by director Chris Steidle, MD
What is premature ejaculation?
Premature ejaculation is very common.
The sexual revolution ushered in by Viagra has made it commonplace to talk about other sexual disorders besides the loss of an erection. Data from a recent national study of several thousand men and women between the ages of 18 and 59 suggest that the most common type of male sexual dysfunction is early, rapid or premature ejaculation.
Prevalence of premature ejaculation
As with other types of sexual dysfunction, there has never been consensus about what exactly constitutes rapid or premature ejaculation. Physicians are not even sure that a rapid ejaculation is an abnormal physiologic process.
For many years there have been attempts to define a normal time period of vaginal penetration prior to an ejaculation. Researchers have studied partner satisfaction and the number of pelvic thrusts before an ejaculation occurs. The collective studies have spawned a variety of physiologic treatments and a number of "off-label" medical treatments, as well.
Statistics about rapid or premature ejaculation are revealing and include the fact that it has been reported in up to 26% of male medical students and in up to 36% of happily married couples who describe transient periods of rapid ejaculation. Furthermore, the data indicate that up to 25% of men's first sexual experiences are unsuccessful as a result of ejaculation outside of the vagina.
Definition of premature ejaculation
One of the major difficulties in developing an effective treatment for this problem is that we do not have a clear-cut definition of premature ejaculation. The Diagnostic and Statistical Manual of the American Psychiatric Association, fourth version (the DSM-IV), a compendium of psychological diagnoses categorized for accurate diagnosis, presents the following definition: A diagnosis of premature ejaculation requires a man to experience persistent or repeated ejaculation with slight stimulation before, on, or shortly after vaginal penetration and before he wishes it. The clinician must take into account factors that affected the duration of the excitement phase such as the man's age, presence of new sexual partners or situation, and the recent frequency of sexual activity.
In other words, a young man who has not had frequent intercourse would be a prime candidate for premature ejaculation. For this to be defined as a problem, the disturbance must cause considerable anguish or interpersonal difficulty and the premature ejaculation should not be exclusively due to the direct effects of a chemical or medication. Additionally, the DSM-IV diagnosis may be qualified in three other ways: 1) that it is either a life-long or an acquired condition, 2) that it is either generalized or specific, or 3) that it is psychologically based with combined factors. These three factors link premature ejaculation to a psychiatric illness, but doctors now know that this is not generally the case.
The primary form of premature ejaculation typically occurs in a man who begins having intercourse for the first time and has a problem with ejaculating before he desires it. Generally, these are younger men with strong libido who experience significant sexual tension prior to intercourse.
Secondary premature ejaculation is much more commonly associated with erectile dysfunction where there are long periods of time between episodes of sexual intercourse and ejaculation. With this type, the man typically loses the erection just at the time of ejaculation.
Another historical, clinical definition is when ejaculation occurs with less than two minutes of penetration during more than fifty percent of intercourse experiences for at least six months duration.
An even less precise definition is the inability to experience one hundred thrusts of vaginal penetration before an ejaculation occurs.
Another vague definition characterizes the condition as the absence of voluntary control over the ejaculatory reflex. It has even been suggested that ejaculation occurring before the partner experiences vaginal orgasm, be defined as premature. If this were used as the definition, however, all men in the world would be considered premature ejaculators!
Physiology of premature ejaculation
To fully understand premature ejaculation, it's helpful to learn the physiology of ejaculation, itself. It is also important to know that ejaculation is not an isolated occurrence but that it encompasses many different physiological events. People often confuse an orgasm with an ejaculation but the two events could not be more different.
Ejaculation is caused by a very brief reflex event of the pelvic floor muscles that contract in rhythmic fashion. This event almost always lasts a specific length of time and is precisely coordinated by the brain, which requires input from multiple levels of the nervous system.
An ejaculation may occur in two ways. The first is a purely central nervous system reflex and may occur in a young man as a nocturnal emission or wet dream. This type usually results from a combination of erotic stimulation during sleep with some limited friction and generally occurs in younger men who have a high libido and high testosterone levels. However, this type may also occur in an older man who, for a variety of reasons, is experiencing a lack of sexual activity and is not ejaculating on a regular basis. The impulse, which is both visual and physical, travels to the spinal cord and then to the brain where the autonomic nervous system stimulates the sympathetic nerves. This results in the contraction of the male accessory sexual organs including the vas deferens, the tube that carries sperm from the testicles to the prostate. The prostate, itself, generates part of the fluid that comprises the ejaculant as it passes on its way. There is even a small contribution from the bulbourethral glands, also known as the Cowpers gland, that are located just before the beginning of the penis.
This is the complicated way to say that the brain stimulates the sympathetic nervous system into creating an emission in which the semen, the fluid from both the prostate and the seminal vesicles, is deposited in the back of the urethra. An ejaculation actually occurs when this fluid is propelled out of the penis by a contraction of the bulbocavernosus and the levator ani muscles, which make up part of the pelvic floor. This event is commonly referred to as an orgasm but an orgasm is the actual contraction of these muscles expelling the fluid forward out of the penis.
Treatments for premature ejaculation
The definition of premature ejaculation varies from individual to individual and depends on the person. I have seen many men who are able to sustain intercourse for five, ten, or even fifteen minutes but feel that they experience premature ejaculation. I have also seen many men able to penetrate for less than a minute who are very happy. Occasionally, I encounter a situation where a man can sustain an erection for a long period of time but does not ejaculate at all. This may sound like a wonderful thing, but, in fact, it is not.
Often the most effective treatment for premature ejaculation is education. Simply discussing premature ejaculation and its physiology convinces men and their partners that they either don't have a problem or they are interested in trying oral medication options to help with climax control. I usually share the following analogy about our ancient predecessors. We would not have evolved had primitive man not been a premature ejaculator. In other words, if reproduction took long periods of vaginal penetration before an ejaculation occurred, mankind would have disappeared. At least from a survival perspective, it was important for man to ejaculate quickly with multiple partners.
Since this condition has never been discussed much until now and was always associated with a psychiatric diagnosis, all treatment has included psychotherapy. This was typically done as a last resort and was only considered after the condition had caused a substantial amount of marital discord. The famous procedure now known as the semen technique, or the stop and start, or squeeze technique, was utilized. It is now understood that this technique worked well initially but rarely provided long-term results.
Topical treatments were always recommended and these were nothing more than local anesthetics applied to the penis to dull some of the sensation. They were marginally effective and in some patients they worked well for short periods. It was important to avoid using these treatments without a condom because they caused vaginal anesthesia and took away some of the female partner's sensation as a result.
SSRIs and other antidepressants as treatments for premature ejaculation
The observation that men who were taking certain types of antidepressants were able to substantially delay ejaculation was the event that focused research on using these drugs as a treatment for premature ejaculation. Initially, studies were done with the drug, clomipramine, an antidepressant in the family of drugs known as tricyclic antidepressants. These drug studies measured latency or the period from the time of penetration to the time of ejaculation. We now know that using these drugs in various regimens can dramatically improve the latency period. At higher doses, however, the same drugs tend to cause side-affects associated with sexual dysfunction. The down side of treatment with clomipramine, for example, is that it tends to produce significant side effects initially including headaches and nausea, and tends to remove some of the spontaneity from intercourse.
Another class of antidepressant drugs that has shown promise is that of the selective serotonin reuptake inhibitors, also known as SSRIs, including fluoxetine, sertraline and paroxetine. These drugs have been used "off-label" for this condition and have been very popular on the Internet. Some studies have been done with the goal of gaining their labeled use for premature ejaculation. In my clinical experience, many men desire oral medication options that can be used on demand or on an “as needed” basis.
Since we now know that treatment for premature ejaculation is possible, research efforts to find a reasonable treatment will continue, especially toward finding a treatment that is without side effects, is cost-effective and allows a man to maintain control. Many of my male patients that have tried "off-label" use of SSRIs have made two interesting discoveries. First, men who are in a stable sexual relationship will undoubtedly try the medication without first telling their wives. The drug causes a substantial increase in the latency time from penetration to ejaculation, which, in turn, causes a great deal of concern on the part of their partners that they are having an extramarital affair. After all, this is not the usual pattern of their lovemaking.
The other discovery is that many men stop using the drug over time because, in fact, they like a shorter latency period and are comfortable with rapid ejaculation as their normal pattern of lovemaking. Education is very important in this situation.
The SSRIs work by increasing the amount of serotonin available to the central nervous system. Certain herbal compounds can produce a similar effect by increasing the amount of natural precursor material available. Increasing serotonin levels using serotonin precursors from a concentrated standardized botanical source is an effective way to mimic the effects of the SSRIs but in a natural, herbal fashion. This increase occurs because serotonin precursors provide the raw material (building blocks) to convert dietary L-5-hydroxytrypophan or L-5-HTP into serotonin for the body to use. By also providing the enzymatic cofactors / nutrients to speed up a chemical reaction in the brain can actually increase the amount of serotonin formed and available for use by the body. In fact, this "enzymatic-approach" to neurotransmitters is how Viagra® works. It (Viagra®) prevents the breakdown of the enzyme that produces the erection. However, Viagra has no effect on serotonin or anxiety levels and consequently has no effect in preventing or delaying early ejaculation.
Anxiety is a major factor in premature ejaculation, especially during the early period of sexual experience. Sexually inexperienced men are often very tense and, as a consequence, will experience premature ejaculation. Naturopaths use an extract of the herb Passiflora coerulea, known as chrysin, to produce anti-anxiety effects through the same receptors as the ones Valium® uses. Of course, it's a natural product (bioflavinoid) that does not cause sedation or muscle relaxation. This herb is widely used among body builders, in very high doses, to maximize the effects of testosterone precursors or anabolic steroids.
Retrograde ejaculation and other ejaculatory dysfunctions
It is possible to have an orgasm without the expulsion of fluid and it is also possible for fluid to go backward into the bladder. This is called retrograde ejaculation and most commonly occurs in men who have had prostate surgery or in men who have had surgery that results in damage to the sympathetic nerves. Another very common cause of retrograde ejaculation is medication, particularly newer medications used to treat prostate blockage symptoms.
Because much can happen along this complex chain of events to disrupt the process, there are many causes of ejaculatory dysfunction. These include congenital problems that affect the structures involved with both orgasm and ejaculation, and more commonly, acquired causes due to trauma including urologic surgery to treat prostatic obstruction. In these men, retrograde ejaculation is common because the bladder neck, which normally acts as a dam, has been cut and the ejaculant, rather than being propelled forward through the penis, follows the easier path backwards into the bladder.
Other problems with ejaculation
Other dysfunctions are caused by parasitic infections or healed venereal diseases and still others may be the result of traumas such as back injuries that cause paraplegia, colon cancer surgery, or even testicular cancer.
One of the most common causes is drug therapy. Many drugs are known to impair ejaculation, including alcohol, medications used to treat depression such as amitriptyline, and Valium® type drugs. Even cold & flu pills can create the conditions for retrograde ejaculation. Many physicians are not aware that these medications may cause problems with ejaculation.
Some new studies indicate that premature ejaculation may be related to hypersensitivity of the nerves that go to the penis and there may even be an organic basis for this problem.
Steidle, CP. The Impotence Sourcebook. Lowell House. 1998.
Posted January 2002
Updated August 2009