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 PREMATURE EJACULATION (PME)

There can be four types of disturbances in semen ejaculation (i.e. orgasmic discharge) 
1. Premature ejaculation i.e. early discharge or early orgasm. 
2. Absent ejaculation, Delayed ejaculation, Retrograde ejaculation & others

What is premature ejaculation Causes of premature ejaculation Investigation & Diagnosis Treatment

What is Premature Ejaculation?

Premature ejaculation (also known as early discharge or quick orgasm, early fall, Shigra-patan) is one of the most frequent, of sexual disorders in the male and is characterized by sudden ejaculation of the semen, just prior to or immediately after vaginal penetration during intercourse (before one wishes or before he could satisfy the female partner). Approximately 10% to 30% people of all age group suffer with quick semen discharge. Premature or 'before time' in other words, is a condition where the man has no voluntary control over his ejaculation. He is quick on the trigger once he starts the coitus. This is a very frustrating disorders of male sexual function in which man feels totally helpless. This leads to bitterness in husbands & wife relationships. For the man, lack of control of his body functioning leaves him feeling unsure of himself. His pleasure is often decreased by the abrupt early discharge. Eventually his preoccupation with trying to postpone ejaculation will hinder his ability enjoy himself to sexual pleasure. When a man is, feeling inadequate, and ejaculating fast, the woman will probably be left unsatisfied. Her frustration will only increase the negative pattern. This is an easily treatable condition.

What is normal time of discharge: In one scientific study European males took approximately ten minutes in discharge whereas Americans took fourteen minutes in getting orgasm.

How common is pre mature ejaculation due to some well-defined internal causes?
Many of recent studies have proved that, most cases of quick ejaculation are Psychogenic is not correct (which was old belief). In one study by Schwartz & Pirke & colleague found that in many patient of pme male hormones were deranged. Similarly Colpi et all found that evoked sacral potentials & Bulbocavernosal reflex were hyper-excitable in many patients. 
Thus psychogenic cause should never be labeled unless Hormonal & other causes have been excluded, by thorough examination, hormones & other tests as mentioned below.

Causes of Premature Ejaculation:

There are number of possible causes have been propounded about the causes of premature ejaculation.

(1) Hormone disorder
(2) Urogenital Infections
(3) Neurogenic causes
(4) Increased penile sensitivity to touch.
(5) Sex Centre disorder i.e. hyper excitability of sex centre
(6) Drug induced: many drug cause PME
(7) Psychogenic i.e. psychiatric illness

In following section we'll discuss these causes in detail:

(1) Hormone disorder: In recent studies it have been seen that many hormone disorder directly causes premature ejaculation. Additionally hormone disorder may cause other sexual dysfunction, which may secondarily cause early discharge. These hormones are important for normal control on your ejaculation.

(2) Deficiency of neuro-transmitters as serotonin & others have been found to be one of the significant causes of early semen fall. 

(3) Urogenital Infections: Any infection of urethra, prostate, epidididymis, seminal vesicle, Orchitis, epididimo-orchitis etc. Leads to irritability of sacro-coccigeal nerves, which govern the function of all these sex organs. This irritability leads to lowers threshold for ejaculation. Thus infections are one of the significant causes of early orgasm. 

(3) Neurogenic causes: Among nervous system disorder, any disorder involving sex centre area in brain as multiple sclerosis, hyper-excitable focus or any organic lesion will lead to very fast semen discharge. Any lesion of conus medullaris of spinal cord leads to premature ejaculation.

(4) Increased penile sensitivity to touch: In many patients there is excess of certain neurotransmitters in the penile skin which makes it highly erogenous at time of sexual excitation leading to reaching peak of excitation & climax fast. In various studies it has been found that bulbo-cvernous reflex is hyperactive.

(5) Psychogenic i.e. many psychiatric illnesses as anxiety, anxiety neurosis, schizophrenia, MDP etc. leads to early climax. 

(6) Sex Centre disorder: There are certain conditions in which sex centre, which is situated in brain, becomes hyper excitable so that peak of orgasmic threshold reaches very quickly. This is a disorder of function, which occurs due to various reasons. Sex centre is a part of brain, which is situated in hippocampal part of forebrain. It controls the time taken for orgasm i.e. ejaculatory discharge during sexual activity. In early orgasm disorders the sex centre is extremely sensitive to sexual stimulation so that sex centre reaches peak of excitation with in few moments after penetration in vagina so that the orgasmic threshold reaches with in seconds of sexual intercourse or even before coitus. The causes of sex centre induced premature ejaculation can be divided into two groups: (1) immediate cause, and (2) remote cause. Such a classification is helpful in the treatment of fast climax. If the early discharge is due to immediate causes, a removal of these factors results in adequate sexual functioning. When premature ejaculation is due to remote causes, detailed sex therapy may be necessary for a more lasting cure. Sex centre also controls the other component of sex cycle namely desire & erection. Thus beside premature ejaculation, patient may also suffer with low desire or erectile dysfunction.

They could be physical body disorders as mentioned above or psychological. It is therefore necessary to rule out the internal organic causes first before commencing treatment. These causes are diagnosed by detailed history and a thorough physical check-up, sexual counseling including penile sensory tests for penile hypersensitivity, blood tests for biochemistry & various hormone tests, central nervous system tests should be done to rule out any internal causes, before starting treatment. 

Thus premature ejaculation causes a man to focus more and more on his own sexual response pattern, thus getting away from the freedom and naturalness of allowing the response to occur by itself. As he concentrates on controlling his ejaculation, this concentration may begin to get in the way of maintaining the erection. This then can bring about the loss of erection. After some time this may even completely inhibit the erection from occurring. Often a problem that might begin with premature ejaculation gets joined to a problem of impotence, and then both issue have to be dealt with. 

After a time the couple will begin to withdraw from each other, not wanting to enter an experience that is going to end up frustrating them. The man doubts his masculinity, and the wife later experiences a lessening of confidence in her, along with anger toward her partner. The anxiety about performing, and the tendency to move into the spectator role and watch how one is doing.

Diagnosis of Cause

1) We take detail history
2) Detailed general & systemic examination
3) Investigation & Diagnostic tests
For accurate diagnosis of the cause patient's blood is tested following tests:
Complete Male Hormone Profile tests
Biochemistry tests
Urine is tested for pus cells
Penile Nerve conduction tests & central nervous system is if required.
Scrotum, epididydmus, prostate is examined for infection.
Semen is examined for pus & semen culture sensitivity. 
Ultrasonography of scrotum & prostate may be required.
Various antibodies are tested against relevant microbial agent
Detail sex counseling is done for knowing the cause of PME. 

Treatment:

(1) Oral Medicines: After the finding out the cause of premature ejaculation. Various drugs to treat sex centre & other causes are prescribed along with sex therapy. These medicines are not costly & have no side effects & patient has to purchase from market. Response comes with in two week & patients are cured in two-month time. Medicines can be
a) Hormone pills when hormone disorder found
b) Medicines to cure the urogenital infections when infection as the cause confirmed
c) Neurotransmitter serotonin level increasing drugs as Anafranil, Paxil, prozac, & Zoloft, Luvox, Celexa, & others are used in those patients having low serotonin is very effective
d) Specific treatment of central nervous disorder need to be done when that is the cause.
e) Other medicines which h may be effective in selective patients are Propranolol & Alpha adrenergic blockers as phenoybenzamine, Alphuzosin, Terazosin, Tamsulosin

(2) INJECTION THEREPY: Rarely injection therapy is advised which is very effective in treating premature ejaculation. It is used only when oral drug therapy has failed. Sometime we also use it as temporary method to build confidence of those patients who are highly demoralized due to their previous failures. Patient is advised various Vasoactive injections by which penis becomes hard in three minutes & remains hard at least for 30 minutes thus almost all patient do the satisfactory sex with injection therapy without any fear. After few weeks of injection therapy & concurrent sex therapy patient develops capacity to control his ejaculation & he may stop injection after sometime.

3) TOPICAL THERAPY is effective but it is only a temporary treatment. By these creams sensitivity of penis to sexual excitation & time of discharge increases. It has no side effects.

4) Phytoterapy: extract of saliva haeamatodes & some other natural products are effective in pre mature ejaculation.

(2) Sex Therapy: 
In sex therapy two exercises are taught to patient along with medicines. These are:
Stop-start technique 
Kegel exercises
Squeeze Therapy
& certain behavioral therapy exercises

These sex therapy exercises when practiced by patient for four weeks then patient is able to sustain erection without ejaculation for at least 8 to 10 minutes. After the full course of treatment once you have reached the point where you can chose when you will ejaculate, you may find it helpful to continue using the sex therapy exercises on various occasions to help lengthen the lovemaking period. This would be particularly true if it has been some time since the last ejaculation, because then you are more likely to ejaculate more quickly. The use of this should be incorporated into love making and used at any point along the way for the rest of your life. 

If premature ejaculation has evolved into impotence, then that should be given attention first. Then impotence must be treated before the premature ejaculation.

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