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Harvard Commentaries
Harvard Commentaries
Reviewed by the Faculty of Harvard Medical School

Man to Man Man to Man

Premature Ejaculation

January 24, 2013

By Harvey B. Simon M.D.

Harvard Medical School

When men think about sexual woes, they usually put erectile dysfunction (ED) at the top of the list. That's understandable, since about 30 million American men suffer from ED — and ads for Viagra, Levitra and Cialis fill the airwaves. Women, too, focus on their partners' erections as the key to sexual success.

But there is more to a good sex life than an erection. In fact, an erection won't satisfy either partner if a man ejaculates too soon.

Premature ejaculation (PE) is the most common ejaculatory disorder, but it doesn't get the attention it deserves. It affects 30% of men at some time. Unfortunately, though, most guys are reluctant to discuss the problem. This leaves them with shame, frustration and strained relationships, which is unfortunate because there are effective treatments.

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Normal Ejaculation

The sex act is instinctive and automatic, but it depends on the complex interaction of the mind, the nervous system, blood vessels and the genital tract itself. With so much involved (and so much at stake), a lot can go wrong. Sexual arousal for men begins with interest and desire and follows these stages:

    • Arousal – Various combinations of erotic thoughts and sensory stimulation lead to arousal. The impulses of desire are transmitted from nerves in the pelvis to the arteries in the penis, which widen to admit more blood and produce a rigid erection.
    • Ejaculation – Nerves trigger muscle contractions that propel semen (a mix of sperm and other fluids) out from the prostate gland into the urethra, the tube that carries urine and semen our through the penis. The muscles of the neck of the bladder close. This prevents semen from entering the bladder. At the same time, muscles in the penis and pelvis begin to contract rhythmically. This forces the semen forward through the urethra and out from the penis. Ejaculation is usually accompanied by the pleasurable sensation of orgasm.
    • Recovery –The arteries in the penis narrow and the veins widen. Blood drains from the penis and it returns to a flaccid (limp) state.

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Premature Ejaculation

From a biological point of view, the whole purpose of sex is to reproduce or have offspring.

In most animals, sex is brief, and ejaculation occurs shortly after penetration. In humans, though, sex involves a broad mix of psychological and interpersonal factors.

Ejaculation is premature when it occurs before either partner wants. Sometimes it occurs with little sexual stimulation early in foreplay. More often, it develops shortly after penetration before both partners are satisfied. (It is not defined by the clock.) Either way, it causes shame and embarrassment for the man, and frustration and discontent for both partners.

Many men experience premature ejaculation from time to time, but for some it's a continual problem. In large surveys, PE is the most frequent form of male sexual dysfunction, affecting up to 30% of men. It is most common in young and sexually inexperienced males but can happen at any age.

Most men with PE are perfectly healthy. Others have psychological disturbances, medical conditions like diabetes, or urologic problems, like inflammation of the prostate. Treatment for PE uses behavioral techniques, medication, or a combination of the two.

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Behavioral Therapy

Behavioral therapy is safe and simple. According to sexologists, it helps 60% – 90% of men with premature ejaculations. Here are three behavioral methods men can use alone or in combination.

    1. The "pause and squeeze" technique – This is the most successful method. It was developed by well-known sex experts Masters and Johnson. When a man feels an orgasm developing prematurely he stops sexual activity. Then he (or his partner) squeezes the shaft of the penis between a thumb and two fingers. After applying gentle pressure just below the head of the penis for about 20 seconds, he can release the squeeze and start sexual activity again. The technique can be repeated as often as needed; if all goes well, the man will eventually learn to delay ejaculation without the squeeze.
    2. The "start-stop" method - The man brings himself close to orgasm with the aid of his partner or by self-stimulation. Before climaxing, he stops, relaxes and then begins again. He can repeat the cycle until he can no longer prevent ejaculation. The goal is to recognize when orgasm is about to happen and to put on the brakes, allowing the successful transition from masturbation to intercourse.
    3. Kegel exercises - Kegels are wellknown for helping to treat urinary incontinence in men and women. A man can identify the pelvic muscles by stopping the flow of urine in midstream. Once he has learned to control these muscles, he practices tightening them while his bladder is empty. He should hold each contraction for 10 seconds, then relax for 10 seconds, repeating the cycle 10 times, three or four times a day.


Behavioral therapy takes a lot of time. It works best when supervised by a sex therapist. It also requires the cooperation of both partners. Relapses are common. If a man has psychological problems that either contribute to or result from PE, these issues need treatment directly.

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Treating PE with Medication

For many men with PE, medication is a shortcut to success. The Food & Drug Administration has not yet approved a medication specifically for PE. But doctors use antidepressants to treat PE. They discovered their effectiveness by accident. Some men taking antidepressant medication complained of delayed ejaculation. From there, it was a logical step to use these medications, especially the popular selective serotonin reuptake inhibitors (SSRIs), to treat PE. The older tricyclic antidepressants have also had favorable results.

Doctors generally start with an SSRI, such as sertraline (Zoloft), paroxetine (Paxil), and fluoxetine (Prozac). All three can produce longer-lasting erections and greater sexual satisfaction. Dapoxetine is a newer, short-acting SSRI specifically for PE, but it is not yet available for clinical use. The older tricyclic clomipramine (Anafranil) appears to be as effective as the SSRIs, but may have more side effects.

Antidepressants are prescription medications that require a doctor's supervision. They can be used for PE daily or taken as a single dose two to four hours before intercourse. Recent studies report that men who don't respond to an SSRI alone may get good results by also taking the ED medicine sildenafil (Viagra).

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Local Anesthetics

Antidepressants are a major advance in the treatment of premature ejaculation. But they can have unpleasant side effects — and they are expensive. So, some men prefer to try desensitizing agents. These include:

    • "Climax control" or "extended performance" condoms, which apply a mild anesthetic, benzocaine, to the penis. They are commercially available but have not been scientifically tested.
    • A cream containing prilocaine and lidocaine, which has had beneficial results in small studies. It is called EMLA cream and is licensed to reduce the pain of a doctor's needle but a doctor can prescribed it "off label" for other uses. The major side effect is numbness. Men who use the cream should wear a condom to prevent genital numbness in their partners.
    • Chloraseptic mouthwash, which some men report anecdotally can provide enough local anesthesia if it's sprayed on the penis before intercourse. It is safe and inexpensive, but experience is scant.

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Harvey B. Simon, M.D. is an Associate Professor of Medicine at Harvard Medical School and a member of the Health Sciences Technology Faculty at Massachusetts Institute of Technology. He is the founding editor of the Harvard Men's Health Watch newsletter and author of six consumer health books, including The Harvard Medical School Guide to Men's Health (Simon and Schuster, 2002) and The No Sweat Exercise Plan, Lose Weight, Get Healthy and Live Longer (McGraw-Hill, 2006). Dr. Simon practices at the Massachusetts General Hospital; he received the London Prize for Excellence in Teaching from Harvard and MIT.

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