Cindy M. Meston & Amelia M. Stanton
Definition, Diagnosis, and Prevalence
Premature (early) ejaculation is defined in DSM-5 as a persistent or recurrent pattern of ejaculation occurring during partnered sexual activity within about one minute following vaginal penetration and before the individual wishes it. Although the diagnosis may be applied to individuals who engage in nonvaginal sexual intercourse, specific duration criteria for such activities have not been established. In order to meet the diagnostic criteria, the problem must have persisted for at least six months, must be experienced on almost all or approximately all occasions of sexual activity, and must cause significant distress. The disorder may be specified by severity and can be categorized as lifelong, acquired, generalized, and situational.
In recent years, there has been considerable disagreement about the definition, nature, and even the name of the disorder. The DSM-5 sexual dysfunction subworkgroup changed the name of the disorder from “premature ejaculation” to “premature (early) ejaculation,” due to criticism of the existing name, which some saw as pejorative. The diagnostic criteria of the disorder have also been critiqued, as researchers have argued that the time to ejaculation after penetration criterion oversimplifies and may limit scientific understanding of the condition (Metz, Pryor, Nesvacil, Abuzzahab, & Koznar, 1997). Hong (1984) argued that premature (early) ejaculation might not warrant the term “dysfunction”; he explained that the disorder should probably not be of clinical concern unless it is extreme, “such as occurring before intromission.”
Varying prevalence rates of the disorder have been reported, likely due to the lack of a universally accepted set of diagnostic criteria. It is important to note that there are currently no published epidemiological studies that assess the prevalence of premature (early) ejaculation as defined in DSM-5. However, many studies have assessed the prevalence of premature ejaculation concerns. Masters and Johnson (1970) identified premature (early) ejaculation as one of the most common male sexual dysfunctions. According to Laumann and colleagues (1994), premature (early) ejaculation is the most commonly reported sexual disorder in men, with approximately 30% of men in the United States reporting the condition in the previous year. 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 premature (early) ejaculation (Corona et al., 2004). When the intravaginal ejaculation latency time criterion is used, however, prevalence rates are much lower, around 1-3% (Althof et al., 2010). High rates of comorbidity are reported for premature (early) ejaculation and ED, with about one third of men who suffer from premature (early) ejaculation also experiencing ED (Corona et al., 2004).
Factors Associated With Premature (Early) Ejaculation
A number of factors have been shown to play an important role in both normal and premature ejaculation. Historically, premature ejaculation has been considered to be a psychological problem. But recent research has implicated different biological systems in the development and maintenance of the disorder, indicating that it may be important to focus on the physiological underpinnings of the ejaculatory process.
Biological Factors
During the first stage of ejaculation (sperm emission), sperm moves from the epididymis 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 premature (early) ejaculation experience emission without ejaculation.
The precise cause of premature (early) ejaculation is not known, but the most promising biological etiologies include malfunction of the serotonin receptors, genetic predisposition, and disruptions of the endocrine system. Waldinger and colleagues (1998) noted that, in rodents, activation of one serotonin receptor speeds up ejaculation and activation of another serotonin receptor delays ejaculation. Therefore, it is possible that men who report symptoms of the disorder may have disturbances in central serotonergic neurotransmission, which could result in a lower threshold for sexual stimulation (Waldinger, 2007; Waldinger, Berendsen, Blok, Olivier, & Holstege, 1998). Genetic predispositions may also play a role in the development of PE. In first-degree male relatives of Dutch men with lifelong PE, researchers found a high prevalence of PE (Waldinger, Rietschel, Nothen, Hengeveld, & Olivier, 1998). Similarly, a genetic study of Finnish male twins indicated that genetics accounts for 28% of the variance in PE (Jern et al., 2007). Recent research has confirmed the role of the endocrine system in the control of the ejaculatory reflex. Carani and colleagues (2005) found that 50% of men with hyperthyroidism also had PE. Indeed, the hormone thyrotropin, in addition to testosterone and prolactin, has been shown to play an independent role in the control of ejaculatory function (Corona et al., 2011; Maggi et al., 2013).
Psychological Factors
Anxiety has been hypothesized to be one of the primary causes and maintaining factors for PE. Althof (2014) explained that there are three different mental phenomena related to PE that are characterized by the term “anxiety.” First, anxiety may reference a phobic response, such fear of the vaginal canal. Anxiety may also refer to an affective response, such as anger towards one’s partner. Finally, anxiety may indicate performance concerns, such that a preoccupation with poor sexual performance leads to decreased sexual function and increased avoidance of sexual situations. Anxiety may have a reciprocal relationship with premature (early) ejaculation; specifically, performance anxiety may lead to problems with early ejaculation, and then those problems could increase performance anxiety (Althof et al., 2010). However, laboratory studies have generally not shown significant differences in levels of anxiety reported by men with and without PE.
One psychological variable that has been shown to distinguish men with PE from men without PE is perceived control over ejaculation. In an observational study of men with and without PE, Rosen and colleagues (2007) determined that subject-reported control over ejaculation and personal distress most strongly predicted a PE diagnosis. A greater understanding of the meaning men attribute to ejaculatory control may provide important insight into the psychological factors involved in this disorder.
Early learned experiences and lack of sensory awareness may also be important psychological factors that lead to PE. Masters and Johnson (1970) examined case histories of men with PE and found that many of these men had early sexual experiences during which they felt nervous and rushed. According to Masters and Johnson, these men learned to associate sex and sexual performance with speed and discomfort. Kaplan (1989) considered lack of sensory awareness to be the immediate cause of premature ejaculation. She believed that men with PE fail to develop sufficient awareness of their own level of arousal.
Assessment and Treatment of Premature (Early) Ejaculation
A medical doctor or clinical psychologist assesses for premature (early) ejaculation with an interview to determine ejaculation latency and discuss reactions to this problem. The most common treatments are behavioral techniques that increase ejaculation latency.
Assessment
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 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.
Treatment
The most commonly used psychotherapy for increasing ejaculatory latency is an integration of psychodynamic, behavioral, and cognitive approaches in a short-term model (Althof et al., 2005; Metz & McCarthy, 2003). According to Althof (2014), the focus of psychotherapy for men with PE is to learn to control ejaculation while understanding the meaning of the symptom and the context in which the symptom occurs. Psychodynamically-oriented therapists consider PE to be a metaphor for conflict in the relationship, while behavior-oriented therapists view the disorder as a conditioned response to certain interpersonal or environmental contexts (Althof, 2014). Common behavioral 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 tactile pressure to the penile glans 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 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 PDE5 inhibitor (e.g., Viagra) along with these techniques so that the man can practice delaying ejaculation without worrying about maintaining an erection. Recent treatments combine these techniques and experimentation with new sexual positions that may reduce the propensity towards premature ejaculation. In one of the few well-controlled premature (early) ejaculation treatment studies, there was significant increase in ejaculation latency time among men treated with the squeeze technique compared to men in a wait-list control condition (Carufel & Trudel, 2006).
Medical treatments include the use of topical anesthetics, such as prilocaine/lidocaine, to diminish sensitivity used in combination with condoms (to prevent to the partner’s genitals from being anesthetized). In men with lifelong PE, treatment with pharmacological antidepressants have been shown to increase the ejaculation latency and increase sexual pleasure and satisfaction. Selective serotonin reuptake inhibitors, such as sertraline, fluoxetine, and paroxetine, have most often been used to treat PE because of their known side effects of delaying or inhibiting orgasm. These medications can be taken either daily or on demand 4 to 6 hours before sexual activity. Clinicians who treat men with PE have come to view the disorder as a “couple’s problem” and recommend including the partner in treatment as much as possible to enhance both treatment compliance and treatment efficacy (Rowland & Cooper, 2011).
Daproxetine has been approved for treatment of premature (early) ejaculation in over 30 countries, but not in the United States. It is considered to be a rapid-acting SSRI with a short half-life (Buvat, Tesfaye, Rothman, Rivas, & Giuliano, 2009; McMahon, Althof, & Kaufman, 2009) (Buvat et al., 2009). In clinical trials, daproxetine taken before sexual activity was shown to significantly increase ejaculation latency compared to a pill placebo (Levine, 2006).
