Concern about sex is a common experience for men. Early or uncontrollable ejaculation is one of the most frequent sexual concerns men worry about.
Premature ejaculation (PE) is reported by around one-third of men, although only around one in ten will be bothered enough by it to seek professional advice or treatment.
As I explained in a previous post on the topic, premature ejaculation is when a man ejaculates sooner during sexual intercourse than he or his partner would like, which is often prior to or within one minute of vaginal penetration, and is coupled with a notable lack of control over the ability to regulate ejaculation.
PE is associated with negative personal consequences such as upset or frustration which can lead to the avoidance of sexual intimacy. Many men feel embarrassed by early ejaculation, and because it is often the subject of humor and ridicule, it can be difficult for those men affected to seek help.
Some men have had premature ejaculation since their initial intercourse experience, and this is called lifelong premature ejaculation, versus acquired premature ejaculation which develops later on in life after previous ability to exert comfortable control over ejaculation timing.
Premature ejaculation has been recognized as a syndrome for well over 100 years, but accurate assessment of prevalence can be difficult to identify accurately due to variance in definitions of PE and the sensitive nature of the concern which leads to under-reporting.
While almost every man will cross the finish line too soon at some point in their sexual lives, persistent lack of ejaculation control and regular experiences of being a “one-minute man” is what usually leads to distress.
The medical definition of premature ejaculation is probably best understood as a man’s inability to delay orgasm and ejaculation so that both partners are able to enjoy a satisfying sexual experience, in the absence of other sexual problems. In some sports an early finish is applauded, but this is not usually the case when it comes to sex.
Realistic expectations of sexual activity is an important starting point in a conversation about premature ejaculation. Most couples are quite surprised to know that the average duration of intercourse, from penetration to orgasm, is around 4 – 10 minutes, with five minutes being the general average (1).
Indeed, it can vary considerably over time in a single sexual relationship; sometimes orgasm may occur within seconds, sometimes after five or minutes, sometimes after a much longer period. Both ten seconds and ten minutes can be “great sex” depending on the expectation of both partners. Longer is not always better; ten seconds of intense excitement and intimacy can be better than ten minutes of routine and boring sex. Men often seek help when an early completion persists upon every sexual act and causes conflict in a relationship.
Research suggests that those affected by PE and their partners have concerns about control over ejaculation, satisfaction with intercourse, emotional impact and distress, relationship problems, and partner reactions. A recent study however reported men have been found to be more concerned about their lack of ejaculation control than their partners.
While studies have focused primarily on heterosexual men, it is understood that a man of any sexual orientation can be afflicted similarly by PE.
Both psychological and biological factors can play a role in premature ejaculation. Although many men feel embarrassed to talk about it, PE is a common and treatable condition. There are many things that can cause premature ejaculation and warrant a conversation with a healthcare provider, including thyroid or prostate disease, urinary tract symptoms, mood disorders, alcohol or drug use, as well as other sexual dysfunctions including erectile dysfunction. Often there are behavioral correlates that are noted in men with PE such as history of rapid masturbation or use of vibratory devices that cause excessive stimulation.
Serotonin is the neurotransmitter of greatest interest in the control of ejaculation and has the most robust data in animal and human models. It is believed that men with difficulty regulating ejaculation timing have possibly increased or decreased sensitivity to certain biochemical receptor which may lead to intrinsically lower ejaculatory thresholds. While there were also earlier reports of possible genetic contribution to PE, recent studies have largely disputed this theory. (2)
There are numerous medical treatments available to improve ejaculation latency, or time from the start of intercourse to ejaculation, including oral medications taken daily, medications taken prior to sexual acts, and sprays applied directly to the penis prior to intercourse. Lidocaine, prilocaine, or benzocaine are topical anesthetics which are formulated in different over the counter products to be highly absorbable when applied to the penis as a spray or gel.
These products have been reported to improve ejaculatory latency, ejaculatory control, and sexual satisfaction when applied topically to the glans penis five minutes before intercourse. In a meta-analysis of eight trials, topical anesthetic agents were more effective than placebo, and were well-tolerated by patients and their partners.
Antidepressant medications are considered the first line of oral medication treatment to improve ejaculation latency time, however, efficacy can be modest in this approach, and only improve ejaculation time by a few minutes for some men.
Paxil has been demonstrated to be the most effective medication taking daily for PE, and has been shown in some studies to improve ejaculation latency time by up to nine minutes.
Dapoxetine is another SSRI antidepressant category medication, which also appears to be effective based upon five trials of over 6,000 men with PE who were randomly assigned to receive placebo or dapoxetine. Unlike other SSRIs, which are most effective when taken daily, dapoxetine is taken on-demand one to three hours before intercourse. Dapoxetine is approved for use in PE in other countries, but is not approved or available in the US.
Tramadol is a medication usually prescribed for moderate to severe pain. However, researchers have discovered that it also may also help men with PE delay ejaculation, if taken two to four hours before sex. No medication is approved for PE in the US, therefore any treatment is prescribed “off label” for this purpose.
Some men concurrently experience early ejaculation as well as erectile dysfunction, in this circumstance only, erectile medications such as Viagra or Cialis may have a modest effect at improving ejaculation timing. A topical cream applied to the penile meatus called alprostadil prior to intercourse has also been shown to improve erection function has small studies suggesting it may be effective for some men in improving ejaculation timing.
Cognitive behavioral therapy with a sex therapist is often warranted in addition to medical care to provide techniques proven to resolve premature ejaculation that focus on mindfulness, education on the sexual response cycle, and techniques to modify ejaculation timing.
Some studies have found talk therapy to be up to 85 percent effective at resolving PE. These interventions are designed to achieve a number of goals: improve self-confidence and communication in the relationship, and ultimately, increase the ejaculation latency. Medical science and clinical practice both demonstrate a strong likelihood that combined pharmacologic and behavioral treatment is more effective than pharmacotherapy alone.
Every man will be a ‘one minute man’ at some sexual occurrences over a lifetime. If rapid ejaculation event occurs periodically most men make an easy apology and know that next time will be different. But if we find ourselves anxious and distressed with every act of intimacy in our relationship, frustration commonly develops, and if efforts to improve the experience have not been successful on our own, support from a healthcare provider becomes warranted and often leads to resolution of the concern — and keeps the applause for an early finish at the horse races.
1. ISSM Patient Information Sheet for Premature Ejaculation. Version 1. December 2010.
2. An Update of the International Society of Sexual Medicine’s Guidelines for the Diagnosis and Treatment of Premature Ejaculation (PE) J Sex Med 2014;11:1392–1422
3. UpToDate.com Treatment of Male Sexual Dysfunction. Literature review current through: Aug 2015