Many of us take ejaculation for granted. Think about it. When we have sex, most of us assume ejaculation is a forgone conclusion. We also assume that ejaculation is something we can control. But that’s not always the case.
One of the most challenging sexual problems in men’s health is ejaculatory dysfunction. Men can have all types of ejaculatory problems. Sometimes men ejaculate too early or too quickly. This is a condition called premature ejaculation, or PE, which will be the focus of the discussion below. Sometimes men take too long to ejaculate or can’t ejaculate at all. These are termed delayed ejaculation and anejaculation, respectively. Certain men experience pain with ejaculation and some ejaculate backward (a condition called retrograde ejaculation).
Premature ejaculation is the most common male sexual dysfunction and yet it gets so much less devoted time and energy than erectile dysfunction (ED). We’ve spent plenty of time on this blog writing about erections and what to do if you have ED. But what about all the guys out there dealing with premature ejaculation? As a medical community, we know very little about PE. Why does it affect some men and not others? Why are some people born with it and others experience it later in life? Is PE caused more by biological or psychological factors? These are some of the many questions about PE to which we still don’t know the answers.
While there is much to learn, what follows is a beginner’s guide to understanding premature ejaculation. We will discuss how you know whether or not you have PE and, if you do, how you might overcome it.
Before jumping in, let’s set the record straight on some premature ejaculation misconceptions. Estimates about how common it is vary, but as many as 30% of men experience PE at some point in their life (Carson 2006). Too often PE is thought to be a condition that plagues only young, inexperienced men. Scenes from the movie American Pie come to mind. However, that simply isn’t true. Premature ejaculation can happen at any age. In fact, the prevalence of PE is pretty stable across age groups (Rosen 2004).
Secondly, men are often misguided when it comes to ejaculation and overestimate what is normal. In a large observational study of men and their partners, half of the 1,500 men studied ejaculated in under 7.3 minutes (Patrick 2005). Moreover, the average time to ejaculation is under 10 minutes (Patrick 2005). Patients who see me often think they have a problem if they can’t last 15-20 minutes or more like they see in the movies. But that’s just not realistic.
Lastly, ejaculation is complicated. As I stated at the beginning, we take cumming for granted, but it’s a complicated process controlled by the central nervous system. When you’re aroused, signals from your genitals are sent to your brain via the spinal cord. When that arousal crosses a certain threshold, your brain sends a signal back to your genitals proclaiming, “Time to shoot!” And just like that, you come.
Well, it’s even slightly more complicated. Ejaculation has two phases: emission and expulsion. Emission is when semen (a complex fluid made of sperm and various fluids) is deposited into the urethra. This process involves the entire genital tract from your balls to your prostate and occurs only after closure of the bladder neck. Once semen has arrived in the urethra, expulsion can take place. Expulsion is the forceful contraction of muscles at the base of the penis that allows for semen to shoot out. This whole ejaculatory dance is typically coupled with orgasm, a climax of sexual excitement and pleasure.
PE is characterized by ejaculation which always or nearly always occurs prior to or within one minute of penetration or the inability to delay ejaculation during all or nearly all penetrative sex acts. To qualify as PE, the ejaculatory issue should cause negative or uncomfortable personal consequences such as distress, frustration, and/or the avoidance of sexual intimacy (Althof 2014).
Premature ejaculation comes in two primary types: congenital and acquired. People with the congenital version have always had a problem controlling their ejaculation, even from their first attempts at masturbation. Men with the acquired kind experience a period of normalcy and suddenly or gradually develop an inability to delay time to or control their ejaculation. Both types can be equally distressing and negatively impact a man’s self-esteem and/or cause problems in his romantic/sexual relationships.
PE can also be generalized or situational. Generalized PE implies that the problem exists in most, if not all, types of sexual activity. Technically, the definition of PE implies intercourse but plenty of people ejaculate too quickly from other types of stimulation. Situational PE describes a problem that occurs only with specific types of activity. For example, some people only experience PE with partners but report normal ejaculatory function when they are alone and pleasuring themselves.
Before we move on to the causes of PE, a quick note about the intersectionality of premature ejaculation and erectile dysfunction. PE is often seen in men who also suffer from ED. In those cases, if the premature ejaculation started after the person’s erection problem, we typically address the ED first. In many cases, once the person’s ED is fixed, premature ejaculation is no longer an issue.
As I mentioned previously, there’s still a lot we don’t know about PE including the exact cause. However, it is thought that serotonin may play an important role in PE. Serotonin is a chemical made and secreted by certain types of nerves in the brain. It’s also the target molecule for many medications that treat depression and anxiety. Selective serotonin reuptake inhibitors (SSRIs) treat depression by preventing serotonin from leaving a neuronal synapse. Basically, they lead to an accumulation of serotonin in the brain. This can do wonders for your mood but isn’t great for ejaculation (this will become important later when we discuss treatments). Conversely, low amounts of serotonin can shorten the time to ejaculation and, in some people, lead to PE.
Another physiological factor often overlooked is the role of the pelvic floor muscles. Like we said before, emission requires the forceful contraction of certain muscles. These muscles are part of the pelvic floor and are not commonly under conscious control. People who have dysfunction (tightness, spasm, etc.) in these muscles can sometimes ejaculate too quickly.
Psychological factors are also common in people who struggle with premature ejaculation. These can include depression, anxiety, stress, feelings of guilt or shame, unrealistic expectations about sexual performance, history of sexual abuse, negative socio-cultural beliefs about sex, lack of confidence, and relationship issues. Making sure to address any potentially confounding psychological variables is extremely important in helping manage PE.
In my experience, people are often embarrassed to discuss PE during their visit to the doctor. Many don’t know that there are safe and effective treatment options available to improve their ejaculatory control. If ejaculation feels out of control and certainly if it is getting in the way of your or your partner’s sexual pleasure, definitely speak up. In most cases, we diagnose PE based on history and physical exam. Rarely are lab tests needed to make the diagnosis. And don’t worry, we don’t expect you to use a stopwatch in bed.
There are several ways to approach treating premature ejaculation. Some treatments rely on behavioral techniques, while others try to interfere with that signal that occurs between our brain and our genitals. Sometimes treatment requires psychological counseling and sometimes it involves medication.
Psychological therapy helps address feelings, emotions, and anxiety that can lead to problems with sexual performance, including premature ejaculation. Therapy can also help couples dealing with ejaculatory dysfunction grow closer. Trained sex therapists can work with their clients to identify behaviors that may be contributing to their poor ejaculatory control.
Some behavioral techniques have been employed to help improve PE. The squeeze method involves firmly squeezing the penis just prior to the moment of ejaculation to cause you to partially lose your erection. The goal of this method is for you to become more aware of the sensations leading to climax. The start-stop technique is exactly what it sounds like: you or your partner stop all sexual activity just prior to the moment of climax. If ejaculation is prevented, then you start stimulating the penis once again, repeating this start-stop process three times. While these behavioral techniques are fairly easy to do, there aren’t many studies showing they have a high success rate.
Trying to reduce penile sensitivity to curb premature ejaculation can be helpful in some cases.
This can involve applying a condom or using a topical anesthetic spray, typically 5-10 minutes before sex. Younger patients and single men may find these options cumbersome and sometimes report they interfere with intimacy or don’t allow for spontaneity with new partners. Thankfully there are other options.
There are no FDA-approved medications for the treatment of PE so everything we will discuss here is considered “off label.” A commonly prescribed treatment for PE is a family of drugs known as SSRIs. As we discussed above, these are commonly used for the treatment of depression and anxiety. One of the most common side effects of SSRIs is delayed ejaculation. So in patients with PE, we use this side effect to our advantage. These medications have been studied and used on-demand (just before sexual activity) and as daily treatments and both are effective.
If PE exists alongside erectile dysfunction, then phosphodiesterase-5 inhibitors (think Viagra, Cialis, etc.) can be helpful. Another commonly used treatment is the pain medication, tramadol. This treatment is most often used on-demand and essentially dampens the brain’s processing of the genital stimulation that leads to PE. Additional treatments, including Botox injections, are under study and considered investigational. Finally, another non-medical approach that can be helpful in PE is pelvic floor physical therapy for the reasons we discussed previously.
Premature ejaculation is a common problem, even more so than erectile dysfunction. It’s also a sexual dysfunction that carries a lot of shame and embarrassment. If you’re a person who feels like their ejaculatory control isn’t great, it’s probably worth discussing with your health care provider. While there is no one way to approach this problem, there are various treatment options worth exploring.
Carson C, Gunn K. Premature ejaculation: definition and prevalence. Int J Impot Res. 2006 Sep-Oct;18 Suppl 1:S5-13. Review.
Rosen RC et al (2004) The Premature Ejaculation Prevalence and Attitudes (PEPA) Survey: A Multi-National Survey. J. Sex Med 1 (Supp 1): 57-58
Patrick DL, Althof SE, Pryor JL, Rosen R, Rowland DL, Ho KF, McNulty P, Rothman M, Jamieson C. Premature ejaculation: an observational study of men and their partners. J Sex Med. 2005 May;2(3):358-67.
Althof SE, McMahon CG, Waldinger MD, Serefoglu EC, Shindel AW, Adaikan PG, Becher E, Dean J, Giuliano F, Hellstrom WJ, Giraldi A, Glina S, Incrocci L, Jannini E, McCabe M, Parish S, Rowland D, Segraves RT, Sharlip I, Torres LO. An update of the International Society of Sexual Medicine’s guidelines for the diagnosis and treatment of premature ejaculation (PE). J Sex Med. 2014 Jun;11(6):1392-422.