Premature Ejaculation (PE)

Premature ejaculation (pe) refers to the persistent or recurrent discharge of semen with minimal sexual stimulation before, on, or shortly after penetration, before the person wishes it, and earlier than he expects it. In making the diagnosis of pe, the clinician must take into account factors that affect the length of time that the man feels sexually excited. These factors include the age of the patient and his partner, the newness of the sexual partner, and the location and recent frequency of sexual activity.

Causes

Premature ejaculation (pe) is a common complaint. The available evidence supports the notion that control and modulation of sexual excitement is learned behavior. If someone has learned it incorrectly or inadequately, they can relearn it. Pe is only rarely caused by a physical or structural problem; in these cases it is usually associated with other physical symptoms, usually pain. In rare cases, pe may be associated with a neurological condition; infection of the prostate gland; or urethritis (inflammation of the duct that carries urine and semen to the outside of the body). With the rising prevalence of substance abuse, an increasing number of cases of pe are being diagnosed in patients withdrawing from drugs, especially opioids.

Pe may be of lifelong duration or develop in later life, especially if a difficult interpersonal relationship is one of its causes. Although pe is commonly associated with psychological symptoms, especially performance anxiety and guilt, these symptoms are its consequences rather than its causes. Once pe is firmly established, however, the accompanying psychological factors, especially in combination with sexual overstimulation, may form a self-perpetuating cycle that makes the disorder worse.

Premature ejaculation is common in adolescents where it may be made worse by feelings of sinfulness concerning sexual activity, fear of discovery, fear of making the partner pregnant, or fear of contracting a sexually transmitted disease (std). All of these may be made worse by performance anxiety. Adults may have similar concerns as well as interpersonal factors related to the sexual partner.

Symptoms

In pe, ejaculation occurs earlier than the patient and/or the couple would like, thus preventing full satisfaction from intercourse, especially on the part of the sexual partner, who frequently fails to attain orgasm. Pe is almost invariably accompanied by marked emotional upset and interpersonal difficulties that may add frustration to an already tense situation, which makes the loss of sexual fulfillment even worse. It is also important to differentiate male orgasm from ejaculation. Some men are able to distinguish between the two events and enjoy the pleasurable sensations associated with orgasm apart from the emission of semen, which usually ends the moment of orgasm. In these cases, the partner is capable of achieving orgasm and sexual satisfaction.

Diagnosis

The physical examination of a patient who is having problems with pe usually results in normal findings. Abnormal findings are unusual. The best source of information for diagnosing the nature of the problem is the patient's sexual history. On taking the patient's history, the clinician should concentrate on the sexual history, making sure that both partners have adequate and accurate sexual information. Ideally, the sexual partner should participate in the history and is often able to contribute valuable information that the patient himself may be unaware of or unwilling to relate. The female partner should also be examined by a gynecologist in order to ascertain her sexual capabilities and to eliminate the possibility that the size or structure of her genitals is part of the reason for the male's premature ejaculation.

Treatment

• Preferably, therapy for pe should be conducted under the supervision of a health professional trained in sexual dysfunction. Both partners must participate responsibly in the therapeutic program. Treatment of pe requires patience, dedication and commitment by both partners, and the therapist must convey this message to both. The first part of therapy requires both partners to avoid intercourse for a period of several weeks. This period of abstinence is helpful in relieving any troublesome performance anxiety on the part of the man that may interfere with therapy.
• Behavioral techniques, taught either individually, conjointly, or in groups, are effective in the therapy of pe. A preliminary stage of all treatment is termed" sensate focus" and involves the man's concentration on the process of sexual arousal and orgasm. He should learn each step in the process, most particularly the moment prior to the" point of no return" the sexual partner participates in the process, maintaining an awareness of the patient's sensations and how close he is to ejaculating. At this point, two techniques are commonly used:
• • the" stop and start" technique. This approach involves sexual stimulation until the man recognizes that he is about to ejaculate. At this time, the stimulation is discontinued for about thirty seconds and then resumed. This sequence of events is repeated until ejaculation is desired by both partners, with stimulation continuing until ejaculation occurs.• the" squeeze" technique. This approach involves sexual stimulation, usually by the sexual partner, until the man recognizes that he is about to ejaculate. At this time stimulation ceases. The patient or his partner gently squeezes the end of the penis at the junction of the glans penis (tip of the penis) with the shaft. The squeezing is continued for several seconds. Sexual stimulation is withheld for about 30 seconds and then resumed. This sequence of events is repeated by the patient alone or with the assistance of his partner until ejaculation is desired. At this point stimulation is continued until the man ejaculates.
• The patient and his partner should be advised against trying any of the many unproven remedies that are available either over the counter or popularized on the internet. Certain prescription medications, especially antidepressants that produce delayed ejaculation as a side effect, may be useful as therapeutic adjuncts. Recently, the use of a class of drugs known as selective serotonin receptor inhibitors (ssris) has shown promise in the treatment of premature ejaculation. The ssris prolong the time it takes the man to ejaculate by as much as 30 minutes. The ssris most commonly used to treat pe are sertraline and fluoxetine. 

Potential complications

Premature ejaculation that takes place before the man's penis enters the woman's vagina will interfere with conception, if the couple is planning a pregnancy. Continued lack of ejaculatory control may lead to sexual dissatisfaction for either or both members of the couple. It may become a source of marital tension, disturbed interpersonal relationships, and eventual separation or divorce.