Premature ejaculation

What is premature ejaculation?

There is no generally accepted definition of premature ejaculation, as what Mr A may regard as a premature ejaculation will be different from what Mr B or C will regard as such.

However, it is a condition where ejaculation occurs sooner than desired by a man or both him and his partner; either before or shortly after penetration.

Some take premature ejaculation to mean a condition where men find it difficult to sustain penile erection for at least 1 minute without ejaculation.

Note that the penis goes flaccid after ejaculation, so, it is often difficult to distinguish between erectile dysfunction and premature ejaculation.

Severity of premature ejaculation varies.
Some men literally ejaculate immediately they touch their sexual partner.

Some do so after 1 to 2 thrust into their partners\’ opening such as the vagina, anus, or mouth depending on the type of sex they are engaging in.

Types of premature ejaculation

There are 2 types of premature ejaculation:

1. Primary premature ejaculation
2. Secondary or acquired premature ejaculation

1. Primary premature ejaculation

This is a situation where a patient has always had the problem from the first day of sexual intercourse.

2. Secondary premature ejaculation (or acquired premature ejaculation)

This is a situation where a patient recently developed the problem.

Here, the patient was performing well sexually before developing the problem.

Causes of premature (early) ejaculation

The cause of premature ejaculation is unknown.

However, the following are factors that can lead to it:

1. Depression
2. Stress
3. Poverty
4. Guilty (of sexual intercourse; especially when one is cheating on their partners).
5. Lack of confidence or poor body image
6. Having sex for the first time or with a new partner
7. Anxiety (existing or during intercourse)
8. Relationship problems
9. High and unrealistic expectations
10. Low serotonin level
11. Erectile dysfunction
12. Inflammation or an infection of the prostate or urethra
13. Fear during sex. This can happen when the male partner is afraid of being caught during sex.

Complications of premature ejaculation

If premature ejaculation is not treated, it can lead to complications.

The following are possible complications that can result from rapid ejaculation, especially when not treated or if the treatment is ineffective:

1. Depression
2. Relationship or marital problems
3. Divorce
4. Infertility
5. Low self-esteem

1. Depression: A rapid or early ejaculation can make a man slide into depression.

2. Relationship or marital problems: Both male and female gender love to be sexually satisfied. When this doesn\’t happen, it can create problems in a relationship.

3. Divorce: some women can tolerate a man with premature ejaculation, but not all. Premature ejaculation makes it difficult for men to sexually satisfy their partners. If not addressed via treatment, it can lead to relationship stress and eventual divorce.

4. Infertility: Premature ejaculation that occurs before vaginal penetration will make it difficult for a man to get women pregnant.

5. Low self-esteem or lack of confidence: premature ejaculation can make a man to lose his self-esteem and confident in the presence of his sexual partner.

Diagnosis

Diagnosis of premature ejaculation is based on sexual history.

The following questions can be asked to help with the diagnosis:

1. What is the frequency of premature ejaculation?
2. What is its duration?
3. When it occurs in relation to specific partners. Does it happen when you are with partner A, B or C or when you\’re with all of them?
4. Does it happen in all your sexual intercourse or only in some?
5. What is the degree of stimulus that leads to it?
6. What is the nature of sexual activities you engage in before you have it: foreplay, masturbation, intercourse, attempt to have sex, thought of sex, watching pornographic material?
7. What is the effect of premature ejaculation in your sexual activity: does it make you to withdraw from having sex?
8. Types and quality of personal relationship and quality of life?
9. What are the aggravating or alleviating factors?
10. Do you have a history of drug use or abuse?
11. Is there any relationship between drugs use or abuse with the presenting condition?

Treatment for premature (early) ejaculation

We have three therapies for premature ejaculation. These are:

1. Psychological therapy
2. Behavioral therapy
3. Pharmacotherapy

The choice of therapy for premature ejaculation, (whether it should be psychological, behavioral, or pharmacotherapy), is based on the known or assumed cause of the condition. History taking can help in determining this.

1. Non-pharmacological treatment

1. Reassure patients and their partners that premature ejaculation is treatable
2. Make them understand that it is a common disorder among men
3. Discuss treatment options available with them, emphasizing the benefits and risks of each to enable them make informed decisions.

As a physician, you should note that no current treatment option for premature ejaculation is approved by the FDA.

2. Pharmacological therapy (pharmacotherapy)

There are two treatment approach for PE under pharmacotherapy. The first approach is on demand treatment approach while the second one is continuous approach.

The on demand treatment approach is often used when there is no obvious cause of premature ejaculation.

Drugs used here affect the ejaculatory pathway, which originates from the spinal reflex centre. They equally inhibit neuronal re-uptake of serotonin. SSRIs do these.

Drugs or agents that can reduce the sensitive of the penis are equally used here. Examples are local anaesthetic agents like lidocaine.

When premature ejaculation and erectile dysfunction coexist, erectile dysfunction should be treated first. Note that many patients with erectile dysfunction develop secondary premature ejaculation.

So, an effective treatment of P.E. in these categories of patients will consequently take care of their premature ejaculation.

A. Selective serotonin receptor inhibitors (SSRIs)

i. Dapoxetine

By mouth: take 30 mg of dapoxetine 1 to 3 hours before sex.

Based on response, the dose can be adjusted up to 60 mg, (still taken 1 to 3 hours before sex).

ii. Fluoxetine

• 5 – 20 mg per day (continuous treatment approach)

iii. Paroxetine 

• 10, 20, 40 mg per day (continuous treatment approach)

Or

• 20 mg taken 3 to 4 hours before sex

iv. Sertraline 

25 – 200 mg per day (continuous treatment approach)

Or

50 mg taken 4 to 8 hours before sex.

B. Tricyclic antidepressants

Clomipramine
25 – 50 mg per day (continuous treatment approach)

Or

25 mg taken 4 to 24 hours before sex.

C. Topical treatment

i. Lidocaine cream or spray

Use 20 to 30 minutes before sex. Wash off immediately before sex to prevent it from numbing the vagina.

ii. Prilocaine cream or spray

Use 20 to 30 minutes before sex. Wash off immediately before sex to prevent it from numbing the vagina

iii. Lidocaine/prilocaine cream combination

Use 20 to 30 minutes before sex. Wash off immediately before sex to prevent it from numbing the vagina.

It is not clear which is more effective in the treatment of premature ejaculation; whether it is continuous dosing of the serotonin receptor inhibitors or on demand usage.

The choice of which to go for should be determined by both the patients and the physician.

We, however, suggest that pharmaco-economics principles be applied in doing so.

D. Miscellaneous: Tramadol

Tramadol is a prescription only medicine that can be used if none of the above listed drugs worked.

2. Non-pharmacological treatment

1. Kegel exercise: this is proven to help patients with premature ejaculation. The only issue with it is that it takes time before its benefits are seen.
2. Stop and start method: stop thrusting when you are close to ejaculating. Resume only after some seconds or minutes, when the feeling of ejaculation is no longer there.
3. Masturbation: doing this 1 to 2 hours before sex may be of help. Most men last longer during the second round.
4. Special condom: there are thick condoms out there that are specially designed to help men with premature ejaculation.
5. Take deep breaths when you are close to ejaculation. This briefly shut down the ejaculatory reflex.
6. Allow your partner to be in control (by being on top). This gives them the power to pull away when you\’re close to ejaculation.
7. Nutrition:
   1. Eat healthy.
   2. Stop smoking cigarettes
   3. Stop drinking alcohol
   4. Stop sugar consumption
   5. Frequently eat these:
      • Ginger
      • Tiger nuts
      • Date
      • Banana etc.

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1. Drogo K. Montague et al. AUA Guideline On The Pharmacologic Management Of Premature Ejaculation. The Journals Urology. Published: July 1, 2004. Accessed June 25, 2022.
2. Can premature ejaculation be controlled? National Health Service. Accessed June 25, 2022.
3. Irvin H. Hirsch MD. Premature ejaculation. MSD Manual. Reviewed March 2022. Accessed June 25, 2022.
4. Nicholas Gillman and Michael Gillman. Premature Ejaculation: Aetiology and Treatment Strategies. Multidisciplinary Digital Publishing Institute (MDPI). Published online October 25, 2001. Accessed June 25, 2022. [/toggle].