Premature Ejaculation - Overview & Treatment Options

Premature ejaculation (PE), also referred to as rapid or early ejaculation, is defined according to three essential criteria: (1) brief ejaculatory latency (reaching ejaculation in two minutes or less according to one study); (2) loss of control; and (3) psychological distress in the patient and/or partner. PE is relatively common with the Mayo Clinic stating that as many as one third of men say they experience this problem at some time in their lives.  Approximately one third of men with PE have concurrent ED, which typically results in early ejaculation without a full erection.

Factors Associated with Premature Ejaculation

Premature ejaculation involves a complex interaction of psychological and biological factors.There are a number of causes that may contribute to premature ejaculation, including:

Psychological Causes

Psychological factors that might play a role include:

  • Performance anxiety or worrying about premature ejaculation

  • Anxiety about initiating or maintaining an erection may lead to a pattern of rushing to ejaculate out of fear of losing an erection

  • High levels of general life stressors or anxiety

  • Early sexual experiences or history of sexual abuse - perhaps unprocessed feelings around sex

  • Poor communications with your partner or anxiety about satisfying them sexually

Biological Causes

A number of biological factors might contribute to premature ejaculation, including:

  • Abnormal hormone levels, i.e. low testosterone levels

  • Imbalance or abnormal levels of brain chemicals called neurotransmitters

  • Inflammation or infection of the prostate or urethra

  • Inherited traits

Premature Ejaculation Treatment Options

Dr. Kass explores the following treatment options for PE. If a patient is experiencing erectile dysfunction concurrently with PE, Dr. Kass will address these simultaneously using a comprehensive approach.

  • Pelvic floor strengthening / BTL Emsella - Weak pelvic floor muscles may lead to problems with PE and strengthening the pelvic floor muscles can enhance a man’s ability to control ejaculation. BTL Emsella uses focused, high-intensity electromagnetic (HIFEM) technology to stimulate the deep muscles of the pelvic floor, causing them to contract. A single Emsella session produces the same result as doing 10,000 kegel exercises in a half hour. You can learn more about this procedure here.

  • SSRIs - medications to address PE include paroxetine, sertraline, fluoxetine, citalopram and escitalopram.  SSRIs should be started at the lowest dose and titrated up as needed at three- to four-week intervals. Most patients begin to see the full therapeutic effect of SSRIs after two to three weeks of therapy, and symptoms return if treatment is stopped. Some men are also able to take an SSRI circumstantially on the day of sexual activity.  A metaanalysis suggested that Paxil may be the most effective - delaying ejaculation up to nine minutes. 

  • Phosphodiesterase (PDE) inhibitors - for men with PE and coexisting ED, PDE inhibitors (i.e. Cialis and Viagra) may also be effective for the treatment. Two meta-analyses have assessed the efficacy of PDE5 inhibitors for PE, finding that both SSRIs and PDE5 inhibitors are more effective than placebo.

  • Tramadol - this analgesic has some activity at opioid receptors but also inhibits reuptake of serotonin and norepinephrine. Tramadol is sometimes used if SSRIs are ineffective or not tolerated. However, it should be used with extreme caution, given the potential risk of addiction and side effects associated with opioids. 

  • Topical anesthetics may also be effective in treating PE. Multicenter trials with an aerosolized, lidocaine-prilocaine spray have been reported to improve ejaculatory latency, ejaculatory control, and sexual satisfaction when applied topically to the glans penis five minutes before intercourse. Topical administration of alprostadil cream to the penile meatus before intercourse may also be beneficial. 

  • Behavioral therapies - start/stop techniques, squeeze therapy and distracted thinking are several strategies that can be used to delay orgasm. Wearing a condom may also decrease sensitivity and help delay ejaculation.

Other Ejaculatory Disorders

  • Anejaculation (aka anorgasmia) - the inability to achieve ejaculation or orgasm.

  • Retrograde ejactulation - able to ejaculate, but no semen emitted because it enters the bladder rather than flowing through the penis.

  • Delayed ejaculation - an extended period of time is needed to reach orgasm and ejaculate

Common contributors to the ejactulatory disorders listed above include lower urinary tract symptoms or BPH (enlarged prostate), medications (especially SSRIs, certain blood pressure medications, prostate medications like Flomax), or prostate surgeries. Hormone conditions such as low thyroid or low testosterone have also been associated with ejactulatory problems. These issues can be discussed with a doctor familiar with ejaculatory disorders. 

katherine kass