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Premature Ejaculation

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ZAKA CLINIC GULBERG LAHORE

Saad Ullah Siddiqui

Overview

Premature ejaculation is a male sexual disorder characterized by ejaculation that occurs sooner than a male or his partner would like during intercourse. 
Premature ejaculation (PE), also known as rapid ejaculation or premature climax, is the most common sexual disorder in men. It can lead to depression, anxiety, and relationship problems. 
&nbsp;

Premature ejaculation (PE)&nbsp;affects one in three men&nbsp;between the ages of 18 and 59<a href="#accordion">[1]</a>. In comparison to the United States, the estimated prevalence in Europe and India is similar<a href="#accordion">[7]</a>. According to research, premature ejaculation may be more common among African Americans (34%) than Hispanics (27%) or Whites (29%)<a href="#accordion">[7]</a>.

According to a study involving 500 couples, the average time for ejaculation is 5-and-a-half minutes after starting sex<a href="#accordion">[5]</a>. As per international guidelines, premature ejaculation is defined as ejaculating regularly within a minute of entering your partner<a href="#accordion">[5]</a>.

Occasional premature ejaculation is not concerning. However, when it becomes chronic, it can be frustrating for both partners, causing sexual dissatisfaction and making sex less enjoyable.&nbsp;

Although PE is a type of sexual dysfunction, it is not the same as erectile dysfunction (ED). However, the two can occur together. Approximately 30% of people with PE also suffer from erectile dysfunction<a href="#accordion">[7]</a>.

While PE is typically considered a psychological disorder, biology may also play a role. 
&nbsp;

The two categories of premature ejaculation are:<a href="#accordion">[3]</a>

<ul>
	<li>Primary (Lifelong) - This begins soon after the patient&rsquo;s first sexual experience. It is mostly triggered by traumatic sexual experiences.&nbsp; </li>
</ul>

<ul>
	<li>Secondary (Acquired) - This begins later in life after having previous sexual experiences without ejaculation problems. It can be triggered by diabetes, substance abuse, or alcohol use disorder. 
	&nbsp;</li>
</ul>

Premature ejaculation may also be classified based on severity. 

<ul>
	<li>Mild - When ejaculation occurs within 30 seconds to a minute of vaginal penetration, it is called mild PE.</li>
	<li>Moderate - The ejaculation occurs within 15-30 seconds of vaginal penetration.</li>
	<li>Severe - In severe PE, ejaculation occurs either before or during foreplay, at the start of sexual intercourse, or within 15 seconds of vaginal penetration.<a href="#accordion">[3]</a> <a href="#accordion">[5]</a> <a href="#accordion">[7]</a> 
	&nbsp;</li>
</ul>

Signs and Symptoms

The main symptom of PE is the inability to regularly defer ejaculation for longer than a minute after penetration. However, it can also happen during masturbation.

In some cases, men may have normal ejaculation sometimes and occasional premature ejaculations at other times. They may be diagnosed with natural&nbsp;variable premature ejaculation.

Occasional PE episodes are typically nothing to be concerned about. However, if PE happens regularly or has happened for a while, therapy might be required. 
&nbsp;

Causes

The central nervous system controls ejaculation. When a man is sexually excited, the brain sends signals to the reproductive organs. This leads to semen expulsion from the penis. There are two phases of ejaculation<a href="#accordion">[2]</a>: 
&nbsp;

<ul>
	<li>Emission - This phase involves sperm traveling from the testicles to the prostate and mixing with the seminal fluid to make semen.</li>
	<li>Expulsion - This phase is characterized by the contraction of the muscles at the base of the penis which forces the semen out of the penis. Orgasm and ejaculation usually occur together. However, some men may orgasm without ejaculating.</li>
</ul>

Premature ejaculation occurs when semen is expelled sooner than wanted during sexual intercourse. Although the exact cause remains unclear, it was once believed to be a purely psychological condition. However, researchers now believe it results from a complex interplay between psychological and biological elements. 
&nbsp;

<h5>Psychological Causes</h5>

<ul>
	<li>
	Early sexual encounters
	</li>
	<li>Poor body image</li>
	<li>Depression </li>
	<li>Anxiety regarding sexual experience</li>
	<li>Victims of sexual abuse</li>
	<li>Bring worried about early ejaculation</li>
	<li>Guilt</li>
	<li>Unrealistically high expectations about performance during sex</li>
	<li>Relationship problems 
	&nbsp;</li>
</ul>

<h5>Physical And Biological Causes</h5>

<ul>
	<li>
	Abnormal serotonin levels - Serotonin occurs naturally in the body. Increased amounts of serotonin in the brain increase the time of ejaculation and lower amounts can shorten the ejaculation time, leading to premature ejaculation.&nbsp;
	</li>
	<li>An underlying problem of erectile dysfunction.</li>
	<li>Hormonal imbalance of oxytocin, luteinizing hormone, prolactin, and thyroid stimulating hormone. These hormones play a role in sexual function in men.</li>
	<li>Penis that is unusually sensitive to stimulation.</li>
	<li>Infection and swelling of the urethra or prostate.</li>
	<li>Inherited genetic traits. 
	&nbsp;</li>
</ul>

There are no specific screening tests for premature ejaculation. Doctors suspect the condition based on the patient&rsquo;s history and clinical presentation. 
&nbsp;

Diagnosis

To establish a diagnosis of premature ejaculation, a urologist will first take a complete history from the patient. During the history, the doctor may ask the following questions: 
&nbsp;

<ul>
	<li>How long have you had PE?</li>
	<li>Do you experience PE at every sexual encounter?</li>
	<li>Does PE occur with all partners?</li>
	<li>How often does PE occur?</li>
	<li>Does PE occur during masturbation?</li>
	<li>Are there any problems with maintaining an erection?</li>
	<li>Has it affected your relationship? 
	&nbsp;</li>
</ul>

Moreover, the doctor will also ask about past traumatic experiences, any medical conditions, and the use of drugs or alcohol.

There are no specific imaging scans or laboratory tests to detect premature ejaculation. However, doctors may evaluate for levels of testosterone and prolactin if erectile dysfunction or loss of libido is present. Since hyperthyroidism can also cause PE, thyroid levels may also be checked.

Furthermore, a psychological/psychosexual assessment may be conducted to detect the emotional causes of PE. 
&nbsp;

As per the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), premature ejaculation is defined as<a href="#accordion">[7]</a>:

<ul>
	<li>Ejaculation occurs within a minute of vaginal penetration and sooner than wanted. It may happen during all or almost all sexual encounters.</li>
	<li>The symptoms may be present for at least 6 months and be a source of significant distress.</li>
	<li>Sexual dysfunction is not a result of a medical condition, nonsexual mental disorder, drug side effects, relationship problems, or other stressors. 
	&nbsp;</li>
</ul>

Treatment

Treatment of PE often involves a combination of psychological, behavioral, and pharmacological therapies. 
&nbsp;

<h5>Behavioral Therapy</h5>

<ul>
	<li>Start-And-Stop Technique: You or your spouse stimulates your penis until you feel like you&#39;re about to have an orgasm. Put an end to the arousal for around 30 seconds, or until the sensation goes away. Repeat the stimulation three or four more times before ejaculating. Try it three times a week, as advised by the American Urological Association, until you feel more in control of your ejaculation<a href="#accordion">[1]</a>.</li>
	<li>Squeeze Method: The patient is told to begin the regular sexual activity until he feels an ejaculation coming on. The patient or his partner will then grab the penis&#39; head and gently squeeze the region where the glans connect to the shaft. This usually causes the erection to subside&nbsp;fairly fast and is not uncomfortable. Sexual activity can resume after a proper break, once sexual arousal has adequately subsided. When done repeatedly, this has the potential to slow down subsequent ejaculation over time.&nbsp;Approximately 64% of patients have found this method to improve their ejaculation time, but the success rate declines to about 1/3rd after around 3 years<a href="#accordion">[7]</a>.</li>
	<li>Masturbation And Second Try: You may masturbate for around an hour before having sex because it can assist in delaying ejaculation during sexual intercourse with your partner. You might also try temporarily giving up sex&nbsp;altogether and engaging in other sexual activities. That might lessen the strain of having to perform during sexual activity.</li>
	<li>Distracted Thinking: This involves focusing on nonsexual things while being sexually excited. For example, naming players on a football team or all the buildings you pass on your way to work. </li>
</ul>

These solutions may take many weeks to become successful, and there is no certainty that they will solve the issue on their own. 
&nbsp;

<h5>Counseling</h5>

A psychologist, psychiatrist, couple&rsquo;s therapist or sex therapist can help in cases of PE caused by emotional or psychological problems. Such as performance anxiety, sadness, stress, guilt, or a troubled relationship. 
&nbsp;

<h5>Oral Drugs&nbsp;</h5>

Many drugs can delay orgasm. Some of these medications are used to treat premature ejaculation even though the Food and Drug Administration has not approved them for this use. It is possible to receive a prescription for these drugs for daily or occasional use. They may also be prescribed alone or in conjunction with other therapies.<a href="#accordion">[3]</a>

<ul>
	<li>Antidepressants - A side effect of antidepressants is delayed orgasm. Selective serotonin reuptake inhibitors (SSRIs), such as paroxetine, escitalopram, sertraline, citalopram, and fluoxetine are used as treatment options. Paroxetine is found to be the most effective in the United States. It can take up to 5-10 days to begin to work, and 2-3 weeks to see the full effect of the treatment. If SSRIs fail to treat the problem then you may be prescribed tricyclic antidepressant clomipramine.</li>
	<li>Painkillers - Tramadol, which is a painkiller also has the side effect of delaying ejaculation. They may be used if SSRIs have been ineffective, but cannot be used in combination with SSRIs.</li>
	<li>Erectile Dysfunction Medication - Phosphodiesterase-5 inhibitors, such as sildenafil, tadalafil, avanafil, and vardenafil are treatments for erectile dysfunction which might also help with PE. They can help by maintaining the erection which can delay ejaculation. Sometimes it can take an hour for these and other ED drugs to start working. Moreover, it can take some trial and error to get the proper dose, so cooperate with the prescribing healthcare provider.</li>
</ul>

&nbsp;

<h5>Topical Numbing Agents</h5>

Another treatment to postpone ejaculation is anesthetic (numbing) lotions and sprays applied&nbsp;to the head and shaft of the penis. The anesthetic cream or spray is applied to the penis and allowed to absorb for 10 to 30 minutes, or until your penis feels less sensitive. Before having sex, you should cleanse your penis to avoid numbing your partner&#39;s vagina or losing your erection. They are offered over the counter. On the other hand, a cream with prilocaine and lidocaine is available on prescription. 
&nbsp;

<h5>Condoms</h5>

Your sensitivity may be slightly lessened by using a condom, which will enable you to keep your erection for longer without ejaculating. There are also condoms sold for &quot;climax control.&quot; The numbing agents in these condoms, including benzocaine, help to gently muffle the nerve reactions in your penis. Thicker condoms can also reduce sensitivity and delay ejaculation. 
&nbsp;

<h5>Home Remedies And Supplements For PE</h5>

<ul>
	<li>
	Zinc supplements can help in the production of testosterone which may help with PE. However, taking too much zinc can lead to side effects, like nausea, vomiting, diarrhea, stomach and kidney damage, and a metallic taste in the mouth.<a href="#accordion">[8]</a>
	</li>
	<li>Ayurvedic herbal medicine, which is India&rsquo;s traditional healing system, is a mixture of herbs that are now also available in the form of capsules. A 2017 study concluded that men who used ayurvedic medicine felt a slight increase in their ejaculation time. However, potential side effects are, dizziness, stomach pain, mild pain, and decreased libido.</li>
	<li>Chinese herbal medicine can treat PE by improving sexual health and energy. A 2017 study found that Chinese herbal medicines can increase ejaculation time by 2 minutes. However, side effects include stomach pain, mild pain, and dizziness.</li>
	<li>Improving your diet can aid in increasing the time taken to ejaculate. These include pumpkin seeds, yogurt, spinach, almonds, kidney beans, garlic, oysters, sesame seeds, peas, dark chocolate, chickpeas, beef, soybeans, and lamb.</li>
	<li>Pelvic floor exercises can impact your climax time greatly. A 2014 study found that men can control their ejaculatory reflex better with pelvic floor exercises. They are performed in the following steps: 
	&nbsp;</li>
</ul>

<ol>
	<li>&nbsp;By halting mid-stream while urinating or tensing the muscles that prevent you from passing gas, you can locate the proper muscles.</li>
	<li>&nbsp;You should tense your pelvic floor muscles for 3 seconds while lying down, then let them rest for 3 seconds. Repeat this at least ten times. Repeat at least three times every day.</li>
	<li>&nbsp;As your muscles get stronger, gradually increase&nbsp;the number of seconds. Try out different positions by standing, moving around, or sitting down.</li>
	<li>&nbsp;Remember to breathe and concentrate just on your pelvic floor muscles. Avoid contracting your buttocks, thighs, or abs. 
	&nbsp;</li>
</ol>

Note: Antidepressants are not approved for the treatment of PE in all countries and should never be used without a doctor&rsquo;s prescription as they can have serious side effects. Dosages can only be recommended by a healthcare professional. All types of medicines and supplements should only be used after a doctor&rsquo;s consultation. 
&nbsp;

Complications of premature ejaculation include:<a href="#accordion">[3]</a>

<ul>
	<li>Fertility Issues - PE can make it hard for couples to conceive. This can be a problem if ejaculation occurs before entering the vagina.</li>
	<li>Relationship issues and stress</li>
	<li><a href="https://merisehat.pk/disease/depression">Depression</a></li>
	<li>Low self-esteem 
	&nbsp;</li>
</ul>

The factors that can increase the risk of premature ejaculation are:

<ul>
	<li><a href="https://merisehat.pk/disease/erectile-dysfunction">Erectile Dysfunction</a> - If you struggle to achieve or maintain an erection, you may be more susceptible to premature ejaculation. You may rush through sex out of concern that you won&#39;t have another erection. This can happen whether or not you are aware of it.</li>
	<li>Stress - Premature ejaculation can be triggered by emotional or mental stress in any aspect of life. Stress can make it difficult to unwind and concentrate while having sex.<a href="#accordion">[3]</a> 
	&nbsp;</li>
</ul>

According to research, several drugs may be helpful in the treatment of PE but require more studies. These drugs include:

<ul>
	<li>Silodosin - This is used to treat prostate gland enlargement</li>
	<li>Modafinil - This drug helps treat narcolepsy</li>
	<li>OnabotulinumtoxinA (Botox) - There is an ongoing study on how injecting Botox can help relax the muscles that cause ejaculation; hence, delaying ejaculation.<a href="#accordion">[3]</a> 
	&nbsp;</li>
</ul>

Key Points

<ul>
	<li>The expulsion of semen from the penis is known as ejaculation. Premature ejaculation (PE) is when semen is ejaculated sooner than a male or his partner would like during intercourse.</li>
	<li>Psychological and biological elements both play a role in causing PE.</li>
	<li>Premature ejaculation affects almost one in three men falling&nbsp;between the ages of 18 and 59.</li>
	<li>To establish a diagnosis of premature ejaculation, a urologist will first take a complete history from the patient. The doctor will also ask about past traumatic experiences, any medical conditions, and the use of drugs or alcohol. </li>
	<li>There are no specific imaging scans or laboratory tests to detect premature ejaculation. However, doctors may evaluate for levels of testosterone and prolactin if erectile dysfunction or loss of libido is present.</li>
	<li>Complications include relationship and fertility issues.</li>
	<li>Treatment of PE often involves a combination of psychological, behavioral, and pharmacological therapies.</li>
	<li>Antidepressants, painkillers, and ED pills are often used to treat premature ejaculation.</li>
	<li>Pelvic floor exercises can impact your climax time greatly. A 2014 study found that men could control their ejaculatory reflex better with pelvic floor exercises. 
	&nbsp;</li>
</ul>