psychology

Premature Ejaculation

Premature ejaculation (PE) is the most common sexual dysfunction in men younger than 40 years. Most professionals who treat premature ejaculation define this condition as the occurrence of ejaculation prior to the wishes of both sexual partners. This broad definition thus avoids specifying a precise duration for sexual relations and reaching a climax, which is variable and depends on many factors specific to the individuals engaging in intimate relations. An occasional instance of premature ejaculation might not be cause for concern, but, if the problem occurs with more than 50% of attempted sexual relations, a dysfunctional pattern usually exists for which treatment may be appropriate. To clarify, a male may reach climax after 8 minutes of sexual intercourse, but this is not premature ejaculation if his partner regularly climaxes in 5 minutes and both are satisfied with the timing. Another male might delay his ejaculation for a maximum of 20 minutes, yet he may consider this premature if his partner, even with foreplay, requires 35 minutes of stimulation before reaching climax. If intercourse is the method of sexual stimulation for the second example and the male climaxes after 20 minutes of intercourse and then loses his erection, satisfying his partner (at least with intercourse), who needs 35 minutes to climax, is impossible. Because many females are unable to reach climax at all with vaginal intercourse (no matter how prolonged), this situation may actually represent delayed orgasm for the female partner rather than premature ejaculation for the male; the problem can be either or both, depending on the point of view. This highlights the importance of obtaining a thorough sexual history from the patient (and preferably from the couple). The human sexual response can be divided into 3 phases: desire (libido), excitement (arousal), and orgasm. The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) classifies sexual disorders into 4 categories: (1) primary, (2) general medical condition–related, (3) substance-induced, and (4) not otherwise specified. Each of the 4 DSM-IV categories has disorders in all 3 sexual phases. Premature ejaculation may be primary or secondary. Primary applies to individuals who have had the condition since they became capable of functioning sexually (ie, postpuberty). Secondary indicates that the condition began in an individual who previously experienced an acceptable level of ejaculatory control, and, for unknown reasons, he began experiencing premature ejaculation later in life. With secondary premature ejaculation, the problem does not relate to a general medical disorder, and it is usually not related to substance inducement, although, rarely, hyperexcitability might relate to a psychotropic drug and resolves when the drug is withdrawn. Premature ejaculation fits best into the category of not otherwise specified because no one really knows what causes it, although psychological factors are suggested in most cases. Pathophysiology Premature ejaculation is believed to be a psychological problem and does not represent any known organic disease involving the male reproductive tract or any known lesions in the brain or nervous system. The organ systems directly affected by premature ejaculation include the male reproductive tract (ie, penis, prostate, seminal vesicles, testicles, and their appendages), the portions of the central and peripheral nervous system controlling the male reproductive tract, and the reproductive organ systems of the sexual partner (for the purpose of this discussion, the partner is assumed to be female) that may not be stimulated sufficiently to achieve orgasm.If the premature ejaculation occurs so early that it happens before commencement of sexual intercourse and the couple is attempting pregnancy, then pregnancy is impossible to achieve unless artificial insemination is used. Perhaps the most affected organ system is the psyche of the partners. Both partners are likely to be dissatisfied emotionally and physically by this problem. Premature ejaculation has historically been considered a psychological disorder. One theory is that males are conditioned by societal pressures to reach climax in a short time because of fear of discovery when masturbating as teenagers or during early sexual experiences "in the back seat of the car" or with a prostitute. This pattern of rapid attainment of sexual release is difficult to change in marital or long-term relationships. The fact that female arousal and orgasm require more time than male arousal is being increasingly recognized, and this may result in increased recognition and definition of premature ejaculation as a problem. Some have questioned whether premature ejaculation is purely psychological. A number of investigators have found differences in nerve conduction/latency times and hormonal differences in men who experience premature ejaculation compared with individuals who do not. The theory is that some men have hyperexcitability or oversensitivity of their genitalia, thus preventing down-regulation of their sympathetic pathways and delay of orgasm. One might find some logical sense, from an evolutionary point of view, that males who can ejaculate rapidly would be more likely to succeed in fertilizing a female than males who require prolonged stimulation to reach climax. (This applies to prehistoric evolutionary development; little, if any, human evolution has occurred over the last 5000 y.) The genes of a person who ejaculates rapidly (but not so rapidly that ejaculation occurs before intromission) would be more likely to be passed on to succeeding generations. The male who does not complete the fertilizing process quickly might be pushed away or killed by a competing male because of his obvious vulnerability during intercourse. Frequency United States The prevalence rate of premature ejaculation in American males is estimated to range from 30-70%. The National Health and Social Life Survey (NHSLS) indicates a prevalence of 30%, which is fairly steady through all adult age categories. (In contrast, erectile dysfunction [ED] rises in prevalence with increasing age). However, various surveys have shown that many men do not report premature ejaculation to their physician. This may be because of embarrassment or a feeling that no treatment is available for the problem. Some men might not even perceive premature ejaculation as a medical problem. Such survey data suggest that the percentage of men who experience premature ejaculation at some point in their lives is almost certainly more than the 30% reported in the NHSLS. International Estimates for European countries and India mirror the prevalence in the United States. The prevalence in other parts of Asia, Africa, Australia, and elsewhere is unknown. Mortality/Morbidity No known direct morbidity or mortality results from premature ejaculation. Indirectly, premature ejaculation may alter self-esteem, cause marital dysfunction, and may be a factor in depression with its obvious consequences. Race Although no reproducible data exist on major differences between racial groups with respect to the incidence or prevalence of premature ejaculation, a few recent surveys suggest that some racial variation may exist with respect to this condition. One recent telephone survey (Carson and associates) found in interviews of 1320 men without ED that 21% of non-Hispanic African Americans reported premature ejaculation, while 29% of Hispanics and 16% of non-Hispanic whites reported premature ejaculation. An analysis by Laumann et al of the NHSLS found that premature ejaculation was more prevalent among African American men (34%) and white men (29%) than among Hispanic men (27%). However, drawing firm conclusions from these data is difficult in view of the small number of such studies and lack of suitable controls. Sex Premature ejaculation is a condition that only affects males. Age Premature ejaculation can occur at virtually any age in an adult man's life. As a reported condition, it is most common in younger men (aged 18-30 y) but may also occur in conjunction with secondary impotence in men aged 45-65 years. <<<< back