Premature ejaculation is ejaculation that occurs sooner than desired, either before or shortly after penetration, causing distress to either one or both partners.
Overview: Premature ejaculation (PE) is a common sexual dysfunction that affects one in three men (of all ages) at some point in their lives. This article explores the very latest research (most published in 2020 or later) on what causes PE, how it is diagnosed, how it can affect relationships, and current and future treatment options.
What is Premature Ejaculation?
Definition: Premature ejaculation is ejaculation that occurs sooner than desired, either before or shortly after penetration, causing distress to either one or both partners. – American Urological Association
If you’ve ever felt embarrassed by premature ejaculation (PE), you may be surprised to learn that it’s a common problem; one in three men have dealt with PE at some time in their lives, according to Mayo Clinic. Premature ejaculation by the AUA definition happens to most men from time to time. In those cases, it’s nothing to worry about.
But if you’ve noticed that this definition is vague, you’re right. There have been many definitions of premature ejaculation over the years, but none had been based on clinical evidence until 2014, when the International Society for Sexual Medicine (ISSM) met to review the research. They developed the following definition:
- “Ejaculation that always or nearly always occurs prior to or within about 1 minute of vaginal penetration from the first sexual experience (lifelong premature ejaculation), OR a clinically significant reduction in latency time, often to about 3 minutes or less (acquired premature ejaculation);
- the inability to delay ejaculation on all or nearly all vaginal penetrations; and
- negative personal consequences, such as distress, bother, frustration, and/or the avoidance of sexual intimacy.”
The definition in the “Diagnostic and Statistical Manual of Mental Disorders” (DSM-V), is similar but more specific. It separates PE into mild (ejaculation in less than one minute of penetration), moderate (between 15 and 30 seconds), and severe (from 30-60 seconds).
The commonly accepted definitions of the term premature ejaculation all have three things in common. They involve:
- A short time from penetration to ejaculation
- A lack of control over orgasm and ejaculation
- Personal distress for one or both partners
(It’s important to note that all currently accepted definitions of premature ejaculation refer to sex involving a penis and a vagina. As of 2020, there is not enough research to make generalizations about gay men or other sexual practices.)
Now that we have a definition for premature ejaculation, the video below may cover some of your basic questions about PE.
How Erections Work
The biology behind erections is complex and involves the brain and the spinal cord as well as the genitals. The process begins in the brain with a stimulus that causes sexual arousal. The signal is then sent down the spinal cord to the genital area.
Normally, there is equal blood flow into and out of the penis. But when a man becomes sexually aroused, the penile arteries relax, allowing blood to rush into two spongy areas of the penis called the corpora cavernosa. In the process, the veins that would normally carry blood out of the penis are pinched closed, as is the urethral sphincter so the man can’t urinate with an erection.
The blood is then trapped in the penis, causing it to become engorged and producing an erection. After ejaculation, the blood flows back to the body, and the penis becomes flaccid again.
How Ejaculation Works
Ejaculation is also a complex process that involves several structures, but the prostate and testicles are the stars of the show.
The prostate makes most of the fluid that’s contained in semen. At the height of arousal, fluid is released from the prostate and other glands into the urethra. Sperm, which is made in the testicles, travels through a tube called the vas deferens and mixes with the fluids in the urethra.
The brain sends a signal through the spinal cord to the muscles at the base of the penis. These muscles then contract, about once every 0.8 seconds, forcing the semen through the urethra and out of the penis.
Understanding Male Arousal
So, what’s really going on here? Why are some men able to control the ejaculation process while others are not? The answer is not completely clear yet, but in order to understand what goes wrong when a man has premature ejaculation, it helps to know something about the male arousal response.
The first sexual arousal model was published by Masters and Johnson in “Human Sexual Response.” It includes four stages:
Excitement (also called the arousal stage)
During this phase, stimulation (such as a visual stimulus or foreplay) causes the penis to become partially or fully erect. The scrotum may tighten up, and the testicles draw closer to the body. You may gain and lose your erection several times during this phase.
During the plateau stage (the time you are actually having sex and prior to orgasm), the heart beats faster, blood circulation increases, and you may feel sweaty. You may make involuntary sounds as your sexual pleasure increases.
During the orgasm phase, the urethral sphincter closes so you will ejaculate and not urinate. You will start to feel the muscles at the base of your penis and possibly in your lower spine contract. The brain is flooded with feel-good chemicals, and you experience intense pleasure. At this point, most men will ejaculate, although it is possible to have an orgasm without it (called anejaculation).
In the resolution stage, the body relaxes and returns to its normal state. Most men feel deep relaxation and even a state of euphoria. Your erection will subside, and your circulation and breathing will return to normal. This phase normally includes a refractory period, a time of rest before a man can have another erection. The time involved is different for everyone. Sometimes there can be no refractory period at all before a man is ready for sex again, but this is not the norm. (However, for some men, Viagra can shorten the refractory period.)
Other Models of Male Sexual Arousal
There are other versions of sexual arousal as well; for example, in a six-phase model, the resolution and refractory stage is separated into two phases, and an emission stage is added. During emission, which happens after the plateau stage, the fluids that make up semen are mixed in the urethra, and a man may emit pre-ejaculatory fluid. The four-stage version is still the most commonly used model.
How Long ‘Should’ a Man Last in Bed?
All of this may make you wonder, so what’s normal? According to one study, the median average intravaginal ejaculatory latency time (IELT) — the time from penetration to orgasm — is only 5.4 minutes.
Surprised? The truth is that many men who believe they have PE may have IELTs that are pretty close to normal. In fact, the 5.4 minutes is a median, which means that half of men finish sooner than that and are still considered normal.
Men who do have PE, however, may have any one of four types.
Four Types of Premature Ejaculation
Until recently, researchers had described two types of premature ejaculation: lifelong and acquired. Men with lifelong premature ejaculation have symptoms from their very first orgasm. Acquired premature ejaculation is more common. This term refers to men who develop premature ejaculation after functioning normally for part of their lives.
More recently, researchers have identified two more types of PE: variable (in which PE only happens some of the time or in specific circumstances, such as with a new partner) and subjective (where IELTs may be normal or near-normal, but the man perceives that he ejaculates too soon).
Classification of Premature Ejaculation
|Lifelong PE||Acquired PE||Variable PE||Subjective PE|
|IELT||Very short (<1-1.5 min)||Short (<1.5-2 min)||Normal (3-8 min)||Normal or long (3-30 min)|
|Symptoms||Consistent||New onset of PE secondary to a known cause; history of normal examination earlier||Inconsistent||Subjective perception of full physical exam despite normal ejaculation|
|Cause||Neurobiological and genetic||Medical and/or psychological||Normal variation of sexual function||Psychological or cultural|
|Treatment||Medication with or without counseling||Medication with or without psychotherapy||Psychoeducation||Psychotherapy|
Most clinical research to date covers only the first two types of PE, lifelong and acquired. Many experts consider variable and subjective PE to be normal variants that don’t necessarily require treatment.
But why does it matter which type of PE a man might have? Because the type may determine which treatments would be most effective. (See Treatment below.)
The Effects of Premature Ejaculation
Premature ejaculation can have profound effects on a man’s self-confidence and self-esteem. A Journal of Urology study published in 2004, based on a questionnaire of men who self-identified as having premature ejaculation, found that men who felt they had PE had the following negative feelings about their sexual health and functioning:
|Concern||Men Who Probably Have Premature Ejaculation||Men Who|
Possibly Have Premature Ejaculation
Do Not Have Premature Ejaculation
|Poor control over ejaculation||49.7%||18.2%||1.4%|
|Low satisfaction with sexual intercourse||22.9%||13.3%||11.4%|
|Low satisfaction with sexual relationship||30.5%||23.4%||17.8%|
|Low interest in having intercourse||27.8%||31.0%||24.8%|
|Difficulty in becoming sexually aroused||34.4%||18.2%||19.8%|
|Difficulty relaxing during intercourse||30.9%||16.5%||7.7%|
Causes of Premature Ejaculation
Now that we know how male arousal works, let’s talk about what causes some men to “jump the gun.”
There are many reasons why a man doesn’t last as long as he’d like in bed. The earliest researchers felt that premature ejaculation was mainly a psychological disorder; men often heard, “It’s all in your head.” But after decades of research, we now know it’s not that simple.
It’s generally accepted today that acquired PE can have physical and psychological causes, while a combination of both is most likely. However, lifelong premature ejaculation is more likely to have a physical cause.
Elevated Serotonin: Of the physical causes, activity of serotonin receptors in the brain seems to be the most common. Serotonin is a neurotransmitter that serves a number of functions in the body, including mood regulation. It’s one of the “feel-good” chemicals responsible for the euphoric feeling you have during orgasm. Antidepressant medications called selective serotonin reuptake inhibitors (SSRIs) control depression by increasing the levels of serotonin available in the brain.
Because of this elevated serotonin activity, a common side effect of SSRIs is to delay orgasms by several minutes. For this reason, lower doses of SSRIs are often prescribed off-label for premature ejaculation. (See Treatment below). Unfortunately, the same action can also lower libido.
Other Physical Causes: A 2019 research review lists the following as other possible physical causes of PE:
- Endocrine disorders: Ddiabetes, thyroid dysfunction, low prolactin, low vitamin B12 levels
- Neurogenic disorders: multiple sclerosis, peripheral neuropathy, medullary expansion processes
- Drug-induced processes: amphetamine, cocaine, dopaminergic drugs
- Kidney disease: (chronic renal insufficiency)
- Low magnesium in semen
- Penile hypersensivity
- Other sexual dysfunction: erectile dysfunction, decreased libido
Other physical causes are less common. They include:
- Anogenital distance: This is a fairly newly discovered association. A 2020 study found that in men with premature ejaculation, the distance from scrotum to anus is slightly shorter on average (77.46 mm) than in men without PE (81.32 mm). Although the reason for this is not yet clear, it’s an area of ongoing study.
- Postorgasmic illness syndrome: This is a rare condition that causes men to become ill after orgasm. It’s sometimes associated with premature ejaculation, though researchers have not yet learned why.
- In rare instances, Inflammation of the prostate or an enlarged prostate.
Anxiety: Many providers still feel that psychological causes are the more likely reason for men to experience PE. Of the psychological possibilities, anxiety appears to be the most likely culprit.
Anxiety in PE can have many causes. It can take the form of performance anxiety, for example, anxiety over body image or past sexual history, even generalized anxiety. The good news is that behavioral or psychological treatments such as physical exercises and mindfulness can often restore normal ejaculation caused by anxiety. (See Treatment below.)
Other Psychological Causes: One study, which was newly updated in 2020, adds other psychological issues to this list:
- Unrealistic expectations
- Sexual abuse
- History of sexual repression
- Relationship issues
Can Low Testosterone Cause Premature Ejaculation?
But what about testosterone? We know that low T can cause low sex drive and erectile dysfunction. Its role is not as clear in PE, but here’s another surprise: A 2020 retroactive case study of 1076 men found that participants with PE had higher levels of testosterone than men without PE. This reinforced a 2008 study that came to a similar conclusion, but researchers are still working on clarifying the role of testosterone in all forms of sexual dysfunction.
Can Circumcision Cause Premature Ejaculation?
No, circumcision does not play a role in PE. According to a 2018 meta-analysis that reviewed 12 studies, a total of 10,019 circumcised and 11,570 uncircumcised men, circumcision has no effect on a man’s ability to control ejaculation.
Can Erectile Dysfunction Cause Premature Ejaculation?
Researchers have found a connection between ED and PE, meaning that many men have both. However, as of a 2020 study, we still don’t know why they often occur together. In fact, as discussed above, we know that low testosterone can contribute to ED, but men with PE often have elevated testosterone levels.
In cases where a man has both ED and PE, at least one study recommends treating the ED first. The November 2020 study noted above, however, recommends treating ED and PE as one disease entity. They note, though, that this study was done on younger men (age <40), so its recommendations may not be applicable to all men with both conditions.
Premature Ejaculation Diagnosis
Diagnosis is usually straightforward and based upon a man’s sexual history and self-report. Providers may or may not ask a man to have a physical exam. No lab or diagnostic tests are needed (unless a physical exam finds something suspicious).
Several questionnaires have been developed to determine whether a man has PE and/or ED. However, questionnaires aren’t always helpful in diagnosing PE because they often confuse the issue, especially for individuals who also have ED. Questionnaires are used primarily to identify participants for clinical trials.
In most cases, an individual’s sexual and relationship history is enough for a urologist or therapist to diagnosis PE.
Treatment for Premature Ejaculation
Treatment for premature ejaculation is imperfect because researchers don’t yet fully understand the causes. There are not yet a lot of studies of long-term treatment results, but the therapies listed here have been found to work for many men.
A 2019 study on treatment of acquired PE finds that treatment depends on the cause of the PE. Current treatment will often depend on which type of PE a man has — lifelong or acquired — but will usually include a combination of one or more of the following:
Psychological or Behavioral Therapy
Many men have been able to control their PE with the use of medications, but one study points out that no other treatment has been researched to the extent that medication has.
Still, while behavioral or psychological therapy can be helpful, therapy is not likely to do the job on its own. A 2019 study found behavioral or psychological therapy to have a high success rate of 65 percent short-term; however, long-term results are disappointing at only 25 percent.
Behavioral and psychological treatment, including relationship counseling and sex therapy, have been found to be more effective when combined with drug therapy or a topical anesthetic (such as benzocaine wipes). This therapy combination is often the most effective for acquired PE, which, again, is often caused by psychological rather than physical factors, and for variable and subjective PE.
A 2019 study review found all of the following treatment types to provide significant improvements of one to five minutes in intravaginal ejaculatory latency time.
SSRIs: A second 2019 randomized clinical trial found that selective serotonin reuptake inhibitors sertraline, fluoxetine, paroxetine, and citalopram are often helpful for PE.
Tricyclic antidepressants: These include both oral and nasal clomipramine. These drugs are usually prescribed when SSRIs don’t work.
Phosphodiesterase-5 inhibitors (PDE5-I’s) such as Viagra, Levitra, Cialis, etc. A 2020 study analysis found that PDE5 inhibitors can significantly improve premature ejaculation. Sildenafil (Viagra) appears to be the most studied PDE5 inhibitor. Although PDE5 inhibitors, including sildenafil and Levitra, are prescribed off-label for premature ejaculation (meaning they aren’t FDA-approved for that purpose), many studies have found it effective when used for PE and often even more effective when combined with an SSRI or topical anesthetic.
Opioid analgesic: Tramadol (Ultram). A randomized controlled trial done in 2020 found tramadol to be more effective than the SSRI paroxetine. Twice as many men with lifelong PE continued to have ejaculation difficulties after taking paroxetine (49.1 percent) compared with those taking tramadol (24.5 percent).
However, as an opioid, tramadol carries the risk of dependence. A December 2019 study found that in men who had developed dependence, tramadol caused erectile dysfunction (44 percent of participants) and decreased libido (48 percent) due to lowered testosterone and elevated prolactin. The risk for sexual dysfunction increased with increasing doses of tramadol.
Topical anesthetics: These include gels, creams, and sprays (usually with benzocaine or lidocaine as numbing agents) designed to decrease sensation to the penis. Some are available over-the-counter and others by prescription only.
NOTE: All drugs used for PE have side effects, which vary from one individual to another.
Condoms: Several condoms are available over-the-counter that are designed to prolong ejaculation. Some use a numbing agent, and others are made of thicker latex to reduce sensation. These can create loss of sensitivity for men and women, however, and some can cause irritation to women. You may need to try a few to find one that’s comfortable for both of you.
Dietary/herbal supplements: For men who might prefer a more natural approach, vitamins and minerals in certain foods may help improve sexual anxiety and stamina. A number of herbal supplements are also said to be effective for PE. Some have more evidence than others, so you’ll want to do your homework and speak to your doctor before choosing to try any of these.
A good source of information about supplements for PE is WebMD. You’ll find a list of supplements commonly used for PE, the strength of the evidence that they are helpful for premature ejaculation, and reviews by others who have tried them.
Of the 10 supplements reviewed on the site, four are considered to have insufficient evidence for treatment of premature ejaculation. The remaining six have more evidence and are rated “possibly effective” for treating PE:
Behavioral techniques and exercises for premature ejaculation: For those who would rather not take medication or supplements of any kind, there are several exercises that men with PE can use to gradually prolong ejaculation without medication or cost. According to WebMD, 95 percent of men with PE symptoms are helped with exercises such as the following:
- Pelvic floor muscle training: A 2019 study review concluded that Kegel exercises, also called pelvic floor muscle training, were effective for both PE and ED. The strength of the evidence was considered low to moderate overall, but in PE cases, pelvic floor muscle training was found to be curative in some studies. See the short video below from post-doctorate physiotherapist Michelle Kenway for an explanation of how to do Kegel exercises (or read more about them here).
- Sphincter control/pelvic floor muscle training with masturbation aid: A 2019 study found that an exercise program combining sphincter control training and a masturbation aid significantly increased the IELT of participants. There were meaningful differences between the group that tried the training alone compared to those who used sphincter training combined with a masturbation aid, as the following chart indicates.
- Penis root masturbation: PRM is a newly recognized exercise that is showing promising results in small studies such as one from 2019, in which PRM resulted in an increase in IELT from 60 seconds to 180 seconds, or 3 minutes.A study done in 2020 compared IELTs of men performing Kegel exercises with those of men who used PRM. The researchers found that IELT for Kegel exercises was approximately 1 minute, while those in the PRM group lasted approximately 5 minutes. Note that the number of men in each study was small, and the study authors cautioned that more research is needed to study the effectiveness of the PRM technique; however, early results are promising. See the study to learn how to perform penis root masturbation.
- Masturbating before sexual activity: This may be the simplest intervention of all. Many men find that if they masturbate to orgasm shortly before planned sexual activity, they will last longer with their partners. Those with supportive partners might try letting the partner bring them to orgasm manually before attempting intercourse following a rest period.
- Edging (start/stop method): In this technique, when the man gets close to orgasm, he stops sexual activity until the urge recedes, then begins again. This can be repeated until he can no longer hold back or chooses not to. A 2020 randomized controlled trial concluded that a modified start/stop technique using a vibrator is also an effective treatment for PE, decreasing levels of sexual distress, anxiety, and depression.
- Squeeze technique: Similar to edging, but when the man approaches orgasm, he or his partner squeezes just under the head of the penis until the urge is gone. This, too, can be repeated to both partners’ satisfaction.
- New sexual positions: Experiment with sexual positions. Many positions provide less sensation or penetration for the man, which may be just enough to allow him to last longer.
Surgery for Premature Ejaculation
While there are several surgical procedures performed for premature ejaculation in Asian countries (such as selective dorsal neurectomy and acellular dermal matrix implantation), there are currently no recommended surgical options for PE available in the U.S.
Counseling for Premature Ejaculation
Cognitive-behavioral therapy: Also known as CBT, cognitive-behavioral therapy is designed to reduce performance anxiety, the most common reason for acquired PE. CBT is a technique that trains men to change their thought processes and helps them to relax during sex, which can have a powerful effect on performance. A 2013 study found that CBT is effective in several ways when dealing with sexual dysfunction. In this study, cognitive-behavioral therapy was found to:
- Increase IELT
- Improve men’s sense of ejaculatory control
- Improve sexual satisfaction of men and their partners
- Increase sexual self-esteem
- Decrease sexual anxiety, depression, and fear
Couples counseling. Therapy can be a very effective way of dealing with premature ejaculation, particularly in acquired PE, where psychological causes are likely to be the root of premature ejaculation symptoms.
But does premature ejaculation affect all relationships? The answer to that question depends on who you ask.
A number of studies (summarized in a 2020 literature review) have shown that premature ejaculation (and other types of sexual dysfunction) can negatively impact men’s relationships with romantic partners.
A 2020 study of 1,779 Finnish women whose partners had PE symptoms found that these women were less satisfied with their relationships and reported “lower levels of arousal, orgasm, satisfaction, lubrication, and pain, but not desire.”
This is only one study of many that have found that partners of men with PE are less satisfied with their sex lives than those whose partners do not have PE.
However, according to an article in Australian Men’s Health, many women commenting about PE in online forums have stressed that premature ejaculation in a male partner is “not a big deal.” Sources of information (such as threads on Reddit or Quora) suggest that in some cases, a man can control how severely premature ejaculation will affect his relationship.
It’s important that men with PE understand that penis-vagina penetration is only one way to have a satisfying sexual relationship. A man can satisfy a sexual partner in other ways, including oral sex, total body massage, etc. In situations where a man takes the time to bring his partner to orgasm first, PE can have a less-detrimental effect on a relationship.
In other words, if you have PE, how badly premature ejaculation affects your relationship adversely can depend on you to some degree. Be open with your partner about the issue and take care of their needs in other ways, and you may be able to reduce the chances that PE will be a relationship deal-breaker.
Can Sex Therapy Cure Premature Ejaculation?
For couples who are seeking treatment, many experts recommend sex therapy for sexual dysfunction, including premature ejaculation, in a relationship. In situations where a man’s PE is caused by psychological factors, sex therapy can successfully reduce anxiety, negative body image, low self-confidence, and fear of negative results with attempts at sexual intercourse.
For men with regular sexual partners, at least one study found that when romantic partners are supportive, treatment is likely to be successful. The key here is to take care of your partner’s needs for mutually satisfying sexual encounters and have open conversations with your partner about taking steps to improve your PE symptoms.
Potential Future Treatments for Premature Ejaculation
If you find that none of the treatments outlined here work well for you, help might still be on its way, as research is ongoing on PE treatment. Here is a small sampling of therapies currently under study for PE treatment:
Transdermal sildenafil: A 2020 study detailed the successful development of a topical form of sildenafil (Viagra) applied directly to the penis. The authors claim a transdermal formulation may have fewer side effects than oral sildenafil, be more bioavailable, and would not require the wait time before sexual activity that’s required by the oral form of the drug. The study did not indicate when a topical formulation may be available.
Dapoxetine: Dapoxetine is an SSRI and the only drug that has been approved for the treatment of premature ejaculation. It is not yet available in the U.S., however, as of January 2021.
Transcutaneous electrical stimulation (TES): A 2020 “proof of concept” study of 23 men with lifelong PE tested a commercial neuromuscular electrical stimulation device applied to the perineum. Researchers found that 85 percent of the participants had a three-fold increase in time to orgasm compared to a control group. However, the study included a small sample of men, and further study is needed to learn if the treatment can be effective during intercourse.
The Bottom Line
Premature ejaculation can have a profound effect on a man’s self-esteem and quality of life. While in most cases, premature ejaculation is treatable, men are often unwilling to seek treatment. While PE symptoms often lead men to stop seeking romantic partners, currently available treatment options can often successfully treat premature ejaculation symptoms in men with acquired PE.
In cases of lifelong PE, identifying the reason for the premature ejaculation symptoms and seeking treatment for them can often cure premature ejaculation symptoms.
In either case, the research indicates that most men don’t have to suffer from premature ejaculation. In cases where the PE is not curable, more often than not, it is treatable. So, if you suffer from PE, the best thing you can do for yourself and/or your relationship is to take that first step.
Schedule an appointment with your primary care provider.
In the meantime, eDrugstore can help. We offer a premature ejaculation kit that can help you have successful sexual encounters. If you suffer from erectile dysfunction as well as premature ejaculation, see our lifestyle medication guide and take advantage of our free online consultation to order ED medications discreetly and with confidence.
You can have a better sex life. Contact us today to get started with a complimentary medical consultation with a U.S.-licensed physician.
Paula Clark worked in the healthcare industry for 17 years before becoming a full-time freelance health and medical writer. Her clients appreciate her ability to convey complex information in terms laypeople can understand. Paula prides herself on the depth and accuracy of her research. Her goal is to add authority to your site in words that will delight both Google and your readers.