Premature Ejaculation

Premature ejaculation is the most common sexual problem for men. It is a lack of control over ejaculation so that it often happens sooner than the man or his partner would want, causing distress for one or both of them. Current evidence supports an average intravaginal ejaculation latency time (IELT) of six and a half minutes in 18-30 year olds.

Some men ejaculate as soon as foreplay starts. Others lose control when they try to insert their penis, while some ejaculate very quickly after penetration. Whatever the case, premature ejaculation can cause distress and create tension between a man and his partner.

When deciding the appropriate treatment, it is important for physician to distinguish premature ejaculation as a “complaint” versus premature ejaculation as a “syndrome”. For many years premature ejaculation was classified into “lifelong premature ejaculation” and “acquired premature ejaculation”. Recently, a new classification of premature ejaculation was proposed based on controlled clinical and epidemiological stopwatch studies, and it included 2 other premature ejaculation syndromes: “natural variable premature ejaculation” and “premature-like ejaculatory dysfunction”.

However only individuals with “lifelong premature ejaculation” with IELT <1 to 1.5 minutes should require medication as a first option, along with or without therapy.

Occasionally losing control over ejaculation is normal

Premature ejaculation is only a problem if it happens frequently. It’s important to remember that most men occasionally reach orgasm sooner than they’d like. For example, it is common for a man to ejaculate quickly the first time he has sex. It is also common if a man hasn’t ejaculated for a long time. The occasional loss of control doesn’t mean the man has a sexual problem.

Causes of premature ejaculation

Generally, premature ejaculation has been considered to be psychological. However, it is now thought that some men (particularly those with life-long premature ejaculation) have a chemical imbalance in the brain centres controlling this function.

Psychological factors are important and include:

Depression or anxiety, particularly about performance
Feeling anxious about rejection
Expecting failure
Feeling afraid of harm (some men have an irrational fear that penetration can cause injury to the penis)
Negative sexual experiences in childhood
Religious beliefs
Stress
Problems within the relationship.

Treatment for premature ejaculation

Seeking help from a doctor or sex therapist is a good idea. The different treatments for premature ejaculation include:

Behavioural techniques – these include Semans’ ‘stop-start’ technique and Masters and Johnson’s ‘squeeze’ technique.

Semans’ technique involves learning to control the sensations prior to ejaculation. The idea is to repeatedly bring yourself close to ejaculation, then stop and rest. If you do this often enough, you will learn to recognise your ‘point of no return’.

The Masters and Johnson (named after the famed sex researchers) technique is similar but involves squeezing the end of the penis just before ejaculation to lessen the urge to ejaculate. This is repeated a number of times until you and your partner are ready for ejaculation. These exercises can be done alone or with a partner.

Kegel exercises – these exercises are designed to strengthen the pelvic floor. To identify the muscles of your pelvic floor, stop yourself from urinating in midstream. This is the action you need to practise when your bladder is empty. Tightly contract the muscles and hold for 10 seconds. Repeat 10 times, three times a day.

Psychotherapy and counselling – with the guidance of an experienced sex therapist, any underlying anxieties about sex can be explored and eased.

SSRIs (selective serotonin reuptake inhibitors) and tricyclic antidepressants – a side effect of these medications is to slow ejaculation when used in men with depression. This effect may be helpful in men with premature ejaculation, and these medicines can be used in conjunction with counselling. Taking SSRIs can have other side effects such as decreased libido (sex drive), nausea, sweating, bowel disturbance and fatigue.

Reducing penile sensation – local anaesthetic gels and creams can be used to reduce penile sensation and should be applied 30 minutes before sexual intercourse. They should be used with a condom to prevent absorption by your partner. Using two condoms may also help.

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 greater than 90% of men.

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

Desensitising topical medications that are applied to the tip and shaft of the penis can also be used to treat premature ejaculation. These topical medications are applied on an “as needed” basis 10-15 minutes before anticipated sexual activity and have fewer potential systemic side effects as compared to pills taken orally. However, use of these topical medications have in the past been associated with loss of penile sensation, and reduction of sensation for the partner due to exposure. Penis insensitivity and transference to the partner are greatly reduced when using new topical anaesthetic sprays based on absorption technology which enable the active ingredient to penetrate through the through the surface skin of the penis(ie stratum corneum) to the sensory nerves which reside in the dermis. Any residual surface medication can be wiped off before sexual activity to further reduce partner concerns.

Where to get help

Your doctor

Things to remember

Premature ejaculation is the most common sexual problem in men.
Occasionally losing control is normal. Most men orgasm sooner than they would like from time to time.
There is a variety of treatments to choose from, including exercises, therapy and drugs.