Premature ejaculation
Steven C. Campbell, M.D., Ph.D.
Synonyms and keywords: Early Ejaculation; ejaculatio praecox; inhibited orgasm in males; premature climax ; rapid ejaculation;

# Overview
Premature ejaculation (PE), also known as rapid ejaculation, premature climax, early ejaculation, or by the Latin term ejaculatio praecox, is the most common sexual problem in men, affecting 25%-40% of men. It is characterized by a lack of voluntary control over ejaculation.
Masters and Johnson stated that a man suffers from premature ejaculation if he ejaculates before his partner achieves orgasm in more than fiftypercent of his sexual encounters. Other sex researchers have defined premature ejaculation as occurring if the man ejaculates within two minutes or less of penetration; however, a survey by Alfred Kinsey in the 1950s demonstrated that three quarters of men ejaculated within two minutes
-f penetration in over half of their sexual encounters. Today, most sex therapists understand premature ejaculation as occurring when a lack of ejaculatory control interferes with sexual or emotional well-being in one or both partners. Masters and Johnson recommended the use of the Lateral coital position to help alleviate premature ejaculation.
Most men experience premature ejaculation at least once in their lives. Often adolescents and young men experience "premature" ejaculation during their first sexual encounters, but eventually learn ejaculatory control. Because there is great variability in both how long it takes men to ejaculate and how long both partners want sex to last, researchers have begun to form a quantitative definition of premature ejaculation. Current evidence supports an average intravaginal ejaculation latency time (IELT) of six and a half minutes in 18-30 year olds.  If the disorder is defined as an IELT percentile below 2.5, then premature ejaculation could be suggested by an IELT of less than about one and a half minutes. Nevertheless, it is well accepted that men with IELTs below 1.5 minutes could be "happy" with their performance and do not report a lack of control and therefore do not suffer from PE. On the other hand, a man with 2 minutes IELT could present with perception of poor control over his ejaculation, distressed about his condition, has interpersonal difficulties and therefore be diagnosed with PE.
Scientists have long suspected a genetic link to certain forms of premature ejaculation. In one study, ninety-one percent of men who suffered from lifelong premature ejaculation also had a first-relative with lifelong premature ejaculation. Other researchers have noted that men who suffer from premature ejaculation have a faster neurological response in the pelvic muscles. Simple exercises commonly suggested by sex therapists can significantly improve ejaculatory control for men with premature ejaculation caused by neurological factors. Often, these men may benefit from anti-anxiety medication or selective serotonin reuptake inhibitors (SSRIs), such as sertraline or paroxetine, as these slow down ejaculation times. Some men prefer using anaesthetic creams; however, these creams may also deaden sensations in the man's partner, and are not generally recommended by sex therapists.
Psychological factors also commonly contribute to premature ejaculation. While men sometimes underestimate the relationship between sexual performance and emotional well-being, premature ejaculation can be caused by temporary depression, stress over financial matters, unrealistic expectations about performance, a history of sexual repression, or an overall lack of confidence. Interpersonal dynamics strongly contribute to sexual function, and premature ejaculation can be caused by a lack of communication between partners, hurt feelings, or unresolved conflicts that interfere with the ability to achieve emotional intimacy. Neurological premature ejaculation can also lead to other forms of sexual dysfunction, or intensify the existing problem, by creating performance anxiety. In a less pathological context, premature ejaculation could also be simply caused by extreme arousal.
Some physical illnesses, such as a prostate infection, are also known to induce premature ejaculation. In other instances, premature ejaculation is caused by a physical injury that affects the nervous system. Certain medications, such as cold medications containing pseudoephedrine, also cause premature ejaculation. Sexual dysfunction is a common symptom of psychiatric afflictions ranging from bipolar disorder to post-traumatic stress disorder. In these cases, it is best to discuss the issues openly with a physician.
Today it is believed that the neurotransmitor serotonin (5HT) has a central role in modulating ejaculation. Several animal studies have demonstrated its inhibitory effect on ejaculation modulated through the PGI system in the brain. Therefore, it is perceived that low level of serotonin in the synaptic cleft in these specific areas in the brain could cause premature ejaculation. This theory is further supported by the proven effectiveness of SSRIs, which increase serotonin level in the synapse, in treating PE.

# Pathophysiology
The process of ejaculation requires two sexually sequentially distinct actions, emission and expulsion.
The emission phase is the first one to happen and it involves deposition of semenal fluid from ampullary vasa deferens, seminal vesicles & prostate gland into posterior urethra (Bohlen, et al., 2000). Second phase is the expulsion of semen which involves closure of bladder neck followed by the rhythmic contractions of urethra by pelvic-perineal and bulbospongiosus muscle and intermittent relaxation of external Sphincter urethrae (Master and Turek, 2001).
Sympathetic motor neurons control the emission phase of ejaculation reflex and expulsion phase is executed by somatic and autonomic motor neurons. These motor neurons are located in the thoracolumbar and lumbosacral spinal cord and are activated in a coordinated manner when sufficient sensory input to reach the ejaculatory threshold has entered the central nervous system (De Groat and Booth 1980; Truitt and Coolen 2002).  Several areas in the brain, and especially the nucleus paragigantocellularis, have been identified to be involved in ejaculatory control (Coolen, et al., 2004),

# Differential diagnosis
- Ejaculatory concerns that do not meet diagnostic criteria
- Substance/medication-induced sexual dysfunction
- Opioid withdrawal
Premature ejaculation should be distinguished from erectile dysfunction related to the development of a general medical condition. Some individuals with erectile dysfunction may omit their usual strategies for delaying orgasm. Others require prolonged noncoital stimulation to develop a degree of erection sufficient for intromission. In such individuals, sexual arousal may be so high that ejaculation occurs immediately. Occasional problems with premature ejaculation that are not persistent or recurrent or are not accompanied by marked distress or interpersonal difficulty do not qualify for the diagnosis of premature ejaculation. The clinician should also take into account the individual's age, overall sexual experience, recent sexual activity, and the novelty of the partner.

# Epidemiology and Demographics

## Prevalence
The prevalence of premature ejaculation is 1,000-3,000 per 100,000 (1%-3%) of the overall population

# Risk Factors
- Anxiety disorders
- Social anxiety disorder (social phobia)
- Drug withdrawal
- Genetic predisposition
- Dopamine transporter gene polymorphism
- serotonin transporter gene polymorphism
- Thyroid disease
- Prostatitis

# Dignostic Criteria

## DSM-V Diagnostic Criteria for Premature Ejaculation

# Treatment
Depending on severity, premature ejaculation symptoms can be significantly reduced.
In mundane cases, treatments are focused on gradually training and improving mental habituation to sex and physical development of stimulation control. In clinical cases, various medications are being trialled to help slow down the speed of the arousal response.
SSRI antidepressants have been shown to delay ejaculation in men treated for different psychiatry disorders. SSRIs are considered the most effective treatment currently available for PE. These include paroxetine, fluoxetine, sertraline and more. The use of these drugs, that require chronic therapy, is limited by the neuropsychiatric side effects. New SSRI drugs specifically targeted to treat premature ejaculation (e.g. dapoxetine) can be taken on an as needed basis and have been recently shown positive results in large phase III studies. Nevertheless dapoxetine is not yet approved by any regulatory authority around the world. There is speculation that some of the associated effects are caused by lowered libido and blood pressure as well as lowered anxiety levels. Other pharmaceutical products known to delay male orgasm are; opioids, cocaine, and diphenhydramine.
The effects of the hyperforin extract of Hypericum perforatum has been evaluated on the ejaculatory reflex duration by using the intravaginal ejaculatory latency time (IELT) and sexual satisfaction (Cannon-Smith and Kaufman, 2007). In this trial sixteen men who desired longer sexual intercourse and without erectile dysfunction took with hyperforin immediately prior to sexual activity. All 16 participants completed the trial and there was a significant increase in mean ejaculation times from 24629 to 33134 seconds (p<0.002) in persons taking the hyperforin. The increase was seen in both the men who reported PE as bothersome and those who did not feel that PE was a problem for them.  The effect of hypericum perforatum is similar to dapoxetine.
Local anesthetic creams (like lidocaine, prilocaine and combinations) have shown to be very effective in clinical trials and are being used of the treatment of PE. Their use is limited by its own anesthetic effect that reduce sensation on the penis and vagina.
Most sex therapists prescribe a series of exercises to enable the man to gain ejaculatory control. While the exercises are intended for men who suffer from premature ejaculation, other men can use the exercises to enhance their sex lives. By far the most common exercise is the so-called start-stop technique. While the technique varies, the purpose is to get the male accustomed to maintaining an erection for an extended period of time while gradually increasing sexual tolerance. In doing this exercise, the male obtains an erection through self-stimulation, or masturbation. After achieving an erection, he stops stimulating himself until he begins to lose his erection; at that point, he begins to stimulate himself again. Gradually, over a period of several weeks, he is able to stimulate himself for longer periods of time, eventually gaining ejaculatory control. In order for this technique to be successful, the male should avoid feeling discouraged if he ejaculates rapidly; instead, he should use his sexual responses to learn how to vary the technique in a way that most benefits him.  Another variant, for example, is to stimulate the shaft and frenulum of the penis, exploring the glans more as control improves.
The male's partner is usually integrated into the exercises. She can stimulate her husband using the stop-start technique. When the male has achieved some level of ejaculatory control, he can insert his penis into his partner without thrusting. After his penis becomes accustomed to being inside his partner, thrusting can be gradually included, according to his abilities, using the stop-start technique. In less severe cases, the male might overcome his premature ejaculation early on, making exercises with his partner superfluous.
The male's partner plays an essential role in enabling him to overcome premature ejaculation. Without understanding and emotional support, the male is unlikely to obtain the level of relaxation required for sexual satisfaction. Both the male and his partner should communicate their feelings openly and with sensitivity. The male should learn to sexually satisfy his partner, orally or otherwise, while they work with him to overcome his premature ejaculation.
External latex rigid sheathes fastened to the body have been developed that cover all part of the penis during penetration so that the penis is protected from all the stimulation of the vagina. These help to gain control and to provide satisfaction to the partner.

## Alternative therapies
Many alternative therapies are available for the treatment of PE.  Caution should be exercised when researching alternative sources of advice however, most treatments have not actually been shown to be effective. Some web sites even advocate the dangerous and antiquated method of pulling the testes downwards when aroused. This is actually a good way to slightly strain the interior of the testes and is associated with reports of injury and weakened/deteriorated erection. For some reason this advice is still widespread on the Internet.
Hypnosis has also proven very effective in the treatment of premature ejaculation. It is believed by some that ejaculation is a subconscious habit and by giving the mind hypnotic suggestions to last longer, the problem can be greatly alleviated if not completely cured. Most men report dramatic improvement after only a few sessions of hypnosis.
The prostate gland plays a very important part in regulating arousal. Pressure in between the engorged prostate and the erection causes most of the pleasurable sensations and it may be emptied manually before sex by prostate massage. This causes the erection to be strong but less sensitive, and increases a patient's awareness of his physiology.
There is a trend toward the use of nutritional supplements when treating men who suffer from PE. Effective supplements must contain 5HTP which is a precursor to serotonin. A highly respected physiologist and author of numerous medical physiology textbooks, Dr. William Ganong, noted that serum serotonin levels could be increased through dietary means. 5-HTP is identified by Dr. Ganong as the supplemental source that can increase the serum level of serotonin thus helping to inhibit the ejaculatory reflex. There are a number of nutritional remedies available primarily on the Internet.

## Associated conditions
- Neurological disorders, e.g., multiple sclerosis
- Prostatitis
- Psychological disorders
- Interpersonal disorders
- ABC's Premature Ejaculation, e.g., ]