Today I would be talking about a problem that affects a large proportion of men. This is a condition most men have experienced before and concerns women very much since it affects them very directly. I still remember a patient telling me about his experience with premature ejaculation (PE), he was really concerned because he really did like his current sexual partner. He said “I know my girl will leave me if this continues“.
Most men have experienced this problem at some point in their lives especially if they have sex whilst under the influence of drugs especially alcohol. Studies do suggest a population prevalence of about 20 – 30 %, suggesting that this is much more common than we think.
Until the late 1990s most physicians assumed this problem was mostly due to psycho-social factors; however studies among individuals with severe PE suggest that 90% are likely to have a 1st degree relative meaning a brother or father affected with the problem. This suggests that lifelong PE may be transmitted genetically. This was not clearly proven till in 2009 Dutch scientists associated lifelong PE with an abnormal gene controlling production of specific neurotransmitters. This was identified to be due to a polymorphism in the serotonin transporter promoter region the 5-HT gene. Twin studies also suggest about 28% concordance rate among identical twins giving further support to the possibility of genetic inheritance of PE in some individuals.
Today PE is classified into 4 subtypes lifelong PE, acquired PE, variable PE and subjective PE. To anyone suffering from any form of PE the different classifications do not mean anything if there is no clear easy solution to their problem. But before I talk about solutions I would like to talk about the different variations of this age old problem.
Lifelong PE – This is defined as PE starting from the first sexual encounter occurring with almost all women that the individual has sex with and is associated with ejaculation within a minute of penetrating the vagina.
Acquired PE is defined as PE occurring in an individual who has had prior normal ejaculation experiences. This occurs mostly in midlife and may be associated with other medical problems including problems with the genital tract, thyroid or even psychological issues.
Variable PE occurs irregularly in most cases and individuals are unable to delay ejaculation. In most cases this starts early in life however in such individuals ejaculatory time can me normal or short. Most sex therapist and other specialist consider this to be a normal variation in the function of the male sexual apparatus. There are however behavioral techniques that can benefit some people with this problem.
Subjective PE. While premature ejaculation is a major problem a significant proportion of those experiencing this condition tend to have this type of PE. Guys with subjective PE usually have normal to prolonged ejaculatory time but have a subjective perception of early ejaculation irrespective ejaculatory time. Unfortunately these guys are the most difficult to treat.
While PE is a fairly common problem those afflicted may feel significant anxiety and shame related to this condition. There are actually a significant number of researchers who consider this as a normal variation; a relic of our evolutionary past. In an environment where war and strife was very common having prolonged intercourse could put a male animal at risk. Most males in the animal kingdom do not last more than a minute or two during sex. In fact humans are the only creatures who have developed enough to prolonged sex purely to delay and intensify pleasure.
PE is defined as ejaculation occurring during a sex act within 2 minutes of vaginal penetration. Unfortunately for our gay brothers PE research at this point has been mostly heterosexually focussed. However anyone can feel free and replace vagina with anus if that is how you express their love.
Whilst our historians and other evolutionary scientist can continue to argue about the evolutionary advantages of being a 2 minute wonder man, in today’s world this is a problem that can really rock one’s world. My patient was right in being worried about how his problem can affect his relationship. I am yet to have a lady bring her partner in to request for treatment for this condition but I have had quite a few requests for viagra by women for their men. What I believe may be happening with our PE sufferers is that their partners may be seeking their own solutions. Whatever solution they choose I believe would be very much dependent on the extent of their imaginations.
At this point I would point out some solutions that have been shown to work.
- Behavioral Techniques – Masturbation does help delay ejaculation so masturbating one to two hours before sex can help individuals with PE prolong sex and partner satisfaction.
- The pause squeeze technique – I would not fully describe this here but this method requires having the female partner squeeze the penis at the junction between the shaft and the glans at the point they feel most excited to delay ejaculation. The male partner must also pause his thrusts whilst waiting for the heightened state of arousal to abate.
- Condoms – Special low sensitivity condoms can help delay ejaculation and could be useful.
- Desensitizing sprays – Applying desensitizing sprays or gels containing benzocaine or lidocaine can help delay ejaculation for PE sufferers. It is important to apply at least 10 – 15 mins before intercourse and wipe off any excess gel before sex.
- Selective Serotonin Re-uptake Inhibitors (SSRI)– In the US there are no FDA approved drugs but some antidepressants have delayed ejaculation as a side-effect and in Europe dapoxetine a SSRI is approved for PE. In the US there is no current FDA approved drug but some doctors prescribe paroxetine, fluoxetine, escitalopram or sertraline or other antidepressants off-label for PE. Daily use has been shown to be effective once medication reach steady state in about 3-7 days and is far superior to on demand therapy.
- Counseling – This is by far the most important part of the management for any man or for that matter couple with PE. This is a problem with few easy and reliably effective solutions so having a positive attitude and being willing to try out different modalities of treatment with counseling can significantly improve treatment outcomes for all those concerned.
Before, I end I would like to say that these solutions may not work for everyone and must serve only as a springboard for more specific discussions with your doctors.
Photo credit –The Real Gist – Chika Ike
Dr. Leonard Sowah is an Internal Medicine Physician in Baltimore, Maryland