Parviz K. Kavoussi, M.D. Reproductive Urologist
Austin Center for Men's Health: A Division of Austin Fertility & Reproductive Medicine
To understand premature ejaculation (PE), we must first understand the process of ejaculation. Ejaculation is the final phase of the sexual response cycle in the male. It is a reflex comprising of sensory stimuli, the response by the brain and the spinal cord, and signals being sent back down from the brain through the spinal cord. Orgasm and ejaculation are not the same. However, orgasm is generally associated with ejaculation and is a pleasurable sensation from the brains processing of increased pressure and contraction of the urethra (the same channel a man urinates through).
So how do we define premature ejaculation? The definition has been evolving throughout the years. In the 1950's PE was defined as the inability to control ejaculation and the inability to satisfy the partner at least 50% of the time. In 2000, the definition changed to ejaculation with minimal stimulation before or shortly after penetration. In 2001, the definition changed to ejaculation before penetration. In 2004, it was decided that it should be defined as ejaculation soon after intercourse, about 15 seconds or so. And in 2008 we changed our minds yet again and defined PE as ejaculation within about a minute of penetration. The International Society for Sexual Medicine panel then concluded that there should be 3 components present for the diagnosis of PE. These should include: ejaculation within 1 minute of vaginal penetration, the inability to delay ejaculation on all or nearly all vaginal penetrations, and the result being negative personal consequences such as distress, bother, frustration, and avoidance of sexual intimacy. Finally, the most accepted current definition of PE is the following: ejaculation prior to when the man wishes it and which is out of his control. The majority of men who identify themselves in this category ejaculate within 2 minutes of vaginal penetration.
Is PE rare? Absolutely not! In fact, it is the most common sexual complaint reported by men and even so, it is certainly under-reported and under-diagnosed. It is so common that 25-30% of men globally report experiencing PE. What are the impacts of PE on a man and his partner? It can cause anxiety, depression, frustration, and an adverse impact on intimacy and the relationship. The causes of PE are not that well understood. It is thought to be a neurological hypersensitivity response to sexual stimuli.
A compounding problem with the inevitable effect of PE is that it causes more anxiety about PE. Ejaculation is primarily controlled by the sympathetic nervous system. This is the same part of the nervous system that is responsible for the "fight or flight" response. So, if you get chased by a tiger, the sympathetic nervous system gets activated causing the pupils to dilate and increasing blood flow to the muscles. To a lesser effect, anxiety - and anxiety about PE - can cause a similar response. In essence, this may be priming that part of the nervous system and might actually be worsening PE.
Traditional treatments for PE have included techniques such as the squeeze technique, using condoms, or using desensitizing medications on the penis. Antidepressants in the selective serotonin reuptake inhibitor class (SSRI) were found to extend the time to ejaculation in some men as a side effect. These drugs have been used for the purpose of treating PE since that was realized, but as an off label use. The concern is systemic side effects that can occur, especially in non-depressed men on these medications, although this treatment option works well with minimal side effects in some men.
Recently, the first FDA compliant medication for PE has emerged. It is called Promescent and it is a topical spray. It has been chemically developed with considerations to its components and pH to optimize its effectiveness and minimize unwanted effects, unlike some its topical predecessors. It should be used by applying to the head and shaft of the penis and then it should be rub in thoroughly, ten minutes prior to intercourse. It is recommended to wash the penis off with a damp wash cloth prior to intercourse. I recommend that my patients start at 2 sprays and then they can go up in dosing by 2 sprays each time, until they have reached the optimal effect without too much desensitization. The maximum dose is 10 sprays. The major advantages of Promescent are that it is the only FDA product on the market for the indication of PE, there are no systemic side effects, it is over the counter and does not require a prescription, it is effective, and if used as instructed will not transfer to the vagina and cause any vaginal insensitivity of the partner.
As our understanding of PE advances, we will surely find better and better treatment options, but we can certainly help men now with the options that are available.