Abstract
Among the different sexual dysfunctions in men, premature ejaculation (PE) is the most common. Although it may be a problem seen in men, he alone is not the sufferer, but also his partner. Modern medicine is able to provide a solution to it, but relief is only temporary. This article provides information about the different aspects related to premature ejaculation and the homeopathic approach to disease treatment.
Keywords: Ejaculatory disorders, premature ejaculation, male sexual dysfunction.
Introduction:
Premature ejaculation (PE) is the most common ejaculatory disorder and a highly prevalent male sexual dysfunction.
The term pe is used commonly though early ejaculation, rapid ejaculation, immediate/early climax also being appropriate. Although the term PE first came into medical literature in 1887 but there was not much work done until 1960s and the disorder came into light in 1970/80s.
Premature ejaculation is a medical classification as listed by who under the range – mental, behavioral and neurodevelopmental disorders.
Several definitions of PE have been given and three common points that stands as the basis of most PE definitions: a short ejaculatory latency time – time from penetration to ejaculation; a lack of self-control about the time of ejaculation; and a sense of distress and interpersonal difficulty (related to ejaculation dysfunction). For a period of more than 6 months.
Defined under dsm-iv & dsm-5(diagnostic and statistical manual of mental disorders, 5th edition) by American psychiatric association (APA) and alsoISSM (international society for sexual medicine).
Studies still going on to understand the exact causes of pe, but it is believed to result from a combination of psychological, biological, and interpersonal factors:
- Psychological factors- performance anxiety, stress, depression, relationship issues.
- Biological factors – neurotransmitters, hormones, and nervous system abnormality
- Interpersonal factors- communication issues with a partner, etc
Its impact is on multiple facets of a patient’s life including psychological and emotional health (stress and loss of self-esteem), resulting in adverse effects on quality of life and relationship of patient and partner.
Premature ejaculation though being distressing , is a treatable condition and with the help of healthcare professionals of holistic approach desirable results could be achieved .
Currently assessment of patients with pe relies mainly on validated questionnaires. Few validated questionnaires that are developed and published to date, including index of pe, pe profile, pe diagnostic tool, arabic pe questionnaire, chinese pe questionnaire.
Physiology
Normal antegrade ejaculation is a highly coordinated physiology process comprising emission and expulsion phases which are under the control of the autonomic and somatic nervous systems, respectively. Orgasm, a feature perhaps unique to humans, is a cerebral process that occurs, in normal conditions, alongside the expulsion of semen.
- Emission- It is the first phase of ejaculation characterized by the passage of seminal fluid from the prostate, seminal vesicles, and vas deferens into the posterior urethra. It occurs concomitant with the contraction of the internal urethral sphincter, which closes the bladder neck and prevents retrograde passage of semen into the bladder. Emission is solely dependent on contractions of the smooth muscles of the prostate, seminal vesicles, and vas deferens, and its initiation can be voluntarily controlled. However, once the semen reaches the posterior urethra, ejaculation becomes inevitable.
- Expulsion (Antegrade Ejaculation)- Expulsion is the second phase of ejaculation in which there is a passage of seminal fluid from the posterior urethra to the external urethral meatus. Expulsion is a spinal cord reflex that occurs as the ejaculatory process reaches a “point of no return.” It depends on contractions of the pelvic floor muscles in addition to the bulbospongiosus and ischiocavernosus muscles. These contractions occur rhythmically at 0.8 sec intervals.[14]
- Orgasm- The human sexual response cycle consists of four distinct stages, desire, arousal, orgasm, and resolution, with the orgasmic stage being the shortest but most intense of the four.[14]
Types
PE can be classified into two main types (based on the onset and duration of the condition):
- Primary premature ejaculation/ lifelong pe- It is a condition where a man experiences early ejaculation from the beginning of his sexual experiences and throughout his adult life. Men with primary pe typically have a persistent pattern of ejaculation occurring within one minute of penetration or even before penetration.
- Secondary premature ejaculation/ acquired pe- In it the person experiences a change in the ejaculation pattern (uncontrolled) which occurs prior to three minutes, from the earlier longer pattern(controlled and satisfactory).
- Causative Factors
Overall, premature ejaculation is primarily psychological in nature. Though the precise cause of pe is still undetermined. Both biological and psychological risk factors have been identified: [5]
- Biological Factors:[6,7]
Abnormal levels of the brain neurotransmitter serotonin (low serotonin levels shorten the time to ejaculation), abnormal hormonal levels, e.g., lh, prolactin, and tsh, hypogonadism, inflammation and/or infection of the prostate (congestion or prostatitis)or urethra,
Erectile Dysfunction (ED): Ejaculatory hyperreflexia,
Genetic Predisposition:
Hyperthyroidism,
Neuropathy (such as multiple sclerosis), alcoholism,
Diabetes,
Recreational drug abuse,
Sleep deprivation (leads to low serotonin levels)
- Psychological Factors:
Depression, anxiety, stress, guilt, narcissism,
Distorted thinking,
Unrealistic expectations about sexual performance,
Performance Anxiety:
History of sexual repression,
Overall lack of confidence/poor body image,
History of sexual abuse(masturbation) or prior bad experience,
Relationship problems, control issues with partner,
Feeling of self-loathing,
Unrealistic fear of harm from vaginal penetration,
Hostility against women,
Other underlying mental health issues
Inexperience
Symptoms
- Rapid/early ejaculation- primary symptom
- Emotional distress- accompanied with embarrassment and performance anxiety
- Lack of control- unable to control ejaculation
- Avoidance in intimacy
- Decreased sexual satisfaction, etc.
Diagnosis
- Medical History: Detailed medical and sexual history of the patient to be taken with inquiring about the frequency and duration of the premature ejaculation episodes, any associated psychological condition, medication use (presence of any pre-ejaculate), and any recent life changes or stressors.
- Physical Examination: To rule any other abnormality(such as erectile dysfunction)
- Partner’s Perspective: To enquire about partner’s view point and also in ruling out female orgasm problem(as it can cause male partner self-doubt)
- Psychological Assessment: To assess the underlying factors such as anxiety, depression ,etc.
- Diagnostic Tests: In some cases, the doctor may order specific laboratory tests or use validated questionnaires or diagnostic tools to aid in the diagnosis and assess the severity of pe.
Treatment/Management:
- Behavioral Therapy– Techniques like start and stop, squeeze method have helped in many cases. Masturbation and ‘second try’ coitus is also used.
- Pharmacological Therapy– Includes topical anesthetics, ssris, clomipramine, dapoxetine, tramadol, use of local applications to reduce the sensitivity of penis.
Desensitizing creams and sprays can cause side effects including hypo anesthesia of the penile shaft and numbing of the vaginal vault of the partner, unless a condom is used. Irritating local and systemic effects have also been reported, although they are rare.
- Psychological Treatment- Such as counseling could be beneficial
- Combination Therapy– Using all this therapies together seen the most success.[8][9][6]
Psychotherapy offers the only true potential for a “cure” for premature ejaculation and should not be overlooked when preparing a treatment plan for patients with this disorder.
- Lifestyle Modification- Lifestyle changes, such as reducing alcohol consumption, quitting smoking, managing stress, and maintaining a healthy lifestyle with proper diet and routine, may help improve overall sexual function and control over ejaculation.
Homoeopathic Treatment
1. Graphites- Sexual debility, with increased desire; aversion to coition; too early or no ejaculation; herpetic eruption on organs. Cramps in calves during coition. Impotence from excessive indulgence or masturbation.
2. Lycopodium- No erectile power; impotence. Premature emission (calad; sel; agn). Enlarged prostate. Condylomata. Emission too speedy or too tardy during coition.falling asleep during coition. Lycopodium is a typical remedy where the young man has abused himself by secret vices and has become tired out in his spine, brain and genital organs.
3. Zincum metallicum– Strong sexual desire, with difficult or too speedy emission.─permanent erections at night.─emissions at night, without lascivious dreams. Falling of public hair. Sadness after emission
4. Damiana (q)- Is an effective homoeopathic remedy in the treatment of sexual disorders in men such as premature ejaculation and loss of sexual desire. It is used as an energy tonic and acts as an aphrodisiac .
5. Selenium metallicum- Homeopathic medicine selenium metallicum is a remedy used to address a wide range of symptoms related to sexual performance, including premature ejaculation and the inability to last longer in bed.
6. Calcarea carb- Frequent emissions. Increased desire. Semen emitted too soon. Coition followed by weakness and irritability. Burning, with seminal emission. Coition followed by profound weakness, vertigo, irritability, lameness of back and knees, headache and sweat.
7. Sulphur- Stitches in frequent pollution, also at noon. Watery semen. Involuntary discharge of semen, with burning in urethra. Too quick discharge of semen during coition. Involuntary emissions. Itching of genitals when going to bed. Penis cold to touch. Seminal emission on touching a woman. Semen is odorless, watery.
8. Caladium- Nocturnal emissions either without dreams or with non-sexual dreams. Imperfect erections and premature ejaculation of the semen.
9. Titanium– Sexual weakness, with too early ejaculation of semen in coitus.
Repertorial Approach:
Based on the working method of the repertory and homoeopathic principles the most similimum medicine will be chosen for the treatment of the cases. Few rubrics for premature ejaculation seen in the repertory (synthesis) are as: [10]
- Male genitalia/sex; ejaculation, quick, too
- Male genitalia/sex; ejaculation, fast
- Male genitalia/sex; ejaculation, premature
- Male genitalia/sex; sensitiveness, penis
- Male genitalia/sex; sensitiveness, penis, glans
- Male genitalia/sex; sensitiveness, sexual desire excessive; poor results with
7. Generals; masturbation, ailments from
Male genitalia/sex; ejaculation, quick, too – Adlu. Agar. Agn. Aloe arn. Bar-c. Berb. Borx. Brom. Bros-gau. Bufo calad. Calc. Canna canth. Carb-an. Carb-v. Carbn-s. Chin. Con. Ery-a. Eug. Gels. Graph. Ind. Lyc. Merc. Nat-c. Nat-m. Nux-v. Ol-an. Onos. Petr. Ph-ac. Phos. Pic-ac. Plat. Sel. Sep. Spong. Staph. Sul-ac. Sulph. Sumb. Thala. Titan. Ust. Vanil. Zinc.
References
1. Rosen rc. Prevalence and risk factors of sexual dysfunction in men and women. Curr psychiatry rep [internet]. 2000 [cited 2023 oct 5];2(3):189–95. Available from: https://pubmed.ncbi.nlm.nih.gov/11122954/
2. Waldinger md. History of premature ejaculation. In: premature ejaculation. Milano: springer milan; 2013. P. 5–24.
3. Icd-10 code for premature ejaculation- f52.4- codified by aapc. (n.d.). Aapc.com. Retrieved october 17, 2023, from https://www.aapc.com/codes/icd-10-codes/f52.4
4. Issm.info. [cited 2023 oct 5]. Available from: https://www.issm.info/media/attachments/2021/08/17/03-clinical-guidelines—issm-quick-reference-guide-to-pe–vjan2015.pdf
5. Aviles ja. Premature ejaculation: the ultimate guide to last longer in bed. Independently published; 2022.
6. Crowdis m, leslie sw, nazir s. Premature ejaculation. Statpearls publishing; 2023.
7. Zhang d, cheng y, wu k, ma q, jiang j, yan z. Paroxetine in the treatment of premature ejaculation: a systematic review and meta-analysis. Bmc urol [internet]. 2019 [cited 2023 oct 11];19(1). Available from: https://pubmed.ncbi.nlm.nih.gov/30606186/
8. Cooper k, martyn-st james m, kaltenthaler e, dickinson k, cantrell a, wylie k, et al. Behavioral therapies for management of premature ejaculation: a systematic review. Sex med [internet]. 2015 [cited 2023 oct 11];3(3):174–88. Available from: https://pubmed.ncbi.nlm.nih.gov/26468381/
9. Melnik t, althof s, atallah án, puga me dos s, glina s, riera r. Psychosocial interventions for premature ejaculation. Cochrane library [internet]. 2011 [cited 2023 oct 11];(8). Available from: https://pubmed.ncbi.nlm.nih.gov/21833964/
10. Schroyens, f. (2018). Augmented clinical repertory. B jain publishers pvt ltd; 9.1 edition (1 january 2008).
11. Clark jh. A dictionary of the practical materia medica. Delhi: b. Jain publishers pvt. Ltd.; 2005.
12. Boericke w. Boericke’s new manual of homeopathic materia medica with repertory:third revised & augmented edition based on ninth edition: including indian drugs, … Affinites & list of abbreviations. Noida: b. Jain large print; 2010.
Lectures on homoeopathic materia medica
13. Kent jt. Lectures on homoeopathic materia medica. India: b. Jain publishers pvt. Ltd.; 1 april 2007.
14.https://journals.lww.com/ajandrology/fulltext/2019/21050/premature_ejaculation__an_update_on_definition_and.1.aspx
