The Sexual Psychophysiology Laboratory - Resources - MSD

Premature Ejaculation
Cindy Meston, Ph.D., Alessandra Rellini, Ph.D., & Christopher Harte, B.A.

The DSM-IV-TR defines premature ejaculation (PE) as ejaculation that occurs with limited stimulation before, or shortly after, penetration and sooner than the man desires. An important criterion for this condition is the feeling that the man does not have control over ejaculation and this causes him distress. The time from penetration to ejaculation (ejaculation latency) varies greatly between men, with 10 minutes being the average for men with no sexual problems. An individual with PE tends to ejaculate within the first minute of intercourse, with the majority of men reporting an average of 15 seconds or 15 thrusts of intercourse before ejaculation. At times, a man may report distress because he is unable to prevent ejaculation for 20 or 30 minutes. In this instance, the diagnosis of PE is not warranted even if the individual reports high levels of distress.

PE is the most commonly reported sexual disorder in men, with approximately 30% of men in the US reporting PE in the previous year (Laumann et al., 1994). Unlike ED, this condition has been estimated to affect younger men more than older men. As many as 40% of men under 40 years of age and only 10% of men over age 70 have been estimated to experience PE (Corona et al., 2004). The cause of PE is usually assumed to be psychological rather than physiological although both medical and psychotherapy techniques have been developed to treat this problem.

FACTORS ASSOCIATED WITH PREMATURE EJACULATION

During the first stage of ejaculation (sperm emission), sperm is emitted from the epididymus into the vas deferens. This process is controlled by the contraction of smooth muscles which is generated by the sympathetic branch of the autonomic nervous system. After sperm emission, the individual has the subjective experience that ejaculation is “inevitable,” known as the “point of inevitable ejaculation” or, more commonly, “the point of no return!” The striate muscles surrounding the spongious tissue, the cavernous tissue, and in the pelvic floor contract rhythmically causing ejaculation to occur. Usually, the subjective experience of orgasm is associated with the contractions of the striate muscles and, in most men, emission, ejaculation, and orgasm are interconnected. For a small portion of men, however, these phenomena are independent. For example, some men train themselves to have the subjective experience of orgasm without ejaculation and some men with PE experience emission without ejaculation.

The precise cause of PE is not known, but it can arise from a deficiency in any of the afferent or efferent circuits involved in the ejaculatory process. For what concerns the sensory (afferent) circuits, researchers have postulated that men with PE have a lower sensitivity threshold such that less stimulation is needed to attain ejaculation. This explanation cannot account for all cases of PE, however, as studies show that PE exists in both men with high and with low sensitivity thresholds. It has also been proposed that men with PE may respond with a higher level of arousal to sexual stimuli (hyperarousability). Again, this explanation cannot account for all cases of PE. One psychophysiological study (Rowland & Slob, 1997) that measured penile rigidity in the laboratory showed that men with PE had a weaker genital response to visual stimuli compared to men with no sexual dysfunction, but had a comparable genital response to men with no sexual dysfunction during tactile plus visual stimuli.

Anxiety has most frequently been hypothesized to be the primary cause and maintaining factor for PE. Anxiety increases sympathetic nervous system activity which is involved in semen emission and, thus, high levels of anxiety could feasibly accelerate ejaculation. Laboratory studies have generally not shown significant differences in levels of anxiety reported by men with and without PE. One psychological variable that has shown significant differences between men with and without PE is perceived control over ejaculation. During exposure to visual and tactile stimuli, men with and without PE showed comparable degrees of genital sexual arousal (measured in penile circumference), but men with PE reported significantly less control over their ejaculation. A greater understanding of the meaning men attribute to ejaculatory control may provide important insight into the psychological factors involved in this disorder.

ASSESSMENT AND TREATMENT OF PREMATURE EJACULATION

A thorough assessment of PE includes measuring three factors; length of time from penetration to ejaculation (ejaculation latency), subjective feelings of control over ejaculation, and personal and relational distress caused by the condition. Usually these dimensions of PE are assessed with retrospective self-reports provided by the patient. Sometimes the patient is asked to use a chronometer to measure the time from insertion to ejaculation or to have their partner provide an estimate of the man’s ejaculatory latency in order to help increase measurement reliability.

The most commonly used psychotherapy techniques for increasing ejaculatory latency are the squeeze technique developed by Masters and Johnson (1970) and the pause technique (Kaplan, 1989). The squeeze technique consists of engaging in sexual stimulation alone or with a partner for as long as possible before ejaculation. Before reaching the “point of inevitable ejaculation” the man is instructed to stop the activity and apply pressure to the penile gland to decrease the urge to ejaculate but not to the point that he completely loses his erection. When the urge has subsided, the man resumes masturbation or intercourse stopping as many times as needed in order to delay ejaculation. The pause technique is similar to the squeeze technique with the exception that no pressure is applied to the penis. At times, clinicians may suggest using a PDE 5 inhibitor (e.g., Viagra) along with these techniques so that the man can practice delaying ejaculation without worrying about maintaining an erection.

Medical treatments include the use of topical anesthetics to diminish sensitivity used in combination with condoms (to prevent to the partner’s genitals from being anesthetized). SSRIs such as clomipramine, sertaline, fluoxetine and paroxetine have been used because of their known side effects of delaying or abolishing orgasm. In men with PE, there is some evidence these drugs increase ejaculation latency and sexual pleasure and satisfaction.