Premature Ejaculation: The Complete Guide

‍Take-home points

• Premature ejaculation is the most prevalent sexual dysfunction in men.
• Many biological and psychological factors may contribute to premature ejaculation.
• Left untreated, the condition may lead to, or worsen, anxiety, depression, personal distress, and overall quality of life.
• A healthcare professional can recommend the best treatment approach on an individual basis, which may involve behavioural techniques, counselling, topical gels, and oral medications.

What is premature ejaculation?

Premature ejaculation is the most common sexual dysfunction in men – sometimes referred to as early or rapid ejaculation. The condition is generally diagnosed by short ejaculatory latency (< 2 minutes of sexual stimulation), poor ejaculatory control (ejaculating before personal intent), and anxiety or distress during most sexual engagements.¹ The definition of premature ejaculation is ever-changing, however. While health associations still characterise premature ejaculation in the context of vaginal penetration, many experts want the definition to include all sexual activities, with or without a male or female partner.²

Most cases of premature ejaculation are classified as either primary or secondary. Primary premature ejaculation is lifelong and begins as soon as the patient becomes sexually active; secondary premature ejaculation begins later in life and usually reports a slightly longer ejaculatory latency period of up to three minutes of sexual stimulation.

Prevalence of Premature Ejaculation

Premature ejaculation affects about 30% of men, possibly more.³ In The Global Study of Sexual Attitudes and Behaviors, a similar prevalence was observed across 19 countries and seven geographic regions, other than the Middle East who reported that premature ejaculation affects only 12% of men.⁴ However, due to the sensitive nature of the condition, it is believed that many cases go unreported, and the actual prevalence may be higher.

Impact of Premature Ejaculation on Quality of Life

Both types of premature ejaculation (primary or secondary) can negatively impact quality of life. The condition is linked with a range of psychological conditions, such as anxiety, depression, and distress.⁵ Not only can premature ejaculation reduce the enjoyment of sexual activity, but the attached frustration and disappointment might strain intimate relationships and create feelings of inadequacy or guilt. Many individuals with premature ejaculation may restrict or even avoid sexual encounters altogether, possibly increasing the risk of relationship dissatisfaction. 

Signs and Symptoms of Premature Ejaculation

The primary symptom of premature ejaculation is the inability to delay ejaculation during sexual activity. Men with this condition lack control over their ejaculation, and premature ejaculation is recurrent and consistent over time. Most sexual activities will last no longer than three minutes. 

In addition to the physical aspect, premature ejaculation can have emotional and psychological effects. Individuals with premature ejaculation may experience embarrassment, guilt, reduced self-esteem, and communication issues within their sexual relationships. These negative emotions can exacerbate the problem and create a vicious cycle of anxiety and premature ejaculation.

Causes of Premature Ejaculation

Normal ejaculation involves a four-step series of events:⁶

1. Excitement/arousal
2. Plateau
3. An increase in excitement/arousal to the point of ejaculation and orgasm
4. Then postejaculatory detumescence and resolution.

In step three, the smooth muscle in and around the penis begins to contract (the “point of no return”), and semen will eject from the penis. Males with premature ejaculation experience a sharper excitement and arousal phase in steps one and three, with a shorter plateau phase. 

Interestingly, experts have postulated that abnormalities causing premature dysfunction do not necessarily have to involve the orgasm phase; instead, they may affect the arousal phase leading to orgasm. In a stop-start stimulation exercise study (briefly stopping stimulation before the point of ejaculation) in men with premature ejaculation, most men could not finish the proposed exercise without ejaculating and usually did so before the fifth stimulation stop.²  Arousal tended to increase even when stimulation paused. The researchers even proposed a new conceptualisation of premature ejaculation as a progressive arousal disorder.

According to the leading theory of premature ejaculation development, Waldinger's theory, serotonin is the major neurotransmitter that inhibits the ejaculation reflex (the nerve signal triggering ejaculation). Thus, a low level of serotonin or a blunted response to the actions of serotonin might cause premature ejaculation. Other contributing biological factors include low testosterone, hyperthyroidism, neuropathy, alcoholism, and genetic predisposition. Men with diabetes, multiple sclerosis, or high blood pressure are at a greater risk of premature ejaculation.

Psychological factors also relate to the condition. Health professionals consistently note that many men with premature ejaculation have received various impulses in early life, such as conditioning, upbringing, or a traumatic sexual experience, that may have triggered the development of premature ejaculation. Other relevant psychological factors may include depression, anxiety, stress, guilt, narcissism, distorted thinking, lack of confidence, relationship problems, or unrealistic expectations about sexual performance.

Treatment options for premature ejaculation

Premature ejaculation can be treated effectively. Several treatment options are available, ranging from self-help techniques to medical interventions. Here are some common approaches:

1. Behavioural Techniques: Techniques such as the start-stop method and the squeeze technique may help individuals gain control over their ejaculation. These involve pausing sexual activity at the point of high arousal and applying pressure to the base of the penis to delay ejaculation.

2. Psychological Counselling: Therapy sessions with a qualified therapist or sexologist can help address any underlying psychological issues contributing to premature ejaculation. Counselling can also provide guidance on reducing anxiety, communicating with your sexual partner, and enhancing sexual confidence.

3. Topical Gel: Applying a topical anaesthetic to the penis before sex can dull sexual sensations and arousal, prolonging the time before ejaculation.

4. Medication: Certain selective serotonin reuptake inhibitors (SSRIs) have been approved to treat premature ejaculation. Taken up to a few hours before sexual activity, these medications increase serotonin levels in the brain and improve control of arousal and ejaculation.⁷

New treatments are frequently being studied and may become available in future. For example, a recent study demonstrated the possibility of treating lifelong premature ejaculation with a small battery-powered electrical device called a vPatch.⁸ This device attaches to the skin and electrically stimulates the perineum (the area between the anus and the scrotum) to contract the muscles responsible for ejaculation. But further research is necessary to determine the safety of this approach and whether it could truly make a difference in the lives of men with premature ejaculation.

If you show signs and symptoms of premature ejaculation, it’s important to seek further advice and support from your healthcare professional.  

More advice and resources on premature ejaculation visit BAUS

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References:

1. Rowland DL et al. Sex Med Rev. 2022;10(2):323-340.

2. Bustos PL et al. Sex Med. 2023;11(2): qfad014.

3. El-Hamd et al. Asian J Androl. 2019;21(5):425-432.

4. Laumann et al. Int J Impot Res. 2005;17(1):39-57.

5. Rosen RC & Althof S. J Sex Med. 2008;5(6):1296-307.

6. Gillman N & Gillman M. Med Sci (Basel). 2019;7(11):102.

7. McMahon CG. Clin Med Insights Reprod Health. 2011;5: 25–39

8. Shechter A et al. J Sex Med. 2023;20(1):22-29.