The Management of Premature Ejaculation: A Patients Guide

HOW DOES EJACULATION OCCUR?

Ejaculation, controlled by the central nervous system, happens when friction on the genitalia and other forms of sexual stimulation provide impulses that are sent up the spinal cord and into the brain. Ejaculation has two phases: PhASE I: EMISSION The vas deferens (the tubes that store and transport sperm from the testes) contract to squeeze the sperm toward the base of the penis through the prostate gland and into the urethra. The seminal vesicles release secretions that combine with the sperm to make semen. The ejaculation is unstoppable at this stage. PhASE II: EJACULATION The muscles at the base of the penis and urethra contract, forcing semen out of the penis (ejaculation and orgasm) while the bladder neck contracts. Orgasm can occur without the delivery of semen (ejaculation) from the penis; this causes a dry orgasm. Normally, erections decline following ejaculation.

WhAT IS pREMATURE EJACULATION?

Premature ejaculation is ejaculation that occurs earlier than desired, causing distress to either one or both partners. It is one of the most common male sexual disorders, affecting about 20-30% of men of all ages. Premature ejaculation is a frustrating problem that can reduce the enjoyment of sex, harm relationships

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and impair quality of life. The occurrence of premature ejaculation is not in itself harmful or a sign of other health problems. If premature ejaculation is not a problem for a man and his partner, treatment is not needed. However, when the problem occurs frequently and/or causes distress to the man or his partner, treatment is available and is often helpful.

CAN pREMATURE EJACULATION DEVELOp LATER IN LIFE?

Premature ejaculation can occur at any age. Surprisingly, aging appears not to be a cause of premature ejaculation. However, the aging process typically causes changes in erectile function and ejaculation. Erections may not be as firm or as large. Erections may be maintained for a shorter period before ejaculating. The feeling that an ejaculation is about to happen may be shorter. These factors can result in an older man having an ejaculation earlier than when he was younger.

CAN BOTh pREMATURE EJACULATION AND ERECTILE DYSFUNCTION AFFECT A MAN AT ThE SAME TIME?
Sometimes premature ejaculation may be a problem in men who have erectile dysfunction; erectile dysfunction is the inability to achieve and/or maintain an erection sufficient for satisfactory sexual performance. In fact, premature ejaculation may be caused by erectile

dysfunction especially in a man who needs continual penile stimulation to maintain his erection. Some men do not understand that the loss of erection normally occurs after ejaculation. They may wrongly complain to their doctors that they have erectile dysfunction when the actual problem is premature ejaculation. It is recommended that the erectile dysfunction be treated first if you experience both ED and premature ejaculation, since the premature ejaculation may resolve on its own once the ED has been adequately treated.

WhAT CAUSES pREMATURE EJACULATION?

Although the exact cause of premature ejaculation is not known, new studies suggest that serotonin, a natural substance produced by nerves, is important. A breakdown of the actions of serotonin in the brain may be a cause. Studies have found that high amounts of serotonin in the brain slow the time to ejaculation while low amounts of serotonin can produce a condition like premature ejaculation.

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MYThS SURROUNDING pREMATURE EJACULATION
Myth: Premature ejaculation is a problem that is entirely in ones mind. Fact: New studies have shown that a low level of serotonin, a natural substance that is produced by nerves, may be a possible cause. Myth: Alcohol is a good method for controlling premature ejaculation. Fact: Although alcohol can delay orgasm, it is not an effective treatment for premature ejaculation.

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WhEN ShOULD A DOCTOR BE SEEN?

When premature ejaculation happens so frequently that it interferes with your sexual pleasure, it becomes a medical problem requiring the care of a doctor. To understand the problem, the doctor will need to ask questions about your sexual history such as the following: How often does the premature ejaculation occur? How long have you had this problem? Is the problem specic to one partner? Or does it happen with every partner? Does premature ejaculation occur with all or just some attempts at sexual relations? How much stimulation results in premature ejaculation? What type of sexual activity (i.e., foreplay,

masturbation, intercourse, use of visual clues, etc.) is engaged in and how often? How has premature ejaculation aected sexual activity? What is the quality of your personal relationships? How does premature ejaculation aect your quality of life? Are there any factors that make premature ejaculation worse or better (i.e. drugs, alcohol, etc.)? Usually, laboratory testing is not necessary unless the history and a physical examination reveal something more complicated.

HOW TO TALK TO YOUR pARTNER ABOUT pREMATURE EJACULATION?

Premature ejaculation affects not only you but also your partner and your sexual relationship. In an episode of premature ejaculation, the intimacy shared with a partner suddenly comes to a quick end. You might feel angry, ashamed, and frustrated, and turn away from your partner. At the same time, your partner may be upset with the rapid emotional change, or the outcome of the sexual encounter. Communication is not only important to successful diagnosis and treatment, but can also help a partner understand the feelings of the individual. Sometimes couple counseling or sex therapy may be useful. Together a couple might develop techniques (for example, the squeeze technique discussed in

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behavioral therapy section) that may prolong an erection. Most importantly, the couple should try to relax. Anxiety (especially performance anxiety) only makes this condition worse.

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WhAT TREATMENTS ARE AVAILABLE?

There are several treatment choices for premature ejaculation: psychological therapy, behavioral therapy, and medications. Be sure to discuss these treatments with your doctor and together decide which of the following options is best for you: Psychological therapy addresses feelings a man may have about sexuality and sexual relationships. Behavioral therapy makes use of exercises to help a man develop tolerance to stimulation and, as a result, delay ejaculation. Medical therapy includes oral medications that can cause a delay in the time it takes from the beginning of sexual stimulation until ejaculation occurs. These oral medications are the same medications that are commonly used to treat depression. But in men with premature ejaculation, they are used to improve the problem of premature ejaculation, not to treat depression. In addition, topical anesthetic creams may be used to increase the time it takes from the beginning of sexual stimulation until ejaculation occurs.

PSYCHOLOgICaL tHeRapIeS Psychological therapy can be used as the only treatment or can be used together with medical therapy or behavioral therapy. The focus of psychological therapy is to help you to identify psychological difficulties that may contribute to the premature ejaculation and/or to solve problems in your relationships that may have added to the cause of premature ejaculation. This therapy can also help couples to talk about problems with intimacy that occurred after premature ejaculation began. Psychological therapy can also help a man learn to be less anxious about his sexual performance and have greater sexual confidence. Typically, a man will receive specific advice on how to enhance his and his partners sexual satisfaction. BeHaVIORaL tHeRapIeS Behavioral therapy can play a key part in the usual treatment of premature ejaculation. Certain sexual maneuvers can be effective; however, they may not always provide a lasting solution to the problem. Also, they rely heavily on the cooperation of the partner, which in some cases, may be a problem. With the squeeze method, an exercise developed by Masters and Johnson, the partner stimulates the mans penis until he is close to ejaculation. At the point when he is about to ejaculate, the partner squeezes the penis hard enough to make him partially lose his erection. The goal of this technique is to teach the man to become aware of the sensations leading up to orgasm,

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and then begin to control and delay his orgasm on his own. With the stop-start method, the partner stimulates the mans penis until just before ejaculation. The partner should then stop all stimulation until the urge to ejaculate subsides. As the man regains control, he instructs the partner to begin stimulating his penis again. This procedure is repeated three times before allowing the man to ejaculate on the fourth time. The couple repeats this exercise three times a week, until the man has gained good control. MeDICaL tHeRapIeS Although not approved by the U.S. Food and Drug Administration (FDA) for this purpose, pills used for depression and anesthetic creams have been shown to delay ejaculation in men with premature ejaculation. Medications are a relatively new form of treatment for premature ejaculation. Doctors first noticed that men and women who were taking drugs for the treatment of depression (antidepressants) also had delayed orgasms. Doctors then began to use these drugs offlabel (this implies using a medication for a different illness than what it was originally manufactured for) to treat premature ejaculation. These medications include antidepressants that affect serotonin such as fluoxetine (Prozac, Sarafem), paroxetine (Paxil), sertraline (Zoloft), and clomipramine (Anafranil). If one medication fails to work, a second one is usually recommended. If the second one fails, trying a third medication is not likely to be beneficial. An alternative

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is to combine medication with behavioral therapy and/ or creams. For use in premature ejaculation, the doses of antidepressants are usually lower than those recommended for the treatment of depression. Though side effects are not inevitable, when they do occur, the most common side effects of antidepressants include nausea, dry mouth, drowsiness, erectile dysfunction and reduced desire for sexual activity. These drugs can be taken either every day or only taken before sexual activity. Your doctor will decide how you should take the medication based on the frequency of intercourse and the effect that they produce for you. The best time for taking the antidepressant medications before sexual activity has not been established, but most doctors will recommend from two to six hours depending on the medication. Because premature ejaculation can recur when the medication is not taken, you most likely will need to take it on a continuing basis. Local anesthetic creams can be used to treat premature ejaculation. These creams are applied to the head of the penis about 20 to 30 minutes before intercourse to lessen the sensitivity. Prior to sexual intercourse, a condom (if used) may be removed and the penis washed clean of any remaining cream. A loss of erection can occur if the anesthetic cream is left on the penis for a longer period of time than recommended. Also, the anesthetic cream should not be left on the exposed penis during vaginal intercourse since it may cause vaginal numbness.

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This patients guide is intended to stimulate and facilitate discussion between the patient and doctor regarding the types of treatment described in summary fashion in this brochure. The brochure was developed by the Erectile Dysfunction Guideline Update Panel of the American Urological Association (AUA). It is based on The Pharmacologic Management of Premature Ejaculation Guideline, a document developed by the AUA. For additional information, please refer to the full text, located at www.AUAnet.org.

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This material may not be reproduced in electronic or other format without written permission of the AUA. For additional copies of this brochure, please contact: American Urological Association Foundation 1000 Corporate Boulevard Linthicum, MD 21090 Phone: 1-800-RING-AUA www.AUAFoundation.org www.UrologyHealth.org For further information Society for Sex Therapy and Research 409 12th Street, S.W., P.O. Box 96920 Washington, D.C. 20090-6920 202-863-1644 www.sstarnet.org American Association for Marriage and Family Therapy 112 South Alfred Street Alexandria, VA 22314-3061 Phone: 703-838-9808 Fax: 703-838-9805 American Association of Sex Educators, Counselors, and Therapists P.O. Box 5488 Richmond, VA 23220-0488 www.aasect.org Sexual Medicine Society of North America, Inc. 1111 North Plaza Drive, Suite 550 Schaumburg, IL 60173 Phone: 847-517-7225 Fax: 847-517-7229 www.smsna.org

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GLOSSARY
anesthetic creams: Creams that contain a small amount of a numbing chemical, most often lidocaine and/or prilocaine. anxiety: a feeling of apprehension, often characterized by feelings of stress. antidepressants: medications used to treat depression and other related conditions. counseling: the providing of advice and guidance to a patient by a health professional. depression: a disorder characterized by feelings of extreme sadness, guilt, helplessness and hopelessness, and thoughts of death. diagnosis: the process by which a doctor determines what disease a patient has by studying the patients symptoms and medical history, and analyzing any tests performed (blood tests, urine tests, brain scans, etc.) ejaculate: the fluid that is expelled from a mans penis during sexual climax (orgasm). ejaculation: when sperm and other fluids come from the penis during sexual climax (orgasm). emission: the delivery of sperm and seminal vesicle secretions into the urethra through the prostate. erectile dysfunction: the inability to develop or sustain an erection satisfactory for sexual intercourse. erection: a state in which the penis fills with blood and becomes rigid.

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foreplay: fondling of the sex partner to produce mutual sexual arousal and pleasure prior to intercourse. orgasm: a state of physical and emotional excitement that occurs at the climax of sexual intercourse. In the male, it is accompanied by the ejaculation of semen. masturbation: self-stimulation of genitals or other parts of the body causing sexual excitement, usually to orgasm. premature ejaculation: ejaculation that occurs sooner than a man wishes, usually before or soon after penetration. prostate gland: the prostate gland is a walnut-sized structure that is located below the urinary bladder in front of the rectum. The prostate gland contributes additional fluid to the ejaculate. seminal vesicles: the sac-like pouches that attach to the vas deferens near the base of the urinary bladder. The seminal vesicles produce a sugar-rich fluid called fructose that provides sperm with a source of energy that helps sperm move. The fluid of the seminal vesicles makes up most of the volume of a mans ejaculatory fluid, or ejaculate. semen: the fluid containing sperm (the male reproductive cells) that is expelled (ejaculated) through the end of the penis when the man reaches sexual climax (orgasm). serotonin: a small molecule (also known as neurotransmitter) that helps the brain cells communicate with each other.

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sex therapy: counseling for sexual disorders. side effects: an action or effect of a drug other than that desired. Commonly it is an undesirable effect such as nausea, headache, insomnia, acute toxic reaction, or drug interaction.

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REFERENCES
Laumann, E.O., Paik, A. and Rosen, R.C.: Sexual dysfunction in the United States: prevalence and predictors. JAMA., 281: 537, 1999

Waldinger, M.D.: Lifelong premature ejaculation: from authority-based to evidence-based medicine. Br J Urol, 93: 201, 2004

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The American Urological Association Foundation was established to support and promote research, patient/public education and advocacy to improve the prevention, detection, treatment and cure of urologic disease. The American Urological Association Foundation provides this information based on current medical and scientific knowledge. This information is not a tool for self-diagnosis or a substitute for professional medical advice. It is not to be used or relied on for that purpose. Please see your urologist or other health care provider regarding any health concerns and always consult a health care professional before you start or stop any treatments, including medications.

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