PE

“Early Ejaculation,” “Rapid Ejaculation,” “Premature Climax,” “Early Climax,” “Ejaculatio Praecox” (Latin)

There are two types of Premature Ejaculation: primary and secondary. Secondary Premature Ejaculation occurs in association with a number of conditions including Erectile Dysfunction (ED), prostate infection, physical injury that affects the nervous system and certain medications. Treating the underlying conditions will resolve the Premature Ejaculation problem. The following information concerns Primary Premature Ejaculation.

What is Premature Ejaculation?

Premature Ejaculation (or PE) is the most common sexual problem affecting men, characterized by a lack of voluntary control over ejaculation. The condition has been said to occur if a man ejaculates before his partner achieves orgasm (Masters and Johnson). Today, most sex therapists view Premature Ejaculation as occurring when a lack of ejaculatory control interferes with sexual or emotional well-being in one or both partners, regardless of the time it takes to ejaculate.

Diagnostic criteria for Premature Ejaculation (DSM-IV):

1. Persistent or recurrent ejaculation with minimal sexual stimulation before, on, or shortly after penetration, and before the person wishes it.
2. The disturbance causes distress or interpersonal difficulty.
3. The Premature Ejaculation is not due exclusively to the direct effects of a substance (e.g., withdrawal from opioids).

In common terms, Premature Ejaculation can be defined as:

• Ejaculating despite a conscious effort to resist it.
• Ejaculating before a man is ready to, or has satisfied his partner.
• Ejaculating before or within several minutes of penetration.

How Cmmon is Premature Ejaculation?

Premature Ejaculation is very common. 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 soon learn to control it. The persistence of Premature Ejaculation however affects 25-40% of sexually active men, according to recent studies. The psychological and social impacts can be profound. While the topic of Erectile Dysfunction is well covered in the media and the medical community, the problem of Premature Ejaculation is generally under-recognized, poorly understood and under- treated. This treatable condition continues to affect men and often creates feelings of shame and embarrassment unnecessarily.

Understanding the Process of Ejaculation

The process of ejaculation is a very intense sensation, part of orgasm, which can be immensely pleasurable and satisfying. Each spurt is associated with a wave of sexual pleasure, especially in the penis and the loins.

Ejaculation has two phases: emission and ejaculation proper.
The emission phase is under the control of the sympathetic nervous system. The ejaculatory phase is under control of the spinal reflex at the level of the lower sacrum.

The beginning of the emission is typically experienced as the “point of no return,” also known as the “point of ejaculatory inevitability,” in which sperm is propelled from its storage in the testicles up to the ejaculatory ducts and is then mixed with the fluids from the seminal vesicles, the prostate and the bulbourethral glands to form the semen or ejaculate.

During ejaculation proper, the rhythmic contractions of the urethra-by pelvic-perineal and bulbospongiosus muscle-against a closed bladder neck causes a build-up of pressure within the system behind the bladder neck. The sudden opening of the bladder neck caused by relaxation of “the external urethral sphincter” allows the expulsion of the ejaculate to occur.

The amount of ejaculate varies widely from male to male, anywhere from 1.5-5 milliliters. Adult ejaculate volume is affected by the amount of time that has passed since the previous ejaculation, the duration and intensity of sexual stimulation leading to the ejaculation and the age of the male.

The number of sperm in an ejaculation also varies widely, depending on many factors, including the recentness of last ejaculation, the average warmth of the testicles, the degree and length of time of sexual excitement prior to ejaculation, the age, the testosterone level, the nutrition and especially the hydration and the total volume of seminal fluid.

Most men experience a lag time between the ability to ejaculate consecutively, called the “refractory period,” and this lag time varies among men. Younger men typically recover faster than older man. During the refractory period, it is difficult or impossible to obtain an erection.

What Causes Premature Ejaculation?

There are essentially three aspects responsible: psychological, physical and habitual. Effective treatment should target all three.

Psychological Aspect or Anxiety-Induced Response

When Premature Ejaculation continues to happen despite the man’s best efforts to resist it, he generally becomes concerned and pre-occupied with the idea of it happening again. Performance anxiety sets in with the very thought of sexual encounter. In practice, anxiety activates the sympathetic nervous system which in turn, causes increased rhythmic contractions of the urethra and an involuntary relaxation of the external urethral sphincter. (See above). The combined effect is the tendency to lose the ejaculatory control within a short time.

Physical Aspect or Hypersensitivity

The head of the penis (called the glans penis) is the most sensitive part of the penis. Men, who have recurrent and persistent Premature Ejaculation, are more sensitive than those who do not. Such sensitivity can be confirmed by measuring the lowest vibratory threshold at various parts of the penis, using an instrument called a biothesiometer. The lower the threshold, the easier it is to provoke an ejaculatory event. Hypersensitivity on its own does not imply a deficiency or weakness. It is just the way a man is “wired,” so to speak.

Note: Scientists have long suspected a genetic link to certain forms of Premature Ejaculation. In one study, 91% of men who suffered from lifelong Premature Ejaculation have a first-relative (father, brother, son) with lifelong Premature Ejaculation.

Habitual Aspect

Ejaculating with minimal stimulation becomes a learning behavior, i.e. men learn to reproduce the same experience with the next sexual stimulation. A habit is formed and becomes reinforced with time. This is often difficult or impossible to break out of without help.

Is Premature Ejaculation a Serious Problem?

The answer is no. It is not a serious medical condition, however, your physician should treat it seriously for the following reasons:

1. Even though some lovemaking sessions may last a little longer than others, the poor ejaculatory control will not just go away without intervention.
2. Premature Ejaculation inhibits full sexual enjoyment, potentially creates disharmony and imposes a strain on the relationship.
3. Successful treatment is readily available.
4. Failure to treat Premature Ejaculation may lead to other forms of sexual disorders such as Erectile Dysfunction.

How Does Premature Ejaculation Affect a Man and His Partner?

Having Premature Ejaculation makes it difficult for a man to fully enjoy his sex life, as most of the time he is preoccupied with trying to resist it. In spite of his best efforts, he often experiences a sense of failure, helplessness, embarrassment and frustration for not being able to satisfy his partner.

The partner, on the other hand, often feels unsatisfied and frustrated when sex is all over too quickly. A significant amount of distress from the man and his partner almost always accompanies this problem. Even though there are other ways to bring the partner to climax, most couples prefer to reach climax by sexual intercourse, the highest form of sexual satisfaction; since that is the moment they can make a mental connection and achieve emotional intimacy. Having Premature Ejaculation can therefore interfere with a healthy sex life, often leads to sexual avoidance and relationship disharmony.

Should Premature Ejaculation Be Treated?

If Premature Ejaculation is affecting a man’s sex life, the answer is yes. The best reason of all however, is that Premature Ejaculation can be successfully overcome. The ability to achieve good ejaculatory control will enable him to last longer, have greater sexual fulfillment, regain confidence and improve his relationship. The potential problem of developing other sexual disorders (e.g. ED) is no longer a threat.

Treatment Options

1. Intra-Cavenous Pharmacotherapy (ICP)

ICP involves painless injection of a small amount of a pre-determined combination of vasodilators into the spongy tissue of the penis, using an auto-applicator. The vasodilators, each of which is FDA-approved, are known as papaverine, phentolamine, atropine and prostaglandine E1. The induced erection will occur within a few minutes of application, is perfectly natural with the exception that it will not go down after ejaculation. The prescribed combination is individually formulated to allow the erection to last approximately 30-60 minutes regardless of the occurrence of ejaculation or the state of mind. With proper dosing, this treatment works reliably and predictably, resulting in a remarkable erection that lasts until the effect of the medication wears off. With its localized effect and an overwhelming success rate, ICP has been used worldwide for two decades. It is safe and well-accepted. In our experience, ICP is the most effective and preferred option to treat Premature Ejaculation.

ICP was historically used to help men sustain an erection just long enough to satisfy the partner. However, more and more men reported a significant improvement in their ejaculatory control, especially those who used this treatment more frequently. Since the early 90’s, easy access to this treatment has offered men not only an invaluable tool to overcome Premature Ejaculation right from the start, but also a prospect of long-term improvement. Such improvement is more commonly seen in men who use this treatment as a course of a treatment program rather than for sporadic or occasional use.

How does ICP help control Premature Ejaculation?

By enabling you to last significantly longer, say for 30-60 minutes after ejaculation, ICP solves the problem of Premature Ejaculation in the following ways:

1. ICP creates an opportunity for the man to completely satisfy his partner without fear of losing the erection. Once this pressure is removed, the anxiety response is “switched off”; i.e. the psychological aspect of Premature Ejaculation is no longer an active component. With renewed confidence and reassurance, he can enjoy lovemaking and begin to learn the signs of pending ejaculation and ultimately learn to gain increased control.
2. The man is encouraged to continue with sexual intercourse even after he ejaculates. With prolonged exposure to sexual stimulation, he will become less and less sensitive hence react less and less readily to the same sexual stimulation.
3. With time, ejaculatory control becomes second nature, like a habit; and a habit learned is a habit kept. The body will react to sexual stimulation in a more controlled and reliable fashion.

What should I do if I want to proceed with ICP?

Your doctor will determine if ICP is suitable for you. He will then work out an ICP formula according to your sensitivity to produce just the desired result. You will learn about ICP injection technique and other pertinent information. To ensure optimal results, your treatment program is supervised by BMG physicians. Your full compliance is expected.

How do I know if ICP is working for me?

If the induced erection lasts approximately 30-60 minutes regardless of the occurrence of ejaculation, the treatment is working. It is acceptable to sense a slightly reduced rigidity after ejaculation; the full erection will soon return. As treatment progresses, you may notice that it takes longer and longer to ejaculate, until you are able to gain complete control of your ejaculation.

How long do I need to use ICP?

You can start and stop ICP any time you wish. ICP enables you to immediately last longer so that you can satisfy your partner, the very reason most men seek help at the first place. In that context, ICP can be used on as needed basis to enhance your sexual performance.

Your physician, however often recommend this treatment for a defined period of time to help you achieve good ejaculatory control on your own. The duration and frequency of treatment typically requires 2 to 3 ICP applications a week, consistently for six (6) months. Individual cases may vary depending on personal preferences, needs and expectations.

You might experience increased control during the course of treatment, but it is important to complete the full course of treatment to ensure a new habit is established and to reduce the likelihood of relapse. Within reason, once you have learned to control Premature Ejaculation, you don’t tend to forget; just like bladder control is rarely forgotten. If you resume sexual activity after a period of abstinence, it is not unusual to first experience a heightened sensitivity. But you should be able to quickly regain your control and last longer on subsequent sexual encounters.

2. Start and Stop Technique, Squeeze Technique, Kegel Exercises

The “Start And Stop” technique essentially involves trying to retard ejaculation by either withdrawing the penis or stopping the motion just before the “point of no return”. The “squeeze” technique involves having the partner firmly squeeze the head of the penis, again just before the “point of no return”. These techniques require dedication, patience and unwavering support from the partner. Once ejaculation occurs, prematurely as it often would during the initial phase of the practice, the erection is lost, making it impossible to continue. The initial failure can be embarrassing to the man and discouraging to his partner; and sometimes creates more anxiety, the very reason that causes Premature Ejaculation in the first place. These techniques however can be effective with proper guidance from a qualified sex therapist. They seem to have limited success otherwise.

Pelvic floor exercise, also known as Kegel exercises or Kegels involves repetitive contractions of the pelvic muscles that control the flow of urination. Strengthening these muscles helps improve the ejaculatory control. The effect of this exercise alone is limited, but can be enhanced when combined with other treatments, such as ICP.

3. Local Anesthetic Gel, Spray or Cream

The use of local anesthetic products (like lidocaine, prilocaine and combination) has been widely marketed. The goal is to numb the head of the penis, reducing the penile sensation, hence reducing the likelihood of uncontrolled ejaculation. This option attempts to address the hypersensitivity aspect of Premature Ejaculation. In practice, the effect is minimal, inconsistent and temporary at best; since the use of anesthetic does not address the psychological or the habitual aspect of

Premature Ejaculation. Furthermore, numbing the penis does not allow one to get used to the real sensation of lovemaking; it just masks it instead. It would be difficult if not impossible for a man to learn to control his ejaculation if he is not aware of the real sensation. The use of local anesthetic is further limited by its own anesthetic effect that reduces the sensation on the penis and vagina, detracting pleasure for both partners.

4. Central Nervous System (CNS) Suppressants

Most commonly used CNS suppressants are anti-anxiety medications or selective serotonin reuptake inhibitors (SSRIs) such as sertraline, paroxetine, fluoxetine. The main purpose of these drugs is to restore a neurotransmitter imbalance in the brain involving serotonin level. A by-product of these drugs is a feeble inhibitory effect on ejaculation. These drugs are not indicated for the treatment of premature ejaculation although they are occasionally employed as off-label use. Chronic therapy is required; but its usefulness is limited by a number of neuro-psychiatric side-effects such as nausea, dry mouth, dry eyes, drowsiness, reduced libido and Erectile Dysfunction. Isolated cases of more serious complications, such as mania and withdrawal symptoms, and potential drug interactions also have been associated with the use of SSRIs.

A new SSRI drug called dapoxetine can be taken on an as needed basis and has recently shown positive results in phase III studies. It was reported subjects taking dapoxetine can generally delay ejaculation up to 2.5 minutes. Even though the increase in ejaculation time is statistically significant in the study, it may not be sufficient for most men to procure satisfactory sexual performance. Dapoxetine is not yet approved by any regulatory authority around the world.

Opioids and cocaine are known to delay male orgasm. They are obviously not intended for use for this purpose.

5. Alternative Therapies

Viagra^® and similar drugs have been tried in the treatment of Premature Ejaculation. They appear to have an effect on shortening the refractory period but not the ejaculation time.

Caution should be exercised when researching alternative sources of advice. Most treatments have not actually been shown to be effective. Some websites even advocate the dangerous and antiquated method of pulling the testes downward when aroused. This method can cause injuries to the testicular structures and is associated with reports of weakened erection. This advice is still widespread on the internet.

Another popularized method is to apply direct pressure on the engorged prostate during sexual arousal. This technique can cause damage to the prostate and the cavernosal nerves resulting in weakened erection, the same way straddling on a narrow unprotected saddle can do to bicyclists.

There is a trend toward the use of nutritional supplements. There is no scientific proof to support its use or substantiate its claims. Most men report a lack of efficacy although some might get relief as a placebo effect.

Disclaimer: The content of this information package is prepared for general reading and education only. It can not be used as a medical advice which can only be obtained by direct consultation with the doctor.