Practice Essentials
Premature (early) ejaculation is the most common sexual disorder in men younger than 40 years, with 30-70% of males in the United States affected to some degree at one time or another. It has historically been considered a psychological disease with no identified organic cause.
Signs and symptoms
Premature ejaculation can be lifelong or acquired. With lifelong premature ejaculation, the patient has experienced premature ejaculation since first beginning coitus. With acquired premature ejaculation, the patient previously had successful coital relationships and only now has developed premature ejaculation.
Patient characteristics in lifelong premature ejaculation can include the following:
- Psychological difficulties
- Deep anxiety about sex that relates to 1 or more traumatic experiences encountered during development
In patients with lifelong premature ejaculation, inquire about the following:
- Previous psychological difficulties
- Early sexual experiences
- Family relationships during childhood and adolescence
- Peer relationships
- Work or school
- General attitude toward sex
- Context of the event (eg, marital versus nonmarital)
- Sexual attitude and response of the female partner
- Nonsexual aspects of the current relationship
- level of involvement of the sexual partner in treatment
Clues from these and similar questions usually point toward causative factors that may be addressed specifically with therapy.
Patient characteristics in cases of acquired premature ejaculation can include the following:
- Erectile dysfunction
- Performance anxiety
- Psychotropic drug use
In patients with acquired premature ejaculation, inquire about the following:
- Previous relationships
- Current relationship
- Nonsexual aspects of the current relationship
- level of involvement of the sexual partner in treatment
- Impotence problems
- Capacity for coitus
- Sexual context
- Sexual response of partner
Diagnosis
In males with premature (early) ejaculation and no other medical problems, no specific conventional laboratory tests aid or affect treatment. Checking the patient’s levels of serum testosterone (free and total) and prolactin may be appropriate if premature ejaculation is observed in conjunction with an impotence problem. If depression or other conditions coexist, laboratory studies specific to depression or to another medical or psychological problem are appropriate.
Other conditions that should be considered in making the diagnosis of premature ejaculation include the following:
- Severely delayed orgasm in the female partner
- Adverse effect from a psychotropic drug
- Presence of preejaculate
- Erectile dysfunction
Management
Medical treatment for premature (early) ejaculation includes several options. Any serious primary medical condition (eg, angina) should be treated, as should any accompanying erection problem (eg, erectile dysfunction). To achieve the best outcome, the female partner should be included as fully as possible in the treatment and counseling sessions. Outpatient care can be scheduled as appropriate for the clinical circumstances.
Nonpharmacologic therapy may include the following:
- Efforts to relief of underlying performance pressure on the male
- Sex therapy (eg, instruction in the stop-start or squeeze-pause technique popularized by Masters and Johnson)
- Second attempt at coitus – If another erection can achieve be achieved shortly after an episode of premature ejaculation, ejaculatory control may be much better the second time
Pharmacologic therapy may include the following:
- Topical desensitizing agents (eg, lidocaine and prilocaine) for the male
- Selective serotonin reuptake inhibitor (SSRI) therapy (eg, sertraline, paroxetine, fluoxetine, citalopram, or dapoxetine); alternatively, use of an agent with SSRI-like effect
- Phosphodiesterase type 5 (PDE5) inhibitor therapy (eg, sildenafil, tadalafil, or possibly vardenafil)
- Other agents (eg, pindolol or tramadol)
No recommended surgical therapy exists.
Background
Premature (early) ejaculation—also referred to as rapid ejaculation—is the most common type of sexual dysfunction in men younger than 40 years. An occasional instance of premature ejaculation might not be cause for concern, but, if the problem occurs with more than 50% of attempted sexual relations, a dysfunctional pattern usually exists for which treatment may be appropriate.
Most professionals who treat premature ejaculation define this condition as the occurrence of ejaculation earlier than both sexual partners wish. This broad definition thus avoids specifying a precise “normal” duration for sexual relations and reaching a climax. The duration of intimate relations is highly variable and depends on many factors specific to the individuals involved.
For example, a male may reach climax after 8 minutes of sexual intercourse, but if his partner regularly climaxes in 5 minutes and both are satisfied with the timing, this is not premature ejaculation. Alternatively, a male might delay his ejaculation for up to 20 minutes of sexual intercourse, but if his partner, even with foreplay, requires 35 minutes of stimulation before reaching climax, he may still consider his ejaculation and subsequent loss of erection premature because his partner will not have been satisfied (at least, not through intercourse).
Because many females are unable to reach climax at all with vaginal intercourse, no matter how prolonged, the second situation described may actually represent delayed orgasm in the female partner rather than premature ejaculation in the male; the problem can be either or both, depending on the point of view. Such differences in perspective highlight the importance of obtaining a thorough sexual history from the patient (and preferably from the couple).
Premature ejaculation may be lifelong or acquired. Lifelong premature ejaculation applies to individuals who have had the condition since they became capable of functioning sexually (ie, post puberty).
Acquired premature ejaculation means that the condition began in an individual who previously experienced an acceptable level of ejaculatory control and, for unknown reasons, began experiencing premature ejaculation later in life. Acquired premature ejaculation is not related to a general medical disorder and usually is not related to substance inducement, though in rare cases, hyperexcitability might be associated with a psychotropic drug and resolve when the drug is withdrawn.
Diagnostic criteria (DSM-5)
The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), classifies premature (early) ejaculation as belonging to a group of sexual dysfunction disorders that are typically characterized by a clinically significant inability to respond sexually or to experience sexual pleasure.
Sexual functioning involves a complex interaction among biologic, sociocultural, and psychological factors, and the complexity of this interaction makes it difficult to ascertain the clinical etiology of sexual dysfunction. Before any diagnosis of sexual dysfunction is made, problems that are explained by a nonsexual mental disorder or other stressors must first be addressed. Thus, in addition to the criteria for premature (early) ejaculation, the following must be considered:
- Partner factors (eg, partner sexual problems or health issues)
- Relationship factors (eg, communication problems and differing levels of desire for sexual activity)
- Individual vulnerability factors (eg, history of sexual or emotional abuse, existing psychiatric conditions such as depression, or stressors such as job loss)
- Cultural or religious factors (eg, inhibitions or conflicted attitudes regarding sexuality)
- Medical factors (eg, an existing medical condition or the effects of drugs or medications)
The specific DSM-5 criteria for premature (early) ejaculation are as follows:
- In almost all or all (75-100%) sexual activity, the experience of a pattern of ejaculation occurring during partnered sexual activity within 1 minute after vaginal penetration and before the individual wishes it
- The symptoms above have persisted for at least 6 months
- The symptoms above cause significant distress to the individual
- The dysfunction cannot be better explained by nonsexual mental disorder, a medical condition, the effects of a drug or medication, or severe relationship distress or other significant stressors
The severity of premature (early) ejaculation is specified as follows:
- Mild (occurring within approximately 30 seconds to 1 minute of vaginal penetration)
- Moderate (occurring within approximately 15-30 seconds of vaginal penetration)
- Severe (occurring before sexual activity, at the start of sexual activity, or within approximately 15 seconds of vaginal penetration)
The duration of the dysfunction is specified as follows:
- Lifelong (present since first sexual experience)
- Acquired (developing after a period of relative normal sexual functioning)
In addition, the context in which the dysfunction occurs is specified as follows:
- Generalized (not limited to certain types of stimulation, situations, or partners)
- Situational (limited to specific types of stimulation, situations, or partners)
Pathophysiology
Premature ejaculation is believed to be a psychological problem and does not represent any known organic disease involving the male reproductive tract or any known lesions in the brain or nervous system. The organ systems directly affected by premature ejaculation include the following:
- Male reproductive tract (ie, penis, prostate, seminal vesicles, testicles, and their appendages)
- Portions of the central and peripheral nervous system controlling the male reproductive tract
- Reproductive organ systems of the sexual partner (if female) that may not be stimulated sufficiently to achieve orgasm
Perhaps the most pronounced effect of premature ejaculation, however, is psychological: Both partners are likely to be dissatisfied emotionally and physically by this problem. Attempted pregnancy is a particular concern. If the premature ejaculation is so severe that it happens before commencement of sexual intercourse, conception will not be possible unless artificial insemination is used.
Some have questioned whether premature ejaculation is purely psychological. A number of investigators have found differences in nerve conduction/latency times and hormonal differences in men who experience premature ejaculation compared with individuals who do not. The theory is that some men have hyperexcitability or over sensitivity of their genitalia, which prevents downregulation of their sympathetic pathways and delay of orgasm.
A group of nerves in the lumbar spinal cord has been identified as the possible generator of ejaculation. This nerve site is thought to be linked to excitatory and inhibitory dopamine pathways in the brain, which play significant roles in sexual behavior. While research continues, this knowledge is providing the foundation for possible development of medications specifically targeting delay of ejaculation.
Other questions have been raised regarding possible biochemical components of premature ejaculation. Testosterone is thought to play a role in the ejaculatory reflex. Higher free and total testosterone levels have been demonstrated in men with premature ejaculation than in men without premature ejaculation.
Research published in a Chinese andrology journal showed that semen from men with premature ejaculation contained significantly less acid phosphatase and alpha-glucosidase than did the semen of control subjects. The researchers concluded that these biochemical parameters may reflect dysfunction of the prostate and epididymis, possibly contributing to premature ejaculation; however, their conclusions have yet to be supported by subsequent studies.
A study by Corona et al found that many men with premature ejaculation have low serum prolactin levels. However, this same study found that men in the lowest quartile of serum prolactin levels who had premature ejaculation also demonstrated associated metabolic syndrome, erectile dysfunction, and anxiety. Thus, whereas biochemical markers (eg, prolactin) may contribute to premature ejaculation, organic and psychological associations (eg, anxiety) suggest that biochemical parameters play only a partial role. Further research is needed.
Psychological factors have been found to contribute greatly to premature ejaculation, beyond merely reducing the time to ejaculation. Whereas patients with premature ejaculation show significantly lower intravaginal ejaculatory latency time (IELT) overall, IELT in those who fit DSM-5 criteria for premature ejaculation overlaps with IELT in patients who do not fit the criteria.
However, whereas a shorter IELT has been the measure of premature ejaculation in many studies, the perception of ejaculation control has been shown to mediate patient or partner satisfaction with sexual intercourse and ejaculation-related distress. Although premature ejaculation probably is not a purely psychological disorder, such associations demonstrate that psychological factors play a significant role in its pathogenesis.
Etiology
As noted (see above), the cause of premature ejaculation is considered psychological, although this has not been definitively confirmed.
One psychological explanation for premature ejaculation is that males are conditioned by societal pressures to reach climax quickly because of fear of discovery when masturbating as teenagers or during early sexual experiences with others. This pattern of rapid attainment of sexual release is difficult to change in marital or long-term relationships. The increasing acknowledgment that female arousal and orgasm require more time than male arousal may lead to increased recognition and definition of premature ejaculation as a problem.
It has been theorized that evolutionary factors are involved. From an evolutionary perspective, it seems logical that males who can ejaculate rapidly might be more likely to fertilize a female than those who require prolonged stimulation to reach climax. The genes of a male who ejaculates rapidly (but not before intromission) would be more likely to be passed on. In some settings, a male who could not complete the fertilization process quickly might be pushed away or killed by a competing male because of his obvious vulnerability during intercourse.
Lifelong premature ejaculation
In patients with lifelong premature ejaculation, in which the male has never experienced sexual relations without also experiencing premature ejaculation, a deep-seated emotional disturbance may be present, and the causes may be multiple.
Sometimes, the behavior is a conditioned response resulting from teen masturbation practices, but it can also result from deep anxiety about sex that relates to traumatic experiences encountered by the patient during development (eg, incest, sexual assault, conflict with one or both parents, or other serious disturbances). In most cases of lifelong premature ejaculation, a primary care physician or a urologist should consult with a psychiatrist, psychologist, or other professional.
Acquired premature ejaculation
With regard to acquired premature ejaculation, some type of performance anxiety is often a major factor.
Performance pressure (ie, fear of failure to satisfy the partner) can arise from various precipitating events. Erectile dysfunction is one of the more common events of this type. Fear that an erection will not last may precipitate premature ejaculation. In such cases, the patient may say that the early climax was the result of being extremely excited by his partner, in an effort to avoid admitting that he was unable to maintain his erection throughout intercourse.
Often, however, the situation is more complex. Erectile dysfunction may not be involved, and the key factor may be, for instance, a belittling attitude on the part of the partner. In addition, a female partner actually may have difficulty achieving climax through intercourse and may require direct clitoral stimulation to experience an orgasm. If she does not communicate this to the male partner (and she may conceal it because of feelings about her own inadequacy), coital satisfaction is unlikely.
Because most physicians are not trained sex therapists, it is important to sort out conflicts in the relationship and then refer couples for counseling to professionals with experience and training in that area. Physicians who have some training or experience in treating premature ejaculation and are comfortable managing the problem may choose to begin treatment. If the patient does not respond favorably or if the physician is uncomfortable with treating the condition, the next step is referral to a sex therapist, psychologist, or psychiatrist.
Epidemiology
United States statistics
An estimated 30%-70% of American males experience premature ejaculation. The National Health and Social Life Survey (NHSLS) indicates a prevalence of 30%, which is fairly steady through all adult age categories. (In contrast, erectile dysfunction rises in prevalence with increasing age).
However, various surveys have shown that many men do not report premature ejaculation to their physician, possibly because of embarrassment or a feeling that no treatment is available for the problem. Some men might not even perceive premature ejaculation as a medical problem. Such survey data suggest that the percentage of men who experience premature ejaculation at some point in their lives is almost certainly more than the 30% reported in the NHSLS.
International statistics
Estimates of premature ejaculation in European countries and India mirror the prevalence in the United States. The prevalence in other parts of Asia, Africa, Australia, and elsewhere is unknown.
According to the DSM-5, the estimated prevalence of premature (early) ejaculation is highly variable and depends on the definition being employed. Although more than 20-30% of men aged 8-70 years report being concerned about the rapidity of their ejaculation, only 1-3% would be classified as having premature (early) ejaculation according to the current DSM-5 criteria (ie, ejaculation occurring within 1 minute after intromission and before the individual wishes).
Age- and race-related demographics
Premature ejaculation can occur at virtually any age in an adult man’s life. As a reported condition, it is most common in men aged 18-30 years but may also occur in conjunction with secondary impotence in men aged 45-65 years.
At present, there are no reproducible data indicating major differences between racial groups with respect to the incidence or prevalence of premature ejaculation. However, a few surveys suggest that some degree of racial variation may exist.
A telephone survey of 1320 men without erectile dysfunction by Carson et al found that premature ejaculation was reported by 21% of non-Hispanic African Americans, 29% of Hispanics, and 16% of non-Hispanic whites. An analysis of the NHSLS by Laumann et al found that premature ejaculation was more prevalent among African American men (34%) and white men (29%) than among Hispanic men (27%).
In a small study of a sexual health clinic in Australia, 59% of premature ejaculation diagnoses were in men of Asian or Middle Eastern descent, whereas 41% were in men of Western or European birth. However, in view of the small number of such studies and the lack of suitable control subjects, it is difficult to draw firm conclusions from these data.
Prognosis
Masters and Johnson maintain that the great majority (>85%) of men with premature ejaculation can be treated successfully with the squeeze-pause technique alone, typically within 3 months of the start of therapy. However, clinical experience varies widely, and some authors have reported much poorer success rates.
With a combination of methods, including selective serotonin reuptake inhibitor (SSRI) therapy, improvement or cure should be possible in most cases, provided that the couple (not just the man) is committed to working on the problem together. Numerous published reports also indicate that counseling and medical therapy can help achieve success rates as high as 85%, matching the high rates originally reported by Masters and Johnson.
The problem with all treatments for premature ejaculation is that the relapse rate ranges from 20% to 50%, depending on the study cited; thus, the durability of the response can be questionable. Some males may need to make a long-term commitment to periodically repeating the behavioral techniques; long-standing habits can be difficult to modify.
Some men who achieve success with medical therapy (ie, SSRIs) might need to use the medication for the rest of their lives, just as some people with depression need lifelong antidepressant therapy to prevent repeated bouts of the disorder and many people with hypertension need lifelong anti-hypertensive therapy to control their blood pressure. Precise long-term failure rates are not well established and depend on the duration of follow-up for a particular cohort of patients.
No known direct morbidity or mortality results from premature ejaculation. Indirectly, premature ejaculation may alter self-esteem, may cause marital dysfunction, and may be a factor in depression, with its obvious consequences. Severe premature ejaculation can cause stress within a marriage or other relationship, which might contribute to conflicts and separation or divorce in some cases. Conception is also difficult in cases of premature ejaculation before vaginal intromission.
Erectile dysfunction may be associated with premature ejaculation, and it may be difficult or impossible to establish which condition developed first. For lifelong premature ejaculation, associations with certain anxiety disorders have been noted. For acquired premature ejaculation, associations with drug withdrawal, thyroid disease, and prostatitis have been found.
Patient Education
Patients with premature ejaculation may be referred to a licensed sex therapist, psychologist, psychiatrist, or marital counselor for additional help. Numerous books and articles in the lay press are available at any public library. Many can also find information on the Internet regarding this subject.
Future research might indicate whether better sex education during adolescence can decrease the incidence of premature ejaculation in young men. Early successful treatment of erectile dysfunction may help prevent acquired premature ejaculation in older men.
