Then, follow one of the structured, symptom-specific treatment strategies based on psychological, relational, and physiological techniques. Find out ways to prevent relapse. Enhance and improve your overall sexual relationship. Designed as a resource for couples, this book is a powerful tool for creating support and positive change in your relationship.
Penner Sometimes couples are overwhelmed and do not know where to begin to start working on their sex life. This step-by-step guide is a great resource to address many of the common sexual barriers in marriage. Douglas Rosenau Thomas Nelson , He sets the stage for a biblical celebration of sex and then walks couples through specific and common areas of concern: creating knowledge, enhancing pleasure, enjoying passionate intimacy, overcoming common hurdles, resolving problems, and healing brokenness.
There is a sacredness to our sexuality that we want to protect from those who might not handle it well. I t is normal for most men to experience some level of difficulty during marriage with low sexual desire, getting or keeping an erection, and controlling the timing of their ejaculation climaxing too quickly or difficulty achieving an orgasm. Many couples also experience conflict over their desire levels.
However, most new medical and surgical therapies for PE or delayed ejaculation, and for erectile dysfunction ED , female sexual disorders, andro- or menopause, and hypoactive sexual desire, are based on the symptom rather than the couple. This might be reductive and therapeutically dangerous. From these criteria, the key points characterising this pathological condition are the timing measured as the intravaginal latency time, IELT , the feeling of loss of control over ejaculation, and the presence of distress within the couple .
The last aspect highlights that relational aspects are important in the pathogenesis of sexual dysfunction . In this regard the female partner can be considered in the way as the man with the symptom. Hence, PE could be considered as a partner-generated symptom. The assessment of the psychological causes of PE includes extensive interviewing, with standardised psychological tests directed to both the patient and his partner, to establish the history of the dysfunction and the circumstances under which it occurs.
Where medical results are normal, a diagnosis of psychogenic PE is considered likely. It can thus be inferred that in the near future there will be new tests capable of detecting new patients with organic PE. During treatment the clinician should consider that marital problems are often involved. PE, like any sexual dysfunction, affects the intimacy of the couple. However, it is not easy to establish if the marital problems are the cause or the effect of PE. Thus, during the assessment, the sexologist should treat both the man and the woman, and investigate the actual time of the vaginal penetration; during coitus and penetration, the perceived time often differs from the actual time.
Although these considerations might suggest the importance of involving the partner in the treatment of PE, as highlighted in a review  , the vast majority of men who present for treatment do not involve their partners. In addition, some studies recommend [8,19,20] , within the perspective of an integrated treatment, using semi-structured questionnaires to collect sexological and relational data.
Primary PE is considered when there are no other sexual dysfunctions, but in the presence of other sexual symptoms, such as ED or a lack of desire, the PE is assessed as secondary. In these cases it is fundamental to assess the sexuality with a specific history and with psychometric tools to evaluate desire and erectile function. Moreover, PE is a common early manifestation of ED  , or can occur with an unstable erection due to fluctuations in penile blood flow.
In this case the man might ejaculate early to hide the weakness of the erection, and thus the PE responds successfully to the appropriate treatments for ED. All these possibilities should be considered when evaluating patients with PE. Female sexual dysfunction such as anorgasmia, hypoactive sexual desire, sexual aversion, sexual arousal disorders, and sexual pain disorders, as in vaginismus are often present and might be secondary to the male PE, so that assessing female sexuality is an integral part of assessing PE.
In addition to a sexological evaluation, it is necessary that the clinician also conducts a physical examination; abnormal findings are unlikely to be associated with this condition. However, penile biothesiometry, and an evaluation of the prostate by TRUS with the standardised Meares and Stamey protocol  , have been proposed as useful methods to evaluate and quantify penile sensitivity in PE . For this reason many sex therapists prefer the stop-start method. The squeeze technique to treat PE. This pressure should inhibit ejaculation and should be done several times before ejaculation is allowed.
As a step in the learning of ejaculation control, the squeeze technique is generally no longer needed after therapeutic success.
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Sexological therapy for PE starts from the approach that it is the couple, not the individual, that is dysfunctional. Sexual counselling can be of benefit for both idiopathic and organic causes of PE. Involving the partner in this process can dispel misperceptions about the symptom, decrease stress, enhance intimacy, and the ability to talk about sex and PE, and increase the chances of a successful outcome.
Counselling sessions are also helpful in uncovering conflicts in the relationship, psychiatric problems, and alcohol or drug misuse. With this term sexologists indicate many behavioural models of the short-term treatment of human sexual dysfunction . Common personality characteristics of men with PE are:. Generally, sex therapy methods for PE have good efficacy, and often allow the man to learn to recognise and respond to his PE. However, these treatments are not easy for the patient, and the man with PE must be actively involved in the therapy with his partner.
In addition, follow-up data have shown that their efficacy tends to decrease over time . The cognitive and informative strategies have been considered particularly useful for single men. The goal of this approach is to modify irrational thoughts and core beliefs inherent in the sexual life of both the patient and his partner, work together on reducing the performance anxiety, strengthen trust and confidence in the relationship between the marital partners, debunk male sexual mythology, improve sexual communication, enhance sexual knowledge, and teach sexual skills.
As PE can arise from ignorance, and sexual teaching is unfortunately largely absent in schools  , bibliotherapy with simple and clear books  , and the prescription of simple behaviours promoting an increase in the ejaculatory time, such as the prescription to ejaculate more frequently, to release the anal sphincter during intercourse, to favour the female-on top position, and possibly to use special condoms, might be a useful adjuvant treatment for PE. Strengthening of the pubococcygeous muscles of the pelvic floor is a behavioural stage in sex therapy for PE.
In these exercises, named after Arnold Kegel who devised them, the patient is trained to identify his pubococcygeous muscles during urination. As the muscles strengthen, the duration and number of slow contractions is gradually extended, together with fast contractions. A typical routine is:. In addition, a multivariate approach to treating PE, based on both ejaculatory latency and perceived control, has been proposed.
The coital alignment technique is a couple-based therapy consisting of a basic physiological alignment that provides an effective stimulation for female coital orgasm . This might be useful in couples with PE. The Reichian therapy for PE is based on the use of sensate rather than verbal communication with the patient. The therapist carefully chooses the environment and atmosphere, with patients and therapists on large cushions, using a friendly relationship on first-name terms, and involving non-erotic massages and role-playing. Treatment programmes have also been designed for a group setting.
The structured group treatment has been described in uncontrolled studies as a cost efficient and effective method to overcome PE  , for both couples and single men . The group treatment does not seem to provide and inferior outcome to the classic couple format . Finally, the efficacy of a yoga-based protocol vs. In that study there was no significant difference between these therapeutic options. Thus, although other scientific evidence is necessary, it is possible that even yoga is useful for overcoming PE. For this reason, pharmacological treatment is now receiving increased attention from both medical sexologists and the pharmaceutical industry.
Whilst behavioural therapies in their original format require a couple, medical treatments can be used by the man alone. However, counselling with the couple is also suitable. The serotonin reuptake inhibitors and tricyclic antidepressants [39—41] have an effect by increasing the penile threshold. In addition, these drugs do not change the amplitude and latency of the sacral evoked response and cortical somatosensory evoked potential. The most important drug in the clinical practice is dapoxetine. It thus represents the first-line officially approved pharmacotherapy for PE .
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Another drug class used for treating PE is the phosphodiesterase type-5 inhibitor sildenafil, tadalafil and vardenafil , usually the first choice for treating ED but that has also been used alone or combined with serotonin reuptake inhibitors as a treatment for PE [11,42]. In addition, for patients with ED and PE, treatment with intracavernous medications, rather than sildenafil alone or combined with paroxetine [43,44] is recommended. Indeed, in some cases PE and ED are comorbid symptoms. Topical agents such as anaesthetics and herbal products are also used, with limited efficacy .
In patients with prostate inflammation and PE, the specific therapy for chronic prostatitis has been suggested. Finally, an interesting possibility is the role of acupuncture in the medical care of PE, but other investigations are necessary . Current methods and measures used to assess the outcomes of treating PE are only standardised with some difficulty.
Antidepressant drugs are generally effective in restoring ejaculatory control. However, as these drugs may significantly worsen ED, they are strongly contraindicated for patients with both PE and ED . Whilst the pharmacological treatment of PE, e. The evidence that dapoxetine, as well as other antidepressants, is a symptomatic therapy, is that patients taking dapoxetine and obtaining good ejaculatory control can still have PE when the pharmacotherapy stops.
The pathophysiology of PE. Stress from sexual failure and subsequent anxiety have a positive feedback during PE Panel A. Pharmacotherapy avoids the patient entering this vicious circle Fig. This effect can be obtained both with an effective treatment by psychotherapy and with an effective and safe treatment with dapoxetine.
As psychoanalysis in sexology aims to recognise the deep subconscious that might have caused the psychological disease  , the approach suggests an aetiological therapy. However, although Freudian theory might successfully explain subconscious conflicts leading to sexological pathologies, the evidence highlights its many limits in resolving sexual difficulties. An approach directed to the treatment of symptoms, rather than to the causes of the disease, was developed in the s. The aim of the sexologist is to identify which causal predominates in a specific patient, and design the therapy on this basis.
This treatment can be successful only if the therapy is structured accordingly, with behavioural approaches and with the sex therapist . Therefore, during the assessment is necessary to provide a combination of psychological and pharmacological therapy to minimise the chance of relapse .
Finally, considering the importance of sexual counselling in the therapy of PE and the role of prostate diseases in their pathogenesis, a prevention policy should focus on both the sexual and andrological education of young and adult males. This form of information and education is absent in many countries. The political institutions should promote information campaigns to prevent andrological and sexological diseases in males and in the couple.
Behavioural approaches and pharmacological agents are both symptomatic therapies, the goal of which is to delay the ejaculation, and they do not consider the underlying causes of the sexual dysfunction. Because of the deep psychological effect that PE can have on patients, the physician must always take the sexological approach into account .
This approach will further increase the therapeutic potency of effective and safe treatments such as dapoxetine. In this aspect, the roles of two sexual experts, i. All other authors declare that they have no conflicts of interest. Peer review under responsibility of Arab Association of Urology. Additional articles were extracted based on recommendations from an expert panel of authors. National Center for Biotechnology Information , U. Journal List Arab J Urol v.
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Arab J Urol. Published online Sep Emmanuele A. Author information Article notes Copyright and License information Disclaimer. Jannini: ti. This article has been cited by other articles in PMC. Abstract Objectives To describe the different approaches to the treatment of premature ejaculation PE , with a final focus on integrated treatment, as conventional theories and therapies for PE are based on an organic or psychogenic dichotomy.
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Methods We list the principal hypotheses of the causes and therapy of PE on the basis of psychological and medical perspectives, after identifying all relevant studies available on Medline up to Conclusions A holistic approach which considers the biological, psychological and relational aspects is the advised treatment for PE. Keywords: Premature ejaculation, Holistic approach, Integrated model, Dichotomy. Introduction In male sexual dysfunction several new pathophysiological and therapeutic discoveries have led to a renewed attention on the lack of ejaculatory control .
Symptom or disease? The history of PE The control of the ejaculatory reflex represents an evolutionary and cultural advance for human sexuality. Sexology of PE: a psychological and neurobiological disorder Some researchers consider that PE is not a psychological disorder but a neurobiological phenomenon  , but the arguments sustaining this thesis are weak.
The anatomy and physiology of ejaculation To understand the pathogenesis, and psychological and pharmacological PE therapies, it is important to understand that normal male copulation culminates in three psychologically and physiologically distinct events: 1.
The neuropharmacology of ejaculation Little information is available on the central control of ejaculation. PE is a symptom of the couple One of the most important features of modern medical sexology as described by Masters and Johnson  is that the object of the sex therapy is not the individual with the sexual problem, but the couple.
The diagnosis of the couple with PE The assessment of the psychological causes of PE includes extensive interviewing, with standardised psychological tests directed to both the patient and his partner, to establish the history of the dysfunction and the circumstances under which it occurs.
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Open in a separate window. Figure 1. Table 1 The components of behavioural therapy. Sex therapy With this term sexologists indicate many behavioural models of the short-term treatment of human sexual dysfunction . Other therapies The cognitive and informative strategies have been considered particularly useful for single men. Follow-up and critical evaluation of medical therapies Current methods and measures used to assess the outcomes of treating PE are only standardised with some difficulty.
Figure 2. Conclusion As psychoanalysis in sexology aims to recognise the deep subconscious that might have caused the psychological disease  , the approach suggests an aetiological therapy. Footnotes Peer review under responsibility of Arab Association of Urology. Appendix A. References 1. Jannini E. Disorders of ejaculation. J Endocrinol Invest. Sexological approach to ejaculatory dysfunction. Int J Androl. Graziottin A. What does premature ejaculation mean to the man, the woman, and the couple? J Sex Med.
Coping With Premature Ejaculation: How to Overcome PE, Please Your Partner & Have Great Sex
Abraham K. Zeitschr Aerztl Psychoanal. Kinsey A. Sexual behavior in the human male. WB Saunders; Philadelphia: