Premature Ejaculation: A Urologist’s Perspective

Hello, my name is Dr. Sriram Eleswarapu, and I’m a urologist at the Men’s Clinic at UCLA, which is a comprehensive center for men’s sexual health, infertility, low testosterone, and other issues. I’m also an Assistant Clinical Professor of Urology at the UCLA Department of Urology. Today I’ll be talking about premature ejaculation. At any time, feel free to ask questions on Twitter using the hashtag #UCLAMDChat, and to start, let’s talk about the motivation for today’s talk. So, premature ejaculation is a common condition. It’s difficult to talk openly about it, particularly with a doctor, but this is something that I hear about on a daily basis as a urologist, and so it came to my attention that we need to have some better information out there. There’s tons of information available on the internet. You can find tons of stuff on YouTube, Twitter, Reddit, and a number of other social media elements, but we don’t know whether that online information is reliable, what’s real and what’s not so real. If you ask 10 people, you’ll get 10 responses. As a urologist with a special focus in male reproductive and sexual health, my interest and my goal is to provide some clarity to the condition and maybe give you some advice on what you can try. Today we’ll talk about a few things. First, we’ll start with definitions–definitions are key. What is premature ejaculation? What’s normal ejaculation? How common is premature ejaculation? How do I, as a urologist, diagnose PE, and what’s my approach to treating men who have PE? And then we’ll talk about why you might want to see a urologist. So what is ejaculation? There are four stages of the sexual response: desire, arousal, orgasm, and then resolution. As you get increasing levels of sexual arousal, you reach a threshold at which you trigger an injector, a response which usually terminates the sexual experience. Ejaculation, I like to think of as three different distinct elements: emission, expulsion, and orgasm. Emission and expulsion are a spinal cord reflex, and I’ll go into what those two words mean in a moment, whereas orgasm is the pleasurable response that occurs in the brain in response to emission and ejaculation. They all happen nearly instantaneously. You don’t–as an individual experiencing orgasm, you don’t distinguish between the three, but I like to distinguish between the three because they are three individualized components of response. So let’s just go through a brief anatomy lesson of ejaculation. Here, you see a cross-section of a spinal cord, and you see some sort of input nerve, and some form of an output nerve or an efferent nerve. So with any kind of stimulus, any reflex stimulus, whether it’s tickling the eye and blinking, or tapping you on the knee and kicking, or ejaculation, there’s some stimulus that, in this case, occurs at the skin level, and that travels into the spinal cord, and then immediately there’s a reflex response that travels out to the structures that are innervated by that particular response, in this case the seminal vesicles and the organs that produce an ejaculate. Looking at that in terms of the anatomy of the pelvis, you see some important structures here, and I’d like you to draw your attention to this area right here. Here you have the bladder, of course. This is the penis. This is the testicle. But in terms of ejaculation and orgasm, emission occurs when the seminal vesicle, where the semen is stored and produced, begins to kick out some of that fluid into the ejaculatory ducts. So that is emission, and that is a spinal cord reflex. And then the other spinal cord reflex is ejection, or expulsion, and that occurs with the muscles in the pelvis, the muscles in the urethra, as well as some deep muscles behind the prostate and underneath the prostate to push out that ejaculate. So those two things, again, spinal cord reflexes, and those spinal cord reflexes are dependent upon a few different things, but in particular, serotonin. So you’ll hear me coming back to serotonin later in the talk, but serotonin is this kind of master neurotransmitter, this chemical throughout the body that regulates different things, but in particular, it’s important for ejaculation. How do we define premature ejaculation? There have been many different definitions over the last 40-50 years, and these definitions have been proposed, they’ve been used, and then they’ve been discarded. Different neurologists would use different terminologies, different definitions. More recently, about 6-7 years ago, the International Society for Sexual Medicine convened a panel to define this to provide some commonality, some structure, to the definition, and the definition consists of three parts. They characterize premature ejaculation as male sexual dysfunction characterized by 1) Ejaculation that always or nearly always occurs before or within approximately one minute of vaginal penetration, which we call lifelong PE, or a clinically significant or bothersome reduction in intravaginal ejaculatory latency time, often to approximately 3 minutes or less– that’s what we call acquired PE, or acquired premature ejaculation. So drawing attention to those particular distinct elements and the intravaginal ejaculatory latency time, we define things as an IELT, an intravaginal ejaculatory latency time, of either less than 1 minute or less than 3 minutes. Now, there are a few things to kind of break down in the verbiage of this discussion. Number one, you’ll notice that there’s a lot of hemming and hawing, there’s quite a bit of variability here. They say “always or nearly always,” they say “within approximately,” you know, they say “approximately three minutes or less,” so of course, there’s some room for error here. It’s not a defined, definitive thing. There’s always some room for a little bit of interpretation when you come to see the doctor. The other thing is that this definition presupposes vaginal penetration as the predominant way of sexual intercourse for a particular man. Now, we do know–and I see all the time–men who do not have vaginal penetrative intercourse. I see men who have sex with other men, men who have sex with women but don’t have vaginal penetration, and so in those men there is, again, some room for interpretation in molding this definition to an individualized treatment. The 2nd component of the definition is that there’s an inability to delay ejaculation on all or nearly all vaginal penetration. So it’s not enough to just have the first component. You also have to be trying to delay things, and you’re not able to, and then the 3rd part is that you have a negative clinical personal consequence, such as distress or bother or frustration, annoyance, and you may even be avoiding sexual intimacy with a partner because of this condition. So again, the types of premature ejaculation–there are two–there’s life-long and there’s acquired, as we discussed, but there’s also two others, variable and subjective. So, variable–going back, variable premature ejaculation are men who have normal ejaculations, they don’t have any issue with premature ejaculation normally, but then on occasion they have these episodes of premature ejaculation, and that’s within the normal variation. Subjective premature ejaculation is men who perceive they have premature ejaculation, but in fact they don’t, so these are men who have IELTs of 15-20 minutes, but for them they feel that it’s not long enough. So variable and subjective PE are largely situational, and they can be affected by stressors, performance anxiety, relationship factors, hormones, erectile dysfunction, and those are important things to assess, but those don’t meet the criteria of lifelong or acquired PE. How common is this condition, and what is normal? So there have been numerous stopwatch studies ver the last 50-60 years, and these are literally studies with a stopwatch, where a man and a woman will be having sex, and immediately on penetration, they hit the button, and then immediately when they orgasm, they hit the button, and they calculate an IELT. On these numerous different studies, there’s anywhere from 4% to 40% of men who have premature ejaculation. So there’s a large variability in these studies. There’s also a variation between what we do with a stopwatch and what we see with a man who comes in and reports a particular problem in general. As a urologist, I’m more interested in what the man experiences than, you know, the stopwatch event. If I can make your sexual life better, that’s my goal. So, you know, take that with a grain of salt in terms of the actual timings and what’s normal. The median across these studies is about 5 1/2 minutes. The range is anywhere from 30 seconds to 45 minutes, and we do know that IELT decreases with age. So if you have a 20 minute IELT, and then, you know, you hit age 50 or 60, and you start to see that number decline, you start to last only 5 minutes, that is expected with aging. So that’s not pathology, necessarily; that’s just you getting older, and this is just a pictorial representation of that distribution. So most men fall in this 200-300 second range, so about 5 minutes, but there are men who perform out to longer periods of time. So, again, variability. There are a number of different causes of premature ejaculation. In terms of the lifelong PE, we tend to explain this by variations in the sensitivity of the serotonin receptor and the interaction between serotonin, that neurotransmitter, and one’s receptors in the nerves that are the spinal cord reflex, and that’s a biological cause. There are, of course, other components to it, there are behavioral components, but we do tend to lean towards the biological cause for acquired PE. Again, there’s a biological cause, of course, but there are some other things that can impact one man’s experience with his premature ejaculation, including anxiety in sexual performance, psychological or relationship concerns, ED, prostatitis, which is inflammation of the area around the prostate, thyroid conditions, any kind of withdrawal for medications or even recreational drugs, as well as metabolic syndrome. So we do see with men who have elevated cholesterol or diabetes or obesity and other factors, these things are comorbid conditions that can precipitate as premature ejaculation or even erectile dysfunction. In terms of the evaluation, like I said before, a lot of it is patient self-report. I want to see you come to my office and tell me that you’ve got a problem. I asked for it in men who don’t come specifically for this problem, but if you’re coming to me, we’ll talk about, you know, what your experience is, how long you last, and then what is your level of bother? Is this something that bothers you every day, or is it something that bothers you, you know, once in a while? There are some important questions that we will discuss in the office visit and that you should discuss with whomever you’re seeing, if you’re seeing a doctor for this condition. What is the time between penetration and ejaculation? Can you delay your ejaculation? Do you feel bothered or annoyed or frustrated? Has this problem been present since your very first sexual experience, or is it something that’s more recent? Is your erection hard enough to penetrate? Do you have difficulty maintaining that erection to the end of sex? Do you have to rush intercourse to make sure that you ejaculate before you lose your erection? And how upset is your partner with your premature ejaculation? Because that’s the relationship component of things. Have you received any kind of previous treatment for PE? We also focus on a discussion of these other comorbid conditions, like I talked about, obesity, diabetes, cholesterol issues, etc. And sometimes we’ll do blood tests to evaluate possible medical causes and maybe treat those to see if we can get a response. In terms of treatment, I start with the simple stuff, and then we’ll talk about some medications and things that I prescribed, and then I’ll close out by discussing some of the experimental therapies and maybe natural remedies that you hear about online. In terms of physical fitness, we have multiple studies that have shown that weight loss and improved cardiovascular fitness, particularly in men with metabolic syndrome, can impact and improve premature ejaculation as well as erectile dysfunction. In terms of cardiovascular exercise, getting the blood flowing, you want to do this at least 3 times per week for at least 30 minutes at a time. You want to be sweating, you want to be panting, you want your heart rate to go up. That means that you’re having a good experience of exercise that’s going to have an impact on your overall health. If you’re just taking a leisurely stroll once or two times a week, that’s not sufficient to see an improvement in your sexual function. Sex therapy is a huge component of any kind of individualized treatment paradigm for premature ejaculations. So, this can take the form of individual counseling or couples counseling, it can help to expand the sexual repertoire, open things up for discussion, bring things out into the open so that you’re not hiding with a condition that really bothers you. This also helps to develop strategies to address avoidance of sexual activities. So, if you have premature ejaculation, we know that you’re more likely to avoid sexual encounters, be afraid of them, and so you could develop different strategies, talk therapy and other things to address that avoidance. It’s particularly useful in men with acquired premature ejaculation, and it can be a component of a larger paradigm of treatment, including medications or topical therapies, etc. So it’s not the only thing that we might do. There are other things, and we’ll go over those other things, but it is a nice backbone if you are interested in giving it a try. In terms of behavioral therapy–this is different from psychotherapy–behavioral therapy is what you can do to improve things. So there are a couple of different methods that were described in literature 50-60 years ago, including the start-stop technique, or what we call edging nowadays on the internet. This is where you stimulate the penis until you feel the urge to ejaculate, and then you let that feeling subside–you pause, you let it subside, and then you repeat the process, and the idea behind this in masturbating or in partner stimulation is that you’re retraining that spinal cord reflex, and you can. It is successful. There was also the squeeze method, which was described by Masters and Johnson, this is where you take yourself up to the point of almost reaching that threshold, and then you squeeze the head of the penis, the glans, to dissipate that effect. It’s almost–it’s not quite painful or anything, but you are kind of rerouting, or abruptly stopping, your sexual encounter in that fashion. Very similar techniques in terms of their effectiveness, and we do see a short-term response. Anywhere from 90% to 95% of guys will see some response. Whether it’s enough to make them happy, that’s a different question. The thing about this is that it is generally a short-term response. So if you have acquired PE, or even lifelong PE, you kind of retrain yourself. You might end up having to do it again later on down the line. So, just know that. There are topical anesthetics, topical agents. We’ve seen multiple studies that show that men who have premature ejaculation have a lower baseline sensory nerve threshold in the penis, and the idea here is that we can maybe mask that sensory input with local anesthetics to increase your IELT. Everybody’s a little bit different, so it may not work for you, but these are pretty cheap and available over-the-counter. There’s creams, there’s sprays. I like to suggest a spray to some of my patients. The thing you have to caution yourself with these sprays is that they can rub off on your partner and cause some degree of diminished sensation in your partner if you don’t give it enough time to absorb and dry up. So, be mindful of that. The other thing is that if you have erectile dysfunction as well, then you likely won’t see a response with the sprays. So you have to have a good, rigid erection to be able to see an effect with the sprays. There’s also antidepressant medications, which take 2 flavors in the treatment of men with PE. So, there’s SSRIs and tricyclic antidepressants. So, antidepressant medication is off-label use, it’s not approved by the FDA for premature ejaculation, but we use it all the time as urologists, pretty safely, at low doses. These are based on the role of the serotonin receptor, as I talked about before, in mediating that ejaculatory response. It can be used daily, or it can be used on demand. We see better effects with daily dosing at a low daily dose. It usually takes about 2-3 weeks to take an effect and see a response, so you have to be patient. And then after about 6-8 weeks, we can start to wean off the medication, if that’s something that we both, as a doctor and as the patient, you’re interested in. And these are some of the names: paroxetine, sertraline, fluoxetine are the SSRIs. Clomipramine is the tricyclic that we tend to rely on. Generally speaking, I’m prescribing mostly paroxetine, a few of the others, and of course, these do have side effects, so it’s important that you know that. In terms of erectile dysfunction medications, we know that men who have concomitant ED and premature ejaculation should have the ED treated first, and the way I like to think about this is, if you have erectile dysfunction, it’s your sort of evolutionary or biological imperative to reproduce, and so if you are not having as rigid an erection, your body, your mind thinks that you need to ejaculate as soon as possible before you lose your erection. So if we correct that, if we restore your erectile function with Viagra or Cialis or one of the other medications like Stendra or Levitra, then we can eliminate the PE by getting you rigid enough. But also, in men who have normal erectile function and premature ejaculation, now, you can use these medications in an off-label fashion to see if we can improve the IELT, and, in fact, that’s what the studies show, that we do see some impact on premature ejaculation just with–even in men who have normal erectile function. These can be taken again daily or on-demand, depending on the individual, and we often combine these with SSRIs. So, there have been clinical studies, controlled trials, that have shown that a combination of an SSRI with an ED medication can improve an IELT. Again, these also have side effects, and when I talk about side effects, this is very individualized, and so this is dependent upon a patient’s overall health, their tolerance of other medications, and we work with you on an individual basis to optimize things. Tramadol is another medication that we occasionally use. This is an opioid medication, so I don’t like to use it for everybody, but in certain individuals, it can be effective. It has a reactivity with the serotonin receptor, again, kind of getting back to that same theme. This is not FDA-approved for premature ejaculation, and in some municipalities and states, you can get into a lot of trouble trying to get this medication if you don’t have actual pain that’s documented. So, opioid medication–but it can be effective as an on-demand medication. It does, of course, have side effects, and then there’s alpha blockers. Alpha blockers are used in men, generally speaking, for urinary symptoms. Guys who have bigger prostates have difficulty peeing at night, for example. But we do know that these medications work by reducing sort of that emission threshold, or raising the emission threshold and reducing the amount of actual fluid that gets kicked out into the ejaculate, and so by doing that, there’s some theory that it can affect you, can affect or help with premature ejaculation. I don’t often use this for premature ejaculation. I use it mainly for men with urinary symptoms or prostatitis who may also have premature ejaculation, and sometimes it will have an effect on the sexual aspect of things as well. In terms of alternative options and experimental therapies, a lot of patients will ask me about physical therapy, pelvic floor physical therapy, and I love pelvic floor physical therapy. I really like to prescribe it to patients who have history of pelvic floor dysfunction, trauma, urinary symptoms, prostatitis, pelvic pain. All those things respond really well to PFPT, or pelvic floor physical therapy. Premature ejaculation–the data is still out on that. But if you have one of those other conditions and premature ejaculation, this is a great option for you to start out with. In terms of acupuncture, there’s emerging data on its effectiveness for different conditions, including premature ejaculation. I’m very interested in seeing what that data will show eventually. It can’t hurt. It certainly might help. So if that’s something you want to try, absolutely. Yoga–yoga is excellent for physical fitness. Good for stretching of the pelvic floor. We do know that men who perform yoga on a regular basis have very strong, relaxed pelvic floors, and that might help with the ejaculatory response, although I don’t have the data on that. In terms of surgical or procedural options like circumcision or Botox or penile nerve surgery, for circumcision, there’s no conclusion that circumcision helps with premature ejaculation. So if you’re interested in circumcision, that’s mainly for medical reasons or cosmetic reasons, not so much for premature ejaculation. Botox–it’s only been studied in animals for this purpose–for premature ejaculation. There’s some good evidence that it might help, but it hasn’t been used in humans yet. So stay tuned, we’ll see. In terms of penile nerve surgery, again, not a whole lot of conclusive evidence one way or the other. It’s not something I offer to patients unless there’s some sort of trauma or something in the history that requires a surgical intervention. In summary, premature ejaculation has a very specific definition. It’s common. It’s under-recognized. The diagnosis involves a thorough discussion of both a medical history and a sexual history, and there are a wide variety of treatments, as I described, and a urologist can really help to come up with an individualized plan for you. So, thank you for listening. And at this point, I’ll take any questions on Twitter at the #UCLAMDChat hashtag. So, we already have a couple of questions here. First question is “What is the contribution of low T–low testosterone?” So we do know that there is, in addition to the serotonin or nervous system component or reflex component of ejaculation, there is also a hormonal component. So, low testosterone can impact the ejaculatory response. In some men, low testosterone will delay orgasm, and in other men, low testosterone will contribute to premature ejaculation. If a man comes to me with ejaculatory symptoms of any sort or erectile symptoms, I will check a testosterone level along with a few other things, including the estrogen level, maybe even the pituitary gland hormones in the brain, to see whether there might be a hormonal contribution, and then treat those things if we need to. I have another question, a very good question. “What is the contribution of stress to premature ejaculation?” So, we do know that stress absolutely causes an effect on sexual function. It does that through a number of different systems in the body. So, people like to talk about mind-body, that it’s all in your head or whatever. It really isn’t just in your head. So, stress– stress actually has a physiologic mechanism that drives up the adrenal glands to produce adrenaline or epinephrine and other mediators like cortisol, and those things can affect the brain, affect the spinal cord, so stress reduction, mindfulness–these are things that are very important. “Do Kegel exercises help PE conditions?” So, the data are mixed on this, and that’s going back to the pelvic floor physical therapy. It’s something that you can actually try yourself since it’s easy and cheap, and if free, you could try Kegel exercises. Generally, Kegel exercises, in my practice, I prescribe to men with urinary symptoms who happen to have had surgery on the pelvis, whether it’s a prostatectomy or a colorectal surgery, and then they have eretile dysfunction or ejaculatory dysfunction. So, Kegel exercises–what those are, are basically contractions of the pelvic floor muscles. The way that I kind of teach a guy to do Kegel exercises is, I tell them, you know, the next time you go to the bathroom and you try to pee, you’re standing there and you’re trying to pee, try to interrupt your stream and it’s that muscle where you stop your stream. That’s the muscle you’re trying to hone in on. You can try it. I don’t know that it’s going to help a whole lot with ejaculatory dysfunction or premature ejaculation, but if you have concomitant prostate related symptoms or urinary tract symptoms, it might help with those and thereby maybe have an effect on your ejaculation. Looks like we’re we’re done with questions, so I think– as always, I’m available and and other urologists are available. Thank you for listening, and I hope to see you soon if you need me. Take care.

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