Premature ejaculation (PE for short) is often defined as a “short latency time” or basically ejaculating before a man desires during intercourse”. Because this is a fairly loose definition, what is “too early” will vary from couple to couple. However for our purposes we will use the following definitions – repeated episodes of intercourse lasting less than one minute.
PE is perhaps the most common type of sexual dysfunction. It is estimated that it affects 25-40% of men at some point in their lives.[i] This is even higher in men with prostatitis where PE can occur in as many as three out of four men.[ii] For our discussion we will divide PE as a disorder into three different categories.
Pre-Intercourse - in some severe cases, men with PE can ejaculate when kissing, undressing, or watching their partner undress. Or minimal stimulation during foreplay can caused unwanted ejaculation before intercourse can begin.
Ante-portal/Penetration - ejaculation occurs either during insertion of the penis into the vagina or within 15 seconds after vaginal penetration.
Short-Intercourse – ejaculation occurs within 15-60 seconds after vaginal penetration
Another type of PE is when ejaculation occurs before the couple wishes it to; however, intercourse was able to be sustained for more than 1-2 minutes. However, it is important to keep in mind that short ejaculation times are common for many men during sexual encounters. In fact, one study found that three-fourths of men ejaculate in less than 2 minutes during half of their sexual encounters[iii] (hence the reason we use less than one minute for our definition of PE as a disorder). The main key for seeking treatment is if latency times are so short that it negatively impacting the relationship or leads to infertility.
There are a number of reasons men may suffer from PE. In some cases, PE can occur in episodes or it can be life-long, beginning during adolescence. This is called Primary Premature Ejaculation. It is estimated that between 1-8% of men[iv] suffering from PE throughout their entire lives which may simply be due to genetic factors.
However, most men with PE have acquired their PE over time (they once had good control over ejaculation time and now they don’t). This is called Secondary Premature Ejaculation and can be caused by a number of factors discussed in the following paragraphs.
Low levels of serotonin and high levels of dopamine can be a definite trigger. This can be seen in men who take antidepressants that trigger dopamine (such as bupropion) or in men that take stimulants methyphenidate or amphetamines for ADHD. It can also occur if the nerves in the penis are overly sensitive. This can sometimes occur in men who have an especially sensitive frenular nerve on the underside of the neck of the penis (see Chapter 29) or high concentration of nerves on the tip (glans) of the penis. These nerves can be highly sensitive leading to rapid ejaculation once stimulated. Another cause can be full reproductive glands. In men who have not ejaculated recently or regularly, the prostate and other glands are typically fuller than normal and send stimulation signals to the ejaculatory centers that speed the time to ejaculation. Given the above factors, it’s not surprising that men often experience PE on their first sexual encounter. This can be especially true of he hadn’t had wet dream or masturbated recently.
Perhaps one of the most common causes of PE is psychogenic (mental). This occurs when a man has suffered from PE in the past and fears that he will ejaculate too early again. This heightened agitated state or fear of PE can actually cause ejaculation to speed up. Reassurance by the spouse or just relaxing and not worrying if PE occurs can be helpful. In some severe cases, simply the anticipation of having sex such as suggesting sex or watching their partner undress can cause ejaculation before foreplay can even begin (in some cases before a man can even get undressed).
Another cause of PE interestingly enough is erectile dysfunction. In fact, 30% of men with PE also have ED (erectile dysfunction).[v] In these cases, men often ejaculate prior to attaining a rigid enough erection for penetration. In addition, these men often feel that they have less “control” over ejaculation.
Medical treatment for PE is usually unnecessary as reassurance and talk therapy are often effective. There are a few tips and non-drug methods that can help men who suffer from PE.
The first technique is often referred to as the “pinch method”. When a man gets close to ejaculating, he can firmly pinch the head of the penis. This will often “reset” the emission clock, setting the time to ejaculation back anywhere for 10-30 seconds. This must be performed prior to emission (the emptying of the reproductive glands), because once emission occurs, ejaculation is unstoppable. Some men may find that they can use the pinch method multiple times during a sexual encounter (during foreplay and prior to inserting the penis into the vagina).
Some men who have a shorter refractory period may be able to compensate and ejaculate twice during a sexual encounter. If ejaculation occurs prematurely during foreplay, they may simply delay intercourse for 20-30 minutes focusing on more foreplay; then engage in intercourse later and ejaculate again.
Using thicker condoms can also be another option for men with an overly sensitive penis. One complaint men have with condoms is that it “slows them down”. This is more common in men who use non-textured condoms (condoms that don’t have ribs or studs texturing the condom). For men with PE, being slowed down is often exactly what needs to happen so wearing a condom can be helpful.
The only reason PE is typically treated medically is if PE prevents intercourse altogether, negatively impacts the marital relationship, or is a main cause of infertility (basically failure of sperm to enter the female reproductive tract).
If medications such as antidepressants or ADHD meds are the cause of PE, an adjustment in the dosage of the drug or timing of intercourse a certain number of hours after the last dose of medication can be helpful. For example, men who take ADHD medications may find that ejaculation times are longer if sexual activity is delayed for 12 hours or more after the last dose.
If men have PE due to an overly sensitive penis
Numbing creams/gels can be prescribed. Lidocaine-prilocaine creams can be placed on the glans and/or the frenular area of the penis as soon as sexual activity is expected. After about 5 minutes, the numbing agent should have taken effect by slowing nerve impulses within the penis, thus prolonging the amount of time it takes to ejaculate. One study found that men who used lidocaine-prilocaine cream were able to extend ejaculation time from 1 ½ minutes to 8 ½ minutes on average.[vi]
For men who suffer from PE due to a particularly sensitive frenular nerve, the frenulum can be clipped in a small in-clinic procedure to reduce stimulation in that nerve and thus delay ejaculation.
Serotonin Medications - Drugs that affect serotonin can actually slow ejaculation time as a side effect. SSRI’sand SNRI’s are a good examples, with paroxetine being the agent that causes the longest delay in ejaculation with fluoxetine, sertraline, citalopram, and escitalopram, venlafaxine, duloxetine causing some delay in ejaculation.
Erectile Dysfunction Medications - Although one would assume that increasing erection rigidity would make ejaculation occur more rapidly, they actually increases a man’s control over his ejaculation time, which can often reverse some of the anxiety that leads men to have PE and allows him to better “pace” himself. Using PDE-5 inhibitors allows many men to have intercourse for one to 15 minutes times longer. [vii] In these men, use of PDE-5 inhibitors was lengthened ejaculation better than using a medication that affected serotonin.
Tramadol – For men who want “on-demand” therapy (and may not be candidates for PDE-5 therapy) may be prescribed tramadol. Tramadol is a weak narcotic pain killer that has some serotonin properties. One study found that men given tramadol increased their average ejaculation time from just over a minute to over seven minutes.[viii] However, because tramadol is a controlled substance and PDE-5 inhibitors work well, these are often used as a last line agent.
[i] L Gurkan, et.al. Premature Ejaculation: Current and future treatments, Asian Journal of Andrology; 10(1): 102-109, 2008.
[ii] Hackett, et. al. International Society for Sexual Medicine’s Guildelines for the diagnosis and treatment of premature ejaculation. J Sex Med 2010; 7:2947-2969.
[iii] Kinsey, Alfred (1948), Sexual Behavior in the Human Male, Philadelphia: W. B. Saunders Co
[iv] A Aversa et.al., Effects of vardenafil administration on intravaginal ejaculatory latency time in men with lifelong premature ejaculation. Internal Journal of Impotence Research (2009) 21, 221-227.
[v] Rastrelli G, et. al. Clinical characteristeics of men complaining of premature ejaculation together with erectile dysfunction; a cross-sectional study. Andrology, 2019 Mar; 7(2): 163-171
[vi] Busato W and Galindo C. Topical anesthetic use for treating premature ejaculation: a double-blind, randomized, placebo-controlled study, BJU International, 2004; 93: 1018-21.
[vii] Chen J, et.al. The Role of Phosphodiesterase Type 5 Inhibitors in the Management of Premature Ejaculation: A Critical Analysis of Basic Science and Clinical Data, European Urology:2007;52:1331-1339.
[viii] E Salem. Tramadol HCl has promise in on-demand use to treat premature ejaculation. The Journal of Sexual Medicine, 2008; 5, 188-193.
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