Assoc Prof Dr Christopher Ho Chee Kong   Consultant Urologist & Sexual Medicine Physician, Department of Surgery, Universiti Kebangsaan Malaysia Specialist Centre

How to Make Love All Night: and Drive a Woman Wild! The Way of the Superior Man! Make Her SCREAM: Last Longer, Come Harder and Be the Best She’s Ever Had!

These are just some of the actual book titles found on Amazon should you search for ‘premature ejaculation.’ Regardless of the content between the covers, these titles alone give the impression that a ‘real man’ (or to quote one of the book titles, a ‘superior man’) should be able to please his partner not just sexually, but also all through the night like the Energizer bunny, with the partner screaming and swooning from the ecstasy of it all.

The average man may flinch from the pressure (or try to rise to the challenge), but for someone with the problem of premature ejaculation (PE), the condition can be especially crippling to the self esteem. Furthermore, a lack of sexual fulfilment would eventually threaten the long-term happiness in any relationship.

HealthToday sits down with Assoc Prof Dr Christopher Ho, a consultant urologist and sexual medicine practitioner, to get down to the root of the condition known as PE, and the various treatment options available.

Not So Fast, Man!

Given how closely a man’s sexual performance is linked to his sense of confidence and self-esteem, it is little wonder that many men would prefer not to think about PE. If they do talk about it, it is usually during a ‘men’s only’ moment at the mamak stall, when ‘bros’ share notes and tips on bedroom matters.

Despite many men putting a lid on the problem, PE is actually quite common. While the estimated number of men with this problem can vary from one study to another, Dr Ho states that, generally, about 30% of men around the world have problems that can be defined as premature ejaculation.

How soon is too soon?

A US study found that the average man’s “lasting power” from the start of penetration to ejaculation is 5.4 minutes. If your arrival schedule is around this value, then you are perfectly normal.

“There are two types of PE – lifelong and acquired,” explains Dr Ho. Lifelong PE describes the condition that initially manifested during the man’s first sexual intercourse; the man has never experienced a ‘normal’ intercourse as a result. Acquired PE occurs when a man who has never suffered the condition before starts to show symptoms, often due to psychological factors (stress, anxiety or impatience, especially when the man has a new partner) or organic reasons such as an underlying medical condition.

• For men with lifelong PE, the average ‘staying power’ is one minute or less.
• For men with acquired PE, the average ‘staying power’ is three minutes or less.

Dr Ho goes on to explain that there are three typical signs of PE. One, the man experiences PE (1-3 minutes or less) consistently over a period of time. Two, he has problems controlling (or delaying) ejaculation nearly all the time. Three, his condition is causing emotional distress, and the man may even begin to avoid intimacy out of frustration or shame.

The Root of the Problem

There are several possible causes for PE, and it is possible that the causes for PE can be different from one man to another.

• It’s psychological. Dr Ho says that strong emotions such as anxiety about his performance can cause a man to end things a little too soon in the bedroom. Other forms of stress such as external ones (from work and such) or unresolved interpersonal issues between the man and his partner could also be factors. 
• It is also possible that early sexual behaviour could contribute to PE. For example, if a man is used to hurrying his climax in the past, he may experience problems slowing down the pace later on.
• It’s biological. PE can arise when things go awry in the body. Some of the possible biological reasons for PE include:
  • Thyroid problems. There is a study which suggests that PE can be linked to an overactive thyroid (hyperthyroidism).
  • Abnormal levels of certain neurotransmitters (brain chemicals that transmit signals from nerve cells to brain). Unusually high levels of histamine, for example, can cause PE. 
  • Abnormal hormone levels. Like many other processes in our body, sexual arousal, stimulation and ejaculation are all carefully controlled and coordinated by interactions among various hormones. A little too much or too little here and there can cause the entire process to go haywire!

Don’t Suffer in Silence – Get Help!

If you suffer from PE, the great news is that the condition is definitely manageable. There are ways to help you enjoy a healthy sex life with your partner.

Forget the many ‘special foods’ or ‘special exercises’ out there, all promising to improve one’s sexual prowess. The first step to managing PE is actually very simple.

“Talk to your doctor!” says Dr Ho.

“There is nothing to be ashamed of. The doctor will not judge or reveal your problems to other people. Therefore, there is no need to suffer in silence!” he adds. Some men get uncomfortable when the doctor asks probing questions related to intimacy, but this is a necessary step for the doctor to fully understand the extent of the problem. What is a little temporary discomfort or embarrassment, after all, compared to the promise of a healthy, fulfilling sex life?

Furthermore, sometimes PE may be a symptom of an undetected medical condition (such as thyroid condition, prostate disease, high blood pressure and diabetes), and may go away once the medical condition is treated. Getting treatment or management advice for those conditions do not just improve one’s sex life – it improves the overall health and quality of life!

“I know I have PE, so I can buy my own medications without seeing a doctor!”

Are you really sure that you have PE? While erectile dysfunction (ED) and PE are two very different conditions on paper, in reality, there are a number of men who cannot tell apart these two conditions. Dr Ho has encountered men with PE who believe that they have ED, and vice-versa. Since treatment methods for both conditions can be different, a diagnosis by a qualified healthcare professional is important, to ensure that you are getting the right kind of treatment. Another reason to visit your doctor, whether you have ED or PE!

Dr Ho goes on to share some of the most common methods for managing PE.

Hands-on Techniques

There are some techniques that your doctor can advise you to practice in the privacy of your home to help with PE. Dr Ho offers some examples:

• The stop-and-start method. The man first masturbates on his own, stopping as he comes close to ejaculation. He will then relax until he has calmed down, before repeating this process several times until he cannot hold back any longer. Once he has become used to this, he can bring in his partner and they can initiate sexual activities without involving penetration. Essentially, this method helps the man learn how to control his arousal and delay his ejaculation over time.
• The squeeze method.  A variation of the stop-and-start method, in which the man masturbates until he is close to achieving an orgasm. At that point, he squeezes the base of his penis to reduce his erection and delay ejaculation. Once the man has the hang of this, his partner can get involved and lend a helping hand, so to speak.
• Try Kegel exercises. While there is not much evidence to conclusively prove that Kegel and other forms of pelvic floor exercises can help with PE, Dr Ho believes that there is no harm in adding these exercises into the daily routine of a man with PE. By strengthening the muscles in the pelvic region, the man may have better control over the delay of his ejaculation.
• There are many other options, such as deep breathing techniques to help with focus during sex and the use of condoms to reduce stimulation on the penis. Your doctor would evaluate your case and suggest suitable solutions.
• Dr Ho adds that these techniques are not “instant cures” – they only show results over time. Some men may get frustrated with  what they perceive to be slow progress and wish for a more “instant” solution, while others may get “distracted” while involving their partners in these techniques. For these men, medications may help tide the frustration.

Medications for PE

Dr Ho explains that medications do not cure PE. Similar to pills for erectile dysfunction, they offer the man an opportunity to participate in sexual intercourse for a certain period of time after taking these medications.

Oral medications.

It may seem odd to many people, but medications normally given to people with depression can also help with PE. These medications can inhibit orgasm and delay ejaculation, usually considered unwanted side effects that, for men with PE, turn out to be favourable outcomes.

Of late, the medication of choice for many specialists is dapoxetine. Dr Ho explains that this is due to the studies that demonstrated its effectiveness on men with PE, as well as having fewer side effects compared to other medications offering similar benefits.

Aside from dapoxetine, other oral medications for PE include tramadol and other medications normally used for treating depression (eg, sertraline, paroxetine). All oral medications require prescriptions from a qualified healthcare professional.

Apply externally.

There are gels, creams, and sprays which work to reduce the sensations experienced in the penis that can bring about ejaculation. They typically contain analgesic or numbing ingredients such as lidocaine and lidocaine-prilocaine, and should be applied on the penis before sex. Because they work less specifically than oral medications, they may not be effective on some men with PE. There are also reports of some men’s partners experiencing discomfort or reduced sensation during sex.

The Lowdown on Dapoxetine

According to Dr Ho, in a normal male, a neurotransmitter called serotonin is involved in passing messages from one nerve cell to another. It is found that high levels of serotonin in the nervous system can lead to delayed ejaculation during sexual intercourse. For men with PE, this is obviously a good thing!

This is where dapoxetine comes in. It is a type of drug that helps to increase the concentration of serotonin at the junctions between nerve endings, hence allowing men with PE to last longer during sex.

It is taken “on demand”, from 1 to 3 hours before an anticipated sexual activity.

Side effects.

These include dizziness, nausea and headache. Fortunately, Dr Ho points out that fewer than 10% of men taking dapoxetine exhibit side effects.

Does it really work?

“Dapoxetine has been tested in robust trials involving thousands of men, and results point to it being effective and safe,” explains Dr Ho. This strong amount of research data is one advantage of dapoxetine over many other PE oral medications in the market.

Can someone with no PE still take dapoxetine to improve their ‘staying power’?

Besides the usual side effects caused by dapoxetine, there is no evidence suggesting that normal men taking this drug will experience health problems. However, Dr Ho also points out that there is no evidence to suggest that usage of dapoxetine can improve a man’s stamina in the bedroom. “Men often have unrealistic expectations when it comes to their stamina anyway,” Dr Ho says with a smile, “thanks to the frequently exaggerated portrayal of sex in popular media.”

Are there certain types of people who should not take dapoxetine?

“Men with severe heart and liver problems should avoid taking this medication,” cautions Dr Ho. Also, certain medications such as other selective serotonin reuptake inhibitors (SSRI, these are drugs that work similarly like dapoxetine to increase serotonin levels in the body), monoamine oxidase inhibitors (MAOIs), anti-fungal and anti-viral medications may cause unwanted side effects when taken along with dapoxetine, so consult your doctor if you are also on these medications.

The best of both worlds

According to Dr Ho, men with PE may be given medications while at the same time they are advised to put into practice the control techniques described earlier.

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