Premature ejaculation (PE) is the most common sexual dysfunction in men. When you think about sexual dysfunction in men, you may consider erectile dysfunction (ED) the most common, but that could be due to the extensive advertising for medications for ED and references in popular culture.

Up to 39% of men in the general population have PE or some form of it. There is a genetic component in first-degree relatives, which makes PE slightly different from other sexual dysfunctions because other sexual dysfunctions do not have this degree of genetic predisposition.

In addition to being biologically driven, PE is driven by relational, emotional, and psychological factors. Men with PE often seek treatment through urologists or primary care doctors before engaging in sex therapy.

Some biological-based forms of PE can be treated solely by a urologist or primary care physician, but PE that involves psychological, relational, or emotional factors would be best treated using a combination of interventions, including medicine, psychotherapy, and sex therapy.

Urologists will be able to work through any medical factors that can be physically contributing to PE and a therapist’s job is to help men with PE adjust and adapt to chronic biological contributions to find sexual pleasure and freedom or utilize psychological and sex therapy interventions to treat more psychological causes of PE.

Different Types of PE

There are different types of PE and knowing what type a man has is important to determining a good treatment strategy.

Lifelong PE (LPE) is when a man has always had the symptoms of premature ejaculation.
Acquired PE (APE) is when there’s a period of normal or healthy ejaculatory latency, but then something happens and premature ejaculation symptoms develop. APE cases are most commonly referred to sex therapists because they are more complex in terms of what is creating the symptoms.
Natural Variable PE (NVPE) is when men experience PE sometimes, but not always. NVPE cases generally do not have biological, but more psychological components.
Premature-Like Ejaculatory Dysfunction (PLED) involves the experience or belief that a man thinks he is ejaculating too quickly but he is technically in the average range for ejaculatory function.

Research has shown that men with lifelong PE and acquired PE had higher rates of counseling with a doctor than men with the natural variable or PLED. Prevalence can also vary depending on a man’s personal or cultural background.

For a more in-depth look at the prevalence of PE in men, sign-up for a MendEd Course »

*The first clinician to sign up for this course will receive a free course download and CEU credits. Please use this discount code PE-Provider during the check-out process.

Etiology of PE

There are many reasons why a man could have premature ejaculation. While we don't know the actual cause of PE, we do know though that it can involve a single or combination of causes, including, genetic, pharmacological, psychological, neurobiological, urological, or endocrine factors.

We also know that men that have acquired PE can have other causes. Acquired PE has been found to be caused by opioid substance withdrawal, prostatic inflammation or swelling, hyperthyroidism, or psychological factors.

Psychiatric and psychological factors that cause PE have been considered from a behavioral lens in which men developed a “hurried” pattern of ejaculation in the development of PE. For example, men that had a particular way of masturbating where they had to hurry out of shame develop this premature symptom when they get into partnered sex. There are currently no evidence-based treatments for this hypothesis, but therapists can treat psychological factors using a variety of clinical interventions and methods.

Frequently PE is defined by intravaginal ejaculatory latency time (IELT), or the length of time it takes for a man to ejaculate after vaginal penetration. This conceptualization is heteronormative in nature since not all men penetrate vaginas to have sex. This conceptualization is being evolved as studies expand to include how PE affects gay or bisexual men or other forms of sexual stimulation.

The concept of IELT is really driven by the need for a method of measurement in clinical research, but in clinical practice, there are other considerations to be discussed with a provider regarding how PE symptoms occur, for example, during masturbation.

Sexual dysfunctions are often siloed with psychological treatment being administered by one healthcare professional and medical treatment being done by another with no integration. Sexual health is much more complex and it combines all the biological, psychological, emotional, and relational factors.

Research has found a correlation between lack of exercise and premature ejaculation. Men with PE will often report they don't have a good body image or they feel overweight. While it is not known whether or not feeling good is driving some of the anxiety, or if it is the actual physiological effects of exercise that can decrease symptoms of PE, exercise is generally helpful in the treatment process.

For a more in-depth look at the etiology of PE, sign-up for a MendEd Course »

*The first clinician to sign up for this course will receive a free course download and CEU credits. Please use this discount code PE-Provider during the check-out process.

History of Diagnosing PE

Diagnosing PE can shift between the different facets of medicine. Urologists make their own diagnostic criteria, as do psychiatrists, different medical societies, and individual researchers.

A consistent theme throughout these definitions is that it increases distress or interpersonal difficulty for the person experiencing PE.

The DSM-5-TR, which is the current diagnostic manual for the American Psychiatric Association, uses the technical term “premature (early) ejaculation”. The definition includes the following factors:

A persistent or recurrent pattern of ejaculation occurs during partnered sexual activity within approximately one minute following vaginal penetration and before the individual wishes it.*
The symptom must have been present for at least six months and must be experienced on almost all or all (75%-100%) occasions of sexual activity.
The symptom causes clinically significant distress in the individual.
The sexual dysfunction is not better explained by a nonsexual mental disorder or as a consequence of severe relationship distress or other significant stressors and is not attributable to the effects of a substance/medication or other medical condition.

*Note: Although the diagnosis of premature (early) ejaculation may be applied to individuals engaged in nonvaginal sexual activities, specific duration criteria have not been established for these activities.

Therapists cannot make assumptions that it would be the same for every type of stimulation. The DSM-5-TR provides a very clear distinction between whether it's lifelong or acquired, generalized or situational, and then the severity, mild, moderate, or severe.

Treating Premature Ejaculation

There is a genetic component in first-degree relatives, which lends biological-based forms of PE to be treated solely by a urologist or primary care physician.

Psychological Factors of PE

While there are many psychological elements that can play a role in PE, a few of the more common factors include:

Attachment Relationships
Perception of Control
Temperament and Character
Alexithymia
Meta-cognitive Abilities
Childhood Maltreatment

Understanding the varying impact that these psychological factors have on people with PE can also help us to treat the disorder appropriately. The primary treatment options for PE include medical intervention, urological treatment, interdisciplinary approaches, and sex therapy.

Medical Treatments

These treatments often include prescription medications, which can be prescribed to delay ejaculation. Several different studies and clinical trials regarding the effectiveness of different drugs on PE treatment have taken place since 2004.

Studies have also shown that topical anesthetics and SSRIs may also be effective treatments for those being impacted by PE.

Generally, the pharmaceutical intervention has been found to be most useful for men experiencing lifelong PE, while counseling, psychoeducation, medication, and local anesthetics for variable and subjective PE.

Urological Treatments

Of approximately 207 interviewed, 73% of urologists reported seeing less than one case of PE per week. On-demand SSRI therapy (where the patient takes an SSRI prior to intercourse) was the primary suggested treatment, with daily dosing SSRIs was the secondary.

Interdisciplinary Approach

As previously outlined, psychological, neurobiological, and genetic factors play a role in PE. Considering that different situations can cause different forms of PE, literature reviews have shown that combining treatments can be beneficial to help those with PE cope with their specific form.

A medical, sexual, psychological, and relationship history should be obtained prior to treatment to develop a specialized treatment plan.

Sex therapy, in combination with medication, is generally the best approach for treating PE.

Sex Therapy

While there’s limited research regarding the efficacy of mindfulness on PE symptoms, a 2020 study discovered that men who underwent sex therapy and practiced mindfulness reported reduced PE-associated sexual distress, depression and anxiety.

Studies have also shown that yoga as a mindfulness practice can have an improvement on PE symptoms.

Psychoeducation for Patients

Understanding the mental, psychological, and physiological workings of ejaculation and orgasms can help overcome issues with PE. Some examples include:

Understanding and learning to identify the sexual excitement cues throughout the body.
Understanding that ejaculation and excitement can be self-controlled.
Understanding that sexual stimulation causes sexual excitement and that sexual excitement can be monitored and modulated.

People may also experience a lot of anxiety surrounding their performance and their inability to extend the duration of their ejaculation. Learning coping skills and breathing techniques provides a tool to use to counteract that anxiety and find more pleasure in intimate experiences. Some of these skills include:

Breathing abdominally
Performing pelvic movements in different positions
Varying the speed, amplitude, and intensity of pelvic movements
Breathing with an open mouth and relaxed jaw

To learn more about techniques for treating PE, please take our full online mini-course. We have an in-depth research-based course for providers and a brief solution-focused informative course for individuals or couples struggling with PE.

For a more in-depth look at PE, sign-up for a MendEd Course »

*The first clinician to sign up for this course will receive a free course download and CEU credits. Please use this discount code PE-Provider during the check-out process.