Premature Ejaculation: Breaking the Silence

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Premature Ejaculation: Breaking the Silence

WebMD Live Events Transcript

According to the American Urological Association, premature ejaculation (PE) may be the most common male sexual disorder and can affect one in four American men. But PE is often misunderstood and underdiagnosed because men are too embarrassed to discuss it with their doctor. Urologist Jon Lee Pryor, MD, joined us to answer your questions on May 24, 2005

The opinions expressed herein are the guests' alone and have not been reviewed by a WebMD physician. If you have questions about your health, you should consult your personal physician. This event is meant for informational purposes only.

MODERATOR:
Welcome to WebMD Live, Dr. Pryor. Thank you for joining us today.

PRYOR:
My pleasure.

MODERATOR:
We've read that premature ejaculation (PE) is the most common
sexual dysfunction among American men. How do you define PE?

PRYOR:
Premature ejaculation is when somebody ejaculates before he wants to on a consistent basis and it causes some distress or interpersonal difficulty. Let's say he ejaculates before he wants to and it's not causing a problem, then it's not premature ejaculation.

From a medical standpoint we say that it cannot be from certain medications. Example: If somebody is on an opioid and you withdraw it, then that can cause premature ejaculation, so not due to certain medications.

The bottom line is if you ejaculate too soon, before you want to, and it causes some distress -- that's the most important part of the definition.

MODERATOR:
What causes PE?

PRYOR:
We don't know for sure, but it has something to do with a chemical in the brain called serotonin. If you have low levels of serotonin you can ejaculate too soon and if you have higher levels, that helps prevent premature ejaculation. That's it from a simplistic standpoint, but there's so much we don't know about why people have premature ejaculation. We're kind of in our infancy in learning about it.

MODERATOR:
Who is likely to have PE? Are some men more likely to have PE than others?

PRYOR:
Just about any male can have premature ejaculation. As opposed to erectile dysfunction, which tends to affect elderly gentleman (it can affect younger people too, but tends to be more common in elderly males), premature ejaculation can affect somebody who is young or old. So it can affect people at any age, it can affect any ethnicity -- virtually anybody could have premature ejaculation.

MODERATOR:
What is the difference between PE and ED (erectile dysfunction)?

PRYOR:
Erectile dysfunction, or as it's often discussed in the public, impotency, is problems getting or keeping a firm erection. Premature ejaculation, again, is when you ejaculate too soon. So somebody could have both, they could have problems with erections and have premature ejaculation but usually they are separate entities.

They both fall under the rubric, the condition, of sexual dysfunction. You could have erectile dysfunction and that could be one sexual dysfunction and another type is premature ejaculation.

Interestingly, there are more people who are likely to have premature ejaculation than ED or impotency.

"Men want to feel like they are good in the bedroom and if they have premature ejaculation, it bothers them; it bothers their self-perception."

MODERATOR:
Why should PE be treated?

PRYOR:
Well, first of all, it causes distress often times for both the person and the partner. So, if you think of having sex or intercourse as being part of a quality of life and something to be enjoyed, we want to make it something that is less distressful, so that it's enjoyable and something that people can become intimate with. That's our goal; it's to make the sexual experience for these people who are often very distressed, a better experience.

I just got an email message today from somebody from Australia for instance, who said that the premature ejaculation was so devastating to him that it was affecting not just what happened in the bedroom, but beyond. It was affecting his whole relationship with his wife and family and he felt terrible about it.

I have personally seen in my clinic, many patients who have premature ejaculation. It's not just something that affects you at the time of intercourse but for many people it extends beyond that event -- it tends to taint how they think about themselves in their daily lives.

MODERATOR:
You are talking about the impact of PE; please tell us more.

PRYOR:
It can be a big impact for people. I think that that's the primary reason why we need to treat it. This is a condition that affects so many people -- approximately 30% of men at any one time can have premature ejaculation and up to 70% of men during their life time will get it at one point or another.

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In the past we didn't have effective therapies and it was really bothering people. They would come in to see me and other physicians and there was nothing that we could do that was satisfactory. There were treatments, but they didn't tend to work very well and they tended to have some side effects. People needed our help and there wasn't any good answer for them up until now.

MODERATOR:
Do you find that most men are silent about PE because of the stigma attached to the condition?

PRYOR:
Yes, I do. I think they are silent for several reasons. One is exactly as you state, because of the stigma. Men want to feel like they are good in the bedroom and if they have premature ejaculation, it bothers them; it bothers their self-perception.

In addition, I think people are silent about it because they thought it was something that affected only them. We clearly recognize that it affected many, many people. Again, it affected more people than have erectile dysfunction. I think that's one of the purposes of shows like this, to get this out there and let people know that they are not alone, that this affects many people.

I think finally, the other reason why people tended to suffer in silence is that they didn't know that there was good treatment available. If you have got a problem but you don't think there's any treatment you tend not to say anything about it.

I think stigma is part of it, but also those other reasons of thinking that it's just them, that they are the only ones suffering with it, and the fact that there's not good therapy available.

MODERATOR:
Are there any FDA-approved treatments for PE?

PRYOR:
No, currently there are no FDA treatments approved for PE. But, there is the one medication, dapoxetine, which Johnson & Johnson research and development has been working on. It has been submitted to the FDA, hopefully for approval to treat people with premature ejaculation.

MODERATOR:
Tell us more about dapoxetine. What kind of medication is it?

PRYOR:
It's called a serotonin transport inhibitor, very similar to an SSRI, in the category of drugs like Paxil. What it does is increase those serotonin levels in the brain and prevents ejaculation, or hopefully slows down ejaculation, so you don't have premature ejaculation.

MODERATOR:
Are any other medications designed to treat PE currently being studied?

PRYOR:
I don't know if there are any others. The only medication that I know for sure that has been studied and actually submitted to the FDA specifically for premature ejaculation is dapoxetine.

There are other off-label therapies out there that people use, but they are not indicated specifically for premature ejaculation and there are problems with them, including some potential side effects.

MEMBER QUESTION:
Is there an age at which PE is most common?

PRYOR:
I haven't seen it broken down specifically by decade, but I know that premature ejaculation really affects men at every decade of life.

I can say anecdotally, from my personal experience, I have seen people who are in their young 20s, people in their 30s, 40s, 50s and people in their 70s and 80s with it. It really can affect people at any point in their life. We tend to think of it as something that just affects young men maybe because of the inexperience of having sex, but it really can affect people at any age.

I would also like to point out that we divide premature ejaculation into two categories. It can be lifelong premature ejaculation or something that may just happen at a particular point in someone's life. So, some people have it their entire lives -- from their very first sexual experience to their very last, other people may not have it and all of a sudden get it.

"There's numerous data out there to suggest, in general, that if ejaculation is in less than two minutes, people are not happy with that."

MEMBER QUESTION:
Is rubbing something on the penis to numb it helpful? If so, what do you recommend?

PRYOR:
Using off-label therapies, such as putting numbing medications on the penis, has been tried and there's no particular one that's better than any other. The one that I tended to use in the past is viscous lidocaine. Viscous lidocaine is like Novocaine but it's thicker and more like a lotion or paste -- a sticky substance that you can rub on the penis. It doesn't work very well because it causes numbness in the penis and also in the vagina. People don't like to be numb down there when they are having sex, so that's the problem with that therapy.

MEMBER QUESTION:
Is there any common reason for its onset in men who have not had a problem with PE in the past?

PRYOR:
No. Part of the problem is we don't understand why people get premature ejaculation -- we don't understand the biology behind it. So, we don't know why someone would not have it and then all of a sudden get it. Certainly in some of these men it may be due to some distress or anxiety in their lives, but there could be also something biologically going on that we just don't know.

MEMBER QUESTION:
There's no delicate way to say this, but if a man experiences PE with one partner, does it mean he will with another partner or by himself? Is it considered PE if it only happens in one type of scenario or with one specific partner only?

PRYOR:
People who have premature ejaculation tend to have it with any partner. If you have it with one partner and then have sex with another, you are likely to have it with that person as well -- if it's real premature ejaculation. Even when they are by themselves and masturbating, they tend to ejaculate sooner than normal.

MODERATOR:
Could you tell us more about the prevalence of PE in American men?

PRYOR:
There are different surveys that have been done, so we tend to get different results. Probably the most famous one is one by Lauman, published in JAMA (Journal of American Medical Association) in 1999. He found that around 31% of all men had premature ejaculation.

There have been other surveys and studies where the figure has been lower -- somewhere between 10% and 20%. I think that somewhere around the 27% to 34%, somewhere in that range, is probably the most accurate number. It is a very common problem.

MEMBER QUESTION:
Is PE subjective? By this I mean, is it simply ejaculating before you want to, or is there a specific point experts define as premature?

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PRYOR:
For the most part, we follow the criteria called the DSM4 that comes from the Psychiatric Association. It is subjective using that criteria -- which is that you ejaculate sooner than you want and it causes distress.

However, when we do studies on this, it's important to have some objective - "something you can hang your hat on" kind of data. So, we time ejaculation in those studies. We did what was called an observational study and when we looked at people in society, surveyed them and found a group of people without premature ejaculation and a group of people with premature ejaculation. We found that people with premature ejaculation did have significantly shorter times to ejaculate than the men without PE. In other words, they ejaculated much quicker than people that claimed they did not have premature ejaculation.

In doing these studies we have defined premature ejaculation in saying that, for these particular studies looking at dapoxetine, you had to have ejaculated less than two minutes in 75% of intercourse attempts.

The two-minute cut-off tends to be a good one, but I have to say that it's not a definition. In other words, somebody can come in to my office and say they ejaculate at one and a half minutes, and not have premature ejaculation -- it may be just when they want, when their partner wants and it may not cause any distress so that person does not have PE. On the other hand, you may have somebody who comes in and ejaculates four minutes after penetration and it may be causing a tremendous amount of distress for both the patient and the partner. So, there's no rigid time cut-off in real life. We use the two minutes, although somewhat artificial, because we needed to have some definition for the study so that the FDA could look at the results with some sort of objectivity.

In addition, in the observational study that we did, people who tended to ejaculate sooner claim that they didn't have control and people who did not the have PE claimed that they feel like they did have control.

There's also some data that we have to suggest that if you ejaculate and it's over a minute, that you're going to be much more satisfied with your sexual experience than if it's less than a minute. There's numerous data out there to suggest, in general, that if ejaculation is in less than two minutes, people are not happy with that.

MODERATOR:
What should men do to find good information and helpful treatment for PE?

PRYOR:
I think they should go to your chat line. Actually, I do believe that getting information from credible sources on the web is really good.

I think that they should also go to a knowledgeable physician in this area. This tends to be urologist, though not all of them will know about PE, but many of them do.

My suggestion is -- don't suffer, try to get some treatment. Today, in May of 2005, there's no therapy specific for premature ejaculation. They are going to have to try things like numbing medications or other medications that may have some side effects. Hopefully in the near future there will be something that's indicated specifically for premature ejaculation.

MODERATOR:
Do doctors often check up on a man's sexual health during routine exams or physicals?

PRYOR:
There are some doctors who do and some that don't. I think that when you go to your general practitioner, your family practice physician, he should ask about it. In general, people don't bring it up on their own. A patient may complain about a back pain or a headache, but does not tend not to say, "By the way, I've got premature ejaculation", or "I have erectile dysfunction."

I think that really good physicians should bring it up to their patients and make them feel comfortable. They should have comfort themselves with the topic and make sure the patient feels comfort so they can have an honest dialogue about this. Through a questionnaire or just talking, doctors should bring this topic up and try to find out if their patients have this problem.

Around 10% to 12% of all men have erectile dysfunction and 30% have premature ejaculation. These are common problems that really affect the quality of life.

MEMBER QUESTION:
What can a man's partner do to help, or maybe I should say what should they do, to not make things worse?

PRYOR:
I think that the best way they can help is to communicate. A lot of times the man wants to be able to talk to somebody about it and it's nice to have somebody that says, "I understand, it's OK, we'll try to get help over this." Communication and understanding are great.

Obviously, the thing not to do, since distress is part of the whole process, is make the person feel guilty about it. Don't make him feel like if he has premature ejaculation that he's a bad person or that he's not the sexual partner that you are looking for. This will cause additional distress.

Women tend, and I'm saying this kind of generally, they tend to be the health care providers or encouragers for their family, including their husbands and they tend to be much more health conscious. In my opinion as an educator in medicine, men need to be more responsible for their own health.

To answer the question, I think that if a woman whose partner has premature ejaculation she should encourage the man to go seek help. Men need to be responsible, but they probably need some encouragement.

"Because ED has been out there on television and passed around in the media, people now feel more comfortable talking about erectile dysfunction."

MEMBER QUESTION:
I ejaculate after four to five strokes into intercourse. I am 28 years old and have been married for five months. It didn't happen much before, but in the last five months it's happening all the time. What is the solution?

PRYOR:
If it didn't happen before but it's happening now, I probably would put you in the acquired category. It also sounds like it's really affecting you.

I would have you go see a urologist and try some treatments. Again, sadly, there's nothing that's specific for premature ejaculation, but there's no harm in trying to get some treatment now to see if you can make it better. The alternative is to wait until something does come out that is specific for premature ejaculation, which again, hopefully will be soon.

MODERATOR:
The stigma and embarrassment that men feel -- could you speak a little more about this?

PRYOR:
I know that it's a very personal thing for people. The fact that it's not talked about very much gives it even more of a stigma than having erectile dysfunction.

Because ED has been out there on television and passed around in the media, people now feel more comfortable talking about erectile dysfunction. They are not as stigmatized about it knowing that people like Bob Dole and others have it, so they feel better about it. But there's no one out there that has gotten up to say, "I have premature ejaculation" so there's a lot of embarrassment. They are thinking that they are the only ones with this problem because they are not hearing that anybody else has it, so I can see why there would be a lot of embarrassment and stigma attached to it.

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I'm sorry that people feel this way, and I think the best thing we can do is let them know that it's not just them, that they can seek help and that in the future we will have even better help for them.

MODERATOR:
You mentioned a questionnaire at the doctor's office. What questions would a doctor ask?

PRYOR:
Questionnaires are great for physicians. For one thing, every one is time conscious -- not just with the physician's time but more importantly the patient's time. A questionnaire is also efficient -- you don't miss asking any questions. But, a questionnaire would not replace dialogue.

This questionnaire could be as simple as one question: Do you have premature ejaculation? If the man answers yes, then the physician can follow it up with questions such as:

  • Does this bother you?
  • Does it bother your partner?
  • Has it been lifelong or recent?

The doctor can then follow up with more questions. It can be just as simple as that.

MEMBER QUESTION:
How many men do you think are suffering in silence, too afraid to seek help?

PRYOR:
I think that virtually everyone with premature ejaculation is suffering in silence. We see, by far, the minority of patients with this problem. If you think about it, 30% of the male population has PE -- that's a lot of men, that's millions and millions of men. There is not good therapy out there and the problem is not known by most people. Sadly, these men are suffering in silence -- a great majority of them.

MEMBER QUESTION:
Is there any evidence that porn watching or masturbation increase the likelihood of PE or any other sexual dysfunction?

PRYOR:
There's no evidence that I'm aware of that watching pornographic television or looking at pornographic magazines contributes to this, I don't think masturbation does either. There's nothing that I'm familiar with that says that that's the case.

MEMBER QUESTION:
I always wake up in the middle of the night not fresh and the whole day I stay dizzy, without concentration and very easily irritated. I have been living like this for more than 10 years but lately it is worse. Because of this, whenever I have sex, I immediately ejaculate -- in just a few seconds. I have visited my doctor who gave some sleeping pills and he's not taking my situation seriously. I relate the issue of my sleep problem with my ejaculation situation. Your thoughts?

PRYOR:
Again, way don't know all the different causes of premature ejaculation. I'm not sure if the sleep problem is causing the premature ejaculation or not, although it is possible that it could be.

I suggest that you get some help from a sleep specialist. This is a very common problem now and we're learning more and more about sleep disorders. Sleep disorders can affect you throughout the whole day and affect your overall health. There are specialty centers that look at this. Perhaps you have sleep apnea or something else going on. The first thing I would strongly suggest is that you seek help from a sleep specialist.

MODERATOR:
You mentioned the woman's role in the family health care; should we wives go in with our husbands' and talk to the doctor about problems like these?

PRYOR:
I tend to be very fair about this. Sure, as long as the husband is willing to come in with the wife when they go to the physician. Maybe that's a little bit too glib. Often times, with sexual dysfunction, we do encourage the partner to come in, so I do think it's a two-way street.

On the one hand, I want the male to be responsible for his own health care. I think that's really important. Everyone needs to be responsible for their own health care and not necessarily rely on other people. On the other hand, sexual dysfunction, in virtually every case, is something that involves both people, therefore it's nice to have both people there. It certainly helps us in the arena of erectile dysfunction, and I know it does in premature ejaculation as well.

The most important thing is for the man to be responsible for his own health care, for the man to go in there and talk to his physician about it. If the woman can go -- great, all the better.

"There are probably some physical causes -- things like prostatitis can cause PE. In most cases it's probably more of a biochemical problem, or a neurological problem."

MODERATOR:
We hear oftentimes that PE is just all in a man's head. Could you talk to us a little about that?

PRYOR:
In most conditions, especially sexual dysfunctions that we don't know much about, that's how we label it -- we say it's in his head.

When I was a medical student, there was a Masters and Johnson text that said that 80% of erectile dysfunction was in a man's head. Now that we understand erectile dysfunction better, we realize that in 90% or more cases, it's truly due to a biological or physical problem.

I think it's the same thing with premature ejaculation; it's easy to say it's up in his head. We say that only because we don't understand the true biological nature of it. I can assure you, there's a lot of evidence out there that in the majority of cases it truly is a biological or biochemical problem.

So to finish this, I think, based on my expertise, I would say in a rare occasion is it truly just a psychological issue.

MODERATOR:
Tell us about physical "causes". And what about medications or stress?

PRYOR:
Certainly stress can contribute to premature ejaculation. We know that there are some medications, for instance, as I said in the beginning, opioids. If you withdraw these drugs it can cause premature ejaculation.

There are probably some physical causes -- things like prostatitis can cause PE. In most cases it's probably more of a biochemical problem, or a neurological problem. These are things that are hard to measure and there are numerous causes for premature ejaculation. If you had a hundred people with premature ejaculation they all wouldn't have the same cause.

MEMBER QUESTION:
How does the ED medication (Viagra, etc.) affect PE?

PRYOR:
The ED medications, in virtually every case don't affect premature ejaculation, if the man only has premature ejaculation. In other words, if the guy has good erections and has premature ejaculation, the erectile medications like Viagra will generally do nothing unless it has a placebo effect.

If somebody has erectile dysfunction and also premature ejaculation, it's possible that curing the erectile dysfunction could help in the premature ejaculation, but this is rare. Usually people with premature ejaculation don't have problems with erections, it's just that they ejaculate quickly and then the erection goes away. But, you expect that -- after you ejaculate, your erection does go away.

MEMBER QUESTION:
I know some meds can inhibit sexual activity, from libido to ability to get an erection, but do some actually cause or contribute to PE?

PRYOR:
We don't know all the different medications that can cause premature ejaculation but there certainly are some that can. I think the biggest ones are, again, the opioids. I'm not familiar with other ones but I'm sure that there are some out there that can contribute to premature ejaculation, but I think that's rare.

In most cases, we don't know why a person has premature ejaculation. In theory, people who take medications that stimulate the sympathetic system, such as Sudafed, could contribute to PE, but we haven't found that to be the case. I don't think there are many medications that we can identify today that we can say are to cause premature ejaculation.

I also don't think that people should be overly hung up about this because in most cases if you're on a medication, you should take it. Again, we think it's from some neurological or biochemical cause that we don't know about at this point.

MODERATOR:
Do men talk with other men about these topics?

PRYOR:
Men definitely do not talk to other men about these issues. It wasn't until just recently that men started talking to other men about erectile dysfunction. Even when Viagra came out, for years the communication was mostly between the male and his partner, then hopefully, he would bring it up with the physician. Even now, after everything in the media about ED, men are still often times embarrassed to bring it up.

Men tend not to take care of themselves very well; they don't go to the physician as often as they should, often times it's the woman that's dragging them in to the physician.

It's just going to take some time for this to get out there, for people to understand it and to start talking about it. I think it's going to be a long, long time before men talk about it amongst themselves. They will talk about backaches and how their golf swing is not good and how they have plantar fascitis or something, but they do not talk about this issue.

"Certainly if PE is bothering you, I encourage you to see your physician."

MODERATOR:
Women talk with each other all the time about health related issues.

PRYOR:
I think it's really important that men talk about it, and it would be nice if they talk about it with other men. You can talk about it with your partner, and I'm sure your partner would be sympathetic, understanding and encouraging you to get help.

I think that we need to start educating men more about taking care of themselves and men's health issues. Not just when you hit 40, but this education really needs to start early on in life.

MODERATOR:
Age 40 or 50 seems to be the "magic number" for the age of when people get concerned and want to become more educated about their health.

PRYOR:
I think you should start being educated on just health in general from the third or fourth grade. I have actually written a book on men's health and one reason why I wrote it was because men tend to be so ignorant of some very basic things. It's amazing to me. Talk about a man's health should start in third grade. The girls learn about menstruation and the boys are excused to go to the playground and swing.

Much of what we do is based on habit. For many reasons girls and young women, very early in their lives, will go and see the physician on a routine basis, at least once a year. So women get in the habit of going to the physician and taking care of themselves. Men don't do that - they go to the physician when they need to for a sports physical, and that's it. Then it's not until they have a significant problem like a broken arm or crushing chest pain that they finally go again. By that point you have had all the bad habits instilled in you.

From the very beginning, in junior high, actually in grade school, I think we should start teaching some basic things about taking care of yourself. I know that's not about premature ejaculation, but as a health educator, I feel strongly about it.

MODERATOR:
Dr. Pryor, we are almost out of time. Before we wrap things up for today, do you have any final words for us?

PRYOR:
I think the important thing is for people to, again, realize that this is a very common problem and that they don't need to think of it as just affecting themselves. I want them to know that there's some treatments out there but currently it's all off-label. Sometimes these work for people and sometimes they don't and sometimes they have side effects associated with them. Certainly if PE is bothering you, I encourage you to see your physician.

There is a medication that's going to the FDA to see if they will approve it. That will be the first specific medication for the treatment of premature ejaculation if it's approved and it is called dapoxetine. We'll just have to wait to see what the FDA does. Hopefully there will be something for these people in the near future.

MODERATOR:
Our thanks to Jon Lee Pryor, MD for joining us today.



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Reviewed on 6/9/2005 4:53:44 PM

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