Article topic: Premature and Delayed Ejaculation
Authors: Michel Alagha, Linda Elias, Karmen Saroufine
Editor: Lubna AL-Rawabdeh
Reviewer: Ethar Hazaimeh
Keywords: Premature ejaculation, delayed ejaculation, diagnosis, treatment, factors, causes.
Ejaculation is the release of semen, which consists of sperm and seminal plasm, from the male reproductive system . One of the most common sexual problems in men is ejaculation disorder. Two contrary complications are delayed and premature ejaculation [1-2, 5-14].
Delayed ejaculation (DE) is a sexual dysfunction described as men having difficulty ejaculating during sexual intercourse [2,6,8]. Ninety percent of men with DE mark a failure, rather than a delay, of ejaculation during intercourse. Medications used to treat other conditions, like depression, anxiety, or prostate symptoms may produce symptoms similar to those of delayed ejaculation. Many patients are misdiagnosed with erectile dysfunction, where a rigid erection cannot be maintained for sexual activity. Delayed ejaculation is the least understood male sexual condition with a prevalence of about 3%, yet it might be that a higher percentage does suffer from it as misdiagnosis is common [2,6,9,14].
Premature ejaculation (PE) is a model of sexual dysfunction represented by an early ejaculation during intercourse, with semen departing the penis in a short period of time. It is seen in 20-30% of male patients of any age and ethnicity and negatively impacts the patient’s life, including interpersonal relationships with partners and psychological issues. This area of men’s health has no therapeutic solution yet and is treated using a combination of therapies used as the primary treatment for other conditions, such as SSRIs (anti-depressants) [9,13].
Etiology and Pathophysiology: Delayed Ejaculation
Expulsion, bladder neck closure, and emission are all involved in ejaculation (ejaculation proper). Seminal fluid is transported to the posterior urethra during emission. The bulbocavernosus muscle contracts during expulsion in time with the pelvic floor muscles to discharge semen retrogradely into the anterior urethra. Numerous neurotransmitters, including serotonin, dopamine, and norepinephrine, are involved in the physiology of ejaculation. A pure cerebral experience known as orgasm frequently but not always results in ejaculation. Regarding the origin of DE, there have been numerous opposing viewpoints for a long time One might make the case that relational, psychological, or psychosexual issues are what lead to DE. On the other hand, it has been suggested that DE may be brought on by drug use or may be caused by genetic, neurological, endocrine, anatomical, and viral factors. Many of these etiologic factors are based on case reports and case series rather than solid evidence-based. These etiological factors—organic and psychogenic etiologies—are neither separate nor mutually exclusive; they may very likely interact, and their pathological effects may differ from person to person [1-10, 13-14].
There have been many suggested psychogenic causes that could be involved in DE etiology. Based on the evidence, Althof categorized these hypothesized psychogenic variables under 4 theories :
- Not enough sex stimulation (mental and physical). The lack of penile stimulation contributes to DE. Additionally, scarce mental stimulation can further aggravate DE. This is thought to be due to aging. Moreover, the loss of sensitivity in penises can also result in decreased or absent penile stimulation [2,14].
- The existence of odd habits and fantasies that revolve around masturbation. For instance, some men exhibit fantasies of masturbation which they favor over sex with their partners .
- Apfelbaum proposed the idea of the third psychological theory. It conceptualizes DE as a covert sexual desire condition that goes by the name of DE. These patients primarily favor solo masturbation over partnered sex, according to this theory .
- Psychic conflict can engender DE. This results in the psychodynamic root of DE. The reported conflicts are the following :
- various forms of trepidation
- hostility against partners
- unwillingness to give oneself
- guilt because of a strictly religious upbringing
DE and anorgasmia may result from any congenital anomaly, illness, operation, or medication that affects the pelvic floor’s somatic efferent nerve supply or the central control of ejaculation [7,8]. These conditions include the sympathetic nerve supply to the vas deferens, bladder neck, prostate, or seminal vesicles . Numerous papers on DE have been published, but several terminological inconsistencies have generated debate.
According to several studies, DE can be brought on by a variety of causes, including those that are age-related, congenital, genetic, neurogenic, infectious/inflammatory, endocrine, and pharmaceutical [6,13,14]. Various studies have reported an age-dependent increase in DE prevalence . This might be connected to the aging-related decline in penile sensitivity to possible ultrastructural or degenerative age-related changes in penile receptors, resulting in progressive loss of axonal sensitivity . Age-related comorbid conditions including depression, diabetes, or late-onset hypogonadism, as well as medical, surgical, or radiotherapy for several age-related diseases that may impair ejaculatory function [4,5,8].
Various conducted studies along with their findings have given rise to the theory that a person’s propensity for DE may be influenced by hereditary factors . However, genetics affect premature ejaculation but not DE, according to a Finnish twin study.
According to this ejaculation distribution theory, both lifelong DE and PE are considered part of normal biological variability in IELT. It is postulated that any random sample of men is likely to include a minority of men with (almost) always early ejaculation and a second minority who (almost) always suffer from DE, while the majority have a normal or average IELT (Intravaginal ejaculation latency time) .
Etiology and Pathophysiology: Premature Ejaculation
Premature ejaculation has an unknown etiology. Doctors previously thought that it had purely a psychological aspect, however, premature ejaculation is now understood to have both psychological and biological factors. The chemistry of the brain has a partial effect on ejaculation. Low serotonin neurotransmitter levels in men are associated with quicker ejaculation .
Psychological elements that may be involved include:
- Early sexual experiences
- Sexual abuse
- Poor body image
- Premature ejaculation concerns
- Hasty intercourse due to feelings of guilt
- Troubled relationship
- Sexual performance anxiety
- Repressed negative sexual emotions. Conditioning whereby early sexual encounters may have an impact on future sexual behavior. For instance, it could be challenging for a teenager to overcome the habit if he trains himself to ejaculate rapidly to avoid being caught masturbating.
- A traumatic sexual experience from childhood. This can include sexual abuse and being caught masturbating.
A variety of physiologic variables may play a role in premature ejaculation. They might include: [9,13].
- Irregular hormone levels
- Irregular levels of neurotransmitters
- Infection of the prostate and urethra that leads to inflammation
- Characteristics that are inherited
Signs and symptoms: Delayed Ejaculation
The five stages of healthy sexual function should be noted in order to comprehend the warning signs and symptoms of delayed ejaculation.
The sexual process connects the body and the mind. For good sexual function, the endocrine (hormonal), circulatory, and neurological systems work together with mental processes to produce a sexual response. The preparation for a strong and successful ejaculation involves five steps.
These consist of:
- Desire (sometimes referred to as libido or sex drive): The initial ideas that make you want to engage in sexual behavior are referred to as desires. This is a sensory experience that your surroundings, including touch, thoughts, words, sights, and odors, could contribute to. Excitement is a result of desire. [4,8].
- Excitement, also referred to as sexual stimulation, is the interaction of sensory systems in which signals are delivered from the brain to the penis via the spinal cord. An erection results from increased blood flow and blood pressure within the penis, which is caused by the arteries that provide blood to the erectile tissues relaxing and dilating. All over the body, muscle tension rises during the excitation period. [2,14].
The time between getting an erection and ejaculating is known as the plateau stage. The respiration quickens and the body’s muscles remain stiff during the plateau period. The enthusiasm phase keeps becoming stronger. [1,5,10].
- Orgasm: The term “orgasm” describes the height of a sexual climax. Muscle tension throughout the body reaches its pinnacle during an orgasm, and the pelvic muscles tighten, causing ejaculation to occur next .
- Ejaculation: Ejaculation happens when the nervous system stimulates the flow of semen into the urethra in cooperation with the male reproductive organs. The neck of the bladder contracts to stop the passage of semen backward, a process known as retrograde ejaculation, while further muscle contractions around the urethra drive semen out of the penis.
The following are warning signs and symptoms of delayed ejaculation: [7,8].
- The inability to ejaculate or have an orgasm for at least 30 minutes or more.
- Failure to go to the “Excitement” stage.
- Failure to go to the “Plateau” stage.
- Having a sexual experience and feeling deflated.
- A sense of estrangement from your sexual partner.
- Experiencing sex-related anxiety
- The inability to ejaculate or have an orgasm for at least half of your sexual encounters.
Diagnosis: Delayed Ejaculation
There has not yet been a single gold standard for diagnosing DE because there aren’t any operationalized criteria. Given that many organic and psychological factors may have an impact on the pathophysiology of DE, a complete clinical history and appropriate physical examination should focus on all related symptoms and signs.
Retrograde ejaculation, absence of puberty, genital tract obstruction, anorgasmia, and other sexual dysfunctions that could be mistaken for DE, like erectile dysfunction, a subtly decreased libido, ejaculatory pain, the partner’s sexual dysfunction, sexual orientation conflicts, or paraphilic inclinations/interests, are excluded as the first steps in the evaluation process. Whether the complaint is connected to DE, the orgasmic experience or both must be determined from the past.
While orgasm is a core sensory event with great subjective diversity, ejaculation takes place in the genitalia. Orgasm and ejaculation frequently occur concurrently, although not always. The experience of orgasm suggests retrograde ejaculation, the absence of puberty, or genital tract obstruction in the absence of antegrade ejaculation. The ability to progress the ejaculatory response, the length of thrusting prior to suspension of intercourse, and the degree of distress or worry this scenario has produced are all questions that should be asked in order to corroborate the presence of DE in the second stage. Determining whether DE is global or situational, acquired, or lifelong may be part of the examination. The history may show whether the patient has a significant delay in or absence of ejaculation/orgasm under all conditions in the generalized form (lifelong or acquired). In a large proportion of DE instances, the patient often cannot ejaculate when with a partner (particularly during coitus) but can climax and ejaculate when masturbating alone. If a man can only ejaculate through masturbation, it is essential to figure out whether he has a distinct masturbation style. In comparison to men who are sexually functional, males with DE exhibit higher levels of relationship distress, sexual unhappiness, sexual performance anxiety, and lower frequencies of coital activity. The third stage involves identifying the risk factors and potential risk factors thought to contribute to the pathophysiology of DE. These possible risk factors may be identified using a targeted clinical examination, questionnaires (such as the Male Sexual Health Questionnaire and the International Index of Erectile Function), laboratory testing, and radiologic imaging.
Particularly in underdeveloped nations, doctors must carefully weigh the danger of missing important causes against the prudent use of frequently insufficient and expensive investigative resources. Sometimes, over the course of numerous episodes of care, the risk factors are diagnosed. Additionally, several locations and specialties may be involved in the etiologic diagnostic process. 
Diagnosis: Premature Ejaculation
Doctors will likely begin by inquiring as to whether the issue has existed in the past or is more recent. They might inquire about relationships or sexual life. The patient is also likely to have a physical examination.
A physician might suggest seeking the help of a mental health specialist who works with persons who have sex-related problems if they believe that emotional problems are to blame for your early ejaculation. They may suggest visiting a physician known as a urologist, who focuses on issues that impact your urinary system if they believe a physical issue is to blame. [9,13].
The key indicator of premature ejaculation is delaying ejaculation for a maximum of three minutes following penetration or any other sexual situation, including masturbating.
Two types of premature ejaculation exist: 
- Lifelong: After the first sexual contact, premature ejaculation lasts for the rest of one’s life.
- Acquired: After past sexual encounters without ejaculation issues, acquired premature ejaculation develops.
Early ejaculation may occur occasionally, without it having to be a diagnosis of premature ejaculation. Many people, however, believe that they have such symptoms that do not fit the diagnostic criteria of premature ejaculation .
Risk factors: Premature Ejaculation
Premature ejaculation is influenced by several variables. They may consist of: 
- Erection problems: if you struggle to achieve or maintain an erection, you may be more susceptible to premature ejaculation. If you’re worried that you won’t have another erection, you might speed through sex. Whether or not you’re aware of it, this could occur.
- Stress: premature ejaculation can be triggered by emotional or mental stress in any aspect of life. Stress can make it difficult to unwind and concentrate while having sex.
Complications: Premature Ejaculation
Your personal life may be disturbed as a result of premature ejaculation. Complications could consist of:
- Relationship and stress issues.
- Fertility issues: sometimes premature ejaculation makes it difficult for a partner to become pregnant. This might occur if ejaculation doesn’t occur in the vagina. The inability of the sperm to reach an egg to fertilize it due to premature ejaculation may also make it difficult to start a family.
Talking about the issue is an essential first step if premature ejaculation is having an impact on your relationship. A relationship therapist or sex therapist might be of use.
Treatment: Delayed Ejaculation
Delayed ejaculation is treated in different ways depending on the underlying cause. It can be dealt with through medication, whether it’s taking new types or making changes to current ones. Other ways of treatment include psychological counseling or tackling issues such as alcohol and illegal drug use.
Delay in ejaculation may be brought on by some types of drugs . In case of such a problem, either the dose should be reduced, or the medication should be switched. Adding another medication to the current one might also help prevent delayed ejaculation.
Currently, there’s no approved treatment for delayed ejaculation. However, medications used as primary treatment for other conditions can be used. Examples of such treatments include:
- Parkinson’s medication, Amantadine
- Anti-anxiety medication: Buspirone
- Allergy medication: Cyproheptadine
Psychological counseling (psychotherapy)
Underlying mental health issues, such as depression and anxiety, which lead to delayed ejaculation might be addressed through psychotherapy. Different types of counseling are available depending on the patient’s concerns. One might benefit from seeing a psychologist or mental health counselor with or without their partner. Another option is seeing a sex therapist, who specializes in talk therapy for sexual problems. Throughout the process, the underlying cause of delayed ejaculation is focused on.
Treatment: Premature Ejaculation
Premature ejaculation is treated using different methods, including behavioral techniques, pelvic floor exercises, and medication. Finding the right technique takes time, however, it was seen that behavioral treatment combined with drug therapy might be the best option regarding effectiveness.
In some instances of premature ejaculation, straightforward therapeutic measures can be taken. An example of such methods includes masturbation 1-2 hours prior to intercourse in order to delay ejaculation during sex.
It can be recommended to focus on sexual play rather than intercourse for a period of time. This strategy might lessen the strain experienced during sexual activity.
Pelvic floor exercises
Pelvic floor exercises, also known as Kegel exercises, can help strengthen weak pelvic floor muscles that make it difficult to delay ejaculation.
To follow this technique the right muscle should be identified. This can be done by stopping urination midway or tightening the muscles that hold back gas, as these actions require pelvic floor muscles.
The muscles of the pelvic floor can be strengthened by repeatedly contractions for three seconds, releasing them, and repeating the process while lying down. Once the exercise is mastered it can be done in different positions, including sitting, standing, and walking. Three sets of ten repetitions should be done every day in order to see results.
It is important to focus on just the pelvic floor muscle, not those of the abdomen, thighs, or buttocks. It is also essential to breathe freely throughout the process.
The pause-squeeze technique
The pause-squeeze technique is done with the help of the partner during sexual activity. The penis is stimulated until the feeling of ejaculation is reached. At this point, either the patient or the partner squeezes the end of the penis until the urge surpasses. Repeating this process can lead to delayed ejaculation and thus the entry of the partner without ejaculating.
In case of pain or discomfort, the stop-start technique can be followed instead. It requires the halt of sexual stimulation right before ejaculation, waiting for the diminishment of arousal, and then restarting the process.
Some condoms are designed to control climax and delay ejaculation via numbing agents such as benzocaine or lidocaine. Other types of condoms are made of thicker latex to make the penis less sensitive.
Topical numbing agents such as creams, gels, and sprays containing benzocaine, lidocaine, or prilocaine can be applied approximately 15 minutes before sex to avoid premature ejaculation. They are effective and well tolerated, however, they may decrease sexual pleasure in both partners.
Oral medications including antidepressants, pain relievers, and erectile dysfunction drugs can be prescribed alone or with other treatments to treat premature ejaculation.
A side effect of antidepressants is premature ejaculation, making selective serotonin reuptake inhibitors (SSRIs) such as dapoxetine the first treatment for premature ejaculation. It takes 5-10 days for the medication to start working and up to 2-3 weeks to see the entire outcome. In case no improvement is seen, tricyclic antidepressant clomipramine, known as Anafranil, is used. Side effects might include drowsiness, nausea, decreased sex drive, and perspiration,
Tramadol is a pain reliever that can be prescribed if antidepressants don’t show to be effective. This is because one of the side effects is delayed ejaculation. Other side effects include sleepiness, nausea, dizziness, and headache. If taken for a long time, Tramadol can become habit-forming.
Phosphodiesterase-5 inhibitors are drugs used to treat erectile dysfunction. Sildenafil (Viagra), for example, can also be used alone or in combination with an SSRI to treat premature ejaculation. Side effects of phosphodiester-5 inhibitors include facial flushing, headache, and indigestion.
Potential future treatments
Research shows that other types of drugs might be effective in treating premature ejaculation. Examples of these drugs include Modafinil (Provigil) and Silodosin (Rapaflo) which treat sleeping disorder narcolepsy and prostate gland enlargement, respectively. Onabotulinumtoxin (Botox) can be injected into the ejaculation-causing muscles.
Discussing relationships and experiences with a mental health provider can help find coping mechanisms. Loss of connection with a sexual partner due to premature ejaculation accompanies anger, shame, and performance anxiety. Speaking up, relationship counseling, and sex therapy, along with drug therapy are important steps to overcome this hardship.
According to the research, the pathophysiology of DE involves a number of organic and psychological components that are neither independent nor antagonistic to one another. Although there have been numerous articles on this illness, the precise pathophysiology is still unknown. Since operationalized criteria don’t exist, there isn’t a single gold standard for diagnosing DE at the moment. The diagnosis depends on the past. It is important to treat the underlying cause. Planning a course of treatment can take many different forms, including different psychological interventions, pharmacology, and treatments specifically for infertile males. Pharmacological therapy remains absent. Not all patients can benefit from a strict therapy regimen. The collection of nocturnal emissions, arduous prostatic massage, prostatic urethra catheterization, rectal probe EEJ (electroejaculation), sperm retrieval from the vas deferens or the epididymis, or testicular sperm extraction are a few techniques that can be used for infertile men.
Several therapies resulted in statistically significant improvements in the time to ejaculation of 1 to 6 minutes introducing the intravaginal ejaculation latency time (IELT). These include topical anesthetics, behavioral therapy, and pharmaceutical remedies such as SSRIs (Selective serotonin reuptake inhibitors) and other antidepressants, PDE5 inhibitors, and tramadol. Numerous therapies also showed improvements in other outcomes, such as sexual satisfaction. When compared to either behavioral therapy or medication alone, the combination of the two was preferable. Some AEs (adverse events) are related to pharmacological and topical therapy. Most therapies had a maximum 12-week trial period (24 weeks for dapoxetine and tramadol). Maintaining a variety of alternatives (to be employed alone or in combination) may continue to be a good approach in the treatment of PE because different interventions have distinct mechanisms of action and different patients may have a preference for pharmacological or behavioral therapy.
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