The BASHH special interest group for sexual dysfunction, chaired by Daniel Richardson, has made a series of recommendations for the management of premature ejaculation. These recommendations were published in the International Journal of STD and AIDS 2006, number 17, pages 1-6.
In the introduction, the authors make the observation that orgasm and ejaculation complete the sexual response for the human male. This sequence of events is made up of three separate mechanisms: emission, ejection, and orgasm.
Ejaculation is a reflex mechanism which is composed of sensory receptors, afferent nerve pathways, and sensory areas in the cerebral cortex, together with associated spinal motor areas, and afferent pathways.
The reflex of ejaculation is determined by a sophisticated interplay between serotonergic and dopaminergic neurons, with the additional involvement of various other neuronal pathways, including oxytocinergic neurons.
Finally, seminal emission and ejaculation are correctly integrated into sexual responses during intercourse through the action of various forebrain and midbrain structures.
Premature Ejaculation – Prevalence
As any student in this area knows, premature ejaculation, or PE, is one of the most frequently reported sexual dysfunction in men. Even so, this is not help to clarify the prevalence of PE in the average human population.
Self-reported study of American men aged between 18 and 59 years of age discovered that about a third of them would admit they have incurred during at least one month over the past year.
For more details of the conduct of the United Kingdom involving 5000 men between the ages of 16 and 44 discovered that as few as 2.7% had experienced problems relating to their ability to last long enough in bed that continued for a period of 6 months or more during the past year.
These figures simply don’t match up to the clinical experience of therapists working in the field, some of whom have even suggested that premature ejaculation is so common that it is actually “normal” amongst men.
Furthermore, as the authors of the BASHH study pointed out, there are significant overlaps in the distribution of ejaculation delay in men who regard themselves as having premature ejaculation and those who do not consider themselves to suffer from the condition.
Clearly, one must conclude that other features of ejaculatory behavior should be considered: the most obvious ones being the degree of control man has over his ejaculation, and the distress caused to him and his partner by the short period of intercourse which they enjoy.
Premature Ejaculation – Definition
It’s hardly surprising in these circumstances that there is no universally accepted definition of this sexual dysfunction.
As long ago as the 1950s, Masters and Johnson suggested that PE should be defined in relationship to a man’s inability to control his orgasm and ejaculation for long enough so that the woman with whom he was having intercourse could reach orgasm at least half the time.
Modern authors, well aware of the difficulty of women reaching orgasm during intercourse, will hardly regard this as a satisfactory definition. Even so, there is no doubt that many more women could achieve orgasm during intercourse than actually do, if men were able to control their ejaculation more effectively and knew how to last longer in bed.
Other studies have produced definitions which center on the number of thrusts the man can achieve before he ejaculates.
Scientific studies, as reported in the relevant journals, have often resorted to using the measure known as intravaginal ejaculatory latency time, or IELT, determined by the female partner using a stop watch.
The disadvantages of such a protocol need hardly be pointed out.
As a result, it is probably no surprise that a vague definition has been determined by the American Association of Psychiatrists: they define PE as persistent or recurrent ejaculation with minimal sexual satisfaction, before or shortly after penetration.
Part of this definition implies that the condition causes distress or interpersonal difficulties and is not due to any other other factors such as withdrawal from drugs.
In my experience, working with men who have PE, it is generally clear that most (but not all) men with PE have had a tendency to ejaculate rapidly since their earliest sexual encounters.
This is why PE has been divided into two categories – primary (lifelong) and acquired or secondary. The latter implies that a man’s initial attempts at sexual intercourse have been satisfactory but that his ejaculation response time began to shorten at some point during his adult sexual “career”.
The cause of premature ejaculation has never been fully understood although this fact has not stopped scientists putting forward various hypotheses.
Most reliably, one can divide the causes of any sexual dysfunction into the physical and emotional, otherwise known as organic and psychogenic, respectively. The first cause is rather easier to identify than the second: it includes things such as pelvic injury, chronic prostatitis, vascular disease, and hypogonadal hypertrophy.
A great deal of work has been conducted on psychopharmacological studies, and as result that it has been suggested that premature ejaculation might be caused by changes in central serotonergic neurotransmission, possibly as a result of 5 hydroxytryptamine receptor hypersensitivity.
Unfortunately, the psychodynamic theories that have been put forward offer an equally compelling and satisfactory explanation for this condition.
BASHH recommendations for treatment
To start with, recommendations are that the doctor should thoroughly assess the patient to discover whether the problem is primary or secondary, or if it is associated with drug use, psychiatric history, sexual desire disorder, or erectile difficulties.
In addition, as you can see from the comments above about the origin of PE, it is necessary to obtain information about any specific urinary symptoms or evidence of prostatitis.
A clinical examination of the penis and the man’s genitals is also necessary, together with an assessment of his physical, emotional and mental state.
The focus of treatment should be always to increase sexual satisfaction in both patient and partner as well as alleviating concerns about whether or not his sexual performance is adequate. In this context, simple education about sexual norms and behavior, as well as explaining how sexual interaction can be effectively negotiated between partners in a relationship, may be of fundamental importance.
Behavioral treatments including cognitive behavioral techniques.
The squeeze technique for controlling premature ejaculation was developed by Dr James Semans in the 1950s.
To apply the squeeze technique, the man’s penile glans is squeezed firmly between the thumb and two fingers of the same hand at the level of the frenulum. Pressure is applied until the man’s erection softens. Usually, it is the man’s partner who applies pressure using one hand, her thumb over the subcoronal frenular region, and her index finger and forefinger placed together on the distal shaft of the penis on the opposite side. Read more here about how to last longer in bed .
And delayed ejaculation, by contrast, can be seen as the opposite of premature ejaculation, in that both are ejaculatory dysfunctions.
One allows a man to ejaculate normally, albeit within a very short time scale, whilst the other prevents him from ejaculating at all. It’s hard to know which of these dysfunctions is the more inconvenient or distressing.
To some extent it probably depends on the emotional disposition of the man, because in my experience premature ejaculation is linked to anxiety, whereas delayed ejaculation is most often experienced by men who have some kind of deficiency in emotional feeling.
I’m not referring to anything deleterious or denigratory – what I mean when I say this is that men with delayed ejaculation often have an internal emotional mechanism which prevents them feeling everything – especially during sex – as acutely as they could.
Perhaps one could see this as a result of historical trauma or childhood experience which was broadly speaking negative or unhelpful.
The fact that is that when a man is cut off from his feelings, particularly during sexual activity, he lacks the input and stimulus necessary to promote sexual arousal and normal sexual excitement developing. This is critical for his sexual response cycle to progress normally, and if it does not, the man will not reach his point of ejaculatory inevitability.
So you can see men who have delayed ejaculation have a low level of arousal during sexual intercourse; very often they can succeed at reaching orgasm during masturbation because they can use either pornography or extreme sexual fantasy that turns them on sufficiently to ejaculate.
During sex with a partner, neither porn nor fantasy comes into play – men with delayed ejaculation often focus attention on their partners – and so arousal remains low ejaculation escapes them.
The cure lies in the use of a training program which allows men to learn how to focus on their emotional and sensory experience during sex with a partner, and become aroused by what is happening in the sexual encounter – in particular, the man needs to become aroused by the sexual touch, scent, and sight of his partner – and his own body.