in the Hyde Park, Chicago, Hyde Park neighborhood on Chicago's South Side, Chic ...
researchers found that between
adolescence Adolescence () is a transitional stage of human Developmental biology, physical and psychological Human development (biology), development that generally occurs during the period from puberty to adulthood (typically corresponding to the age o ...
and age 59, approximately 30% of men reported having experienced PE at least once during the previous 12 months, whereas about 10 percent reported
erectile dysfunction Erectile dysfunction (ED), also referred to as impotence, is a form of sexual dysfunction in males characterized by the persistent or recurring inability to achieve or maintain a Human penis, penile erection with sufficient rigidity and durat ...
(ED). In males, although ED is the most prevalent sex problem after age 60, and may be more prevalent than PE overall according to some estimates, premature ejaculation remains a significant issue that, according to the survey, affects 28 percent of men age 65–74, and 22 percent of men age 75–85. Other studies report PE prevalence ranging from 3 percent to 41 percent of men over 18, but the great majority estimate a prevalence of 20 to 30 percent—making PE a very common sex problem. There is a common misconception that younger men are more likely to develop premature ejaculation and that its frequency decreases with age. Prevalence studies have indicated, however, that rates of PE are relatively constant across age groups.


History


Naturalism

Male
mammals A mammal () is a vertebrate animal of the class Mammalia (). Mammals are characterised by the presence of milk-producing mammary glands for feeding their young, a broad neocortex region of the brain, fur or hair, and three middle e ...
ejaculate quickly during intercourse, prompting some biologists to speculate that rapid ejaculation had
evolved Evolution is the change in the heritable Phenotypic trait, characteristics of biological populations over successive generations. It occurs when evolutionary processes such as natural selection and genetic drift act on genetic variation, re ...
into genetic makeup of human males to increase their chances of passing their
genes In biology, the word gene has two meanings. The Mendelian gene is a basic unit of heredity. The molecular gene is a sequence of nucleotides in DNA that is transcribed to produce a functional RNA. There are two types of molecular genes: protei ...
. Ejaculatory control issues have been documented for more than 1,500 years. The '' Kamasutra'', the 4th century BCE Indian marriage handbook, declares that "if a male be long-timed, the female loves him the more, but if he be short timed, she is dissatisfied with him." Waldinger summarizes professional perspectives from early in the twentieth century. Sex researcher Alfred Kinsey did not consider rapid ejaculation a problem, but viewed it as a sign of "masculine vigor" that could not always be cured. The belief that it should be considered a disease rather than a normal variation, has also been disputed by some modern researchers.


Medicalization

In the 19th century, a symptom called '' spermatorrhoea'' invented by William Acton in 1857, meaning excessive or involuntary semen discharge, was developed and at the time used as a medical justification of
celibacy Celibacy (from Latin ''caelibatus'') is the state of voluntarily being unmarried, sexually abstinent, or both. It is often in association with the role of a religious official or devotee. In its narrow sense, the term ''celibacy'' is applied ...
. Spermatorrhoea was later sub-classified into other symptom clusters based partially on how it affected semen. Treatment for spermatorrhoea at the time included catheterisation, cauterisation,
circumcision Circumcision is a procedure that removes the foreskin from the human penis. In the most common form of the operation, the foreskin is extended with forceps, then a circumcision device may be placed, after which the foreskin is excised. T ...
, and sticking needles through the
perineum The perineum (: perineums or perinea) in placentalia, placental mammals is the space between the anus and the genitals. The human perineum is between the anus and scrotum in the male or between the anus and vulva in the female. The perineum is ...
into the
prostate The prostate is an male accessory gland, accessory gland of the male reproductive system and a muscle-driven mechanical switch between urination and ejaculation. It is found in all male mammals. It differs between species anatomically, chemica ...
. In the 19th and early 20th centuries, cultural stigma towards researching sexuality drove its unpopularity as a subject of study among doctors and in publications. The first recognition the symptoms described in spermatorrhoea as a disorder in itself is believed to be in 1883, termed ''ejaculatio praecox''. The origin of the modern version of ejaculatio praecox, called premature ejaculation, is thought to have begun with
Alfred Adler Alfred Adler ( ; ; 7 February 1870 – 28 May 1937) was an Austrian medical doctor, psychotherapist, and founder of the school of individual psychology. His emphasis on the importance of feelings of belonging, relationships within the family, a ...
before major developments of psycohanalytic theory. Through the mid 20th century,
Sigmund Freud Sigmund Freud ( ; ; born Sigismund Schlomo Freud; 6 May 1856 – 23 September 1939) was an Austrian neurologist and the founder of psychoanalysis, a clinical method for evaluating and treating psychopathology, pathologies seen as originating fro ...
published widely accepted and virtually unchallenged theories that rapid ejaculation was due to neurosis, that penetrative sex was the only right way to achieve female orgasm, and that a man's erection was essential to female orgasm. It stated that males who ejaculate prematurely have unconscious hostility toward females, so they ejaculate rapidly, which satisfies them but frustrates their partners, who are unlikely to experience
orgasm Orgasm (from Greek , ; "excitement, swelling"), sexual climax, or simply climax, is the sudden release of accumulated sexual excitement during the sexual response cycle, characterized by intense sexual pleasure resulting in rhythmic, involu ...
that quickly. Freudians claimed that premature ejaculation could be cured using psychoanalysis. But even years of psychoanalysis accomplished little, if anything, in curing premature ejaculation. In 1974, there was no evidence found to suggest that men with premature ejaculation harbor unusual hostility toward females. This so-called ''coital imperative'' has later been argued as a medically recognised disorder that did not actually serve the satisfaction of women but rather contributed to the pressure on and pathologisation of men in obtaining a so-called optimal time to ejaculation.


See also

* Anorgasmia * Delayed ejaculation * Edging (sexual practice) * Pre-ejaculate *
Retrograde ejaculation Retrograde ejaculation occurs when semen which would be ejaculated via the urethra is redirected to the urinary bladder. Normally, the sphincter of the bladder contracts before ejaculation, inhibiting urination and preventing a reflux of semen ...
*
Erectile dysfunction Erectile dysfunction (ED), also referred to as impotence, is a form of sexual dysfunction in males characterized by the persistent or recurring inability to achieve or maintain a Human penis, penile erection with sufficient rigidity and durat ...
* Blue balls * Pull-out method * Foreplay


References


Cited sources

* *


Further reading

*


External links

{{Authority control Andrology Male genital disorders Human penis Sexual dysfunctions Ejaculation