Men who are not able to last longer in bed are usually suffers from premature ejaculation (PE). PE, a common male sexual disorder is defined as ejaculation occurring, without control, on or shortly after penetration and before the person wishes it, causing marked distress or interpersonal difficulty. According to WHO, PE is the inability to delay ejaculation sufficiently to enjoy love making, which is manifested by either an occurrence of ejaculation before or very soon after the beginning of intercourse or ejaculation occurs in the absence of sufficient erection to make intercourse impossible.
Certain studies which evaluated its prevalence suggest that PE is known to affect about one in three men, however, two in three men may have suffered from this disorder at some time in their lives. Some studies suggest that peak age in men suffering from PE was 31–40 years old.2
Although the cause of not able to last longer in bed or PE is largely unknown, hormonal imbalances are partly to be blamed. It has been observed that men who have low levels of the serotonin in their brains are more likely to take a shorter time to ejaculate.
Psychological factors such as stress, depression, anxiety, guilt, emotional issues such as relationship problems, lack of confidence or poor body image, consciousness over your sexual performance, sexual repression, etc. Some physical conditions including imbalanced hormone levels, abnormal levels of neurotransmitters, inflammation or an infection in prostate or urethra. Moreover, genetic traits can also be a cause of PE.3
However, in major portion of men, PE is rarely caused due to a medical condition, it has psychological reasons behind it which leads to a good prognosis. Even then it is important to identify the cause of PE , as it can lead to secondary symptoms such as distress, embarrassment, anxiety, and depression.4 Several studies inferred that PE remarkably effects men in a negative way and their partners. Besides, single men fails in building a new partner relationships. Although men affected with PE are unwilling to desire a treatment from their physicians, they should be encouraged and supported by their partner to seek the available effective treatment.5
Although numerous techniques are available by which men, either alone or with the help of their partners can try to achieve more control over ejaculation, their efficacy is not backed by scientific studies. It has been observed that many people also develop their own techniques to deal with this disorder.6 Few techniques are discussed below:
Counseling has found to be beneficial in combination with other treatments. Although it has been seen to be advantageous in improving self-esteem, it is not efficacious in treating the cause of lifelong PE. It is usually given to men to manage psychological problems secondary to PE, instead to treat the cause.1
It consists of two methods namely, stop-start technique and squeeze technique. Both these techniques are considered to be inefficient in resolving relationship issues. Major portion of men found these to be intrusive, mechanical that may fracture a normal love/lust act, relationship and spontaneity.1 A small study conducted using the start-stop method and the squeeze method resulted in increased time until ejaculation, but it was achieved by a few minutes after twelve weeks of training. However, the methods were used as part of sex therapy, thus it is unclear whether these techniques can benefit, when a man uses them on his own.6
1. Stop-start technique
According to literature, treatment of PE has started over 50 years ago with stop-start technique developed by Semans which supports that ejaculation can be controlled through prolonging the neuromuscular reflex responsible for it.1 The aim of this method is to gain over man’s ejaculation, as it involves stimulating the penis until just before orgasm and then stopping it until the sensation of impeding orgasm goes away. This can be done either by the man himself or his partner. This action is repeated several times in order to identify the phase of sexual arousal occurring right before orgasm. By achieving that particular phase can help man control the level of arousal which in turn can delay the ejaculation for a certain time. Seman’s study, however lacked a control group, because of which it can be proved.
2. Squeeze technique
This is similar to start and stop technique which involves stimulation of penis until just before orgasm. Further a little bit of pressure on the head of the penis is applied to decrease the level of sexual arousal. This can be done by man or his partner by placing index finger on the back side of the penis, at the junction of head and shaft and thumb is placed on the other side of the penis, and then gentle squeezing is done. Wait for about 30 seconds is essential before resuming simulation and then repeat this steps several times in a row. The technique developed by Wolpe and Lazarus and Masters and Johnson was not able to establish that these behavioral techniques can cure PE.1,6
Pelvic floor exercises
Weak pelvic muscles can sometimes lead to PE. Pelvic floor exercising is a useful way to strengthen them. These exercises are performed to voluntarily move and strengthen the pelvic floor muscles, the layer of muscles supports sphincter muscle of the urethra. The right method is to identify the right muscles to tighten by stopping urine in midstream. Hold them tight for 3 seconds and then release them for 3 seconds. Repeat this 10 times, at least three times a day. However, a small study which used pelvic floor exercises showed that these exercises were able to increase the time until ejaculation only from half a minute to two minutes on average.3,6
Men are often asked to think about something else during sex in order to distract themselves which can help in delay ejaculation. Although it gets effective in some men, other say that thinking about something else lead to their erection got weaker or go away completely. Moreover, some men identify this with being dishonest to their partner during sex.6 Other option includes man can also try slowing things down by doing foreplay or taking breaks.
Use of condoms
Another alternative is to use a condom which can make the penis less sensitive and can further delay ejaculation.
Masturbate before sex
Sometimes, men are advised to masturbate before sex, which results in delayed ejaculation when they are then aroused for a second time and have sex. However, this can be achieved, if the man can get a second erection.1,3
Various clinical trials have evaluated several drugs that can help in ejaculatory control and alleviate personal distress, however, none of these agents are currently approved by Food and Drug Administration for the treatment of PE. Some of the therapeutic modalities recommended by the The American Urological Association (AUA) for the management of PE include behavior modification strategies and pharmacological agents such as selective serotonin reuptake inhibitors (SSRIs), tricyclic antidepressants (TCAs), and topical preparations (e.g., lidocaine/prilocaine cream).
Selective serotonin reuptake inhibitors
Various studies have shown that SSRIs such as sertraline, fluoxetine, paroxetine and citalopram have common side effect of delaying ejaculation in around 50% of healthy patients, this fact makes them preferred off label treatment option for PE. Various randomized controlled trials have shown that paroxetine aids in delaying ejaculation from 1.5 min before treatment to 7.7 min after treatment. Other placebo controlled studies of sertraline and fluoxetine have also shown that these drugs increase ejaculatory time and improve patient satisfaction in contrast to placebo.
Dapoxetine, a rapidly absorbed SSRI and an investigational agents for PE has been particularly developed for the “on demand” treatment of PE. It is currently considered as the first and only drug to be approved for the treatment of PE in several countries around the world. Various placebo-controlled clinical trials of more than 6000 participants have found dapoxetine to be efficacious and well tolerated agent for the management of PE.
Moreover, SSRIs used as a therapy for PE have an added advantage as the doses that are used are usually lower than those given in the treatment of depression, which in turn suggests that the frequency and severity of adverse events could be less. However, most common side effects of continuous dosing include nausea, fatigue, headache, confusion, and diarrhea. In regard to severe complications, mania and withdrawal symptoms, and potential drug interactions can also exist with the use of SSRIs.
Evidences demonstrate that TCAs, especially clomipramine has shown beneficial effects for the treatment of PE by delaying ejaculatory time. A trial was conducted on 36 men with PE, they were administered fluoxetine, sertraline, clomipramine, and placebo. The outcome revealed that among all the agents used, clomipramine had the greatest effect on PE as the ejaculation time was increased from 46 sec at baseline to 5.75 min and patient reported sexual satisfaction. However, adverse effects such as drowsiness, dizziness, dry mouth, and fatigue were reported in clomipramine-treated patients which resulted in discontinuation of therapy.
These can be used to reduce glans penis sensitivity. Application of lignocaine-prilocaine aerosol for 20-30 min thinly to the glans and distal shaft before sexual intercourse and removed before contact with the partner has shown significant prolongation of ejaculation time in comparison to placebo. Similarly, lignocaine spray can also be applied to the glans in 3-6 sprays, 5-15 min before sexual intercourse. However, there are still no randomized controlled studies proving its efficacy for the treatment of PE. Moreover, prolonged application of topical anesthetic, e.g. 30-45 min can cause loss of erection due to numbness of the penis.
Various commonly used herbal ingredients for the management of PE are epimedium leaf extract, cuscuta seed extract, ginkgo biloba leaf, asian ginseng root, saw palmatto berry - fructus serenoae, muira pauma bark extract, catuaba bark extract, hawthorn berry - fructus crataegi. However, more scientific studies are required to assess the interaction of different herbs in complex herbal formulation.1
1. Gajjala SR, Khalidi A. Premature ejaculation: A review. Indian J Sex Transm Dis AIDS. 2014;35(2):92-95.
2. Kalejaiye O, Almekaty K, Blecher G, Minhas S. Premature ejaculation: challenging new and the old concepts. F1000Res. 2017;6:2084. Published 2017 Dec 4.
3. Premature Ejaculation. Available at: https://www.webmd.com/men/what-is-premature-ejaculation#1. Accessed on:19-09-2020.
4. How to treat premature ejaculation. Available at: https://www.medicalnewstoday.com/articles/188527. Accessed on:19-09-2020.
5. Rosen RC, Althof S. Impact of premature ejaculation: the psychological, quality of life, and sexual relationship consequences.J Sex Med. 2008 Jun;5(6):1296-307.
6. Premature ejaculation: What can I do on my own? Available at: https://www.ncbi.nlm.nih.gov/books/NBK547551/. Accessed on:19-09-2020.
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