Premature ejaculation: causes, symptoms, diagnosis and treatment

By Cristiano Antonino On Jun 7, 2023

Premature Ejaculation is a common sexual dysfunction. “A persistent or recurrent mode of ejaculation that occurs during sexual intercourse, approximately one minute after vaginal penetration and before the individual desires it” (DSM-5, 2014)

It must cause discomfort or interpersonal difficulties and not be due to the direct effects of a substance/drug or medical condition.

There are various types of premature ejaculation: permanent (lifelong), acquired (onset after a period of normal sexual functioning), situational (only with specific stimulation, situation or partners) and generalised (occurs in all situations).

Symptoms of premature ejaculation

Premature ejaculation consists of the persistent or occasional occurrence of ejaculation following even minimal sexual stimulation, before (“ante portam”), during or shortly after penetration, and in any case before when the subject desires.

Generally, premature ejaculation occurs between 60 seconds and 2 minutes but may vary from subject to subject.

Men with this disorder experience fast and unsatisfactory sexual intercourse, impairing their quality of life.

The impairment often manifests itself in the couple’s relationship (hetero- or homosexual) generating conflicts, misunderstandings and bad moods that reinforce and aggravate the symptomatology itself.

To speak of premature ejaculation, the abnormality must cause considerable discomfort or interpersonal difficulties and it must not be due solely to the direct effects of a substance.

In general, most males with premature ejaculation can delay orgasm during masturbation for considerably longer than during coitus.

Criteria for diagnosis and criticality

There is no precise criterion, nor precise symptoms, to define when one can speak of true premature ejaculation, because there is no a priori established time that a man should ‘last’.

Some researchers take as a point of reference, in order to be able to speak of precocious ejaculation, the fact that the man is unable to hold back so that the woman is satisfied in at least 50 per cent of the cases.

Even this criterion, however, is highly questionable, as the woman’s orgasmic capabilities must be assessed.

In any case, it can be said that a premature ejaculator is certainly the one who ejaculates after a handful of coital thrusts (5-10) or even before introducing the penis into the vagina.

Consequences of ejaculatory precocity

Those who suffer from premature ejaculation complain of a lack of control over it and apprehension of the inability to delay it.

This dysfunction can lead to low self-esteem, low self-efficacy, feelings of inadequacy, frustration, lack of assertiveness and decreased desire, sexual pleasure/satisfaction with repercussions in relationships.

The discomfort is also experienced by the partner who, unconsciously, aggravates the disorder and suffers himself. Rapid ejaculation is often read by the partner as a lack of respect and attention or as an indication of selfishness.

Development and course of the dysfunction

Premature ejaculation is mostly observed in young men and is generally present from their first sexual experiences (lifelong).

However, some men lose the ability to delay orgasm after a period of adequate functioning.

Most young males learn to delay orgasm with sexual experience and age, but some continue to ejaculate prematurely and may seek help for their disorder.

Some males succeed in delaying ejaculation within a stable relationship, but experience symptoms of premature ejaculation again when they have a new partner.

When the symptoms of premature ejaculation begin after a period of adequate sexual functioning, the context is often one of decreased frequency of sexual activity.

Or intense performance anxiety with a new partner or a loss of control over ejaculation related to difficulty in achieving or maintaining an erection.

Some males who discontinue regular alcohol intake may develop premature ejaculation, since they relied on alcohol intake to delay orgasm.

Causes of premature ejaculation

The causes of premature ejaculation are multifactorial: organic and psychological.

In the vast majority of cases, however, they are psychological.

Psychological causes

The psychological aspect is decisive.

Social anxiety, performance anxiety, depression, relationship problems, dissatisfaction with body image, masturbation addiction and negative sexual experiences are all factors that often contribute to the disorder.

Organic causes

There are rare cases of ejaculatory precociousness, generally transient, related to organic causes.

These include anatomical abnormalities of the (short) frenulum, hypersensitivity of the glans, inflammatory states, urethritis, vesiculitis, prostatitis, multiple sclerosis, bone marrow tumours, stress or hormonal problems (hypo-hyperthyroidism, low prolactin, high leptin levels).

These conditions, however, are generally noticeable as they involve other symptoms in addition to early ejaculations.

Risk factors

Substance intake can cause the disorder: drugs, alcohol and medication can induce premature ejaculation.

In particular, drug withdrawal is often responsible for acquired premature ejaculation.

In some cases, stopping regular alcohol intake can lead to premature ejaculation as a result of the inability to delay orgasm in the absence of the substance’s effects.

Many people who suffer from premature ejaculation use alcohol as a disinhibitor, or/and as an anxiolytic, but doing so in the long run aggravates the problem with detrimental effects on ejaculatory control.

Premature ejaculation may also be associated with erection problems (erectile dysfunction) and this may complicate the differential diagnosis.

Finally, any female sexual dysfunctions in the partner (anorgasmia, hypoactive sexual desire, sexual aversion, sexual arousal disorders and sexual pain disorders such as vaginismus or dyspareunia) may be related to acquired premature ejaculation.

False myths: do-it-yourself cures

Premature ejaculation sufferers often remain silent out of fear and shame.

Thus, they resort to do-it-yourself strategies, aggravating the symptoms without solving the problem.

Some of these are:

per-coitus masturbation in order to increase performance
repeated coitus with the aim of improving ejaculatory control over time
use of over-the-counter sprays, creams (anaesthetisers) without a doctor’s prescription
inflicting pain to shift attention and delay ejaculation
use of distracting thoughts to delay orgasm

All these dysfunctional strategies maintain and feed the problem by contributing to frustration, inadequacy, poor ejaculatory control, stress and anxiety.

Subjective (or false) premature ejaculation

Premature ejaculation is a sexual dysfunction that should not be confused with subjective or false premature ejaculation.

Today, the world of porn has influenced young people by leading them to false beliefs about sexual performance.

A distorted sexuality that leads to judging oneself negatively in terms of size and duration.

The false premature ejaculator has an absolutely normal ejaculation, but his perception of ejaculatory latency is altered to such an extent that he worries and develops an emotional symptomatology superimposed on real premature ejaculators.

The emotional distress thus ends up affecting performance (poor ejaculatory control), sexual desire and the quality of the relationship.

Treatment of premature ejaculation

Once biological causes have been ruled out, the treatment of premature ejaculation focuses on the psychogenic aspects, through two main forms of intervention: behavioural therapy and psychopharmacological therapy.

There are currently no other forms of treatment that are scientifically founded and proven to be effective.

Behavioural therapy

Behavioural therapy appears to be the most effective therapy for this problem.

It focuses on psychological aspects and is aimed at increasing ejaculatory latency and a sense of self-control.

The latter generally involves the participation of both members of the couple and involves a series of prescriptions and exercises to be performed together with the partner.

This is a treatment strategy focused on the problem of premature ejaculation, which is addressed through specific techniques.

For example, ‘stop and start’ (repeated interruption of sexual intercourse close to orgasm) and ‘squeeze’ (blocking ejaculation by finger pressure between the glans and the beginning of the body of the penis).

If necessary, attention will also be paid to the analysis of deeper psychological aspects (personality, relationships, sexual beliefs, life history and socio-cultural context).

Pharmacotherapy

Pharmacotherapy often accompanies psychotherapy and is based on two classes of drugs that induce the effect of delaying ejaculation.

Very few drugs are approved for the treatment of premature ejaculation.

The problem is the effectiveness is limited to the hours after taking the tablet.

Approved drugs include alpha-adrenergic blockers and serotonergic antidepressants (including dapoxetine).

In reality, the drugs in question are not specifically for the treatment of premature ejaculation, but their side effect is used to desensitise the genital area and postpone orgasm.

In clinical practice, however, it has been proven that to treat premature ejaculation it is always useful to combine pharmacological therapy with a course of behavioural therapy, which involves a gradual reduction and withdrawal of the drug as soon as the subject acquires a greater sense of self-control.

Pharmacotherapy alone is not enough to solve the problem, it must be accompanied by appropriate psychotherapy (behavioural therapy).

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