9 Treatment Tactics to Overcome Premature Ejaculation

Premature Ejaculation (PE) is a condition in which sexual climax occurs before, upon, or shortly after vaginal penetration, prior to one’s desire to do so, with minimal voluntary control. It is the most common form of male sexual dysfunction.

The key features are:

  • Brief time to ejaculation (often less than one minute)
  • Lack of control over ejaculation
  • Sexual dissatisfaction, distress and frustration of partner

How Long Should it Take to Climax?

In a study of more than 1,500 men, The Journal of Sexual Medicine reported that the average time between penetration and ejaculation for a premature ejaculator was 1.8 minutes, compared to 7.3 minutes for non-premature ejaculators.

Another study of 500 couples across five countries reported results ranging from 33 seconds to 44 minutes with the median being 5.4 minutes.

What Causes Premature Ejaculation?

PE can be psychological and/or biological and can occur because of over-sensitive genital skin, hyperactive reflexes, extreme arousal or infrequent sexual activity. Other factors are genetics, guilt, fear, performance anxiety, inflammation and/or infection of the prostate or urethra and also can be related to the use of alcohol or other substances.

PE occurs in up to 30% of men, involving all ages, ethnicities, and socio-economic groups. PE can cause embarrassment, frustration and loss of self-confidence and can be devastating to a relationship. It is very typical among men during their earliest sexual experiences.

PE can be lifelong or acquired and sometimes occurs on a situational basis. Lifelong PE is thought to have a strong biological component. Acquired PE can be biological, based on inflammation/infection of the reproductive tract or psychological, based upon situational stressors. PE can sometimes be related to Erectile Dysfunction (ED), with the rapid ejaculation brought on by the desire to climax before losing the erection.

Emphasis on ejaculation as the focal point of sexual intercourse tends to increase the performance anxiety that can initiate the problem. Once PE has occurred and established itself, fear of and mental preoccupation with the issue can actually induce the unwanted rapid ejaculation, creating a vicious cycle.

How to Overcome Premature Ejaculation

  1. Diversionary Thoughts: Non-erotic mental diversionary tactics (concentrating on thoughts other than ejaculating) may prevent PE. Baseball, work, counting backwards, etc., are examples of such thoughts, but these are rarely effective and diminish the pleasure of sexual intimacy.
  2. Down Tempo: This requires one to develop a mindfulness of the sensation immediately before ejaculation. By slowing the pace of pelvic thrusting and varying the angle and depth of penetration before the “point of no return” has passed, the feeling of imminent ejaculation may dissipate.
  3. Pause-Start Method: If slowing the tempo is not sufficient to prevent the PE, one may need to stop thrusting completely while maintaining penetration in order for the ejaculatory “urgency” to go away. Once the sensation to ejaculate subsides, pelvic thrusting may be resumed.
  4. Squeeze Technique: Originated by Masters and Johnson, as imminent ejaculation approaches, the penis is withdrawn and the head of the penis is squeezed until the feeling of ejaculation passes, after which intercourse is resumed. Although effective, it requires sexual interruption, is cumbersome and demands a very cooperative partner.
  5. Pelvic Floor Muscle Training: Contracting one’s pelvic floor muscles is a less cumbersome alternative to the Master and Johnson technique. Instead of the clunky and obvious squeeze technique, a more subtle and discreet method is to slow the pace of intercourse, pause the pelvic thrusting and do a sustained pelvic muscle contraction. This is an internal “squeeze” without the external hand squeeze and can achieve the same goal, short-circuiting the premature ejaculation. With sufficient practice and the achievement of “muscle memory,” this process can become easier and the problem of PE improved, particularly with commitment to a pelvic floor muscle training program.
  6. Decreasing Sensitivity: One method of doing so is by using thick condoms. Alternatively, local anesthetics in the form of topical creams, gels, and sprays can desensitize the penis. These include Lidocaine cream or gel, Lidocaine and Prilocaine (EMLA cream) or Lidocaine spray (Promescent) that are applied before intercourse. Another desensitization technique is increasing the frequency of ejaculation since PE tends to be more pronounced after longer periods of sexual abstinence. By masturbating prior to engaging in sexual intercourse, the PE may be controlled.
  7. Erection Pills: Viagra, Levitra, Cialis and Stendra, which are commonly used for ED, can have a role in the treatment of men with acquired PE that is due to ED.
  8. SSRI Antidepressants: These selective serotonin reuptake inhibitors can substantially delay ejaculation. One is generally started on a low dose, with an increase in dosage as necessary. Once an effective dosage is achieved, the medication can be used on a situational basis, several hours prior to sexual intercourse.
  9. Counseling: Since PE can be on a psychological basis, it may be beneficial to seek the counsel of a sexual therapist. This can be done in conjunction with some of the aforementioned techniques to hasten the resolution of the PE.

Although not life-threatening, PE is a common and distressing quality of life problem that is sometimes relationship-threatening. The good news is that there are a number of effective treatment options available, so one need not suffer with the problem.

Written by Dr. Andrew Siegel 

Male Sexual Dysfunction: A Predictor of Heart Disease

Erectile Dysfunction (ED) serves as a good proxy for cardiac and general health. The presence of ED is as much of a predictor of heart disease as is a strong family history, tobacco smoking, or elevated cholesterol!

All fat is not created equal.

Having some fat on our bodies is not a bad thing. Fat serves a number of useful purposes, such as cushioning internal organs, providing insulation to conserve heat, and storing energy and fat-soluble vitamins. Fat is also part of the structure of the brain and cell membranes and is used in the manufacturing process of several hormones.

However, not all fat is the same. It’s important to distinguish between visceral fat and subcutaneous fat. Visceral fat– also referred to as a “beer belly” – is internal fat located deep within the abdominal cavity. Subcutaneous fat – also known as “love handles” – is superficial fat located between the skin and the abdominal wall.

In addition to the physical distribution of the fat being different, so is the nature of the fat. Although neither type is particularly attractive, visceral fat is much more hazardous to one’s health than subcutaneous fat. Visceral fat increases the risk of heart disease, diabetes and metabolic disturbances. Subcutaneous fat is inactive, relatively harmless, and generally does not contribute to health problems.

Visceral fat is essentially a metabolically active endocrine “organ” that does way more than just create an unsightly protrusion from our abdomens. It produces numerous hormones and other chemical mediators that have many detrimental effects on all systems of our body, including risk of diabetes, cardiovascular disease, low testosterone, erectile dysfunction (ED) and premature death.

So how can erectile dysfunction predict heart disease?

Visceral fat and metabolic syndrome are highly associated with low testosterone and poor erection and ejaculation function. The fatty tissue present in obese abdomens contains abundant amounts of the enzyme aromatase which converts testosterone to estrogen, literally emasculating obese men. So, visceral fat can steal away our masculinity, male athletic form and body composition, mojo, strength, and the ability to obtain and maintain a good quality erection.

This is why ED serves as a good proxy for cardiac and general health. The presence of ED is as much of a predictor of heart disease as is a strong family history, tobacco smoking, or elevated cholesterol.

FactoidThe penis can function as a “canary in the trousers.” Since the penile arteries are generally rather small (diameter of 1- 2 mm) and the coronary (heart) arteries larger (4 mm), it stands to reason that if vascular disease is affecting the tiny penile arteries and causing ED, it may affect the larger coronary arteries as well — if not now, then at some time in the future. In other words, the fatty plaque that compromises blood flow to the smaller vessels of the penis may also do so to the larger vessels of the heart and thus ED may be considered a genital “stress test.”

What does this all mean?

  • Visceral fat is a bad, metabolically-active form of fat that is highly correlated with metabolic syndrome, diabetes, heart disease and sexual dysfunction.
  • ED often occurs in the presence of “silent” heart disease (no symptoms) and serves as a marker for increased risk for heart disease (as well as stroke, peripheral artery disease and death). ED will often occur 3-5 years before heart disease manifests. Early detection of ED provides an opportunity to decrease the risk of heart disease and the other forms of blood vessel disease. ED has a similar or greater predictive value for heart disease as do traditional factors including family history, prior heart attack, tobacco use and elevated cholesterol. The greater the severity of the ED, the greater the risk and extent of heart disease and blood vessel disease.

What can I do?

Lifestyle intervention has the potential for reversing visceral obesity, metabolic syndrome and sexual dysfunction. This lifestyle intervention involves achieving a healthy weight, losing the belly fat, eating healthy, exercising regularly, quitting smoking, limiting alcohol intake, and managing stress.

Written by Dr. Andrew Siegel


Is This Normal? 10 Common Penile “Flaws” You May Have

A penis is a special organ—a man’s joy, if not pride—and certainly one of his most prized, appreciated and cherished possessions, to which he has a significant attachment. As multifunctional as a Swiss Army knife, it allows him to stand to urinate (an undervalued capability), rises and firms to the occasion to allow for sexual penetration, and ejaculates genetic material–the means to perpetuate the species. A marvel of hydraulic engineering, within nanoseconds of sexual stimulation it is uniquely capable of increasing its blood flow 50 times over baseline, transforming its shape and size. Penis magic!

Each and every penis is unique. As variable as snowflakes, they come in every size, shape, and color. Beyond “size matters”—often a source of male preoccupation—men are often obsessed, if not preoccupied, with the appearance of their genitals. In my interactions with patients, concerns are often voiced about symmetry, color, pigmentation, angulation, spots, blemishes, vein patterns, shrinkage, and other oddities. Unless you are in the habit of closely inspecting other men’s genitals (as urologists are), you are unlikely to realize how common and completely normal most of these genital variations are.

10 Common Penile “Flaws” You May Have That Are Actually Quite Normal

  1. Penis leans to one side. No human is perfectly symmetrical and the flaccid penis rarely hangs perfectly centered. Wherever your penis naturally lies when you are clothed—whether left or right—is not indicative of your political leaning or left vs. right-sided brain predominance and is of absolutely no significance or consequence whatsoever!Interesting trivia: “Throckmorton’s sign” is a term used jokingly by medical students, residents and attending physicians. A positive Throckmorton sign is when the penis points to the side of the body where the pathology is, e.g., if a man is getting surgery for a right groin hernia and the penis points to the right side. The Throckmorton sign indicates the proper side of the pathology at least 50% of the time! Operating room humor!
  2. Slight penile curvature when erect. Again, although perfect symmetry may be desirable, the norm for the erect penis is not to be perfectly straight. There is often a subtle bend to the left, right, up or down. Some men have a penis that has a banana-like curvature. Slight bends—considered totally normal—are to be distinguished from Peyronie’s disease, a condition in which there is significant angulation due to scarring of the sheaths of the erectile chambers. It is a potentially serious condition that can cause painful erections and erectile dysfunction.
  3. One testicle hangs lower. If you ever wondered why one of your testes is slightly bigger or heavier and hangs lower than the testes on the other side, you are in good company. Paralleling women with breast asymmetry, the vast majority of men have testes asymmetry, so your mismatched gonads are perfectly normal.
  4. Dark genital skin. Hyperpigmentation (darkening) of the median raphe (the line running from anus to perineum to scrotum to undersurface of the penis) and other areas of the penis is extremely common. In fact, it is normal for the penile skin color to be darker than other areas of the body, because of the effect of sex hormones on the cells that produce pigment (melanocytes). The circumcision line, as well, is often deeply pigmented
  5. Freckles, moles and skin tags. The penis is covered by skin–just like the rest of the body–and is therefore subject to common benign skin growths, including moles, freckles and skin tags. These are generally harmless and usually, do not require any treatment unless desired for cosmetic reasons. However, if you have a growth that changes in size, color or texture, you should have it checked out because penile cancers do occur on occasion. Skin tags are small fleshy protuberances and can be confused with genital warts, so if you have any doubt, get checked.
  6. Other penis and scrotal bumps and lumps. Pearly penile papules are raised “pearly” bumps that appear around the corona (the base of the head of the penis). They consist of one or more rows of small, fleshy, yellow-pink or transparent, smooth bumps surrounding the penile head. They are benign and do not cause harm, but sometimes are treated for cosmetic reasons, usually with freezing or lasering. Sebaceous glands produce oil that nourishes the hair follicles of the genitals. These glands appear as numerous small yellowish bumps on the scrotum and penile base. In some men, they are prominent and referred to as sebaceous gland hyperplasia. At times, they can exist without a hair follicle even being present. Regardless, they are a normal occurrence.
  7. Scattered scrotal spots. Angiokeratomas are benign purplish skin growths with a scaly surface that are not uncommonly present on the scrotum. They consist of dilated thin-walled blood vessels with overlying skin thickening. These skin lesions can occasionally bleed and also cause fear and anxiety since they can resemble more serious problems such as melanoma. If in any doubt, get it checked out.
  8. Veiny vanity. Every man has a unique penile venous pattern, the anatomy as unpredictable as the distinctive venous anatomy of the hand and wrist. In some men, the veins are twisted and prominent and in other men, they are barely noticeable. No matter what the pattern, venous anatomy is highly variable and individualized and is normal.
  9. Loose skin. Unlike most other skin on the body that is more tightly attached, penile skin is loosely attached to underlying tissues, allowing for expansion with erections. Since the physical state of the penis can vary from totally flaccid to totally rigid, when the penis is fully deflated, the skin may appear to be somewhat floppy and redundant, which is absolutely normal. Scrotal skin often becomes increasing lax with the aging process, such that the testicles typically hang quite low in the elderly male, paralleling the common situation of pendulous breasts of the elderly female.
  10. Shrinkage. Penile size in an individual is quite variable, based upon penile blood flow. The more blood flow, the more tumescence (swelling); the less blood flow, the less tumescence. “Shrinkage” can be provoked by exposure to cold (weather or water), the state of being anxious or nervous, and participation in sports. The mechanism in all cases involves temporarily reduced blood circulation. Don’t worry, that sorry and spent looking penis can magically be revived with some TLC!

Bottom line: If you have an imperfect penis…welcome to the club! No penis or scrotum is perfect. Far from being an object of beauty, genital imperfections are the norm, so there is no need for feeling self-conscious. Just be happy that your little “fella” can function properly and enjoy his own happiness from time to time! Function over form!

Written by Dr. Andrew Siegel


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