Premature ejaculation

Premature ejaculation (PE) is a condition in which a man ejaculates earlier than he or his partner would like him to. Premature ejaculation is also known as rapid ejaculation, rapid climax, premature climax, or early ejaculation. Masters and Johnson defines PE as the condition in which a man ejaculates before his sex partner achieves orgasm, in more than fifty percent of their sexual encounters. Other sex researchers have defined premature ejaculation as occurring if the man ejaculates within two minutes of penetration; however, a survey by Alfred Kinsey in the 1950s demonstrated that three quarters of men ejaculate within two minutes of penetration in over half of their sexual encounters.

Most men experience premature ejaculation at least once in their lives. Because there is great variability in both how long it takes men to ejaculate and how long both partners want sex to last, researchers have begun to form a quantitative definition of premature ejaculation. Current evidence supports an average intravaginal ejaculation latency time (IELT) of six and a half minutes in 18-30 year olds. If the disorder is defined as an IELT percentile below 2.5, then premature ejaculation could be suggested by an IELT of less than about 2 minutes. Nevertheless, it is well accepted that men with IELTs below 1.5 minutes could be "happy" with their performance and do not report a lack of control and therefore would not be defined as having PE. On the other hand, a man with 2 minutes IELT may have the perception of poor control over his ejaculation, distressed about his condition, has interpersonal difficulties and therefore be diagnosed with Premature Ejaculation.

Possible psychological and environmental factors
Psychological factors commonly contribute to premature ejaculation. While men sometimes underestimate the relationship between sexual performance and emotional well-being, premature ejaculation can be caused by temporary depression, stress over financial matters, unrealistic expectations about performance, a history of sexual repression, or an overall lack of confidence. Interpersonal dynamics strongly contribute to sexual function, and premature ejaculation can be caused by a lack of communication between partners, hurt feelings, or unresolved conflicts that interfere with the ability to achieve emotional intimacy. Neurological premature ejaculation can also lead to other forms of sexual dysfunction, or intensify the existing problem, by creating performance anxiety. In a less pathological context, premature ejaculation could also be caused simply by extreme arousal.

One study of young married couples (Tullberg, 1999) reported that the husband's IELT seems to be affected by the phases of the wife's menstrual cycle, the IELT tending to be shortest during the fertile phase. Other studies suggest that young men with older female partners reach the ejaculatory threshold sooner, on average, than those whose partners are their own age or younger.

Mechanism of ejaculation
The physical process of ejaculation requires two sequential actions: emission and expulsion. The emission phase is the first phase. It involves deposition of seminal fluid from the ampullary vas deferens, seminal vesicles, and prostate gland into the posterior urethra. The second phase is the expulsion phase. It involves closure of bladder neck, followed by the rhythmic contractions of the urethra by pelvic-perineal and bulbospongiosus muscle, and intermittent relaxation of external urethral sphincters.

It is believed that the neurotransmitter serotonin (5HT) plays a central role in modulating ejaculation. Several animal studies have demonstrated its inhibitory effect on ejaculation. Therefore, it is perceived that low level of serotonin in the synaptic cleft in these specific areas in the brain could cause premature ejaculation. This theory is further supported by the proven effectiveness of selective serotonin reuptake inhibitors (SSRIs), which increase serotonin level in the synapse, in treating Premature Ejaculation.

Sympathetic motor neurons control the emission phase of ejaculation reflex, and expulsion phase is executed by somatic and autonomic motor neurons. These motor neurons are located in the thoracolumbar and lumbosacral spinal cord and are activated in a coordinated manner when sufficient sensory input to reach the ejaculatory threshold has entered the central nervous system.

Several areas in the brain, and especially the nucleus paragigantocellularis, have been identified to be involved in ejaculatory control. Scientists have long suspected a genetic link to certain forms of premature ejaculation. In one study, ninety-one percent of men who have had premature ejaculation for their entire lives also had a first-relative with lifelong premature ejaculation. Other researchers have noted that men who have premature ejaculation have a faster neurological response in the pelvic muscles. Simple exercises commonly suggested by sex therapists can significantly improve ejaculatory control for men with premature ejaculation caused by neurological factors. Often, these men may benefit from anti-anxiety medication or SSRIs, such as sertraline or paroxetine, as these slow down ejaculation times. Some men prefer using anaesthetic creams; however, these creams may also deaden sensations in the man's partner, and are not generally recommended by sex therapists.

Differential diagnosis
Premature ejaculation should be distinguished from erectile dysfunction related to the development of a general medical condition. Some individuals with erectile dysfunction may omit their usual strategies for delaying orgasm. Others require prolonged noncoital stimulation to develop a degree of erection sufficient for intromission. In such individuals, sexual arousal may be so high that ejaculation occurs immediately. Occasional problems with premature ejaculation that are not persistent or recurrent or are not accompanied by marked distress or interpersonal difficulty do not qualify for the diagnosis of premature ejaculation. The clinician should also take into account the individual's age, overall sexual experience, recent sexual activity, and the novelty of the partner. When problems with premature ejaculation are due exclusively to substance use (e.g., opioid withdrawal), a substance-induced sexual dysfunction can be diagnosed.

Other ejaculation disorder types

 * Delayed ejaculation - Ejaculation takes a long time
 * Retrograde ejaculation - Semen flows from the prostate gland into the bladder rather than exiting out of the penis.
 * Inhibited orgasm in males

Treatment
In mundane cases, treatments are focused on gradually training and improving mental habituation to sex and physical development of stimulation control. In clinical cases, various medications are being tested to help slow down the speed of the arousal response.

Dapoxetine (Priligy) is a short-acting selective serotonin reuptake inhibitor (SSRI) marketed for the treatment of premature ejaculation. Dapoxetine is the only drug with regulatory approval for such an indication. Currently, it is approved in several European countries, including Finland, Sweden, Portugal, Austria and Germany. Dapoxetine is also being considered for approval in other European countries and in the United States, where it is currently in Phase III of the U.S. Food and Drug Administration (FDA) approval process.

The Masters and Johnson Method is a start and stop technique, where the man learns to feel and control the sensations that lead to orgasm. The method is to bring himself close to orgasm and then rest for a sufficient amount of time that he is below 'the point of no return'. Once adequately below this point, he can start thrusting again till he is close to orgasm and then rests again. With practice, this start and stop technique can be repeated many times to have a long period of intercourse, with ejaculation when the man chooses. The rest period may be for seconds or minutes, and men may be able to rest whilst inside the partner, and continue kissing or caressing so that intimacy continues (i.e. the partner may not even realise the man is resting his penis). The rest period may be simply slowing the rate of the thrusting rather than the a cessation of thrusting. Men can practice this start and stop technique with a partner or by themselves, and they could time themselves and see if they can improve the amount of time they can maintain an erection without ejaculation. They could even learn to rate their level of arousal on a ten-point scale to assess that their level of arousal is sufficiently high, but below ejaculation level. An arousal level of 7/10 is optimal, with rest if arousal is higher and increased thrusting if arousal is lower

Another method is control instead of prevention. Performing routines such as Kegel exercises, which, as mentioned above, relate to gaining voluntary control of the PC muscle and thus give a person more control over ejaculation. When ejaculating, the control of this muscle is said to be lost, and thus, learning to maintain control of it can be of aid to some.

One more method is entitled intracavernous pharmacotherapy. This is a method of injecting a drug known as a vasodilator directly into the penis to help men control premature ejaculation and maintain their erection. It has been proven to be effective in over seventy percent of test patients. This method is used by companies such as Florida Men’s Medical Clinic, Boston Medical Group and others.