Paul H. Byerly
There are many definitions of premature ejaculation (PE). Some say it’s when a man can’t prolong intercourse long enough for his wife to climax. Does this mean a man who can last half an hour is premature if his wife does not climax? Does it mean the man who never lasts two minutes is not premature if his wife usually climaxes? (Both such couples exist.) The usual medical definition is a man who ejaculates less than two minutes after entering the vagina; but the reality is three minutes is not enough time for the vast majority of women to reach climax. The best definition we have found deals not with the woman’s climax, or how long intercourse lasts, but with the man’s ability to control his ejaculation most of the time, climaxing only when he chooses. Admittedly this is a subjective measure that cannot be quantified for use in studies, but it is a good real world standard.
How many men deal with PE? We’ve seen estimates as low as 2% and as high at 70%! Some of these are high because they ask if men have ever experienced PE. A variety of relation issues, as well as not having had sex in a long time, affect how long a man can last, so such a question is of little use. The best studies put the number of men who can’t last two minutes at 11% to 14%. The number of men who don’t have real control is higher than this – possibly as high as one third of all men1.
Originally, it was thought that rapid ejaculation was the result of mental issues such as anxiety, fear, anger, or embarrassment. Based on this, treatment was to deal with the mind via psychoanalysis. In 1970, Masters and Johnson said PE was a result of self-learned behaviours: rapid masturbation or hurried sex resulting from fear of discovery. This theory resulted in trying to cure PE by behaviour modification – retraining a man to make sex last longer.
While all the things listed above may be factors in some cases of PE, there is growing research-based understanding that some men are “hard wired” to ejaculate quickly during intercourse (most men can last much longer during masturbation and other sex acts – intercourse is different). Studies of twins2 have suggested heredity is involved, studies of penile sensitivity have found that men with PE have greater sensitivity than those without3, and several studies have found certain genes to be more common in men with PE4,5. This new understanding of PE has brought about the search for ways to treat PE with medication, and studies of medications have further supported the idea that PE is not “all in the head” by showing that the placebo effect is very weak for PE.
PE is divided into two categories. If a man has always climaxed rapidly during intercourse, he has primary or lifelong PE. If he started to have problems after a period of good control, he has secondary or acquired PE. Secondary PE is far more likely to have a psychological component. Secondary PE is also common in men who develop erectile difficulty, with almost half of such men reporting PE6. Anxiety about losing an erection causes men to speed up so they can climax “before it’s too late”. In this case, the solution is to deal with the ED so the man can take his time.
Rapid ejaculation is very much a couple issue. It clearly affects the man and the woman, their sex life, and their marriage as a whole. It is also unlikely that a man will be able to succeed in changing without the loving support and help of his wife. Women should understand that most men find PE shameful; he feels like he is not really a man, and he does not want anyone else, even a doctor or counsellor, to know of the condition. It’s common for a man to refuse to seek help because of his embarrassment. In such a situation, the wife should lovingly but firmly communicate to her husband that she will not accept him ruining their sex life because of fear or pride.
We will begin with ways for a couple to train the man to have control of when he ejaculates, then suggest other alternatives for those who find this does not work. Studies of men with primary PE find that 80% ejaculate after less than half a minute of intercourse, with the rest averaging two minutes or less7. A man who regularly lasts three or more minutes probably does not have a predisposition to ejaculate quickly, and as such can likely learn to last longer. Men who always climax in less than a minute can try to learn to last longer, but most in this group will be unable to make a change. Don’t beat up on yourself (or your husband) if you can’t learn to last longer – genetics may be against you. There are other ways to deal with PE.
Ejaculatory control is a learned skill, so don’t despair if you’re having trouble with it. There are several issues involved in gaining control: being able to feel what is happening, accurately knowing how close you are to orgasm, and knowing how to slow down when you are close but don’t yet want to climax.
Being able to feel what is happening
If you have negative feelings about sex or your sex organs, you may be keeping your mind from focusing on your penis, and on the sensations you are experiencing during sex. If your orgasm “takes you by surprise,” shame or negative attitudes may be something you need to address. God gave you a penis for many reasons, including giving and receiving sexual pleasure with your wife. It is good and right to focus on your penis during sex – to concentrate on and fully experience the pleasure of sex.
Some men have unintentionally trained themselves to ignore the signs of approaching orgasm. A man who has repeatedly masturbated in a hurry (for fear of being caught), or engaged in hurried sexual contact before marriage (again out of fear of being caught), can develop the habit of ignoring the “warning signs” and going full speed until climax occurs. Similarly, if a man has been with a woman who wanted him to get sex over as fast as possible, he learned to hurry as a necessity. In these situations what seems to be PE is actually just a habit, and as with any habit, it can be unlearned.
One thing that will help you is exercising the muscles that contact during ejaculation. Making these muscles stronger will help you gain control, and exercising the muscles will help you learn to feel what is happening in that area of the body. So start by learning to do Kegels to build up your pelvic muscles.
Knowing how close you are
Imagine your arousal/stimulation level as a number between 0 and 100, with 1 being just barely erect, and 100 being the point where orgasm occurs. It’s not enough to just know when you get to 99, because at that point you will have neither the desire nor ability to stop; you have to learn to tell the difference between 50 and 70, and between 80 and 90.
Learning to gauge your level of arousal requires paying close attention to your body during sex, and it’s going to take some trial and error. It’s much easier to learn to feel the signals of arousal level during manual stimulation than during intercourse (some men learn this from masturbation when they are single), so you should start learning while stimulating yourself, or even better, while having your wife stimulate you by hand.
If you have trouble learning to tell how aroused you are, your wife can help. The genitals give a variety of visual cues about how aroused a man is, and with a bit of experience a wife may become a better judge her husband’s arousal level than he is. She should look for telltale changes as he is manually stimulated to orgasm. Common changes are elevation of the testicles (pulled closer to the body), a slight increase in fullness and/or firmness of the penis, darkening of the head of the penis, and the head looking like the skin is becoming more taut (more details about signs of arousal). These changes occur gradually, in a regular, overlapping sequence, so after a couple of times the wife should be able to gauge how close her husband is by what she sees. She can then pass this information on verbally, helping him learn to tell where his arousal is by comparing what you feel to what she reports.
The most important thing is not getting too close to orgasm until you want to climax. Sexual stimulation is cumulative: it takes a lot less to go from 50 to 100 than it takes to go from 1 to 50. Most men can go from 80 to 100 in a few seconds, and once a man reaches about 90, he will probably have to stop all stimulation to avoid ejaculating in the next 10 to 30 seconds. At 95 even stopping thrusting may not prevent orgasm, since being in the vagina is stimulating even without movement.
So, to have any hope of control, you have to be able to tell when you are approaching the 70 to 80 range. With practice, you may be able to learn to stay at this level for a long time. You can certainly stay in this range much longer than you could stay at a higher level of arousal. Practice learning to tell how aroused you are during manual stimulation. There are going to be some “accidents”, so don’t get upset if you miss judge and climax unintentionally. Each time this happens, you have learned a bit more, and are closer to the answer.
Work at slowing or stopping simulation before you reach the danger point. Learn to enjoy the pleasurable sensations of being very aroused but not yet on the verge of orgasm. Orgasm is nice, but it’s also very short. You can get a great deal more pleasure out of sex by learning to prolong the amount of time you spend in the very enjoyable higher levels of arousal.
Don’t be in a hurry to move from manual simulation to intercourse – the more you learn now the easier it will be later. Add a lubricant to manual stimulation to more closely simulate intercourse. Learn to tease the pleasure for a long, long time.
The “real thing”
During intercourse there is the additional problem of reducing his stimulation without reducing her stimulation; if her arousal is slowed as much as his, no real progress is made. The following suggestions are designed to allow you to reduce his stimulation without significantly reducing hers.
Multiple condoms: The idea is extra layers will reduce sensation and slow climax. Most men find this does not make a real difference.
Squeeze and stop start techniques have been long touted as a cure for PE, but there is a lack of good solid studies to support these claims. Early reports of great success were based on self reported feeling of greater control. Several small well-done studies have shown about half of couples feel these methods have helped initially, but that rate drops to less than 25% after three years. Not a great success, but free and without side effects, so worth a try for most.
The stop start technique is similar to what is outlined above. Starting with masturbation the man learns to get very close to orgasm, and then stop. He repeats this a number of times before climaxing. After doing this ten to twelve times, the same is repeated with the wife providing the stimulation. Finally, they move to intercourse.
The squeeze technique was introduced by Masters and Johnson. It is similar to the stop start method, but with the addition of a squeeze that is designed to stop ejaculation and reduce physical arousal level. The squeeze is done with the thumb on the underside of the penis, centered on the frenulum. The first and second fingers are on the glans and the top part of the shaft, just below the glans. Firm pressure is applied for several second – firm enough to be uncomfortable, but not enough to cause pain. When he feels he is past danger of climax, stimulation begins again. The squeeze is used a number of times before climax is intentionally allowed. After doing this many times, the couple moves to intercourse with the woman on top. When he feels climax is close, she pulls off and applies a squeeze.
SSRIs, a class of anti depressants, can significantly slow ejaculation, resulting in going from one minute to as long as seven minutes. Men who climax faster than one minute will see smaller increases of time. Testing of SSRIs for PE is ongoing, and currently most are available only “off label” – meaning the drug is not FDA approved for PE. SSRIs can be use used daily, or taken a few hours before sex – daily gives better results. Some side effects are reported by some men. Side effects are generally mild and may go away after a few weeks of use. The most common side effects are dry mouth, headache, nervousness, insomnia, nausea, diarrhea, drowsiness, reduced sex drive, and mild ED. It may take several weeks of daily use for effects to be seen. Of currently available drugs used off-label for PE, Paroxetine (Paxil, Aropax, Seroxat, Sereupin) seems to give the best increase in time before ejaculation.
Dapoxetine Dapoxetine (brand name Priligy) is an SSRI developed especially for PE. It is in final testing in Europe and the USA. This drug is fast acting, reaching peak level in the blood an hour and a half after being taken, and it stays in the body a shorter time than other SSRIs. In tests the typical benefit was going from one minute of intercourse before ejaculation to three to four minutes. While this is not as great a gain as is desired, it does show that it may be possible to develop an “on demand” SSRI that reduces PE significantly with a much lower incidence of side effect. Expect other new PE drugs in the future.
With SSRIs, any increase in how long intercourse lasts needs to be weighed against the cost of the drug and potential long-term side effects of the drugs. It should be noted that the gains from SSRIs usually result in time from insertion to climax of less than five minutes. While lasting five to ten times longer is a significant statistical improvement, it falls short of the amount of time needed for most women to reach climax by intercourse. If the husband, the wife, or both enjoy the added time, regardless of whether or not she climaxes, treatment can be justified. If the added time does not result in her climax, and makes no real improvement for either, it is more difficult to justify using the drug.
Desensitising products (creams or sprays) have been available for many years. Early products were fairly poor, often leaving a man so numb he felt nothing at all, possibly could not climax, or lost his erection. Fortunately newer products are much better, with even more promising one’s in development. Studies have found increase of six to ten minutes with desensitizing products8.
The spray or cream is applied five to twenty minutes before sex (varies by product). Timing is important – some creams will result in too much numbness as time passes, while others may wear off if too much time passes. It is important not to get any on her! Some products can be washed off the penis before sex (most has absorbed and done its job) while others require wearing a condom to prevent transfer.
Some couples have problems associated with these products: partial erection loss, vaginal burning (a condom will fix this), penile irritation, and complaints of numbness by both men and women (again, a condom will prevent her from having numbness). It may be possible to reduce or eliminate these problems by varying the amount used and when the product is applied.
In tests, the desensitising agent that seems to work the best is a mixture of Lidocaine and Prilocaine. A product with these ingredients, called Tempe Spray, has completed testing in the USA and Europe, and is awaiting regulatory approval. According to the manufacture’s web site, they expect approval in 2012.
There are a number of desensitising products, containing a variety of ingredients. Our suggestion is to buy the smallest size possible until you find one that works well for you. We have heard good reports about a lidocaine product called Stud 100(AffLnk).
If you decide to use a desensitising product, do some testing to get the best result. In addition to varying how much you use, and how long before sex you apply it, you can vary what part of the penis you desensitise. The most sensitive part of the penis is the underside, so applying just there while not applying to the top will give a different affect than applying to the whole glans, or to just the top.
One study9 found that a Lidocaine and Prilocaine spray was 24% less effective in men who have been circumcised. This is due to the toughening of the skin of the glans, which reduces absorption. Other produces likely have a similar reduced effectiveness in circumcised men. However, the reduced effectiveness still gives a significant boost in length of intercourse, and applying more may compensate.
Even without delaying ejaculation, a couple can have a mutually satisfying sex life. This could include:
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5 Serotonin Transporter Promoter Region (5-HTTLPR) Polymorphism is Associated with the Intravaginal Ejaculation Latency Time in Dutch Men with Lifelong Premature Ejaculation The Journal of Sexual Medicine Volume 6, Issue 1, pages 276–284, January 2009 Abstract
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7 M.D. Waldinger, M.W. Hengeveld, A.H. Zwinderman, B. Olivier. An empirical operationalization study of DSM-IV diagnostic criteria for premature ejaculation. Int J Psychiatry Clin Pract 2 (1998) (287 – 293)
8 Busato W, Galindo CC. Topical anaesthetic use for treating premature ejaculation: a double-blind, randomized, placebo-controlled study. BJU Int. 2004;93(7):1018–1021 Abstract
9 Hellstrom W, Carson C, Wyllie M. PSD 502 appears to be effective in both circumcised and un-circumcised men with premature ejaculation (PE) [Abstracts of the Annual Meeting of the American Urological Association. May 29-June 3, 2010. San Francisco, CA, USA]. J Urol 2010; 183 (Suppl. 4): e576.
Background information from Evolution of the Understanding of Premature Ejaculation: Historical Perspectives
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