Premature Ejaculation

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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. While there is no agreed upon criteria, the most common definition is that Premature ejaculation occurs if the man ejaculates within two minutes of Sexual penetration|penetration Waldinger M.D., Berendsen H.H., Blok B.F., et al. Premature Ejaculation and Serotonergic Anti-Depressants - Induced Delayed Ejaculation: The Involvement of the Serotenergic System Behavioural Brains Res. 1998 92(2):111-118; 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. Premature Ejaculation can be differentiated between two types. Primary, which is present from the time a male begins puberty, and Secondary which is acquired later in the man's life. Premature Ejaculation can be further divided between; Global Premature Ejaculation, which occurs with all partners and in all contexts and Situational Premature Ejaculation which occurs in certain situation or with specific partners. Godpodinoff M.L. Premature Ejaculation: Clinical Subgroups and Etiology Journal of Sex and Marital Therapy 1989; 15(2):130-134

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, if at all, an accurate prevalence rate is hard to determine, estimates range from as low as 5% to as high as 30% 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 possible that men with abnormally low IELTs could be "happy" with their performance and do not report a lack of control. Likewise men with higher IELTs may consider themselves premature
ejaculators, suffer from detrimental side effects normally associated with premature ejaculation, and even benefit from treatment.

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 clinical depression|depression , stress over financial matters, unrealistic expectations about performance, a history of sexual repression (psychology)|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 emotion al 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.

Another suggestion offered by evolutionary biologists to explain premature ejaculation in young or inexperienced men is that early ejaculation maximizes the chances of impregnating a female if sex is infrequent, furtive, or rushed. For example, males who are lower in the social hierarchy, especially among troupe primates such as chimpanzees, sexual access to females can be usually limited to dominant males; therefore, male chimpanzees taking covert advantage of rare copulatory opportunities will have greater likelihood of impregnating a female and passing on his genes if he achieves climax quickly. The body may interpret infrequent sex as evidence of scarcity and therefore attempt to utilize that potentially limited opportunity by passing genes as quickly as possible.

Possible physical factors

Mechanism of ejaculation

The emission phase is the first phase. It involves deposition of seminal fluid from the ampulla of ductus deferens|ampullary vas deferens , seminal vesicle s, and prostate gland into the Posterior (anatomy)|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 sphincter s.

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 genetics|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 , paroxetine or Dapoxetine , as these slow down ejaculation times. http://www.healthfinder.gov/newsletters/relation092506.asp 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, and a diagnosis should be made using the patients sexual history looking for a history of; decreased intravaginal ejaculation latency time ( IELT ), a poor control over ejaculation, dissatisfaction felt by patient or partner, as well as feelings of distress by patient or partner. Diaz, V.A., Close, J.D. Male Sexual Dysfunction. Primary Care. 2010; 37(3):473-489.. Premature Ejaculation may co occur with Erectile dysfunction , with almost half of men suffering from premature ejaculation experiencing erectile dysfunction as well. Lauman E.O., Nicolosi A., Glasser D.B., et al. Sexual Problems among Women and Men Aged 40 - 80 Years; Prevalence and Correlates Identified in a Global Study of Sexual Attitudes and Behaviours. International Journal of Impotence Research 2005; 7(1):39 - 57. Some individuals with erectile dysfunction may omit their usual strategies for delaying orgasm, while 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

When deciding the appropriate treatment, it is important for physician to distinguish PE as a "complaint" versus PE as a "syndrome". About 20 years ago, PE was classified into "lifelong PE" and "acquired PE". Recently, a new classification of PE was proposed based on controlled clinical and epidemiological stopwatch studies, and it included 2 other PE syndromes: "natural variable PE" and "premature-like ejaculatory dysfunction". Only men with lifelong PE with Intravaginal ejaculation latency time (IELT) <1 to 1.5 minutes should require medication as a first option, along with or without therapy. For men who fall into one of the other categories, treatment should consist of patient reassurance, behavior therapy, and/or psychoeducation to explain irregular early ejaculation is a normal variation.

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., February 11, 2009 Dapoxetine is currently waiting for U.S. Food and Drug Administration (FDA) approval after concluding the Phase III study, which included participants from 25 other countries, including the United States. In this diverse population, dapoxetine significantly improved all aspects of PE and was generally well tolerated.

Tramadol (Ultram or Tramal) is an FDA approved atypical oral analgesic for mild pain. It is atypical because it is similar to an opioid, is an agonist at the mu receptor, but also is similar to an anti-depressant in that it increases levels of serotonin and norepinephrine. Tramadol also has few side effects, low abuse potential, and increases (IELT) 4-20 fold in >90% men.,Kaynar, M. & Abdel-Hamid, I.A. On-Demand Tramadol Hypochloride Use in Premature Ejaculation Treatment. Journal of Urology 2012; 71(31):145-149

Clomipramine (Anafranil) is sometimes prescribed to treat PE. One side effect of the drug can help delay ejaculatory response. The side effect is described by the Mayo Clinic as "Increased sexual ability, desire, drive, or performance."

Desensitizing creams that are applied to the tip and shaft of the penis can also be used prevent premature ejaculation. Such creams are applied on an "as needed" basis and have fewer systemic side effects. Although use of these creams may lead to insensitivity in the penis, and reduction of sensation for the partner due to contamination .MacCarty E.J. & Dinsmore W.W. Premature Ejaculation: Treatment Update International Journal of STD AIDS 2010; 21:77-81

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. BioMedSearch, 14. A A Sidi; J S Cameron; D D Dykstra; Y Reinberg; P H Lange, (2007)

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