When the going gets fast

It is said that premature (early/rapid) ejaculation (PE) is the most common type of sexual dysfunction in males below the age of 40. This problem usually occurs with more than 50 percent of attempted sexual intimacies. The prevalence rates of PE found in population studies slightly differed between 10 percent and 25 percent of men surveyed.  Actually this kind of ejaculation problem occurs at a time earlier than both partners desire.

Premature ejaculation can be classified as lifelong or acquired. Lifelong PE refers to men who had the problem since they became capable of functioning sexually.  Acquired PE is not due to a general medical disorder and in rare cases, may be induced by a substance like a psychotropic medicine and most likely has a psychological component.

Diagnostic criteria

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), classifies premature (early) ejaculation as belonging to a group of sexual dysfunction disorders that are typically characterized by a “clinically significant inability to respond sexually or to experience sexual pleasure.”  DSM-5 recommends that prior diagnosis of PE, the following factors must be investigated: 

1. Partner factors — partner’s sexual problems or health issues.

2. Relationship factors — communication problems and differing levels of desire for sexual activity.

3. Individual vulnerability factors — history of sexual or emotional abuse, existing psychiatric conditions such as depression, or stressors such as job loss.

4. Cultural or religious factors — inhibitions or conflicted attitudes regarding sexuality.

5. Medical factors — an existing medical condition or the effects of drugs or medications.

The specific DSM-5 criteria for premature ejaculation are the following:

1. In almost all or all (75 to 100 percent) sexual activities, the experience of a pattern of ejaculation occurring during partnered sexual activity within one minute after vaginal penetration and before the individual wishes it.

2. The symptoms above have persisted for at least six months.

3. The symptoms above cause significant distress to the individual.

4. The dysfunction cannot be better explained by non-sexual mental disorder, a medical condition, the effects of a drug or medication, or severe relationship distress or other significant stressors.

The severity of premature ejaculation may be:

1. Mild — occurring within approximately 30 seconds to one minute of vaginal penetration.

2. Moderate — occurring within approximately 15 to 30 seconds of vaginal penetration.

3. Severe  — occurring before sexual activity, at the start of sexual activity, or within approximately 15 seconds of vaginal penetration.

The  body organ systems directly affected by PE are the following:

1. Male reproductive tract, namely the penis, prostate, seminal vesicles, testicles and their appendages.

2. Parts of the central and peripheral nervous system controlling the male reproductive tract.

3. Reproductive organ systems of the sexual partner (if female) that may not be stimulated satisfactorily to achieve orgasm.

Causes

For married couples, the most disturbing effect of PE is the emotional and physical effect of the inability to achieve orgasm and the inability to get the wife pregnant. A number of researchers have found variations in nerve conduction/latency times and hormonal differences in males who experience PE compared with men who do not. The theory is that certain males have hyper-excitability or oversensitivity of their genitalia, which prevents the down-regulation of their sympathetic pathways and therefore delay the acquisition of orgasm.

Another explanation for premature ejaculation is that single males are conditioned by societal pressures to reach climax quickly because of fear of discovery when masturbating as teenagers or during early sexual experiences with others. This pattern of swift attainment of sexual release is said to be difficult to change in marital or long-term relationships. The increasing acceptance that female arousal/orgasm requires more time than male arousal may lead to increased awareness of premature ejaculation as a problem.

A group of nerves in the lumbar spinal cord has been identified as the possible generator of ejaculation. The said nerve area is thought to be linked to excitatory and inhibitory dopamine pathways in the brain, which play significant roles in sexual behavior. 

Management of PE include:

1. Sex Therapy — The sex therapy, as elaborated by Masters and Johnson (1970), consisted of short-term but intensive work with the couple (conjoint therapy). Detailed information about relevant human anatomy (structure) and physiology (functioning) are given, as well as general counseling.  Direct therapy for PE often involves the therapist’s stepping outside the usual therapeutic posture of responding to the patient, and instead taking an active, directive, and initiating role with the patient in regard to general life-style and sex-role issues. To date, sex therapists now appear to employ a broad range of treatment modalities, including “bibliotherapy (expressive therapy that uses an individual’s relationship to the content of books and poetry and other written words as therapy) and group therapy” (Hawton, 1992; Shah, 1996). Likewise, sex therapists have witnessed an increased “medicalization” of treatment for many sexual problems (Schover & Leiblum, 1994; Tiefer, 1994).

2. Pharmacologic Therapy —  Selective Serotonin Reuptake Inhibitors (SSRIs) useful for treating premature ejaculation include the following: Sertraline, Paroxetine, Fluoxetine, Citalopram and Dapoxetine.

In connection with the premise that there is a medical basis for certain cases of PE, Menarini, the largest Italian biopharmaceutical company in the world, has recently launched an advocacy campaign that will focus on promoting awareness on PE among Filipino couples. A panel discussion was held last month where media and celebrity couples were given time to speak up on what they know about the topic and to share their insights. Among the celebrity couples featured in the said launch were Anthony and Maricel Pangilinan, Paolo and Suzi Abrera and Lander and Regine Vera-Perez.  The resource persons for the summit panel discussion in the Menarini launch were noted author and psychologist specializing in sex therapy Dr. Margie Holmes  and well-known urologist and men’s health expert Dr. Dennis Serrano.

Dapoxetine, launched recently locally by Menarini as Priligy, is the first compound specially developed for the treatment of PE in men 18 to 64 years old. Dapoxetine acts by inhibiting the serotonin transporter, increasing serotonin’s action at the postsynaptic cleft, and as a consequence promotes ejaculatory delay. As a SSRI, dapoxetine was initially created as an antidepressant. However, unlike other SSRIs, dapoxetine is absorbed and eliminated swiftly in the body. Thus, its rapid acting property makes it very suitable for the treatment of PE but not as an antidepressant.

In summary, premature ejaculation, a male sexual dysfunction, warrants thorough assessment and understanding of the biopsychosocial factors that led to the problem. Thus, a combination of approaches (psychological, cognitive, behavioral and pharmacologic) will be of benefit.

(For questions on love, looks and relationships, do e-mail this author at nina.halilijao@gmail.com.)

(The Department of Psychiatry and Behavioral Medicine

is celebrating its 50th anniversary with a Post Graduate Course on Dec. 18, 2014.  For inquiries, please call 554-8470 or e-mail larimerhugo@gmail.com.)