| Premature Ejaculation
Premature ejaculation (PE) is an extremely common condition. Until recently PE was thought to be a psychological problem for which the best treatment was behavioral modification or learning techniques involving control of sensation during sexual intercourse. Then, as is often the case in medicine, doctors shifted their thinking that (PE) was due to a physical problem. Indeed, some studies suggest that an abnormal serotonergic system exists in the brain of men suffering from PE. More recently however, our thinking has gotten more sophisticated. We currently believe that some individuals born with a predisposition to PE are more vulnerable to a combination of mental and physical stimulation. In other words biological factors, culture, upbringing, anxiety and energy levels, health status, sexual circumstance and interpersonal relationship are factors that influence the dysfunction. Anxiety during sexual activity seems to be the most common behavior associated with PE.
Behavioral modification techniques have been historically unsuccessful. More recently, physicians have observed that certain medications used to treat other problems (anxiety, depression, obsessive compulsive disorders, erectile dysfunction
) have the side effects of preventing or delaying orgasm. Thus the idea of using these medications (for their side effects) to treat PE came into being. Indeed, delayed ejaculation was observed in patients taking Anafranil, Zoloft, Paxil, Viagra, Levitra and Cialis. These medications are not uniformly successful for this purpose and further investigation is needed to gather more reliable data and develop more efficacious compounds.
Definition of Premature Ejaculation
There is no clear agreement on the definition of PE. Recent studies give some indication as to what should be considered normal ejaculatory delay versus PE. The average duration of normal "sexually functioning" men is 5 to 6 minutes during vaginal penetrative sex. Any man with intercourse duration of 1.5 minutes or less is considered as having premature ejaculation.
There are a few interesting facts regarding this condition which are worth mentioning in order to gain better understanding of the problem. First, men who claim to suffer from PE have similar duration of masturbation as normal men. This suggests that the problem is indeed not a physical one. More likely sexual arousal and/or performance anxiety as a consequence of being with a sexual partner may be the cause of the PE. Second, the frequency of reported sexual activity (ejaculation) in both normal men and in men who complain of PE is the same. Thus the theory that the cause of PE is a result of long intervals between ejaculations is brought into question. Finally, it is estimated that 10 to 30% men suffer from premature ejaculation and therefore this condition is quite common.
It is important to distinguish whether PE has always been there for the patients' entire life or a newly acquired problem. Men who suffer from erectile dysfunction
will suffer from PE because they no longer are able to "stop and go" and will either lose their erection or ejaculate.
A detailed and complete sexual history is obtained for all patients. The diagnosis of PE is essentially made from self-report. It is important to rule out erectile dysfunction in men who develop PE late in life.
Genital physical examination is usually normal. Laboratory and physiological testing are usually unrevealing and there are no devices that are currently available to evaluate the problem.
Initially, PE was treated using the pause technique. Masters and Johnson modified this by adding the "squeeze" technique in 1970. As late as the early 1990's, this technique was thought to be the most appropriate technique for PE. However, recently conducted clinical trials have shown this technique to fail in majority of men suffering from PE.
Medications used to treat men suffering from obsessive-compulsive disorder and excessive anxiety will cause men to have delayed ejaculation. These falls into two categories: Tricyclic antidepressants and selective serotonin reuptake inhibitors (SSRIs). Although successful for many patients these provide symptomatic relief and do not solve the problem.
We believe that treatment begins with raising patient's awareness of their condition through education. Combining sexual and emotional counseling, with the temporary but simultaneous use of medications is in our opinion the best approach.
Although all men are likely to experience PE once in their lifetime, a certain group of patients are affected by it in a consistent fashion. The definition and cause of the problem remain unclear. We believe that men who are unable to maintain an erection
for less than 1-2 minutes should consider treatment if the condition is bothersome. Patient education, interpersonal counseling and judicious use of medications give the best chance of long-term success.