Premature Ejaculation

All the information on the causes, symptoms, and most effective treatments for the expulsion of semen earlier than desired.

Symptoms and Causes

Premature ejaculation is one of the most common sexual dysfunctions in men. It occurs when orgasm is reached and semen is expelled earlier than desired, that is, before penetration or shortly thereafter. These patients progress rapidly from arousal to climax, with an almost nonexistent plateau phase (maximum excitation before orgasm).

There are three types of premature ejaculation, depending on how it presents:

Primary premature ejaculation: present from the onset of sexual activity.
Secondary or acquired premature ejaculation: develops after previously having normal sexual intercourse.
Naturally variable premature ejaculation: periods of normal-duration sexual intercourse alternate with others that are shorter than expected. This is considered a normal sexual pattern.

The incidence of premature ejaculation is high, as it is estimated to affect approximately 20–25% of men at some point in their lives. When it is naturally variable, it resolves spontaneously without causing sequelae, although it may recur over time. If it presents recurrently, whether primary or secondary, it can be reversed with appropriate treatment.

Symptoms

A patient is considered to have premature ejaculation if all of the following symptoms are present:

Intravaginal ejaculatory latency time (IELT) of less than three minutes: ejaculation occurs before penetration or within one to three minutes after intercourse.
Inability to delay ejaculation almost always or always.
Avoidance of sexual contact because ejaculating earlier than expected causes feelings of frustration or shame.

Causes

Premature ejaculation is due to a lack of control over the ejaculatory reflex, which may occur for various reasons:

Psychological causes:

Early sexual experiences.
Sexual abuse.
Performance anxiety: concern about not meeting expectations or reaching orgasm too early.
Excessive consumption of pornography, as it creates unrealistic expectations and generates performance anxiety.
Depression.
Anxiety.
Low self-esteem.
Interpersonal relationship problems.
Couple conflicts.

Biological causes:

Hormonal imbalances: usually due to low testosterone levels.
Abnormal levels of brain chemicals: abnormal quantities of neurotransmitters can affect ejaculation:

Low serotonin levels.
High oxytocin levels.
Imbalance between dopamine and acetylcholine.

Prostatitis: inflammation and irritation of the prostate.
Urethritis: inflammation of the urethra.
Glans hypersensitivity.
Hereditary factors: abnormalities of the 5-HTT gene, which is responsible for serotonin transport, affect ejaculation. The functional polymorphism of this gene (5-HTTLPR) has two alleles: L (long variant) and S (short variant). Genotypes composed of these alleles may be LL, SS, or SL. Studies show that men with the LL allele have a higher probability of experiencing premature ejaculation, as it captures more serotonin.

Erectile dysfunction: concern about achieving or maintaining an erection may promote a tendency toward rapid ejaculation.
Use of illicit substances.

Risk Factors

Factors that increase the risk of premature ejaculation are closely related to its causes. The most notable include:

Erectile dysfunction: inability to achieve an erection or difficulty maintaining it long enough for satisfactory sexual intercourse.
Stress: emotional tension directly affects the ability to relax and, consequently, to engage in sexual activity.
Genetic predisposition.

Complications

The main complication of premature ejaculation is the inability to maintain satisfactory sexual relationships, both for the patient and for their partner. As a result, it often leads to difficulties with conception and relationship problems.

Prevention

To prevent premature ejaculation, although this is not always possible, the following measures are recommended:

Manage stress and anxiety.
Take care of the couple’s relationship.
Avoid alcohol and drug consumption.
Maintain realistic expectations regarding sexual relationships.
Avoid excessive consumption of pornography and, when consumed, be aware of how it differs from real-life sexual relationships.

Which physician treats premature ejaculation?

Premature ejaculation is diagnosed and treated collaboratively within the specialties of urology and clinical psychology.

Diagnosis

The diagnosis of premature ejaculation is primarily clinical, as it focuses on the assessment of symptoms. The following procedures are commonly used during the diagnostic process:

Medical history: collection of information on the patient’s medical background, lifestyle, health status, and perceived symptoms.
Standardized questionnaires: used for the patient to answer a series of questions that are evaluated in a standardized manner.
Blood tests: performed to detect possible hormonal abnormalities and determine the cause of premature ejaculation.
Psychological evaluation: assessment of the patient’s mental health to determine whether the cause is emotional.
Urological examination: physical examination to detect possible abnormalities, such as prostate enlargement or urethral inflammation.
Imaging studies: ultrasound or magnetic resonance imaging (MRI) to obtain more detailed images if the physical examination is inconclusive.

Treatment

The treatment of premature ejaculation usually combines several approaches to achieve the desired outcome. The most common include:

Pharmacological treatment: may be administered in different forms:

Topical medication: contains lidocaine and prilocaine, two anesthetics that, when used together, block nerve signals and increase intravaginal ejaculatory latency time. Cream formulations should be applied twenty minutes before sexual intercourse, whereas spray medications are used five minutes beforehand.
Oral medication: taken in tablet form:

Dapoxetine: a selective serotonin reuptake inhibitor (SSRI) that helps increase IELT.
Phosphodiesterase type 5 inhibitors (PDE5 inhibitors): increase patient confidence, thereby providing greater perceived control over ejaculation. They also enhance the ability to achieve a second erection after ejaculation.

Use of condoms: by reducing penile sensitivity, some patients are able to delay ejaculation.
Behavioral therapy: helps patients become aware of the psychological factors causing premature ejaculation. Once identified, relaxation techniques and stress- and anxiety-management strategies during sexual activity are practiced.
Ejaculatory control exercises: aimed at strengthening the muscles involved in ejaculatory control.

The most common is the "start–stop" technique, which involves beginning sexual stimulation and stopping just before reaching climax. The process is repeated several times before allowing ejaculation.
In the "stop–squeeze" technique, penile stimulation continues until ejaculation is imminent, at which point the tip of the penis is compressed to reduce urgency.
Kegel exercises help strengthen the pelvic floor, as it is difficult to delay ejaculation when muscle weakness is present. To perform them correctly, the patient should simulate stopping urination, hold the contraction for a few seconds, and repeat the exercise ten times consecutively.

Couples therapy: open communication without taboos helps reduce shame, fear, and frustration. Transparent dialogue increases trust between partners and promotes mutual support, which is essential for eliminating the psychological factors that contribute to premature ejaculation.