Before diving into premature ejaculation, it’s helpful to understand the normal ejaculation process. Believe it or not, erections, ejaculation and orgasm are all distinct physiological events. This means that a different part of the nervous system is responsible for each of these events.
When everything is working properly, it’s like a well conducted orchestra: sexual stimulation leads to an erection, continued stimulation reaches a climax in a simultaneous ejaculation and orgasm.
Ejaculation actually has two distinct parts:
- Emission: In this phase, the body is preparing for ejaculation. The bladder opening closes shut. Fluid from the prostate, seminal vesicles, and vas deferens are all deposited in the urethra (urine tube). They mix together to form your semen.2
- Expulsion: Now you’ve reached climax and the muscles of the prostate, penis, urethra and pelvic floor are going to "shoot out" the semen from the urethra.2
What is the normal length of ejaculation?
Now we have to have reasonable expectations regarding sexual performance. Contrary to popular belief, most episodes of sexual intercourse aren’t the marathons people witness with "Long Dong" John on adult websites.
The best study we have to answer this question, examined 500 heterosexual couples from different countries and had them time the length of vaginal intercourse with a stop watch.3 The results? Sex lasted, on average, 5.4 minutes.3 Of course there are a lot of variables and questions to consider:
- Were both partners satisfied?
- What about non-heterosexual couples?
- Was there any foreplay?
What is premature ejaculation?
Now that we have defined normal, what is premature ejaculation? The American Urological Association has defined premature ejaculation as "ejaculation that occurs sooner than desired, either before or shortly after penetration, causing distress to either one or both partners."4
Alternative definitions include ejaculation within 2 minutes of intercourse. At Pazona MD Urology, we find this definition to be helpful again with setting expectations. We’ve evaluated patients who were "lasting" 10+ minutes but wanted to perform for 30+ minutes.
In a 2020 update from the American Urological Association and Sexual Medicine Society of North America, there was a distinction made between lifelong vs. acquired premature ejaculation.4
1. Lifelong premature ejaculation
"Is defined as poor ejaculatory control, associated bother, and ejaculation within about 2 minutes of initiation of penetrative sex that has been present since sexual debut."4
2. Acquired premature ejaculation
"Is defined as consistently poor ejaculatory control, associated bother, and ejaculation latency that is markedly reduced from prior sexual experience during penetrative sex."4
What is markedly reduced ejaculation time? It’s a judgment call. Again we can use the less than 2-3 minute guideline. Or we can say that sex is consistently 50% shorter than previous experiences.
Regardless, premature ejaculation is one of the most common male sexual dysfunctions and can occur in any sexually active man, irrespective of age. While occasional premature ejaculation is common and typically not a cause for concern, recurrent or persistent premature ejaculation can significantly impact one's quality of life and intimate relationships.
What are the causes of premature ejaculation?
Despite everything we know about premature ejaculation, the exact causes of premature ejaculation are poorly understood. In our experience at Pazona MD Urology, we see men from all walks of life, at all ages, who are bothered by premature ejaculation.
However there are certain factors that appear to play a role in causing premature ejaculation:
1. Psychological factors leading to premature ejaculation:
It’s clear that psychological factors are associated with premature ejaculation. Specifically, these include:
- Depression
- Anxiety
- A history of sexual abuse
- Decreased emotional intimacy
- Relationship conflicts
It’s unclear however, if these factors are causative or correlative. In other words, did depression lead to premature ejaculation or did having premature ejaculation cause a man to be depressed. What is clear is that premature ejaculation is associated with emotional distress for both the man and his partner.
Psychological factors are more likely the underlying cause of lifelong premature ejaculation. On the other hand, acquired premature ejaculation requires investigating other factors.
2. Biological factors leading to premature ejaculation:
A biological factor means something physiologically has led to premature ejaculation. It’s not stress or anxiety, rather other medical conditions or hormone issues are contributing to premature ejaculation.
We know that serotonin plays an important role in ejaculation. Serotonin is a neurotransmitter that acts as a messenger chemical for the body’s nervous system. When serotonin levels are low, ejaculation happens more quickly (e.g. premature ejaculation). Raising serotonin levels can delay ejaculation.
Erectile dysfunction, and all of its associated risk factors (e.g. obesity, diabetes, high blood pressure) are linked to higher rates of premature ejaculation. The theory is that the brain knows there’s a risk of losing an erection before climaxing, so it speeds up the process by ejaculating more quickly. In a man with concurrent erectile dysfunction, improving erections should be the first step to treating premature ejaculation.
Lastly, infections or inflammatory conditions of the prostate may play a role in premature ejaculation. In men with pelvic pain and urinary symptoms, ruling out an inflammatory process should be considered.
3. Other contributing factors:
Anecdotal evidence would suggest that sexual experience, cultural factors and parental upbringing can plan a role in premature ejaculation. In our experience we have seen men in the following scenarios struggle with premature ejaculation:
- Delaying sexual activity until marriage
- Arranged marriages
- Cultures or religions with negative discussions about sexuality and sexual activity
- Infrequent sexual activity
These beliefs or practices may lead to negative thoughts about sexual activity (e.g. "sex is bad"). In turn, these men tend to have sexual dysfunction including premature ejaculation.
Does circumcision affect premature ejaculation?
Despite myths that state circumcision will worsen or enhance sexual performance, when it comes to premature ejaculation, the circumcision status of a man does not seem to impact how long it will take to ejaculate.4
How to prevent premature ejaculation naturally?
Yes and no. The line between prevention and treatment of premature ejaculation is blurry. Prevention implies behaviors that will stop something from ever occurring. Men with lifelong premature ejaculation have it from day #1 of sexual activity. As we reviewed earlier, psychological factors and one’s environment play an intimate role with lifelong premature ejaculation.
On the other hand, acquired premature ejaculation can be prevented naturally through lifestyle changes. Preventing obesity, high blood pressure and diabetes through a healthy diet and exercise will prevent erectile dysfunction. Preventing erectile dysfunction can prevent premature ejaculation naturally.
Can you treat premature ejaculation naturally, without medications? Absolutely. We will review those shortly.
What are the symptoms of premature ejaculation? How can you diagnose premature ejaculation?
There are a number of diagnostic surveys that can be used to assess the symptoms of premature ejaculation and provide a diagnosis. One commonly used questionnaire is the Premature Ejaculation Diagnostic Tool.5 It asks:
- How difficult is it for you to delay ejaculation?
- Do you ejaculate before you want to?
- Do you ejaculate with very little stimulation?
- Do you feel frustrated because of ejaculating before you want to?
- How concerned are you that your time to ejaculation leaves your partner unfulfilled?
What type of doctor evaluates or treats a man with premature ejaculation?
At Pazona MD Urology, we feel a urologist is the best healthcare professional to evaluate, diagnose and treat premature ejaculation. We are the "penis" experts. That being said, many options exist for treating premature ejaculation and you should seek medical attention from someone you trust.
Every good healthcare professional treating premature ejaculation should start with a thorough history. Not only is it important to obtain a medical history for premature ejaculation, but psychological, relationship and sexual histories are important as well. The more we understand about the psychological and other contributing factors to your premature ejaculation, the better care we can deliver.
Next, we may or may not perform a physical exam. Since premature ejaculation is rarely associated with physical abnormalities, telemedicine appointments are a great way to have an evaluation for premature ejaculation.
Lastly, if we feel like there’s a strong psychological component to your premature ejaculation we may recommend a referral to a sex therapist or mental health expert to aid in your treatment. Healthcare is a team sport and sometimes we need to approach premature ejaculation from multiple angles.
Treatment Options for Premature Ejaculation
Now let’s explore getting you the treatment you deserve for your premature ejaculation. At Pazona MD Urology we always prefer a natural approach to healthcare when it’s done safely.
What are the natural remedies for premature ejaculation?
Let’s consider natural remedies for premature ejaculation as lifestyle choices you can make that may improve your performance in the bedroom.
At Pazona MD Urology we believe in the following 4 pillars of wellness:
- Healthy food choices: whole, unprocessed foods rich in antioxidants, fiber, healthy fats, and/or protein.
- Consistent exercise: high intensity 5 days a week with weight training and cardio.
- 8 hours of quality sleep
- Stress management
It’s amazing how many medical conditions improve the moment you lower stress levels with great food choices and daily exercise, coupled with high quality sleep. This includes being natural remedies for premature ejaculation.
What are the best premature ejaculation treatments at home?
Now let’s get into some bedroom activities that can treat premature ejaculation from the comfort of your own home. Both of these behavioral techniques are aiming to "practice" delaying ejaculation. Although they can be performed alone, they are more fun and effective when you get your partner involved.
1. The Start-Stop Method for Premature Ejaculation:
This one is pretty straightforward. It involves stimulating the penis until you feel you are about to ejaculate, then stopping until the urge passes. Once the excitement settles down, get back at it until you again approach that point of no return. Stop. Then start back up again.
We recommend starting with having your partner perform manual stimulation. This is typically less sensitive than oral or vaginal stimulation and allows for more control.
Get your buddy used to being stimulated by something other than your own hand. Then, when you feel like you’re improving your premature ejaculation, graduate to more sensitive forms of stimulation.
With time you are training your brain to delay climaxing by becoming more accustomed to the stimulation by your partner.
2. The Squeeze Technique for Premature Ejaculation:
You can think of the "squeeze technique" as a variation of the "start-stop" method for treating premature ejaculation. We would definitely recommend manual stimulation for this one. Again, start stimulating the penis and when you start approaching that point of no return, squeeze the end of the penis for several seconds until the urge to ejaculate passes. Once the sensitivity of the penis and brain settle down, start back up again with stimulation.
Don't ever bend an erect penis. This can lead to a penile fracture (which is as bad as it sounds). All you need to do is apply gentle but firm pressure to the head of the penis to calm down the build up to orgasm.
3. Kegel Exercises for Premature Ejaculation
A common question we receive is, "are there Kegel exercises for men to last longer?" The answer is yes. A review of available studies shows that Kegel exercises for premature ejaculation can help anywhere from 55% to 83% of men.6
The problem is that there are no proven or agreed upon Kegel exercise protocols for men. It’s also incredibly difficult to walk a man through proper Kegel exercises without the guide of a pelvic physical therapist. But here are some general recommendations:
- Get in a comfortable position. Sitting, standing, lying down, doesn’t matter.
- Try to identify and squeeze the muscles behind your scrotum (the perineum or “taint”). Think about what you’d squeeze if you were trying to stop your urine flow.
- If you’re squeezing your buttocks or abdominal muscles, then you’re not hitting the correct area.
- Aim for 10 one-second contractions. Then perform 10 max effort contractions (2-3 seconds is probably all you can do at first).
- Repeat this 3 times a day.
Need more help? Our team at Pazona MD urology works alongside some exceptional pelvic physical therapists who can guide you through a proper technique. We also recommend against Kegel exercises for premature ejaculation if you struggle with constipation, difficulty emptying your bladder, or pelvic pain. In these cases, your pelvic floor muscles may be too TIGHT and Kegels can exacerbate these symptoms.
Behavioral Techniques For Premature Ejaculation
If we remember that orgasm is initiated 100% from our brain, then it’s not crazy to think that incorporating some form of therapy can help a lot of men who are suffering with premature ejaculation. Anxiety, depression, history of sexual abuse, relationship stress, and negative beliefs about sex, all play a role in premature ejaculation.
Sex Therapy for Premature Ejaculation
Sex therapy attempts to address the psychological factors contributing to premature ejaculation. Sessions can involve the man alone or even bring his partner into the discussion.
The goals of sex therapy for premature ejaculation can include:7
- Learning techniques that help to delay ejaculation.
- Identifying and eliminating thoughts that could lead to premature ejaculation.
- Building self-confidence in order to reduce anxiety around sexual performance.
- Expanding the couple's idea of sexuality and how people can be intimate together.
- Recognizing obstacles to intimacy.
- Helping couples to speak more openly about their needs and problems.
- Resolving conflicts in the relationship.
One practical tip that some therapists use is called sensate focus.7 The goal of this exercise is to gradually increase the level of physical intimacy to help the man become more accustomed to the touch of his partner. At first, the couple may undress each other. Then touch each other while avoiding the genitalia and erogenous areas. Each session you progress until the point of genital stimulation.
Finding a sex therapist for premature ejaculation that’s right for you can be a challenge, but at Pazona MD Urology we can help guide you.
Cognitive-Behavioral Therapy (CBT) for Premature Ejaculation
Men who are primarily dealing with negative thought patterns like self-doubt and anxiety may benefit more from cognitive behavioral therapy. In this approach, the goal is to identify and get rid of negative thoughts. When a man has negative mindset about sex, he may have the following thoughts:
- “I'm terrible in bed and no one will want to be with me.”
- “I can't last very long. I'm such a loser!”
- “My partner is going to leave me because I can't satisfy him/her.”
- “My partner tells me everything is fine because he/she doesn't want to hurt my feelings.”
This negative mindset can further exacerbate the symptoms of premature ejaculation and often prevent men from seeking help. The basis of cognitive-behavioral therapy for premature ejaculation is to help men find a different inner voice. Change their perspective so now they view themselves as capable lovers.
Stress Management Techniques for Premature Ejaculation
If you're suffering from any medical issue, including premature ejaculation, then stress reduction techniques should always be a part of your treatment protocol. Stress raises cortisol levels ("the stress hormone"). In turn cortisol leads to high blood pressure, poor wound healing, and a number of other deleterious effects on the body. We’ve all experienced the effects of stress on our mindset. When you’re stressed, negative self-talk increases which further worsens the effects of stress. Yoga, exercise, meditation, listening to calming music, and walking are all great free stress relievers. They may not cure your premature ejaculation, but they will make the other treatments more likely to succeed.
Medications and Pills for Premature Ejaculation
What are the best pills for premature ejaculation? Let’s review the over-the-counter and prescription medication options for premature ejaculation
Selective serotonin reuptake inhibitors (SSRIs) are an effective pill for premature ejaculation. But these medications may already sound familiar to you. That's because they were the first effective, safe antidepressant medications on the market. Medications like Prozac, Zoloft and Paxil. So why are we talking about antidepressants for premature ejaculation?
If you remember from earlier, serotonin plays an important role in the process of ejaculation. So it makes sense that medications which increase serotonin levels at our nerve endings will help to treat premature ejaculation.
In fact the way we discovered these medications for treating premature ejaculation is numerous patients first placed on them for treating depression starting complaining to their physicians about difficulty reaching orgasm. As urologists, we saw an opportunity to use this side effect in treating men with premature ejaculation.
Technically, SSRIs have an off-label usage in the treatment of premature ejaculation. This means treating premature ejaculation is not the primary indication for prescribing the medications. However, rest assured that urologists have been prescribing them for men with premature ejaculation for years and are currently listed as 1st line therapy according the American Urological Association Guidelines on Disorders of Ejaculation.4
Although SSRIs can be used as needed prior to intercourse, daily usage seems to work better for the treatment of premature ejaculation.4 The average man will gain 1-5 minutes of fun before reaching orgasm. It can take 5-10 days to start working but maximum benefit is seen in 2-3 weeks. Side effects may include:
- Fatigue
- Headache
- Mild nausea or diarrhea
- Decreased libido (which defeats the purpose we know)
It's also important to note that SSRIs should be used with caution in men with a history of depression. Lastly it’s best to slowly wean off of SSRIs as a withdrawal syndrome can occur in some men.
SSRIs are effective for the treatment of premature ejaculation if we remember that the purpose is to take advantage of their side effect rather than to label a man as “depressed.”
Topical anesthetics
Logic would dictate that if premature ejaculation is caused by having hypersensitive genitalia, then "numbing" the penis should help. In fact this logic holds true. Lidocaine and prilocaine topical anesthetics are considered 1st line therapy in the treatment of premature ejaculation.4
You can buy wipes, creams, sprays etc. over-the-counter without a physician’s prescription. One trusted product is Promescent Delay Spray. It’s not quite as messy as creams/gels and is absorbed quickly into the skin. Otherwise it’s important to wipe off any excess topical anesthetic or risk causing vaginal numbness (which your partner wouldn’t appreciate).
Remember to have reasonable expectations. The average benefit from the topical spray in studies was an extra 2 minutes.4
PDE5 inhibitors
Earlier we alluded to the fact that premature ejaculation may be a defense mechanism for men with ED. The brain is saying, “I better climax quickly before this erection goes away.” As a result, it’s alway a good idea to treat ED first, in men who have difficulty with erections and premature ejaculation.
PDE5 inhibitors like tadalafil and sildenafil (generic versions of Cialis and Viagra respectively), are the most effective and common prescribed ED medications. They are well tolerated (side effects of headaches, visual changes, facial flushing) and work well for mild to moderate ED.
A man may still require an SSRI or other medication for premature ejaculation, but treating the ED first is the best way to go.
Tramadol
For men not responding to first line therapies, there are other options. Tramadol is a commonly prescribed pain medication that has an off-label usage as a medication for premature ejaculation. It is an opioid, so it should be prescribed with caution due to the small but real risk of developing an addiction. Typically tramadol is used on demand as a premature ejaculation medication and 20% of patients have non-serious side effects (e.g. nausea, vomiting, dizziness, fatigue).4
Conclusion
If you or your partner are struggling with premature ejaculation, it’s important to know that help is available. By exploring various treatment options and making lifestyle changes, you can regain control and enjoy a satisfying sexual relationship.
If you're experiencing symptoms of premature ejaculation, don't hesitate to seek professional help. Contact a healthcare provider today to discuss your symptoms and explore treatment options tailored to your needs.
At Pazona MD Urology in Nashville, Brentwood, and Cookeville, we are proud to serve the men of middle Tennessee. We offer both in-person and telemedicine visits from the privacy and comfort of your home. If you’d like some guidance on how to treat your premature ejaculation, contact us today.
Schedule An Appointment
References:
- https://www.urologyhealth.org/urology-a-z/p/premature-ejaculation
- https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4708301/
- https://pubmed.ncbi.nlm.nih.gov/16422843/
- https://www.auanet.org/guidelines-and-quality/guidelines/disorders-of-ejaculation#x14890
- https://www.nature.com/articles/3901567
- https://www.sciencedirect.com/science/article/abs/pii/S0031940619300070
- https://www.ncbi.nlm.nih.gov/books/NBK547553/
