Portrait Dr. Birte Nachtwey

What is Premature ejaculation?

Premature ejaculation (PE) is ejaculation that occurs either before or shortly after penetration, in any case sooner than desired in the majority of sexual encounters, thus distressing at least one of the involved partners. Ejaculation can not be controlled very well.

If this is not perceived as distressing, there is no need for treatment. There are international classifications like the American DSM – 5 where the ejaculatory latency time needs to be before or under 1 minute after penetration and the symptoms must persist since at least 6 months in 75 – 100% of the attempts in order to be properly diagnosed.

At the beginning of their sexual activity in life, most men will have experienced lack of control. For some, this remains that way through their whole life (primary PE), some develop it later (secondary PE). Some men have generalised PE (always and also in masturbation), for some it is situative (only with a partner or under certain circumstances.

So if under 1 – 2 minutes is premature or rapid, what is the general geometric mean in different studies? It ranges between 5.4 and 8.5 minutes and seems to decrease with age for some. The way this was assessed, the criteria for inclusion in the study and other factors can cause deviation.

Only 2 out of 100 men could last longer than 30 minutes, which can also be unpleasant if this is not desired, meaning the lack of ability to come. This can also be unpleasant and undesired by the partner, so it is not a good idea to compare oneself with pornography takes that often do not reflect the real world and may give you a false image causing unnecessary performance pressure and self – expectations.

Premature ejaculation prevalence and common causes

The prevalence of PE has been assessed by numerous large studies worldwide. The range varies between 3 – 40%. This is partly due to differences in different regions and ethnic backgrounds, but largely also due to different criteria in definition. Some studies have used 1 minute (or 2 minutes) as a cut off point, others just asked open questions as self – assessment of subjective feeling like: „How often do you come too quickly?“, making it difficult to compare results.

Some large studies suggest that the overall median is around 29%, with Northern Europe being a bit lower at 20,7%, meaning that every 5th man has or had encountered this condition.

There are some biological causes like infections or inflammations of the prostate gland or urethra or conditions that would cause high levels of hormones or neurotransmitters. These can be outruled by a GP or Urologist.

There can also be underlying psychological causes. F.ex. if previous sexual experiences have led to fear, guilt or other negative conditions, this can create tension and hypervigilance. Performance pressure and fear of failure can diminish sexual self-confidence and lead to avoiding behavior. This leads to or is often influenced by relationship problems and can be a negative vicious cycle causing or aggravating the PE. Anger or distrust can play a role as well.

Very frequently, PE is associated with anxiety and/or stress, hence high activation of the sympathetic autonomous nervous system. This and a hyperactively contracting pelvic floor can trigger the ejaculation reflex.

Also, if you are struggling with Erectile Dysfunction and are facing difficulties to get or maintain an erection, you may develop a tendency to worry, stress yourself and rush to ejaculate.

PE can also be associated with a negative body image, poor self – perception of the body and point of no return during arousal. Arousal modes and patterns are not inborn, but learned, and some can enhance PE.

If you would like to read more about this, this link may be helpful:

Premature ejaculation Sexual Therapy

The are medical treatments for PE. SSRI (Selective – Serotonin – Reuptake – Inhibitors) are the most common one. Dapoxetine is approved for this use in men between 18 and 64 years, others are used „off label“, meaning they are not officially approved for PE. There are contraindications such as heart disease and other conditions, it can also interfere with other medications, so it is essential that it is prescribed and monitored by a GP or Urologist.

SSRI cause the levels of the neurotransmitter serotonin (a signal giver) in the brain to increase and are usually used as antidepressants or to treat obsessive – compulsive disorders or post traumatic stress syndromes.

The unwanted adverse effects they can have: loss of desire, erectile dysfunction and delayed ejaculation or anejaculation (no ejaculation at all), are used to delay the so called IELT (intravaginal ejaculatory latency time) on purpose in men with PE. This is also valid if intercourse is not with a vagina but anus or other body opening.

There have been large studies where 3 groups of men with PE got placebo (a pill with no active ingredient) or a lower (30mg) or higher dose (60mg) of Dapoxetine (Priligy) for 12 weeks. The geometric mean IELT was 0.8 minute before and 1.3 minutes after 12 weeks of taking placebo, 2.0 minutes with the lower dose (group 2), and 2.3 minutes with the higher dose (group 3).

The effect can be different in every individual, so some men gained more and some gained less time than that.

Almost one third of the men said they had gained better control over ejaculation in group 2 and 3 (1 out of 10 in the placebo group). Nearly 25%, 1 out of 4 men reported good or very good satisfaction in the placebo group, about 40% in the other two groups.

There were adverse effects reported by one third of the men in the placebo group (!!!), about half in group 2 and two thirds in group 3. The most common complains were nausea and dizziness.

This means in summary that treating PE with Dapoxetine is showing a longer IELT from just under 1 minute to 2 to 2,3 minutes which one third or more found beneficial. One forth saw an improvement without having been administered the drug. The rate of general adverse events was high, also in people who didn’t get the drug.

If this treatment is a desirable perspective for a man with PE is an individual decision. I have found that many do not find this very attractive, as it means that you are likely having to take a drug for life. If you stop, the effect is reversible.

Another medical treatment is the use of anaesthetic creams, gels or sprays containing f.ex. lidocaine, aiming to numb the skin of the penis a bit so the man feels less. There are studies showing that it can prolong the IELT, in a rather small study, some of the participants even reached average IELTs in combined use with a condom.

It is also a matter of preference if a man wants to numb his penis and prepare it with a cream or spray 20 – 30 min before intercourse.

Aside from drugs, there are well meant self – help advices like: „think about something that will turn you off“ or „masturbate a couple of hours before intercourse“ „interrupt stimulation and take breaks before you come (may be difficult to do if you come before penetration or very shortly after)“, „squeeze your glans penis hard“ , „try to contract your pelvic floor to hold back“ or wear a thick condom or several condoms.

Some of this may work for some men, I have not heard too many positive comments about this though. It doesn’t seem to lead to a satisfactory sex experience for many. Contracting your pelvic floor may even lead to the opposite result.

If you have read the text above (or even followed the link to the article) describing some of the causes of PE like a hyperarousal of the sympathetic autonomous nerve system, arousal patterns using hight muscular tension and little body self – perception, you may have already guessed that it is worthwhile to assess and evaluate the individual causes in more depth and find individual solutions, be it by learning to perceive and regulate yourself better, using different breathing techniques and movement instead of high static muscular tension and expanding your arousal mode, or resolving underlying conflicts in a relationship.

Therapy can mean to identify negative vicious cycles and influences and finding solutions. This often involves working through and with the body in sessions (always dressed and not with sexual arousal) and practicing yourself in-between sessions.

This may take weeks or months, so you need to be patient, do the exercises and talk about your experiences in the sessions so that the process can be built up step by step and change can slowly occur. The way your arousal system is conditioned at the beginning of therapy has been a data – motorway to the brain for decades, so it is important to realize that change will take time and consistency with practice to be able to establish improvement and new data – motorways.

Please contact me by email or phone for your first appointment.

Portrait Dr. Birte Nachtwey