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March 2017
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PREMATURE EJACULATION

Introduction

Male sexual dysfunctions related to the orgasm phase are considered to be quite common nowadays and recently there has been a notable increase in ejaculatory problems and the attention paid by experts in this field to diagnosis and remedial therapy.

Premature ejaculation disorders were originally considered to be psychological dysfunctions and it is only recently that medical sexology has been able to identify possible organic causes, thus creating possibilities to treat this dysfunction with pharmaceuticals.
Trying, at all costs, to find the physiological reason that is behind a symptom which appears to be related to emotional, anxious and relationship states, and is therefore psychological, has become somewhat of a trend by medics in the field of resolving sexual dysfunctions in general, who mainly do so using pharmaceuticals. However, the risk here is something which we are already quite familiar with: pharmaceutical abuse. The best solution is, as always, something in the middle, that is, combining medical and psychological disciplines to come up with the best solution.
Before going into a description about premature ejaculation and discussing possible psycho-sexological and medical treatments, we first need to look at the physiology behind the ejaculatory process. Furthermore, we must also remember that all the different male orgasm problems are particularly disabling and cause the individual to suffer from intense insecurity, relationship problems low self-esteem and, in more serious cases, depression.

Physiology of the ejaculatory process
Whilst trying to make what happens during the male orgasm phase more simple and clear and considering that the ejaculatory process is a complex psychoneuroendocrine interaction, it is useful to remember that ejaculation is made up of two precise and distinct parts: the emission and the actual ejaculation. The orgasm itself is the result of the brain processing all the sensitive stimulants coming from the penis (pudendal nerve), which are amplified by the strong sensations caused by automatic muscle contractions in ejaculatory phase.
The emission phase, which is kept under control by the male himself, is the result of a spinal reflex (sympathetic nerve system) which triggers a series of consequential contractions of the so called accessory sex organs, that is, the main structures that contribute to the making of seminal fluid (the seminal vesicle, prostate, bulbourethral glands and testicles). It is also important to remember that, in order to activate the emission phase, genital erotic stimulation (tactile or oral) and central erotic stimulation which is the result of visual, auditory and olfactory factors, fantasies and memories. The visual component is particularly important for men: the majority of men are particularly enticed by visual and tactile stimulation.
The ejaculatory phase is also determined by a spinal reflex of the sympathetic nervous system, but diversely from the previous one, it can be controlled by the individual. In fact, when a male feels that he is about to orgasm, it is hard for him to return to a state of arousal and this is followed by the path of no return which results in orgasmic contractions, causing the release of sperm from the urethra. The ischio-cavernous and bulbocavernosus muscles are the muscles (pelvic floor muscles) that are responsible for the propulsion of the semen in the urethra, whilst the automatic rhythmic contractions of the external urethral sphincter works as a suction-ejection pump, sucking in the sperm from the posterior urethra during the relaxation phase and then vigorously expelling it into the bulbous urethra in the contraction phase. During the ejaculation phase, thus when the male orgasms, the anal sphincter also contracts which causes intense feelings of pleasure.



Premature ejaculation 
Premature ejaculation (PE) is what is nowadays called self-diagnostic, unlike other sexual disorder like erectile dysfunction for example, however this makes it difficult to create useful and stable criteria which can be used to identify possible boundaries with other problems.
The definition from the DSM IV TR (Diagnostic and Statistical Manual of Mental Disorder) states that premature ejaculation is 'persistent or recurrent ejaculation with minimal sexual stimulation before, on, or shortly after penetration and before the person wishes it.' Recently, some authors have tried to classify this disorder by associating it with IELT (Intravaginal Ejaculation Latency Time) and this resulted in a having three categories: a severe level of PE which occurs before or ≤ 15 seconds after penetration; a moderate level which occurs ≤ 1 minute after penetration; and a mild level which occurs ≤ 2 minutes after penetration. Considering that penetration is not necessarily linked to vaginal penetration alone, it is a good idea to remember that the time taken to ejaculate may vary a lot in general and according to the individual.
PE is, without a doubt, the most understandable sexual disorder if it is associated to the strong and unstoppable feeling of loss of control during the ejaculatory phase, whether penetrative or not, and, unfortunately, this disorder is responsible for intense psychological distress and unease in relationships.
For clearer diagnosis, PE should be observed in all its phases, including when it first happened, which are:
Primary PE, when PE has been present since the first sexual experience (puberty-adolescence) and it has never gone away;
Secondary PE, when it appears suddenly after a period that the individual describes as acceptable in terms of controlling ejaculation. In these cases, the reasons behind this ejaculatory dysfunction are unknown and can be disruptive for the individual.
The moment when it happens also needs to be identified from the following categories:
Ante Portas PE, which is when ejaculation happens before penetration – there are some men who get so aroused that they ejaculate before they have even got undressed!
Intra moenia PE, which happens exclusively during penetration.
Lastly, the frequency and the occasion on which it happens must also be observed:
Absolute PE, which is when premature ejaculation happens even without his partner being there;
Relative and situational PE, which is when it only happens with a certain partner.

Thanks to clinical experiments, it is easy to see that premature ejaculation can occur with a constant partner (wife, fiancé, girlfriend, etcetera), but it can also happen with occasional partners (lovers, prostitutes and so on). As mentioned, PE is the most common male sexual dysfunction (about 20% of males suffer from it), even though the majority of specialist consultations are for erectile dysfunctions, and, as is often the case, when going for a specialist consultation, men believe the problem is linked to an erectile dysfunction or a drop in desire, excluding the fact that the real culprit could be primary, intra moenia and absolute PE.
It appears that there are some areas of the world where PE is more common than others: in the USA, approximately 24% of men suffer from PE; in Europe the amount of men ranges from 3.7-66% depending on the country; in the Far East the approximation is 29.1%; whilst for Eastern and African countries the number is 17.3%.
Since we know that PE is not an illness, rather it is a particular psychosomatic symptom which causes the individual to feel uneasy and suffer from psychological, relationship and emotional problems, we can now mention the possible psychological and medical causes and contributory factors behind this undesirable event. However, even before doing that, it is worth remembering that every male is ‘potentially’ a premature ejaculator since, physiologically, the time that passes between the moment in which a man gets excited and when he reaches orgasm is not is strictly related to the anatomical and physiological process of sexual response. In fact, if the male wants to prolong feelings of pleasure (preorgasmic feelings) or stay in sync with the rhythms of the woman’s orgasm (which is different and takes longer), both the male and female need to work together to develop the male’s ejaculatory control. Therefore, the male must not give in to his instinctual sexual pleasure, rather he has to adapt to the situation.
PE has always been present amongst men and, over time, it has changed and become dysfunctional, so much so as to compromise the main (and possibly selfish) part of male pleasure.

A small anecdote: most probably, some decades ago, erotic sexual experiences did involve some prematurity in terms of the male’s orgasm, however, this was not necessarily something to worry about since they did not consider this abrupt finish to be dysfunctional. This may be because female sexuality was somewhat neglected and dominated  by male sexuality in those times; men and women did not pay attention to female orgasm, women did not know their bodies very well and sexuality involved experiencing the ’pleasure’ of giving the male an orgasm, which was usually done to get pregnant. Only after feminism in the 1960s and 1970s did sexuality undergo big changes, especially in terms of female pleasure (which was rediscovered), and this resulted in the evolution of sexual liberalisation and equal rights, however some men were not able to adapt to this and they are still stuck with their ‘internal rules’ which in their opinion were, and for some still are, completely natural!

When PE is diagnosed and is considered to be psychological, the following reasons may be taken into account when deciding on the various psycho-therapeutic approaches:
psychodynamic interpretations:
a) excessive masturbation during adolescence (excessive narcissism) without learning how to control preorgasmic feelings;
b) repressed anger/aggression (subconscious misogyny/sadism of ‘stealing’ the female orgasm);
behavioural factors:
a) traumatic first sexual experiences;
b) what he has learnt over time (for example, reaching orgasm quickly so as not to be discovered);
cognitive factors:
a) performance worries (superficial anxious state related to desire to show one’s true sexual potential, worrying about not using contraception, worrying about failing) which, due to hyper-arousal, cause the male to have less control over pre-ejaculatory feelings;
b) feeling guilty (premarital sexual activities, having an affair);
c) fear (of getting the woman pregnant, fear of catching a STD).

When PE is diagnosed and is considered to be organic, the following biological theories and organic causes are taken into consideration:
a) altered hormonal mechanisms (hypotestosteronemia);
b) reflex problems (problems with pelvic floor muscles);
c) neurological problems;
d) vascular changes;
endocrine illnesses:
a) hypogonadism and/or hypothyroidism;
urological illnesses:
a) prostatitis;
b) phimosis;
c) frenulum breve;
iatrogenic causes: amphetamines;
self-inflicted causes: taking drugs (cocaine).

Therapy
As already mentioned in the introduction, the best approach for treating premature ejaculation is the perfect combination of psychological and medical-pharmaceutical components. This is the reason why a precise diagnostic frame is needed as soon as possible so as to avoid sending the patient down confusing and unproductive paths; quite often, patients who were sent by psychosexologists have already ‘tried’ a lot of therapeutic treatments which may be pharmaceutical or just psychological. However, this results in the individual having very low self-esteem and trying to look for ‘magic’ solutions to the problem.
If initial diagnosis is purely organic, the individual should undergo the following:
- specific antibiotic treatment (in the case of prostatitis and infections of the male accessory glands);
- anti-inflammatory pharmaceuticals (if the infections of male accessory glands are chronic);
- methimazole and/or beta blockers (hyperthyroidism);
- hormone replacement therapy (in the forms of hypogonadism);
- surgery (for phimosis and frenulum breve).
If, on the other hand, the problem is diagnosed as psychological, the individual must undergo an integrated psycho-sexological approach. It is important that psychosexual therapy is done together with the partner (if present), or, if the male is single, treatment should be aimed at recreating self-perception and relearning about one’s body. Some behavioural techniques used in psychosexual therapy are: the squeeze break, technique which consists of applying light pressure to the glands (for 3-4 seconds) when the penis is erect and immediately before ejaculation; there is also the stop-start technique, which consists of interrupting the sexual intercourse and withdrawing the penis when the male feels like he is close to orgasm because he is not able to control the ejaculatory reflex; Kegel exercises are also used and these are based on the male’s gradual control of the pubococcygeal muscles in the pelvic floor muscles area. These techniques are just a few examples of integrated psychosexual approaches but the chosen approach will include re-educating the individual about his body and sexual pleasure, as well as improving relationship methods, breaking down false myths and stupid sexual taboos.

Conclusion
Accurate diagnosis, that is, precise guidelines regarding the diagnostic frame of premature ejaculation, is behind successful therapy and improvements of the quality of life of the those who are affected by this problem. Research (mainly medical) has shown that there has been a good response to certain pharmaceuticals, even though there are some side effects. What is more, it appears that none of these pharmaceuticals can ensure permanent results once the treatment is finished.
As far as psychosexual therapy is concerned, there is not a lot of scientific data for this approach, nor is there precise evidence about its actual post-treatment efficiency.
Ongoing experimentation with long term anti-depressant pharmaceuticals and improved and more scientific studies about psychosexology will guarantee better understanding of the solution for the symptom of premature ejaculation from an integrated psychoneuroendocrinology and social point of view. It would be quite incomprehensible to separate mind from body when considering a response that has "vital" importance, like an orgasm does.

PREMATURE EJACULATION

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