Overview | Causes | Treatment

Overview
Premature ejaculation is a problem that plagues up to 36 million men if it is defined as ejaculation within five minutes. It is important to recognize, however, that premature ejaculation is a subjective diagnosis and totally depends on the satisfaction of the partners.

You don't have a premature ejaculation problem unless you frequently ejaculate before or shortly after beginning intercourse.

There are a great number of misconceptions and myths about premature ejaculation. The following are NOT typically causes of premature ejaculation:

  • Men are too excited to focus on bodily sensation.
  • Some men's first experience with intercourse was in a tense situation where hurrying was beneficial, like in a car, and they then learned a bad habit.
  • Being so concerned about performance they didn't pay attention to their own sensations
  • Guilt about enjoying sex or pleasure of any kind
  • Worrying about maintaining erections
  • Unresolved relationship issues
  • General life stress

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Causes
Through the years, many physical causes have been linked to premature ejaculation. However, there are very few medical reasons that have been documented as causing premature ejaculation.

In the early 1990s, research indicated that the pelvic muscles, specifically the muscles that surround the erectile bodies in the penis, are in a hyperactive state in men with premature ejaculation.

Further, it is known that during the ejaculation process there is increased activity of these same muscle groups. Consequently, it is likely that men who have premature ejaculation have hyperactive muscles that are already on their way toward the threshold to producing ejaculations.

Over the past few years that I have been evaluating and treating men with impotence and premature ejaculation (in excess of 3,000 men), we have noticed that men with premature ejaculation have increased sensitivity to vibration in the penis when compared to men without premature ejaculation. It is likely that premature ejaculation, at least in some men, may be due to a combination of hypersensitivity of the penis and hyperspasticity of the pelvic muscles. I should stress, though, that this is my idea and not one that’s been evaluated in controlled trials.

There is also a biochemical explanation for premature ejaculation that is showing a great deal of promise. The first hints of this came with the release of several anti-depressive medications called selective serotonin reuptake inhibitors (SSRIs), the best known of these being Prozac. One common side effect of SSRIs is delayed ejaculation or even inability to ejaculate. Since serotonin in he brain is one of the molecules involved in ejaculation, this led to the idea that low serotonin levels might cause premature ejaculation. We’ll discuss this further in the treatment section.

Currently, my approach to premature ejaculation consists of a history and a physical examination specifically geared to determine the amount of sensitivity of the penis and detect any neurological problem. In many of my cases, the patient's problem relates to hypersensitivity of the penis.
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Treatment
Most cases of premature ejaculation are now treated pharmaceutically, but it’s worth briefly mentioning behavioral-training methods that were widely used in the past. Masters and Johnson developed the squeeze method decades ago, and there is also Dr. Helen Kaplan’s stop-start method. Both of these methods can and do achieve successes. Unfortunately, the results don’t appear to last. They might work for more than half of couples initially, but by three years later that number drops to 25% or less.

Drug therapy
As I noted above, delayed ejaculation is a known side effect of anti-depressive medications, especially those called SSRIs. Over the past decade, considerable experience has been gained in using them to actually treat premature ejaculation. No drug has been approved by the FDA for treating premature ejaculation, but several do help.

The most intensely studied medications have been Prozac, Paxil, Zoloft and Anafranil (a different kind of anti-depressant). Of these, Paxil seems to be the most effective. Depending on the dose, it may increase time to ejaculation from 1 minute to as long as 10 minutes. The others are also effective, although Anafranil tends to produce more side effects than the SSRIs.

The drug may be taken daily or about four hour before intercourse, although daily use is more effective. It takes one to two weeks for the daily dosing to become effective, and many men find that they can then stop the daily dose and just take the medication when they’re expecting to have intercourse.

Few of my patients mention any side effects with the SSRIS, but the recognized, if rare, effects are reduced libido, dry mouth, nervousness, nausea, diarrhea headache, drowsiness.

On the Horizon
There is a drug in the last phase of clinical trials that is designed specifically to treat premature ejaculation. Dapoxetine hydrochloride is similar to an SSRI in that it prevents the transport, rather than the reuptake, of serotonin. Its pharmacological profile, however, is much more desirable. Unlike SSRIs, dapoxetine reaches maximum concentration in the body in about an hour and is flushed from the body quickly. Thus, there’s no need for daily dosing, and it can be taken an hour before intercourse. Even at the minimum dose, it has been found to double time to ejaculation, and stronger doses bring longer delays. Initial trials also indicate that dapoxetine produces minimal side effects and doesn’t interact in bad ways with other medications or alcohol.

Johnson & Johnson submitted an application for approval for dapoxetine to the FDA in late 2004, and the FDA rejected the application in October of 2005. Johnson & Johnson says it is working to answer questions raised by the FDA and is continuing development. Pfizer is also developing its own version of dapoxetine.

Counseling
Although premature ejaculation is a common and frustrating problem, the Male Health Center had great success in treating the problem. Frequently, marital and relationship issues were an underlying cause of premature ejaculation. And in recent years, numerous studies have confirmed the negative effect that premature ejaculation can have on self-esteem and relationships. These issues should also be addressed to improve the success of the therapy.

As to treating premature ejaculation, here is a list of things that DON'T work:

    * long-term psychoanalysis
    * getting drunk
    * using one or more condoms
    * concentrating on something other than sex while having sex
    * biting one's cheek as a distraction
    * frequent masturbation
    * testosterone injections
    * tranquilizers

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