What is Premature Ejaculation?
What Causes Premature Ejaculation?
Premature ejaculation can be caused by many factors.
If we classify the causes of premature ejaculation, we can divide them into two main groups: psychological and biological factors.
Psychological causes include stress, anxiety, sexual beliefs, frequency of sexual activity, and sexual techniques.
Biological causes include excessive sensitivity of the penis, excessive ejaculatory reflex, hormonal factors, and genetic predisposition.
Chronic prostatitis can also be considered one of the biological causes of premature ejaculation originating from urological factors.
Main causes:
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Psychological causes:
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Sexual technique
According to one hypothesis, ejaculation control is the result of delaying techniques learned consciously or unconsciously during sexual activity.
It is known that men with good ejaculation control can delay ejaculation by making certain changes in their behavior during sexual activity.
These changes include relaxing the pelvic muscles, slowing down the pace, and changing the depth or type of vaginal thrusting.
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Early Sexual Experience
According to another hypothesis, early sexual experience has been claimed to be an important cause of premature ejaculation.
For example, it has been suggested that experiences such as having one's first sexual experience in different places or with sex workers
experiences may lead to conditioning for premature ejaculation.
Such relationships may also be referred to as "quick sex" or "rushed sex." While it is thought that quick sex may contribute to premature ejaculation, there is no definitive and evidence-based strong data in the literature on this matter.
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Frequency of Sexual Activity
Frequent sexual activity may lead to increased sensory experiences before ejaculation, prolonged ejaculation, reduced anxiety, and decreased penile sensitivity.
However, studies on the relationship between sexual activity frequency and premature ejaculation have yielded conflicting results.
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Psychoanalytic Theories
According to Kaplan's psychoanalytic theory, premature ejaculation is linked to an unconscious and deep-rooted hatred toward women.
Men's rapid ejaculation symbolically defiles the woman and diminishes her value.
It is claimed that his sexual pleasure was taken away from him. However, the same author argues that most men with sexual dysfunction do not have personality disorders and therefore reverses the previous psychodynamic explanation.
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Biological causes:
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Genetic:
Studies conducted support the idea that premature ejaculation has a genetic component. A study conducted in the Netherlands found a high prevalence of premature ejaculation among relatives of men with the condition.
Additionally, studies on twin males also confirm this theory.
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Penile Hypersensitivity
The effects of the peripheral nervous system on ejaculation have been well established. However, it has been reported that dorsal penile nerve networks are more dense in men with lifelong premature ejaculation than in other men.
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Hormonal Causes
While some studies suggest that premature ejaculation is not associated with testosterone levels, other studies have reported that high testosterone is associated with premature ejaculation.
Although the cause is unknown, higher rates of premature ejaculation have been observed in patients diagnosed with diabetes mellitus.
Elevated thyroid hormone levels (hyperthyroidism) have also been associated with premature ejaculation. These findings suggest that hyperthyroidism may be a new and reversible etiological risk factor for premature ejaculation.
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Urological Diseases
It has been reported that chronic prostatitis, one of the urological diseases, may cause premature ejaculation.
Although the exact cause is unknown, it is thought that the intense inflammatory condition that occurs may lead to increased neural sensitivity.
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Neurological Diseases
Neurological disorders such as multiple sclerosis and peripheral neuropathy, whose causes are not fully understood, have been reported to cause premature ejaculation. However, there are insufficient studies on this subject.
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Drug-Related
It has been reported that amphetamines, cocaine, and dopaminergic medications may cause premature ejaculation.
However, there is insufficient data on this topic, so evidence-based studies are needed.
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Chronic kidney failure
Although the exact cause is unknown, chronic kidney failure is thought to cause premature ejaculation by leading to hormonal, neurogenic, and psychological changes. In addition, premature ejaculation has been reported to improve in many patients after kidney transplantation.
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Varicocele
Some studies have found a link between varicocele and premature ejaculation in patients seeking treatment for sexual dysfunction.
; however, the mechanisms underlying the relationship between varicocele and premature ejaculation are complex and currently difficult to explain.
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Erectile dysfunction (erectile dysfunction)
Studies have shown that 30-50% of men with erectile dysfunction (ED) experience premature ejaculation. This is thought to be because men with ED worry about losing their erection and develop a habit of ejaculating early to keep it up.
Types of Premature Ejaculation
The classification of premature ejaculation has changed over time. The current classification accepted in the DSM-5 includes four different types
1.Lifelong premature ejaculation: This type of premature ejaculation occurs from the first sexual encounter. In this type, ejaculation often occurs immediately before or within one minute of vaginal penetration.
2.Acquired premature ejaculation: This group of patients did not experience premature ejaculation during their first sexual encounters but reported ejaculating more quickly than before during subsequent sexual encounters. It often occurs within 3 minutes or less. This type of premature ejaculation is usually caused by organic or psychological factors. These factors may include erectile dysfunction, prostatitis, hyperthyroidism, psychiatric or relationship problems, sexual performance anxiety, or discontinuation of certain medications.
3. Natural Variable Premature Ejaculation: These individuals experience varying ejaculation times, which may be associated with certain circumstances (such as temporary stress, anxiety, fatigue, or illness).
4.Premature Ejaculation-Like Ejaculation Disorder (Subjective Premature Ejaculation): This type of ejaculation disorder represents patients who complain of premature ejaculation even if the ejaculation time is normal or even long (5-25 minutes). In this case, there is no organic or neurobiological disorder, and it is associated with misperception of ejaculation time. Additionally, a situation where the partner experiences delayed orgasm can lead to the perception of a short ejaculation time.
Patient Evaluation
There are several psychometric tools that can be used to diagnose premature ejaculation: The Premature Ejaculation Diagnostic Tool (PEDT) questionnaire is the most commonly used of these.
Couples should be evaluated together as much as possible, because a situation that may be problematic for one person may be completely normal for the other partner. Identifying the couple's expectations is also of great importance, as the duration of intercourse and the arousal threshold are highly subjective and personal. Many men may not want to include their partner in a urological examination. However, understanding the woman's expectations, addressing marital issues, and addressing potential sexual dysfunction in the woman (such as orgasmic dysfunction, low sexual desire, sexual arousal disorder, vaginismus) is extremely important.
The purpose of diagnosing premature ejaculation is to define it based on the time of onset of symptoms, whether it is associated with a partner or a situation, and whether it is associated with other sexual dysfunctions.
Premature Ejaculation Diagnostic Tool
PREMATURE EJACULATION DIAGNOSTIC TOOL
(Premature Ejaculation Diagnostic Tool-PEDT)
- How difficult is it for you to delay ejaculation?
0 Not at all difficult
1 Somewhat difficult
2 Moderately difficult
3 Very difficult
4 Extremely difficult
- Do you ejaculate before you want to?
1 Almost never or never (0%)
2 Less than half of all attempts (25%)
3 About half of all attempts (50%)
4 More than half of all attempts (75%)
5 Almost always or always (100%)
- Do you ejaculate immediately with very little stimulation?
1 Almost never or never (0%)
2 Less than half of all attempts (25%)
3 Approximately half of all attempts (50%)
4 In more than half of all attempts (75%)
5 Almost always or always (100%)
- Do you feel inhibited because you ejaculate before you want to?
0 Not at all
1 A little
2 Moderately
3 Very
4 Extremely
- To what extent are you concerned that the time it takes for you to ejaculate prevents your partner from achieving sexual satisfaction?
0 Not at all
1 A little
2 Moderately
3 Very
4 Extremely
PEDT SCORE SYSTEM:
- Premature ejaculation is present; PEDT≥ 11
- Possible premature ejaculation; PEDT = 9 or 10
- No premature ejaculation; PEDT≤ 8
Premature Ejaculation Treatment
Behavioral therapies:
The main methods are "Start and Stop" and "Squeeze and Release."
As their names suggest, these methods can be roughly described as stopping after a period of sexual intercourse, then starting again, and squeezing the penis when close to ejaculation during intercourse, then releasing and starting again.
The effectiveness of these methods alone is limited, with a success rate of 60% in the short term and 25% in the long term.
They are not the first line of treatment for lifelong premature ejaculation. Behavioral therapies enhance the effectiveness of medication and may therefore be recommended in addition to medication. Behavioral therapies often take a long time and require partner support, making them time-consuming and expensive. Additionally, their effectiveness may decrease over time.
Pelvic Floor Exercises:
The duration of ejaculation can be increased by strengthening the pelvic floor muscles. Kegel exercises are the most practical method for developing the pelvic floor muscles. The pelvic floor muscles are the muscles used to control urination. Practically, to strengthen these muscles, you should contract the muscles as if you were trying to stop urinating, hold for 10 seconds, and repeat this at least three times a day. However, this method alone has limited effectiveness in treating premature ejaculation.
Counseling:
If your premature ejaculation is caused by psychological, emotional, or relationship issues, you may need to seek help from a sexual therapy specialist.
Local Methods:
It is the oldest treatment method. It works by reducing the sensitivity of the penis head. After applying the anesthetic cream or spray to the penis head, you should wait 20 minutes and wash the penis head before intercourse. If you do not wash it, the cream or spray will also numb the vaginal area, resulting in the inability to ejaculate in the partner.
The numbness felt in the penis head and shaft often makes this method less preferred due to reasons such as inability to enjoy intercourse and a loss of natural sensation.
Use of Antidepressants
Some antidepressant drugs that block serotonin reuptake have been found to prolong ejaculation times during their use as antidepressants. For this reason, they have also begun to be used to treat premature ejaculation. Nowadays, short-acting forms of these drugs are available and are used only for premature ejaculation. They do not require regular use and can be taken only before intercourse.
New Applications in the Treatment of Premature Ejaculation
Penile hypersensitivity has long been recognized as a risk factor for premature ejaculation.
New treatment methods that reduce this sensitivity through various methods
is being developed. Penile head augmentation using hyaluronic acid injections, cryoablation (freezing) using needles advanced through the skin to the dorsal penile nerve under computed tomography guidance,
micro-surgical selective dorsal neurotomy, and dorsal penile nerve neuromodulation are new treatment methods. These treatment methods are frequently used in Asian countries.
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Penile Glans Filling
Filling the glans penis with hyaluronic acid injections can delay ejaculation by reducing the sensation of touch reaching the sensory receptors in the glans penis. This type of injection method can delay ejaculation for up to 9 months on average, and repeated injections may be necessary in severe cases.
Transperineal Transcutaneous Electrical Stimulation (TES)
TES may delay ejaculation by preventing rhythmic contractions that occur during ejaculation by applying electrical current to the muscles that cause semen to be expelled.
Botulinum Toxin-A Injection into the Bulbospongiosus Muscle
Botulinum toxin injection can delay ejaculation by reducing the rhythmic contractions of the bulbospongiosus and ischiocavernosus muscles during the ejaculation phase.
Dorsal penile nerve cryoablation (freezing) and neuromodulation:
These methods are used to reduce the sensitivity of the sensory nerve fibers of the penis.
Surgical (dorsal neurotomy)
This method involves the surgical removal of part of the sensory nerve fibers of the penis.
What is the treatment for premature ejaculation? I am looking for a solution. Patients seeking a solution to premature ejaculation should first consult a urologist, especially one who is qualified in andrology.