Dr.SPSingh Clinic Pvt.Ltd.

Sexual life is the most important part of life. Its impact on our life are very deep. It affects our social and personal behaviour. Relationship with our sexual partner is affected by success in sexual life. Job performance,even financial matters also get affected by our sexual life. Healthy sexual life imparts positivity in our sexual relationship, job and other sphere of life. On the other hand unhealthy sexual life worsen our relationship, less efficiency in job and lost peace of mind. Such a disorder of sexual health is Premature Ejaculation, also called early ejaculation. This is very disappointing,embarrassing condition. Female partners in such condition,remains unsatisfied, and male partners even refused to accept it they have any sexual problem due to shame or ego, whatsoever it is.

Facts About Premature Ejaculation

• Premature ejaculation is the second most common sexual problem affecting between 1 in 3 to 1 in 5 men aged 18-59. 
• Some men ejaculate as soon as foreplay starts. Others ejaculate during penetration or very soon after.
• One-third to one-quarter of men with premature ejaculation also have problem of erectile dysfunction.
• PE is estimated to affect 30–40% of men at some point in their lives.
• An estimated 30%-70% of American males experience premature ejaculation.
• Polygamous men have a lower incidence of premature ejaculation and higher sexual satisfaction than monogamous men.
• Erectile dysfunction is the leading risk factor for about 36% to 50% of PE.
• Lower frequency of sexual intercourse significantly related to a higher incidence of PE.
• The National Health and Social Life Survey (NHSLS) indicate a prevalence of 30%, which is spread across all adult age groups.
• In almost 75-100% sexual activity, the experience of ejaculation occurring during sexual intercourse within 1 minute after vaginal penetration.
• A large-scale survey conducted by the European Urology Journal found that 20-30% of men between the ages of 18 and 60 report having experienced PE regularly.
• A study published in the British Journal of Urology found that early ejaculation is more common in younger men aged 18-25, with about 25% of them reporting frequent episodes.
• Study by the American Urological Association found that 45% of men with PE reported anxiety and lower self-esteem related to their sexual performance.
• Global Survey of Sexual Attitudes and Behaviors (GSSAB)found that approximately 16% of men globally experience chronic premature ejaculation.
• The Journal of Sexual Medicine in a study found that Lifelong PE results in ejaculation within 30-60 seconds of penetration.
• A study showed that almost 25% of women ended a relationship due to their partners PE.
• PE tends to be under-reported by patients who do not typically seek medical help.   

What is Premature Ejaculation?

Premature ejaculation is defined as a condition where a man ejaculates within one minute of vaginal penetration and is unable to control it, causing distress to either the man or his partner. The average intravaginal ejaculatory latency time (IELT) for men with PE is under 1-2 minutes. Most men without PE ejaculate within 5-6 minutes of penetration. The Intravaginal Ejaculatory Latency Time (IELT) is the average time between vaginal penetration and ejaculation estimated by the patient. Also if a person makes less than 60 penile strokes in one minute continuous with stopping,he may be suffering from premature ejaculation. PE can be a frustrating experience for both partners and can make sex less enjoyable. International Society of Sexual Medicine (ISSM) defined PE as a male sexual dysfunction characterized by:

• Ejaculation which always or nearly always occurs prior to or within about 1 minute of vaginal penetration;
• Inability to delay ejaculation on all or nearly all vaginal penetrations;
• Negative personal consequences, such as distress, bother, frustration and/or the avoidance of sexual encounters.

If PE causes you (or your loved one) to worry or to feel stressed, then you should ask your Sexologist for help. Remember that you are not alone, and your Sexologist knows what to do. Together, you can find the underlying cause and find treatment.

Types of Premature Ejaculation

Four Subtype of Premature Ejaculation

Lifelong PE	Acquired PE	Variable PE	Subjective PE
Hypertonic State	Hypotonic State	Normotonic State	Normotonic State
Type B	Type A	——-	——–
Erectio praecox	No  Erectio praecox	No  Erectio praecox	No  Erectio praecox
Detumescentia praecox	No Detumescentia praecox	No Detumescentia praecox	No Detumescentia praecox
IELT<1	IELT= 1<3	Variable IELT	Normal IELT
Neurobiological and Genetic	Medical and/or Psychological	Normal variation	Psychological
Consistent	History of normal ejaculation earlier	Inconsistent	Subjective perception of PE despite normal ejaculation

Sign & Symptom Of Premature Ejaculation

In most cases of premature ejaculation patient does not reveals exact situation. PE may be associated with other sexual dysfunctions such as erectile dysfunction, decreased libido etc. These signs are common in all patient of PE:-

• A short ejaculatory latency;
• A lack of control over ejaculation;
• A lack of sexual satisfaction.

The four main interweaving sets of symptoms are:

• Short IELT, with Control;
• Short IELT, No Control;
• Normal IELT, No Control;
• Normal IELT, with Control.

Physiology Of Premature Ejaculation

Ejaculation is the sudden, pleasurable release of semen through the penis. It is controlled by your brain i.e.your central nervous system. When you are sexually stimulated, signals are sent up through your spinal cord to your brain. When you reach a certain level of excitement, your brain tells your reproductive organs to “go!” This causes semen to be ejected through the penis called ejaculation. Ejaculation has two phases: emission and expulsion.

• Phase 1:Emission:- Emission is when sperm moves from the testicles to the prostate. There it mixes with seminal fluid to make semen. The vasa deferentia are the tubes that help move the sperm from the testicles through to the prostate to the base of the penis. Parasympathetic is responsible for epithelial secretion, while the sympathetic nervous system is responsible for tonal control and contractions of smooth muscle in the seminal trait. Activated by genital or cerebral erotic stimulation. In emission phase sequential contractions of accessory sexual glands occurs. Emission is dependent on contractions of the smooth muscles of the prostate, seminal vesicles, and vas deferens, and its initiation can be voluntarily controlled. Once the semen reaches the posterior urethra, ejaculation becomes inevitable. The male organs involved in the emission process are Epididymis,Vas deferens,Seminal Vesicles,Prostate and Bulbourethral i.e. Cowper glands.
• Phase 2:Expulsion:- Expulsion is a spinal cord reflex that occurs as the ejaculatory process reaches a “point of no return.”Expulsion is when the muscles at the base of the penis contract. This forces semen out of the penis. Often, ejaculation and orgasm (climax) happen at the same time. Some men climax without ejaculating. In most cases, erections go away after this phase. It is controlled by somatic and sympathetic nervous system. Activated by sensation resulting from distension of posterior urethra. In expulsion phase rhythmic contractions of bulbocavernosus,ischiocavernosus and levator ani muscles take place.These contractions occur rhythmically at 0.8-s intervals. These rhythmic contractions are extremely pleasurable and are part of the sensation of orgasm. A young healthy individual has 10 to 15 contractions per ejaculation. The organs involved in expulsion are smooth muscles of Bladder neck,Stratified epithelium of Urethra and Pelvipereneal striated muscles.

Pathophysiology of lifelong PE is mediated by a very complex interplay of central and peripheral serotonergic, dopaminergic, oxytocinergic, endocrinological, genetic and also epigenetic factors. Characterized by a diminished central 5-HT neurotransmission and/or a hyperfunction of 5-HT1A receptors and a hypofunction of 5-HT2C receptors causing a disturbed serotonergic modulation of the IELT. Therefore, it would have to include serotonergic and other neurotransmitter and endocrinological processes—e.g., increased oxytocinergic, and/or increased dopaminergic neurotransmission, decreased Prolactinergic functioning and increased activity of gonadotrophic factors. Also involved is the peripheral nervous system, e.g., the sympathetic and parasympathetic nervous system.Physiology of PE involve disturbance in any of the following mechanisms:

• Penile Hypersensitivity;
• Hyperexcitable Ejaculatory Reflex;
• Hyperarousability;
• Genetic predisposition;
• 5-hydroxytryptamine (5-HT)-receptor dysfunction.

Process of ejaculation is controlled by some cerebral areas. The cerebral areas that actively participate in ejaculation are the posteromedial division of the bed nucleus of the striaterminal (BNST pm), the posterodorsal area of the amygdala (MeApd), the posterodorsal preoptic nucleus (PNpd)and the parvicellular part of the subparafascicular thalamus (SPFp). One of the most important excitatory paths includes neurons in the preoptic medial area (MPOA)that project in the paraventricular hypothalamus (PVN). The inhibitory centres originate from neurons in the gigantocellular nuclei (Gi) and ventral raphe in the ventral medulla. Spinal part include Preganglionic sympathetic neurons located in the intermediolateral cell column and the dorsal grey column (T12- L2) innervate the urogenital area. Preganglionic parasympathetic that innervate the urogenital area are found in intermediolateral cell column between S2-S4. Somatic neurons responsible for motor innervation of pelvipereneal and urethral sphincter are found on the Onuf nucleus on the ventral horn of S2-S4. A component to the generation of ejaculation was identified on the lumbar region of L3-L4.These spinothalamic neurons segments, also known as spinothalamic ejaculation generators, coordinate the autonomous and somatic (pudendal) processes, in order to initiate ejaculation.Activation of the autonomous nervous system and the somatic nervous system is essential for ejaculation [as is the role of non-adrenergic non-cholinergic (NANC) in modulating the activity of accessory glands].

Many Neurotransmitters take part in the process of ejaculation, which are at peripheral level are Norepinephrine, Acetylcholine, Nitric oxide, Oxytocin, Purines, Serotonin and at medullar level are GABA, Oxytocin, P substance and at central level are Serotonin, Dopamine, Opioids, Oxytocin.

Causes of Premature Ejaculation

The exact cause of PE is not known, but there are many reasons why a man may have PE. PE can be caused by a number of factors, including: Biological factors, such as inflammation of the prostate gland or a spinal cord problem. Chemical factors, such as abnormal hormone levels. Emotional factors, such as anxiety, stress, or relationship problems. Genetic factors related to the molecules that signal between nerves. Serotonin is a natural substance in your body made by nerves. It helps to control the way the brain manages mood, emotion, sleep and sexual desire. High amounts of serotonin in the brain increase the time to ejaculation. Low amounts can shorten the time to ejaculation, and lead to PE. Below are some more specific causes.

Diagnosis Of Premature Ejaculation

An accurate clinical history is the best diagnostic method, and in the majority of the cases it is enough to differentiate between primary and acquired premature ejaculation. Clinical history plays an important part in the diagnosis of PE since it is by definition a self-reported diagnosis. However, clinical assessment can be challenging owing to the nature of the problem. Patients may be embarrassed and shy when relating details of their sexual experiences and exact details are not forthcoming. It may then be useful to involve the partner in the consultation. To elicit a diagnosis of PE, the three main components of PE (timing, control and satisfaction) should be specifically addressed. Once a diagnosis of PE is established, other related things that should be explored are:

• The nature of the PE (lifelong or acquired);
• The presence or absence of any associated erectile dysfunction (ED);
• The impact of the PE on the relationship with his partner;
• The impact of the PE on quality of life;
• Previous Treatment (including over the counter medication) and response to that treatment.

Physical Examination and Tests

Examination:- Physical examination is usually normal in patients with Primary PE. Patients with Secondary PE, may have an altered physical exam that suggest presence of anatomical anomalies and disorders. Examination of the patient involves a general examination as well as a more focused examination of the genitalia, outlining the scrotal contents and the penis in detail. A digital rectal examination to palpate the prostate gland is also recommended. Clinical examination can identify anatomical anomalies, disorders and risk factors that may favor PE.

• Shortness of the frenulum, pathology of the Prepuce (Phimosis) or Glans (Balanitis);
• Other anatomical anomalies of the urogenital system;
• Examination of the perineum and Prostate (Prostatitis);
• Search for signs of Dysthyroidism.

Laboratory Tests:- Laboratory and other physiological tests are rarely indicated. History and examination are sufficient to reach a diagnosis. Still it is advised to perform, blood count, lipid profile, glycosylated haemoglobin, urinalysis, testosterone (free and total), prolactin and thyroid stimulating hormone (TSH).

Treatment Of Premature Ejaculation

Nowadays the treatment PE is not curative, but is effective in increasing the Intravaginal Ejaculatory Latency Time, improving the couple’s sexual satisfaction. You and your Sexologist can work together to decide the best choice for you. Many people try more than one treatment at the same time. Psychological therapy, Behavioral therapy and drugs are the main treatments for PE. The first oral medication used for the treatment of PE were monoamine oxidase i.e.MAO inhibitors,such as Isocarboxazid, Phenelzine; and Alpha-1 adrenergic blocking agent,such as Phenoxybenzamine, alfuzosin, terazosin. However, the side effects associated with these drugs limited their use. These agents are not used for PE anymore.

FAQ About PE