Definition of PE
The most common ejaculation dysfunction is premature ejaculation which is defined as ejaculation which always or nearly always occurs prior to or within about one minute of penetration. This is associated with the inability to delay ejaculation on all or nearly all penetrations. The definition also involves the presence of negative personal consequences such as distress, bother, frustration and/or the avoidance of sexual intimacy. So the definition always involves the ejaculation time and the amount of distress to the man and his partner.
The prevalence of premature ejaculation in most communities is between 20 and 30%. Research has shown that the average ejaculation time is 5.4 minutes, though most men ejaculate within 5-15 minutes.
Ejaculation involves emission controlled by the hypogastric nerves at T12 to L1 and expulsion involving the pudendal nerve at S1 to S3. It involves a number of chemicals including dopamine, serotonin and prolactin. The stages of normal ejaculatory physiology consist of emission where the bladder neck closes, ejection of the seminal fluid associated with coordinated pelvic floor contractions and the pleasurable sensation of orgasm.
PE causes and types
Premature ejaculation has four subsets:
- Primary lifelong PE usually occurs in younger men with an ejaculation time of less than 1-1.5 minutes. Primary PE is a neurobiological condition associated with changes in the hypothalamus of the brain, associated with a hypersensitive ejaculatory reflex now believed to arise from serotonin receptor sites in the brain.
- Secondary or acquired PE occurs in older men and can be associated with erectile dysfunction or various life stressors. The ejaculation time is around 2-3 minutes. Secondary PE can be associated with anxiety and other medical conditions such as erectile dysfunction, prostatitis and hyperthyroidism. PE resulting from anxiety often has a situational component, such as when starting a new relationship. Men with PE will usually have better control over their ejaculation time with masturbation. Older men who develop erection problems may develop PE as a compensatory mechanism.
- The third category is called natural variable PE where ejaculation time is inconsistent in that sometimes it is quick and sometimes it takes longer but the essence of this condition is that ejaculation time is unpredictable.
- The last category is a subjective condition called PE like ejaculation syndrome where the ejaculation time is “normal” though the man for various psychological reasons believes he is too fast though on questioning he may last anywhere between 10 and 30 minutes.
Treatment of PE
Treatment of premature ejaculation involves psychological, pharmacological, sexology and behavioural approaches. Even though there may not be a psychological cause of the PE, any man having this condition may develop a secondary performance anxiety that can benefit from psychological help. When considering treatment, consideration should be given to the man’s expectations of how long he should last as well as other factors such as the state of the relationship. Sometimes communication between the couple and simple adjustment of the couple’s sexual technique is adequate therapy.
The classic behavioural exercise is the stop start technique which involves repetitive stimulation of the penis each time stopping short of the point of ejaculatory inevitability allowing the arousal to temporarily subside. Over time this repetitive stimulation pushes back the point of ejaculation though it does require persistence and commitment over some months. The stop start technique can be carried out in 3 stages involving use of a dry hand, lubricated hand and finally penetration.
Another ejaculation delaying technique is the squeeze technique where the tip of the penis is firmly squeezed for about 10-15 seconds just before penetration.
Medication: The use of an anaesthetic spray combined with a condom may delay ejaculation. Stud Spray™ is available without a prescription from a pharmacy but must not be used without a condom. Pelvic floor exercises are said to improve erection quality and improve control of ejaculation. The only approved medication for the treatment of PE is dapoxetine (Priligy™). This medication is a short acting SSRI anti-depressant medication that is taken as a single dose between 1 and 3 hours before planned sexual activity. SSRI medication can be used off label on a daily basis though the medication must be taken daily without interruption for up to 1-2 years.
Sex therapy and counselling can help PE even if the cause is physiological as the inevitable secondary psychological component can be treated which can help improve the outcome.
Mindfulness exercises may help treat performance anxiety, erectile dysfunction and premature ejaculation. This involves putting aside a 15-20 minute session about 2 or 3 times a week but not at a time when stressed or tired. Using yoga type relaxing breathing techniques during mindfulness exercises can be helpful. The idea is to create an erotic focus not just in the genital region but other pleasurable areas of the body. These exercises can be done on ones own or together with a partner. These exercises begin with clearing one’s mind of everyday life hassles and stressors. The genitals can be touched but are not necessarily the focus of the exercise though the stop start exercise for PE can be incorporated into this routine. Please view the separate document on mindfulness excercises.