Ejaculation Problems: Too Fast, Too Slow or Not at All?

Some men ejaculate immediately after intromission or even before intromission. Most studies suggest that premature ejaculation has a psychological or neurological basis. That is, it is a learned rapid response that can be unlearned.

How to prevent premature ejaculation

The disorder is not rapid ejaculation in itself, but primarily the inability to control ejaculation at the moment desired by the man, which has consequences for himself and for his partner. From this perspective, rapid ejaculation is thus a pathology of control and it is the inability to exercise this control over sexual function that has dysphoric implications for the man. Premature ejaculation is reaching sexual climax within one minute of starting intercourse. Another option is squeezing behind the head of the penis until the sensation passes. To continue reading this article, you must log in.

Behavioral techniques

Subscribe to HarvardHealthOnline+ FREE for 30 days for unlimited access to the site – where all content is reviewed by an HMS physician or faculty expert. With HHO+ you get these exclusive benefits: Unlimited access to all Harvard Health Online content Customized website experience aligned to your health goals In-depth health guides on topics like sleep, exercise, and more Members-only access to exclusive articles and resources UNLOCK EXPERT ACCESS for 30 days FREE! As a service to our readers, Harvard Health Publishing provides access to our library of archived content. In rare cases, premature ejaculation is caused by prostatitis or a disease of the nervous system. In addition to being frustrating to the man, premature ejaculation can limit his female partner’s sexual fulfillment, as women have a greater chance to achieve orgasm the longer intromission lasts before ejaculation.

2015, Sexual MedicineKaty Cooper PhD, .. Catherine Hood BMBCh Premature ejaculation (PE) is a male sexual dysfunction characterized by short ejaculatory latency. PE can be either lifelong (primary, present since first sexual experiences) or acquired (secondary, beginning later).

• Dapoxetine is specifically designed for on-demand use in PE.
• Topical anesthetics require minimal use to avoid excessive numbness.
• SSRIs impact neurotransmitters involved in ejaculation control.
• Tramadol's side effects limit its routine use for PE.
• Non-drug approaches include psychological counseling and exercises.
• Pelvic strengthening exercises aid in delay of ejaculation.
• Partner education enhances understanding and support.
• Managing stress and anxiety can significantly improve PE.
• Some therapies combine medication with sex therapy sessions.
• Medical evaluation is essential before initiating treatment.
• Lifestyle factors like smoking can influence sexual performance.
• Patient adherence to treatment plans improves outcomes.

The 2014 update of the International Society for Sexual Medicine (ISSM) Guidelines for the Diagnosis and Treatment of Premature Ejaculation define PE as a combination of (i) ejaculation usually occurring within about 1 minute of vaginal penetration (for lifelong PE) or a clinically significant reduction in latency time, often to around 3 minutes or less (for acquired PE); (ii) inability to delay ejaculation; and (iii) negative personal consequences such as distress, bother, frustration, and/or the avoidance of sexual intimacy [1]. PE is similarly defined by Diagnostic and Statistical Manual of Mental Disorders 5 (DSM 5) (2013) as ejaculation usually occurring within about 1 minute of vaginal penetration and before the individual wishes it and causing clinically significant distress [1].

Find your care

Estimating the prevalence of PE is not straightforward due to the difficulty in defining what constitutes clinically relevant PE. Surveys have estimated the prevalence of Diagnostic and Statistical Manual of Mental Disorders IV‐defined PE as 20–30% [2-4]; however, these estimates are likely to include men who have some concern about their ejaculatory function but do not meet the current diagnostic criteria for PE [1]. It has been suggested that the prevalence of lifelong PE according to the ISSM and DSM‐5 definitions (with an ejaculatory latency of about 1 minute) is unlikely to exceed 4% [1]. Men with PE are more likely to report lower levels of sexual functioning and satisfaction, and higher levels of personal distress and interpersonal difficulty, than men without PE [5]. They may also rate their overall quality of life as lower than that of men without PE [5].

Vardenafil (Levitra®) for PE

In addition, their partner's satisfaction with the sexual relationship has been reported to decrease with increasing severity of the condition [6]. Management of PE may involve a range of interventions. These include systemic drug treatments (such as selective serotonin reuptake inhibitors, tricyclic antidepressants, phosphodiesterase type 5 inhibitors, and analgesics), topical anesthetic creams and sprays, and behavioral therapies (BTs) [7,8]. Behavioral and psychological therapies for PE include two main classes of therapy, with overlapping elements [1]. The first consists of psychotherapy (such as psychosexual or relationship counselling) for men and/or couples, to address psychological and interpersonal issues that may be contributing to PE. Estimating the prevalence of PE is not straightforward due to the difficulty in defining what constitutes clinically relevant PE.

Surveys have estimated the prevalence of Diagnostic and Statistical Manual of Mental Disorders IV‐defined PE as 20–30% [2-4]; however, these estimates are likely to include men who have some concern about their ejaculatory function but do not meet the current diagnostic criteria for PE [1]. It has been suggested that the prevalence of lifelong PE according to the ISSM and DSM‐5 definitions (with an ejaculatory latency of about 1 minute) is unlikely to exceed 4% [1].

Ethics declarations

The physician should be aware of the rare instances in which organic dysfunction is associated with premature ejaculation. The index of suspicion for an organic cause increases in cases where the problem is preceded by a period of normal performance (secondary failure of ejaculatory control). Organic causes of premature ejaculation may include urologic conditions such as urethritis, prostatitis, and benign prostatic hypertrophy. Careful review of the literature reveals poor substantiation of the belief that these urologic conditions cause premature ejaculation. Better accepted causes of premature ejaculation are instances in which the sympathetic nervous system has been directly lesioned (abdominal aortic aneurysm surgery and pelvic fractures).

Squeeze technique

Premature ejaculation has also been reported after withdrawal from antipsychotics or narcotics, with the use of desipramine, and with alcoholism. The postulated association with cardiovascular disease, arteriosclerosis, or venous leakage is also poorly substantiated. It has been stated that premature ejaculation may be caused by certain neurologic conditions such as multiple sclerosis, spinal cord tumors, polyneuritis, and alcoholic neuropathy. A closer review of some of the quoted sources fails to reveal with clarity the evidence on which these statements are based, particularly in the case of multiple sclerosis and spinal cord tumors. We still recommend that the clinician search for elements in the history or neurologic examination that raise the possibility of a true organic neurologic disorder underlying premature ejaculation. Men with PE are more likely to report lower levels of sexual functioning and satisfaction, and higher levels of personal distress and interpersonal difficulty, than men without PE [5]. They may also rate their overall quality of life as lower than that of men without PE [5].

In addition, their partner's satisfaction with the sexual relationship has been reported to decrease with increasing severity of the condition [6]. Management of PE may involve a range of interventions.

These include systemic drug treatments (such as selective serotonin reuptake inhibitors, tricyclic antidepressants, phosphodiesterase type 5 inhibitors, and analgesics), topical anesthetic creams and sprays, and behavioral therapies (BTs) [7,8]. Behavioral and psychological therapies for PE include two main classes of therapy, with overlapping elements [1]. The first consists of psychotherapy (such as psychosexual or relationship counselling) for men and/or couples, to address psychological and interpersonal issues that may be contributing to PE. The second consists of physical techniques to help men develop sexual skills to delay ejaculation and improve sexual self‐confidence. The “stop‐start” technique, developed by Semans, involves the man or his partner stimulating the penis until he feels the urge to ejaculate, then stopping until the sensation passes; this is repeated a few times before allowing ejaculation to occur [9]. The aim is to learn to recognize the feelings of arousal in order to improve control over ejaculation.

Alternative medicine

The second consists of physical techniques to help men develop sexual skills to delay ejaculation and improve sexual self‐confidence. The “stop‐start” technique, developed by Semans, involves the man or his partner stimulating the penis until he feels the urge to ejaculate, then stopping until the sensation passes; this is repeated a few times before allowing ejaculation to occur [9]. The aim is to learn to recognize the feelings of arousal in order to improve control over ejaculation. With the related “squeeze” technique, proposed by Masters and Johnson, the man's partner stimulates the penis until he feels the urge to ejaculate, then squeezes the glans of the penis until the sensation passes; this is repeated before allowing ejaculation to occur [9]. Within sensate focus or sensate focusing [7], the man and his partner begin by focusing on touch, which excludes breasts, genitals, and intercourse, to encourage body awareness while reducing performance anxiety; this is followed by gradual reintroduction of genital touching and then full intercourse [10].

Physical causes

Pelvic floor buy cenforce pills muscle rehabilitation exercises may also assist with ejaculatory control [11]. The aim of this study was to systematically review the evidence base for BTs in the management of PE. Numerous mechanisms have been invoked, including generalized or performance anxiety, unconscious negative feelings (hostility, fear) toward women, and unresolved marital problems. In addition to purely intrapsychic or relationship factors, a constitutionally faster ejaculatory reflex (based on shorter latency of bulbocavernosus reflex) has also been invoked. This latter finding appears to apply to primary premature ejaculators (premature ejaculation from the beginning of their sexual lives) but cannot be used for diagnosis because of the overlap of results with controls. With the related “squeeze” technique, proposed by Masters and Johnson, the man's partner stimulates the penis until he feels the urge to ejaculate, then squeezes the glans of the penis until the sensation passes; this is repeated before allowing ejaculation to occur [9]. Within sensate focus or sensate focusing [7], the man and his partner begin by focusing on touch, which excludes breasts, genitals, and intercourse, to encourage body awareness while reducing performance anxiety; this is followed by gradual reintroduction of genital touching and then full intercourse [10]. Pelvic floor buy cenforce pills muscle rehabilitation exercises may also assist with ejaculatory control [11]. The aim of this study was to systematically review the evidence base for BTs in the management of PE. Numerous mechanisms have been invoked, including generalized or performance anxiety, unconscious negative feelings (hostility, fear) toward women, and unresolved marital problems. In addition to purely intrapsychic or relationship factors, a constitutionally faster ejaculatory reflex (based on shorter latency of bulbocavernosus reflex) has also been invoked. This latter finding appears to apply to primary premature ejaculators (premature ejaculation from the beginning of their sexual lives) but cannot be used for diagnosis because of the overlap of results with controls. The physician should be aware of the rare instances in which organic dysfunction is associated with premature ejaculation. The index of suspicion for an organic cause increases in cases where the problem is preceded by a period of normal performance (secondary failure of ejaculatory control).

• Dapoxetine used before sex provides quick relief from PE.
• Topical anesthetic applications should be tailored to individual needs.
• SSRIs may cause delayed orgasm or decreased sexual desire.
• Tramadol is an alternative but carries substantial risks.
• Training with behavioral techniques can lead to lasting improvements.
• Fatigue and stress reduction support sexual performance.
• Pelvic floor strengthening is a natural method to control ejaculation.
• Psychological support addresses underlying emotional issues.
• Mechanical aids are an option for some men.
• Combining medications with psychotherapy enhances efficacy.
• Avoid self-medicating without professional advice.
• Consistent follow-up optimizes long-term management.

Organic causes of premature ejaculation may include urologic conditions such as urethritis, prostatitis, and benign prostatic hypertrophy. Careful review of the literature reveals poor substantiation of the belief that these urologic conditions cause premature ejaculation. Better accepted causes of premature ejaculation are instances in which the sympathetic nervous system has been directly lesioned (abdominal aortic aneurysm surgery and pelvic fractures). Premature ejaculation has also been reported after withdrawal from antipsychotics or narcotics, with the use of desipramine, and with alcoholism. The postulated association with cardiovascular disease, arteriosclerosis, or venous leakage is also poorly substantiated. It has been stated that premature ejaculation may be caused by certain neurologic conditions such as multiple sclerosis, spinal cord tumors, polyneuritis, and alcoholic neuropathy. A closer review of some of the quoted sources fails to reveal with clarity the evidence on which these statements are based, particularly in the case of multiple sclerosis and spinal cord tumors. We still recommend that the clinician search for elements in the history or neurologic examination that raise the possibility of a true organic neurologic disorder underlying premature ejaculation. If clinically warranted, further neurologic investigation (i.e., magnetic resonance imaging, evoked responses, and cerebrospinal fluid analysis to rule out multiple sclerosis) may be necessary. Otherwise, there are no neurologic or non-neurologic paraclinical investigations specifically indicated for premature ejaculation, and referral to a sexologist or sex therapist is the next recommended step.

Key takeaways:

If clinically warranted, further neurologic investigation (i.e., magnetic resonance imaging, evoked responses, and cerebrospinal fluid analysis to rule out multiple sclerosis) may be necessary. Otherwise, there are no neurologic or non-neurologic paraclinical investigations specifically indicated for premature ejaculation, and referral to a sexologist or sex therapist is the next recommended step. 2003, Office Practice of Neurology (Second Edition) Premature ejaculation was first listed in the classification of sexual disorders of the DSM III in 1980. It was defined as: “ejaculation occurring before the person desires it, due to a recurrent and persistent absence of reasonable control over ejaculation and orgasm during sexual activity”. The criteria of “control” was dropped after the revision of the DSM III-R in 1980 (1987?) and the following definition was listed: “persistent and recurrent ejaculation after minimal sexual stimulation, or before or shortly after penetration, and sooner than the person wishes”.

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In this first definition, we can consider premature ejaculation to be defined as an undesirable behavior. In 1994, with the publication of the DSM IV and its revised version, DSM IV-R, in 2000, the criteria of “personal or interpersonal distress”, that is to say the negative subjective impact of this behavior on the individual, was added to the definition of 1987: “(…) to ensure that changes or variations in sexual behavior that are not associated with dysfunction or distress are not diagnosed as a disorder” (Segraves, 2010). This definition insists, therefore, that the subjective dimension of the complaint be taken into account in the definition of the disorder. The definition listed in the International Classification of Diseases is also very interesting: “premature ejaculation entails an inability to control ejaculation sufficiently in order that both partners to enjoy sexual interaction (sexual relations? The relational notion, which was developed by Masters and Johnson but abandoned in early definitions of the DSM, makes its return in this definition from the WHO: sexuality, even sexual function, is hereby considered a matter of the couple. 2003, Office Practice of Neurology (Second Edition) Premature ejaculation was first listed in the classification of sexual disorders of the DSM III in 1980. It was defined as: “ejaculation occurring before the person desires it, due to a recurrent and persistent absence of reasonable control over ejaculation and orgasm during sexual activity”. The criteria of “control” was dropped after the revision of the DSM III-R in 1980 (1987?) and the following definition was listed: “persistent and recurrent ejaculation after minimal sexual stimulation, or before or shortly after penetration, and sooner than the person wishes”. In this first definition, we can consider premature ejaculation to be defined as an undesirable behavior. In 1994, with the publication of the DSM IV and its revised version, DSM IV-R, in 2000, the criteria of “personal or interpersonal distress”, that is to say the negative subjective impact of this behavior on the individual, was added to the definition of 1987: “(…) to ensure that changes or variations in sexual behavior that are not associated with dysfunction or distress are not diagnosed as a disorder” (Segraves, 2010).

Phosphodiesterase Type 5 Inhibitors

Some men ejaculate immediately after intromission or even before intromission. Most studies suggest that premature ejaculation has a psychological or neurological basis. That is, it is a learned rapid response that can be unlearned. In rare cases, premature ejaculation is caused by prostatitis or a disease of the nervous system. In addition to being frustrating to the man, premature ejaculation can limit his female partner’s sexual fulfillment, as women have a greater chance to achieve orgasm the longer intromission lasts before ejaculation.

Basic questions to ask your doctor

2015, Sexual MedicineKaty Cooper PhD, .. Catherine Hood BMBCh Premature ejaculation (PE) is a male sexual dysfunction characterized by short ejaculatory latency. PE can be either lifelong (primary, present since first sexual experiences) or acquired (secondary, beginning later). The 2014 update of the International Society for Sexual Medicine (ISSM) Guidelines for the Diagnosis and Treatment of Premature Ejaculation define PE as a combination of (i) ejaculation usually occurring within about 1 minute of vaginal penetration (for lifelong PE) or a clinically significant reduction in latency time, often to around 3 minutes or less (for acquired PE); (ii) inability to delay ejaculation; and (iii) negative personal consequences such as distress, bother, frustration, and/or the avoidance of sexual intimacy [1]. PE is similarly defined by Diagnostic and Statistical Manual of Mental Disorders 5 (DSM 5) (2013) as ejaculation usually occurring within about 1 minute of vaginal penetration and before the individual wishes it and causing clinically significant distress [1]. This definition insists, therefore, that the subjective dimension of the complaint be taken into account in the definition of the disorder. The definition listed in the International Classification of Diseases is also very interesting: “premature ejaculation entails an inability to control ejaculation sufficiently in order that both partners to enjoy sexual interaction (sexual relations? The relational notion, which was developed by Masters and Johnson but abandoned in early definitions of the DSM, makes its return in this definition from the WHO: sexuality, even sexual function, is hereby considered a matter of the couple. The disorder is not rapid ejaculation in itself, but primarily the inability to control ejaculation at the moment desired by the man, which has consequences for himself and for his partner. From this perspective, rapid ejaculation is thus a pathology of control and it is the inability to exercise this control over sexual function that has dysphoric implications for the man. Premature ejaculation is reaching sexual climax within one minute of starting intercourse. Another option is squeezing behind the head of the penis until the sensation passes. To continue reading this article, you must log in. Subscribe to HarvardHealthOnline+ FREE for 30 days for unlimited access to the site – where all content is reviewed by an HMS physician or faculty expert. With HHO+ you get these exclusive benefits: Unlimited access to all Harvard Health Online content Customized website experience aligned to your health goals In-depth health guides on topics like sleep, exercise, and more Members-only access to exclusive articles and resources UNLOCK EXPERT ACCESS for 30 days FREE! As a service to our readers, Harvard Health Publishing provides access to our library of archived content.