According to DSM-5, Premature Ejaculation is characterized by a repetitive or persistent tendency to ejaculate during sexual activity within one minute of vaginal penetration and prior to the individual’s desired timing. In 2019, the World Health Organization published the 11th revision of the ICD-11 (International Classification of Diseases and Related Health Problems) and proposed replacing the term “premature ejaculation” with “early male ejaculation.”
However, this definition is vague, subjective, and lacks specific criteria for diagnosis. DSM-5 also instructs the clinician to specify whether the PE is lifelong or acquired, generalized or situational, and to rate its degree of severity based on intravaginal ejaculatory latency time (IELT).
Acquired Premature Ejaculation
The ISSM initially found insufficient evidence to create a definition for acquired PE. Still, in 2013, they offered a definition that characterized it as a reduction in latency time, often to about 3 minutes or less, with negative personal consequences such as bother, distress, frustration, and/or the avoidance of sexual intimacy. (1)
The cause of acquired PE can be recent psychosocial stressors or an illness, and many men with acquired rapid ejaculation also have erectile dysfunction. These men adaptively hurry lovemaking to maintain their erection and condition themselves to ejaculate rapidly.
Carlos is a 42-year-old Hispanic male who developed PE after a humiliating sexual encounter with a new partner who scolded him when he lost his erection during sex. He stopped dating for several months but eventually tried again with a new partner he liked. However, he ejaculated rapidly during their first attempt at lovemaking and subsequent encounters, which made him feel unattractive, weak, and undesirable as a sexual partner. He attributed his self-consciousness with women to losing his hair at 18 and being chubby as a child, and he felt the need to overcompensate and demonstrate his machismo to women.
“Ante-portal ejaculation” refers to men who ejaculate before vaginal penetration and is considered the most severe form of premature ejaculation (PE), affecting around 5% of men with lifelong PE. Additionally, two subtypes of PE were proposed by Waldinger in 2008, namely “variable PE” and “subjective PE.”
Variable PE is characterized by early ejaculations that occur irregularly and inconsistently. In contrast, in subjective PE, individuals may be preoccupied with the idea of early ejaculation or a perceived lack of control over ejaculation, even if the actual intravaginal ejaculation latency time falls within the normal range.
Early articles characterized premature ejaculation (PE) as the most common male sexual dysfunction affecting 20-30% of all men, but these studies relied on self-report rather than clinical diagnosis.
Recent studies using a random proportional sampling method in Turkey and China found that a relatively high proportion of men (20.0% and 25.8%, respectively) acknowledged concern with ejaculating too quickly. The prevalence rates for lifelong, acquired, variable, and subjective PE in these populations were also reported.
There are biological and psychological theories for premature ejaculation (PE).
Possible biological causes include serotonin or oxytocin receptors, genetic predisposition, hyperthyroidism, prostatitis, and increased penile sensitivity.
Multiple psychological theories have been proposed, but they are not evidence-based. Psychoanalytic theories focus on unconscious hostile feelings towards women, excessive unresolved issues, or psychosomatic disorders. Psychodynamic theorists view anxiety as the primary cause, but anxiety can take various forms, including anticipatory anxiety, state anxiety, and trait anxiety.
Behavioral-learning perspectives propose that early sexual experiences can condition men to ejaculate rapidly, while Kaplan considered a lack of sexual sensory awareness to cause rapid ejaculation. Performance anxiety can perpetuate dysfunction by distracting the man from focusing on his level of arousal. The initial precipitating event is often obscured when the patient seeks psychological intervention.
Premature ejaculation (PE) can have significant psychological and relational impacts on men, their partners, and their relationship. Men with PE are often preoccupied with controlling their orgasm, fear embarrassment, and focus on sexual performance rather than arousal and satisfaction.
Women in relationships with men with PE often report distress at not being satisfied sexually and experience significantly greater sexual distress compared to women with partners who do not have PE. The disconnect between partners due to PE leads to considerable relationship tension. In treating men/couples with PE, mental health clinicians should address the psychological impacts in addition to teaching sexual skills.
- Suppose the man with PE is in a relationship. In that case, the therapist may ask to see the couple together and then each partner separately to assess the relationship quality, communication ability, sexual scripts, and factors that may contribute to the woman wanting to hurry the pace of ejaculation.
- Suppose the partners are unwilling to participate, or the man with PE doesn’t want to invite his partner. In that case, the therapist sees the man alone and asks about the history of the problem, average intravaginal ejaculation latency time (IELT), voluntary control, distress, sexual satisfaction, previous treatment attempts, and sexual history.
- The therapist also asks about the patient’s strategies to delay ejaculation, awareness of sexual arousal level, and any medical issues like prostatitis or hyperthyroidism.
- The assessment focuses on the impact of PE on the couple’s intimacy and the partner’s willingness to participate in treatment.
- The therapist tries to understand the patient’s interpersonal style, psychological comorbidities, limitations or strengths regarding treatment, and factors that may interfere with treatment.
Psychological Therapy vs. Pharmacological Treatment
The therapist should engage in shared decision-making with the patient to select the most appropriate treatment method for premature ejaculation (PE). The options are individual therapy, couple therapy, pharmacotherapy, or combined pharmacological and psychological treatment.
Pharmacotherapy is recommended for patients with lifelong PE, while behavioral intervention/psychotherapy is suggested for those with acquired PE. Natural and subjective PE can be treated by reassurance, education, and psychotherapy/behavioral intervention. However, despite research supporting its efficacy, combining pharmacological and psychological treatment has yet to become a mainstream intervention. This is likely due to resistance from established practice patterns.
What to Offer and When
Psychotherapy alone is best for men with clear psychological factors, while individual psychotherapy is recommended for single men. Combined therapy, which combines pharmacotherapy and psychotherapy, is considered the most effective treatment option for premature ejaculation (PE) as it provides relatively rapid changes in Intravaginal Ejaculation Latency Time (IELT) and helps overcome psychosocial obstacles.
Psychotherapy helps the man or couple to maximize gains from pharmacotherapy and teaches techniques to overcome fear and broaden their sexual repertoire. In time, the man can be slowly weaned from pharmacotherapy and implement what he has learned in psychotherapy.
Psychotherapy for rapid ejaculation integrates psychodynamic, systems, behavioral, and cognitive approaches within a short-term model. The treatment focuses on learning to control ejaculation, changing dysfunctional patterns of lovemaking, and understanding the meaning of the symptom and the context in which it occurs.
Behavioral interventions may include exercises such as stop-start or sensate focus aimed at diminishing performance anxiety and allowing the man and his partner to gain an appreciation for exciting exchanges of touch. Men are taught to focus on their sexual arousal and identify intermediate levels of sexual excitement.
Addressing cognitive distortions that help maintain the dysfunction is also helpful. Psychoeducational interventions aim to rework the behavioral repertoire of the man or couple, referred to as their “sexual script.”
Pharmacotherapy and Medical Options
Premature ejaculation (PE) can be treated with pharmacological and medical options, including SSRIs, clomipramine, phosphodiesterase type 5 inhibitors (PDESi), tramadol, sildosin, topical prilocaine/lidocaine sprays, hyaluronic acid, acupuncture, circumcision, dorsal neurectomy, and electrical nerve stimulation. However, studies on the effectiveness of most options are not sufficiently robust to recommend their use.
There are no FDA-approved medications to treat PE in the United States, although Promescent, a lidocaine spray, can be purchased over the counter. Dapoxetine (Prilogy) has received approval for treating PE in over 60 countries but not in the United States. It is a rapid-acting and short half-life SSRI that is more effective than a placebo in increasing IELT, ejaculatory control, decreasing distress, and increasing satisfaction.
Off-label treatment with SSRIs and the tricyclic antidepressant clomipramine has been successfully employed to treat rapid ejaculation, but they can cause side effects and should be closely monitored. The use of topical local anesthetics such as lidocaine and/or prilocaine as a cream, gel, or spray is well-established and is moderately effective in delaying ejaculation.
PSD502 (Fortacin) is a prilocaine spray approved in Europe and has been shown to increase IELT and improve control and sexual satisfaction. PDE5Is may also be of benefit to men with rapid ejaculation.
Combined psychological-pharmacological treatment is more directive, advice-oriented, educational, and technique-focused than psychotherapy alone. The goals of combined therapy include augmenting the positive effects of the medical intervention, identifying and working through resistance to medical intervention, reducing performance anxiety, helping the patient gain sexual confidence, and modifying maladaptive sexual scripts.
This treatment may be especially helpful when pharmacotherapy effects are modest and may be more acceptable to certain ethnic groups, such as Muslim men, due to the perceived stigma of psychological treatment. Resistance to psychological/behavioral interventions has been encountered in Muslim men with PE residing in London.
Psychotherapy, pharmacotherapy, or a combination can help men and couples improve ejaculatory latency, reduce distress, and improve their sexual and interpersonal lives. Treatment has been found to be effective in diminishing the negative impacts that PE can have on men and couples.
Although there are cases in which intervention may not be successful, most men and couples generally experience modest gains sexually, psychologically, and relationally.