Definitions, Causes, and Treatments
Ejaculation is something that many of us take for granted—when we have sex, most of us assume ejaculation is a given. We also believe that we have control over when we ejaculate. However, this is not always the case.
Ejaculatory dysfunction is one of the most difficult sexual problems in men’s health because there are a variety of ejaculatory issues. Men occasionally ejaculate too early or quickly, a condition known as premature ejaculation or PE. It will be the subject of the following discussion. The other issues include taking too long to ejaculate or not being able to ejaculate at all. These problems are known as delayed ejaculation and anejaculation. Some men experience pain when ejaculating, and others ejaculate backward (a condition called retrograde ejaculation).
Premature ejaculation is the most common male sexual dysfunction but receives far less attention and resources than erectile dysfunction (ED). We have spent a lot of time writing about erections and what to do if you have ED on this blog. But what about all the guys out there who are suffering from premature ejaculation?
We know very little about PE as a medical community. Why does it affect certain men but not others? Why do some people have it from birth while others develop it later in life? Is it more likely that PE is caused by biological or psychological factors? These are just a few of the many questions about PE that remain unanswered.
While there is still much to learn, what follows is a primer on premature ejaculation. We’ll talk about how to tell if you have PE and how to overcome it if you do.
Background
Before we get started, let’s clear up some myths about premature ejaculation. Assessments of how common it is vary, but it is estimated that up to 30% of men will experience PE at some point in their lives (Carson 2006). PE is frequently thought to be a condition that only affects young, inexperienced men, like some of the scenes from the film American Pie. But in reality, that is not the case—premature ejaculation can occur at any age. In fact, the prevalence of PE is fairly consistent across all age groups (Rosen 2004).
Secondly, men frequently overestimate what is normal when it comes to ejaculation. In an observational study of 1,500 men and their partners, half of the men ejaculated in less than 7.3 minutes (Patrick 2005). Furthermore, the average time to ejaculate is less than 10 minutes (Patrick 2005). Patients who come to see me frequently believe they have a problem if they cannot last 15-20 minutes or more as they see in movies, and that is simply not realistic.
Finally, ejaculation is difficult. As I mentioned at the outset, we take cumming for granted, but it is a complex process governed by the central nervous system. Signals from your genitals are sent to your brain via the spinal cord when you are aroused. When your arousal level reaches a certain point, your brain sends a signal back to your genitals that says, “Time to shoot!”
And that’s when things get complicated.
Ejaculation has two stages: emission and expulsion. Emission occurs when semen (a complex fluid composed of sperm and other fluids) is deposited in the urethra. This process involves the entire genital tract, from your testicles to your prostate, and occurs only after the bladder neck is closed. When sperm enters the urethra, it can be expelled. Expulsion is the forceful contraction of muscles at the base of the penis that allows semen to shoot out. This entire ejaculatory dance is usually accompanied by orgasm, a climax of sexual excitement and pleasure.
PE Defined
PE is recognized by ejaculation that occurs prior to or within one minute of penetration, or by the inability to delay ejaculation during all or most penetrative sex acts. To be classified as PE, the ejaculatory problem must result in negative or unpleasant personal consequences such as distress, frustration, and/or avoidance of sexual intimacy (Althof 2014).
Types of PE
There are two types of premature ejaculation: congenital and acquired. People with the congenital version have always had difficulty controlling their ejaculation, even from their first masturbation attempts. Men with the acquired kind go through a period of normalcy before suddenly or gradually losing the ability to delay or control their ejaculation. Both types can be distressing and have a negative impact on a man’s self-esteem, as well as cause problems in his romantic/sexual relationships.
PE can also be situational or generalized. The term “generalized PE” implies that the issue exists in the majority, if not all, types of sexual activity. Although the definition of PE implies intercourse, many people ejaculate excessively in response to other types of stimulation. Situational PE refers to a problem that only occurs with certain types of activity. Some people, for example, only have PE with partners but report normal ejaculatory function when alone and pleasuring themselves.
Before we get into the causes of PE, it is worth noting the connection between PE and erectile dysfunction. PE is frequently seen in men who also have ED. If premature ejaculation began after the person’s erection problem, we usually go to the ED first. Premature ejaculation is often no longer an issue once the person’s ED is corrected.
Causes of PE
As I previously stated, we still don’t know much about PE, including the exact cause. What we do know is that Serotonin is thought to play an important role in PE. A chemical that is produced and secreted by certain types of nerves in the brain, Serotonin is also the target molecule for many medications used to treat depression and anxiety. Selective serotonin reuptake inhibitors (SSRIs) treat depression by preventing serotonin from leaving a neuronal synapse. Essentially, they cause a buildup of serotonin in the brain. This can improve your mood but is not ideal for ejaculation (this will become important later when we discuss treatments). Low serotonin levels, on the other hand, can hasten ejaculation and, in some cases, lead to PE.
Another physiological factor that is frequently overlooked is the role of the pelvic floor muscles. As previously stated, emission necessitates the forceful contraction of specific muscles. These muscles are part of the pelvic floor and are not usually under conscious control. People who have dysfunction (tightness, spasm, etc.) in these muscles may ejaculate too quickly.
Psychological factors are also common in people who struggle with premature ejaculation. Depression, anxiety, stress, feelings of guilt or shame, unrealistic expectations about sexual performance, a history of sexual abuse, negative socio-cultural beliefs about sex, lack of confidence, and relationship issues are examples. Addressing any potentially confounding psychological variables is critical in helping to manage PE.
Diagnosis
People, in my experience, are often uncomfortable discussing PE during a doctor’s visit. Many men are unaware that there are safe and effective treatments available to help them improve their ejaculatory control. If ejaculation feels out of control, and especially if it is interfering with you or your partner’s sexual pleasure, speak up. We usually diagnose PE based on the history and a physical exam. Lab tests are rarely required to make a diagnosis. We also do not expect you to use a stopwatch in bed.
Treatment
There are various approaches to treating premature ejaculation. Some treatments rely on behavioral techniques, while others attempt to disrupt the signal between our brain and our genitals. Sometimes treatment entails psychological counselling, while other times it entails medication.
Psychological therapy assists in addressing feelings, emotions, and anxiety that can lead to sexual performance issues, such as premature ejaculation. Couples dealing with ejaculatory dysfunction can benefit from therapy as well. Trained sex therapists can help their clients identify behaviors that may be causing their lack of ejaculatory control.
Some behavioral techniques have been used to aid in the improvement of PE. The squeeze method entails firmly squeezing the penis just before ejaculation to cause a partial loss of erection. The goal of this method is to make you more aware of the sensations that lead up to the climax. The start-stop technique does exactly what it says: you or your partner stop all sexual activity just before the climax. If ejaculation is not possible, you begin stimulating the penis again, repeating the start-stop process three times. While these behavioral techniques are relatively simple to implement, there haven’t been many studies demonstrating their effectiveness.
In some cases, attempting to reduce penile sensitivity in order to reduce premature ejaculation can be beneficial. This can include using a condom or a topical anesthetic spray 5-10 minutes before sex. These options may be difficult for younger patients and single men, and they may interfere with intimacy or limit spontaneity with new partners. Fortunately, there are other options.
Because there are no FDA-approved medications to treat PE, everything we will discuss here is considered “off-label.” A class of drugs known as SSRIs is a commonly prescribed treatment for PE. As previously stated, these are commonly used to treat depression and anxiety. One of the most common SSRI side effects is delayed ejaculation. So, in patients with PE, we take advantage of this side effect. These medications have been studied and used both on-demand (just before sexual activity) and as daily treatments, and both have been shown to be effective.
If PE coexists with erectile dysfunction, phosphodiesterase-5 inhibitors (such as Viagra, Cialis, and others) can be beneficial. Tramadol, a pain reliever, is another commonly used treatment. This treatment is typically used on an as-needed basis. essentially dampening the brain’s processing of the genital stimulation that causes PE. Additional treatments, such as Botox injections, are being researched and are considered experimental. Finally, for the reasons stated previously, pelvic floor physical therapy is another non-medical approach that can be beneficial in PE.
Concluding Thoughts
Premature ejaculation is a more common issue than erectile dysfunction. It is also a sexual dysfunction that is associated with a great deal of shame and embarrassment. If you have a feeling that your ejaculatory control is not as good as it could be, talk to your doctor about it. While there is no single solution to this problem, there are several treatment options to consider.