To Become A Longer Lasting
Sexual Therapy For PE
Michael Perelman works at Cornell University and has developed ideas for sexual therapy around the diagnosis and treatment of premature ejaculation.
In an article published in the Journal of Sexual Medicine in 2006, he proposed that the best cure would be a combination of sex therapy and pharmaceuticals.
His basic thesis is that a widespread failure to understand the fact that PE is caused by many factors acting together makes it more difficult to diagnose and treat. While doctors have tried pharmacologic treatments, they have failed to understand how complicated the condition is; whereas sex therapists appreciate the multidimensional nature of premature ejaculation.
Treatment must involve the man and his partner, for example, but few men seek treatment, and even fewer bring their partners along. Indeed, most men with this dysfunction do not receive treatment, mostly because they're embarrassed about discussing it, and perhaps also because doctors (and maybe even therapists) are reluctant to ask about it.
As Perelman also observes, even for those men who do seek help, diagnosis of premature ejaculation may be inconsistent, because a universally accepted definition of the condition and clear diagnostic criteria are more or less non-existent. And yet this is a condition that requires treatment, because men with premature ejaculation experience considerable anxiety and lack sexual self-confidence: this means that their sexual, and indeed their overall relationship, frequently suffers.
In short, Perelman believes that because PE involves both psychosocial and physiological factors, any treatment methodology should address both issues. So let's examine his case that treatment which integrates pharmaceuticals and sex therapy would indeed be the optimized approach to dealing with PE.
Treatment of Premature Ejaculation
There been many treatments devised over the years, mostly psychological in nature, possibly with a behavioural component added. Methods that have been reported over the years include the stop start technique of Dr James Semans and the squeeze technique of Masters and Johnson. Single men have been treated using sexual surrogates, whilst men in relationship have been encouraged to bring their partner to the treatment sessions. These approaches are actually highly effective in controlling premature ejaculation when the man shows the commitment necessary, and his partner is willing to cooperate with him.
However, these treatments are likely to fail in the case of men whose ejaculation is so rapid that they get absolutely no warning of it; these are the men who speak of their climax in terms of "it just happens with no warning". These men are desperate for information about how to stop premature ejaculation. Perelman's conclusion is that sexual therapy cannot be regarded as an effective treatment for all men, a fact which I would agree with for those not involved in a continuing relationship or those who are starting a new relationship. This brings us to the question of how premature ejaculation treatment might be addressed in men who fall into these categories. The obvious answer is to use some kind of pharmaceutical or drug based option.
Drugs As Treatment Options
These include anaesthetic lotions, selective serotonin reuptake inhibitors or SSRIs, and even Viagra, which, although not a medication designed to inhibit ejaculation, may allow a man to sustain an erection after he has ejaculated so that he can continue making love. The unfortunate reality is that anesthetic creams are ineffective, possibly irritating to the genitalia, and often messy and impractical to apply. Many men report a burning sensation when they use them.
The development of SSRIs is an interesting possibility for the treatment of premature ejaculation, although the fact that Dapoxetine (aka Priligy) is not been licensed by the FDA for use in America does sound a warning note. In a subsequent article we will examine why it's been licensed in Europe, but not in America for this purpose. Development of Dapoxetine followed the observation that the use of SSRI's the treatment of depression often produced retarded ejaculation - a long delay in ejaculating during intercourse or even total anorgasmia. Clinical studies have confirmed the role of serotonin in the ejaculatory mechanism, thus making it certain that this area would be investigated by the pharmaceutical companies.
The use of Viagra is clearly inappropriate for most men with premature
ejaculation, and it's used for those men who suffer from premature ejaculation
as a consequence of erectile dysfunction.
On a practical note, it's a wonderful experience to observe a man who's gained control of his ejaculation, and listen to his experience of sex as becoming a relaxed experience which is not any more an experience akin to serious effort.
It's possible that medication may provide a useful breathing space for a man to learn to recognise the symptoms of his impending ejaculation, and as he becomes more skilled in recognising these symptoms, and responding to them in an appropriate way, medication could be gradually reduced.
Development of SSRI Treatment For Premature Ejaculation
Times have moved on, of course, and in the absence of any better behavioral therapy, it was inevitable that a body of research would emerge into the role of physical factors in premature ejaculation. This seems to ignore one very important aspect of sex therapy: that where emotional factors are associated with sexual dysfunction, psychodynamic therapy or counseling is essential to reduce anxiety, lack of confidence, difficulty in sexual interaction with the partner, emotional difficulties or stresses within the relationship, and so on. The same is also true of simple factual education – because even today, there are many couples who do not realize that foreplay is essential to female sexual arousal before penetration.
Scientists have worked long and hard to identify physical factors which might be responsible for premature ejaculation. None moreso than Marcel Waldinger, who has been an advocate of medication as a cure for premature ejaculation for quite some time. Writing in 1998, Waldinger observed that premature ejaculation "was and still is considered a psychosexual disturbance". Naturally enough, as he states, this led to the idea that the main (if not the only) way to treat it was behavioral therapy using either the squeeze technique or the stop-start technique, together with other therapeutic interventions. He also reports longitudinal studies in which the initial positive effects of these behavioral techniques disappeared after three years – a common view of the therapies in question, but one which is not borne out by my experience.
Perhaps in view of the disappointing perception of behavioral therapy, pharmacotherapy became popular to delay ejaculation: the first treatment agent available consisted of anesthetic ointments were used on the glans penis, but later it became apparent that men on antidepressants tended to experience a delay in ejaculation. The initial use of clomipramine and benzodiazepines as agents to delay ejaculation was later succeeded by the use of selective serotonin reuptake inhibitor antidepressants such as fluoxetine and more recently Dapoxetine.
From this, Waldinger concluded that whilst premature ejaculation was still generally considered to be of psychological origin, it may well be caused by disturbances in the serotonergic transmission of impulses in the nervous system, and that in turn might be due to genetic factors.
Obviously both genital and cortical stimulation involved in triggering the ejaculatory reflex. And this is where serotonin may have a role to play in the ejaculatory pathways. Serotonin is also known as 5 hydroxytryptamine, or 5 HT. Some of the earliest evidence for the involvement of serotonin in cortical processes was the way in which reserpine, a drug used to treat hypertension, caused depressive mood in many people: this drug initially causes the release of serotonin from presynaptic terminals, but later inhibits its release. This led to the conclusion that low serotonin levels could cause depression. Serotonin is itself a monoamine, so it would appear that low levels of monoamines can cause depression… Hence the development of selective serotonin reuptake inhibitors, which have been used extensively ever since as antidepressants.
Science of Serotonin and Ejaculation
There are actually many different serotonin receptors in the brain, which has led to extensive research on the possible role of serotonergic cell groups in the ejaculatory mechanism. Without going into excessive detail, it would appear that SSRIs actually have an inhibitory effect on ejaculation in a remarkably quick way, and effect which is not fully understood, but allows a kind of on demand dosage of short half life medication to act as an effective regulation over the speed of a man's ejaculation. Animal studies were used to elucidate the mechanism by which SSRIs might inhibit human ejaculation: in essence it would appear that hypersensitivity of 5HT-2c and 5-HT1a receptors is responsible for premature ejaculation.
Naturally enough, considerably more scientific evidence has accumulated since this work was initially written up in 1998, and on another page of this website we shall investigate this further.
Over the last few years a variety of premature ejaculation treatments have been promoted, often by drug companies who have an inherent interest in financing drugs that are supposedly effective at curing premature ejaculation (potentially a massive marketplace). In particular, a wide range of SSRIs (selective serotonin reuptake inhibitors) have been tried as a cure for premature ejaculation.
It should be said that these drugs were actually developed to treat depression, and are still used for that purpose. They interfere with brain chemistry by raising the level of serotonin, a neurotransmitter which is found outside the brain cells. They do this by interfering with its uptake into the presynaptic cell, and increasing levels of serotonin available to bind to the postsynaptic neuron receptors. SSRIs also bind to some degree with other monoamine transporters, although it's been found that they have very little ability to bind to dopamine or noradrenalin transporters.
SSRIs are fairly heavy duty pharmaceuticals – as you might expect from something that interferes with brain chemistry. It is therefore hardly surprising that they cause several side effects - to be blunt, they cause sexual dysfunction in men. While these drugs may slow down ejaculation, it is possible for a man to experience anorgasmia when he takes SSRIs – a complete inability to ejaculate or achieve orgasm - and it's certainly possible for them to cause diminished sex drive and erectile dysfunction. It's not entirely clear how frequent these side-effects are, but they are certainly common enough for the FDA to have refused to license the drugs as a treatment for premature ejaculation.
Despite this, some doctors willingly prescribe them "off label", a euphemism for prescribing a drug for some use for which it was not designed. Whether this is ethical or not is not germane to this discussion; it happens, and I guess for as long as men wish to increase the time to ejaculation, stop premature ejaculation, and improve their sexual performance it always will happen. Even so, I strongly advise you not to take SSRIs – Dapoxetine is the one usually prescribed – as a treatment for PE. There are many reports of side effects - including sexual dysfunctions such as anorgasmia - which are usually explained away by saying that they will reverse spontaneously when the medication is stopped, but there have been reports of men whose sexual functions have not been restored. (If it's of any help to you, the effect of SSRIs can be reversed by administering mirtazapine, bupropion, amphetamine, buspirone, methylphenidate, or ropinirole.)
Dapoxetine, a new antidepressant (2006), has been found to be comparatively safe and somewhat effective for the treatment of mild cases of premature ejaculation, if you believe two major clinical trials. Dapoxetine is a reasonably short-acting SSRI or selective serotonin reuptake inhibitor (SSRI). It is not so unusual (though possibly unethical) for SSRIs to be used s so-called "off-label" medication for premature ejaculation. However, experts doubt Dapoxetine will be approved by the FDA (Federal Drugs Administration) any time soon because SSRIs are associated with undesirable and sometimes troublesome side-effects after long-term application, such as mental and emotional issues, psychiatric problems, skin reactions, weight gain, lowered libido, sickness and nausea, headache, stomach upsets and muscle weakness. Even so, Dr. Jon Pryor, head researcher, University of Minnesota, said that according to his research (check if this was funded by Johnson and Johnson or their successors), Dapoxetine actually lengthened ejaculation time and, he claimed, gave men more ability to avoid premature ejaculation.
Dapoxetine received marketing authorization in Finland and Sweden in February 2009 for the on-demand treatment of rapid ejaculation (PE) in men aged between 18 and 64 years of age. It's now approved in Sweden, Austria, Germany, Spain, Italy and Portugal and Finland. This compound is delivered by tablet and is claimed to be short-acting when taken between one and three hours before sex. There are side effects, including nausea, and the dramatic claims (a doubling of the latency time) are not so impressive when you see it only worked for about 45% of the men who took it, and they originally could only have sex for around a minute and a half before reaching climax. If you want to try Dapoxetine, you will have to see a qualified medical practitioner.
The Elusive Medical Cure For Premature Ejaculation
The on-demand use of SSRIs to stop premature ejaculation continues, and is still rather controversial. Dapoxetine is more promising for on-demand treatment. Maximum concentrations of the pharmacologically active substance are achieved about one hour after a 30-mg oral dose. Two randomized, placebo controlled studies of over 2000 men with PE revealed that Dapoxetine increased not only IELT, but also a man's perception of the level of his control over the timing of his ejaculation, and most especially his and his partner's satisfaction with sexual intercourse. The IELT increase amounted to 2.8 times and 3.3 times for the 30 mg and 60 mg groups, and only 1.8 times for placebo. The effectiveness of the drug is less than for daily SSRI administration, but even so it is convenient and fast acting. The FDA has not granted a license for the drug in the treatment of PE.
Another study looked at patient preferences for learning how to cure premature ejaculation. It compared men's responses to anesthetic ointment with on-demand and continuous use of SSRIs. Perhaps rather surprisingly, a large majority of men preferred continuous treatment: the numbers wanting on-demand SSRIs and anesthetic ointment were rather low. And in fact this did not change even when the men were told about possible side-effects. However, the problem is that the men were only offered a variety of SSRI which needs to be taken several hours before intercourse - hardly a recipe for successful spontaneous sex. In other words, the study is pretty useless about interpreting men's intentions around premature ejaculation treatment.
Tramadol is a reportedly effective, centrally acting analgesic with two different mechanisms of action: a weak p-opioid effect, and an inhibition of noradrenalin and serotonin reuptake, which apparently activates descending monoaminergic inhibitory pathways. While the drug can be taken an hour or so before intercourse, and a 50 mg dose is highly effective in extending the time for which men can thrust (increasing the IELT by 13 fold), this dosage does have some rather marked side-effects: 28% of men experience nausea, vomiting and dizziness, which may mean it is not a suitable treatment for early ejaculation. With a lower dosage of 25 mg, men experienced a 6.3 fold increase in IELT compared to a 1.7 fold increase in a placebo group. In this case, about 13% of the men reported adverse side-effects including dyspepsia and mild somnolence.
Viagra - aka sildenafil citrate - has also been researched as a possible treatment for early ejaculation: chiefly because many men with premature ejaculation also have erectile dysfunction. However, the results of these studies have been encouraging, showing that Viagra can produce a 15 fold increase in IELT when taken 3 - 5 hours before intercourse. Furthermore, the use of Viagra also increased sexual satisfaction markedly; unfortunately, about 18% of men who tried this drug reported headaches and facial flushing, which are known side-effects of Viagra.
Combined Drug and Psychotherapy Treatments
Another piece of research compared how effective Viagra was in extending IELT and controlling premature ejaculation when used with (1) a daily SSRI (paroxetine) and (2) the squeeze technique. The research also investigated how satisfied the men were with sexual intercourse. After six months' treatment, the investigators found a 5.7 fold, a 2.5 fold, and a 4.4 fold increase in IELT in men treated with Viagra, the squeeze technique and the SSRI paroxetine respectively. The greatest increase in sexual satisfaction was reported in the men who received treatment for PE with Viagra. Once again, the most noticeable side-effects were nasal congestion, flushing, and headaches.
However, in men who do not have erectile dysfunction, the results are confused. Studies show that there is no difference in improvement in ejaculation control among men able to get an erection between those given Viagra and those given a placebo. However, the men who received Viagra did report much greater sexual satisfaction, and also said they had greater control over their ejaculation and greater ejaculatory confidence. It may well be that the benefit of the Viagra centers on providing an enhanced erection after ejaculation has occurred.
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Other treatment options include alpha-adrenoceptor antagonists, which are used to improve obstructive urinary symptoms. There has been limited work on animals in this field, so the evidence on human sexual behavior is unclear, although one clinical study appeared to show some improvement in about half of men with premature ejaculation who were resistant to psychotherapy.
There are, of course, other treatment methods under investigation. The best treatment would be an on-demand treatment which worked well with minimum side-effects, had a short delay before it became effective, and allowed spontaneous sexual activity. Obviously one approach to this is to rely on a drug based approach. A combination of 5-HTIA receptor blockers and SSRI seems to produce a very significant increase in IELT, though the potential adverse side-effects of the combination have not yet been evaluated.
Another approach is to use a combination of behavior therapy and physiological therapies. Premature ejaculation is condition with many aspects, and may represent a physiological response which is compounded by psychological and interpersonal issues. It may well be, therefore, that combination therapy is the way forward.
Of course, since premature ejaculation is a self-reported condition, the diagnosis is mainly based on perception, and none of the guidelines suggest a formal diagnostic testing, there are problems inherent in all stages of any investigations into the problem. The first stage is to confirm that three elements of the definition are present: short time before ejaculation, lack of control over ejaculation, and emotional distress for both partners. Therapy needs to be tailored for the individual man, so that all treatments for premature ejaculation are considered and each treatment option reviewed. For many men with a lack of ejaculatory control, collaboration between doctor and sex therapist has a significant impact on treatment success rates and men's ability to last longer in bed.
Other pages on controlling premature ejaculation& lasting longer