Premature ejaculation

Premature ejaculation (PE) is a male sexual dysfunction that occurs when a male expels semen (often accompanied by orgasm) shortly after initiating sexual activity, and with minimal penile stimulation. It is also referred to as early ejaculation, rapid ejaculation, rapid climax, premature climax, and historically, ejaculatio praecox. There is no standardized cut-off defining "premature, " but a consensus among experts at the International Society for Sexual Medicine supports a definition of around one minute post-penetration. The International Classification of Diseases (ICD-10) uses a cut-off of 15 seconds from the start of sexual intercourse. While men with premature ejaculation often feel they have less control over their ejaculation, it is unclear if this perception is accurate, as many average men also express a desire to last longer. In males, the typical intravaginal ejaculation latency time is approximately 4–8 minutes. The opposite condition is known as delayed ejaculation. Men with PE frequently report emotional and relational distress, leading some to avoid sexual relationships due to embarrassment associated with the condition. Compared to men, women view PE as a less significant issue, but several studies indicate that it still causes distress for female partners.

Cause

The causes of premature ejaculation are unclear. Many theories have been proposed, including the idea that PE results from masturbating quickly during adolescence to avoid being caught, performance anxiety, passive-aggressive behavior, or having insufficient sexual activity; however, there is little evidence to support any of these claims. Several physiological mechanisms have been hypothesized to contribute to premature ejaculation, including serotonin receptors, a genetic predisposition, elevated penile sensitivity, and atypical nerve conduction. Scientists have long suspected a genetic link to certain forms of premature ejaculation. However, studies have been inconclusive in identifying the gene responsible for lifelong PE. The nucleus paragigantocellularis in the brain has been identified as playing a role in ejaculatory control. PE may also arise from prostatitis or as a side effect of medication.

PE has been classified into four subtypes: lifelong, acquired, variable, and subjective PE. The pathophysiology of lifelong PE is influenced by a complex interplay of central and peripheral serotonergic, dopaminergic, oxytocinergic, endocrinological, genetic, and epigenetic factors. Acquired PE may occur due to psychological issues, such as sexual performance anxiety, and psychological or relationship problems, alongside co-morbidities, including erectile dysfunction, prostatitis, and hyperthyroidism.

Mechanism

The physical process of ejaculation encompasses two actions: emission and expulsion. Emission is the initial phase, which involves fluid deposition from the ampullary vas deferens, seminal vesicles, and prostate gland into the posterior urethra. The second phase, expulsion, is marked by the closure of the bladder neck, followed by rhythmic contractions of the urethra via the pelvic-perineal and bulbospongiosus muscles, alongside intermittent relaxation of the external male urethral sphincter. Sympathetic motor neurons control the emission phase of the ejaculation reflex, whereas somatic and autonomic motor neurons execute the expulsion phase. These motor neurons reside in the thoracolumbar and lumbosacral spinal cord, and they are activated in a coordinated fashion when adequate sensory input reaches the ejaculatory threshold within the central nervous system.

Intromission time

The 1948 Kinsey Report suggested that three-quarters of men ejaculate within two minutes of penetration during more than half of their sexual encounters.

Current evidence supports an average intravaginal ejaculation latency time (IELT) of six and a half minutes for individuals aged 18 to 30. If the disorder is defined as an IELT percentile below 2.5, then premature ejaculation could be indicated by an IELT of less than approximately two minutes. Still, some men with abnormally low IELTs may be satisfied with their performance and not report a lack of control. Likewise, those with higher IELTs may consider themselves premature ejaculators, suffer from quality of life issues typically associated with premature ejaculation, and even benefit from non-pharmaceutical treatment.

Diagnosis

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) defines premature ejaculation as "a persistent or recurrent pattern of ejaculation occurring during partnered sexual activity within approximately one minute following vaginal penetration and before the person wishes it." This definition includes additional criteria: the condition must persist for more than six months, cause clinically significant distress, and cannot be better explained by relationship distress, another mental disorder, or the use of medications. These factors are identified through discussions with the individual rather than through any diagnostic test. The DSM-5 also permits specifiers regarding whether the condition is lifelong or acquired, whether it applies generally or only in certain situations, and its severity based on the duration being less than one minute. However, these subtypes have faced criticism for lacking validity due to insufficient evidence. The 2007 ICD-10 defined premature ejaculation as ejaculating without control, and within approximately 15 seconds.

Treatments

Several treatments have been tested for premature ejaculation, with a combination of medication and non-medication methods often proving to be the most effective approach. Self-Treatment Many men attempt to self-treat premature ejaculation by distracting themselves by focusing their attention away from sexual stimulation. There is little evidence suggesting that this is effective, and it often detracts from sexual fulfillment for both partners. Other self-treatments include thrusting more slowly, completely withdrawing the penis, purposefully ejaculating before sexual intercourse, and using multiple condoms. Some men report that these methods have been helpful.

Sex Therapy

Various techniques have been developed and employed by sex therapists, including Kegel exercises (to strengthen the pelvic floor muscles), Masters and Johnson's "stop-start technique" (to desensitize male responses), and the "squeeze technique" (to reduce excessive arousal).

To treat premature ejaculation, Masters and Johnson developed the "squeeze technique, " based on the Semans technique created by James Semans in 1956. Men were instructed to pay close attention to their arousal patterns 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 would squeeze the head of the penis between their thumb and index finger, suppressing the ejaculatory reflex and allowing the male to last longer.

The squeeze technique was effective, 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 focusing on a simpler, more effective method called the "stop-start" technique. During intercourse, as the male senses he is 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 and Gilles Trudel, offers a novel method that emphasizes improving sexual function without interrupting sexual activity. This treatment, distinct from traditional behavioral techniques such as the squeeze and stop-start methods, has demonstrated significant enhancements in the duration of intercourse, sexual satisfaction, and overall sexual function. A pivotal study by De Carufel and Trudel (2006) showcases the effectiveness of this method. Moreover, the Cochrane review on psychosocial interventions for premature ejaculation acknowledges the De Carufel study as having a low risk of bias, underlining its methodological strength among psychosocial intervention studies. This recognition indicates that the functional-sexological treatment presents a promising option for individuals and couples facing premature ejaculation, suggesting a movement towards more contemporary and evidence-based treatments in the field.

Medications

Dapoxetine, a selective serotonin reuptake inhibitor (SSRI), has been approved for the treatment of premature ejaculation in several countries. Other SSRIs, such as fluoxetine, paroxetine, sertraline, citalopram, escitalopram, and clomipramine, are used off-label to treat PE. The opioid tramadol, an atypical oral analgesic, is also utilized. Results show that PDE5 inhibitors are effective as part of combination treatment with SSRIs. These medications typically exhibit their full effects after 2-3 weeks, with studies indicating that ejaculatory delay can vary between 6 to 20 times longer than prior to medication use. Premature ejaculation may recur upon discontinuation, and the side effects of these SSRIs can include anorgasmia, erectile dysfunction, and diminished libido.

Topical anesthetics, such as lidocaine and benzocaine, which are applied to the tip and shaft of the penis, have also been employed. They should be applied 10–15 minutes before sexual activity and tend to have fewer potential side effects compared to SSRIs. However, some individuals may dislike these due to the reduction of sensation in the penis and the potential impact on their partner, as the medication may rub off onto them. Another study was conducted involving 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, are available to permanently treat premature ejaculation: selective dorsal neurectomy (SDN) and glans penis augmentation using hyaluronan gel. Circumcision 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, as well as a violation of the medical principle of non-maleficence, since the surgery can lead to complications, some of which might not yet be known. The most common complication of surgery is the recurrence of PE, which is reported to occur in about 10% of surgeries. Other sources consider SDN a safe and efficient treatment, and these surgeries are popular in Asian countries.

Epidemiology

Premature ejaculation is a prevalent 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 researchers found that between adolescence 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 (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 ejaculate quickly during intercourse, prompting some biologists to speculate that rapid ejaculation had evolved into the genetic makeup of human males to increase their chances of passing their genes.

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 is long-timed, the female loves him the more, but if he is 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, coined by William Acton in 1857, meaning excessive or involuntary semen discharge, was developed and used at the time as a medical justification for celibacy. Spermatorrhoea was later sub-classified into other symptom clusters based partially on its effects on semen. Treatment for spermatorrhoea during that period included catheterization, cauterization, circumcision, and inserting needles through the perineum into the prostate. In the 19th and early 20th centuries, cultural stigma surrounding research into sexuality contributed to its unpopularity among doctors and in publications. The first recognition of the symptoms described in spermatorrhoea as a disorder is believed to have occurred in 1883, termed ejaculatio praecox. The modern concept of ejaculatio praecox, known as premature ejaculation, is thought to have originated with Alfred Adler before the major developments of psychoanalytic theory.

Through the mid-20th century, Sigmund Freud published widely accepted and virtually unchallenged theories suggesting that rapid ejaculation was due to neurosis, that penetrative sex was the only correct way to achieve female orgasm, and that a man's erection was essential for it. He asserted that males who ejaculate prematurely harbor unconscious hostility toward females, leading them to ejaculate quickly, which satisfies themselves but frustrates their partners, who are unlikely to experience orgasm that swiftly. Freudians maintained that premature ejaculation could be treated with psychoanalysis. However, even years of psychoanalysis yielded little, if anything, in curing premature ejaculation. In 1974, no evidence was found to suggest that men with premature ejaculation hold unusual hostility toward females. This so-called coital imperative has since been argued as a medically recognized disorder that did not actually enhance women's satisfaction but instead contributed to the pressure on and pathologization of men in achieving a so-called optimal ejaculation time.

External links

More information is available at [ Wikipedia:Premature_ejaculation ]