by M. P. Vora, M.B.B.S, D.V.D.
Hon. Sr. Venereologist, St. George’s Hospital, Bombay.
Current Medical Practice
A Monthly Journal Devoted to Modern Medicine and Surgery.
Volume No- 7, Number – 12 of December 1963.
Page No. 757 to 760.
Premature ejaculation is probably the most common disturbance of the male potency and one of the frequent causes of unhappiness in married life. According to Dr. Kinsey, three-fourths of all men reach the climax in less than two minutes, and in his opinion, this is a sign not of weakness but of strength. In his sexual life every male suffers, at one time or other, from this trouble when he is worried, fatigued, tense or apprehensive. If the premature ejaculation occurs occasionally in between long periods of satisfying sexual relations, there is hardly any need to worry about it. However, when it is frequent and causes concern or marital discord, medical attention becomes urgent and vital. Not to over-rate, one out of ten men suffer from this uncontrollable affliction. If allowed to persist for a long time, it leads to sexual impotence.
There are two forms of this condition.
In the former, the involuntary ejaculation of semen occurs immediately on intromission or very soon after that. Ejaculatio ante-partus is a more serious condition in which ejaculation occurs before the penis is introduced into the vagina. Ejaculation may take place with semi-erect condition of the penis or without any erection. He is in a state of constant erithism and merely kissing the partner or a close body contact which is natural in foreplay, is enough to stimulate ejaculation. In both forms of this condition, the female partner has no opportunity to achieve full-flowering sexuality, to obtain the height of expressive sensuality and thus to reach the ultimate sexual ecstasy or orgasm. She is thus denied the essential simultaneous sexual satisfaction. Of course, it is assumed that the female is sexually normal and can reach a climax within a reasonable time.
The man who is unable to delay his ejaculation and thus complete a sexual union, satisfying to himself and to his partner, soon begins to feel inadequate, maladjusted and unhappy. Each failure leads to the expectation of another failure. This creates a state of constant tension which makes successful sexual intercourse unlikely afterwards.
The male by nature is very touchy and sensitive of his potency. Usually he does not like to present his case straightaway. He often tries to hide it as something shameful. Hence many men who are victims of this condition do not seek medical advice on premature ejaculation. The stimulation is often brought to the notice of the family physician by the sexually frustrated wife, complaining of vague and divergent ailments without any discernible cause.
Mechanism of ejaculation: - Like automatic brakes and accelerator, which work together in close harmony to keep the motor car machine moving smoothly, two opposing nerves, regulate one’s ejaculation. These nerves, regulate one’s ejaculation. These nerves, automatically control ejaculation without one’s conscious bidding. Ejaculation is, therefore, called a reflex act.
Contrary to common interpretation, a psychosomatic illness does not mean that it is an imaginary one but implies unrelieved emotions. One’s inner thoughts and feelings constantly and continuously reach into one’s physical tissues and automatically cause changes in one’s body. The unrelieved emotions, anxieties and conflicts can upset the harmony and cause the nerve-tensed organ of the body to falter in its proper functioning.
The organs of sex and reproductive are largely under the autonomic nervous system control. Sexual arousal and energy built-up, released during coitus, flow along the autonomic nerves to the sexual organs. In a healthy man, distressing premature ejaculation, impotence or frigidity is rarely caused by anything physical but by mental tensions about sex, which inhibit the healthy flow of desire and satisfaction along autonomic nerves to these body organs. The golden mean or the balance of robust activity and peaceful response is badly disturbed.
Caused of premature ejaculation:- In majority of cases, hypersensitivity of the male sexual mechanism is the basic cause of premature ejaculation. Ejaculation is a reflex act in response to intense sexual stimulation. When the man’s sexual mechanism is hyper- or super-sensitive, the body’s response is naturally swifter than he desires it to be, and the reflex act of ejaculation is necessarily quicker, hasty and rapid.
Treatment:- Since a long time physicians have tried to treat, with varying degree of success, premature ejaculation by various methods such as drugs, suggestions, hypnosis, woman-superior position and various delaying tactics. Of paramount importance, general good health, balanced diet, open air exercises and lastly but not the least important, his wife’s genuine co-operation should not be forgotten as is usually done.
A significant proportion of men, exposed to the stress, react by developing psychosomatic illness. When the physician identifies the underlying stress and guides the patient towards its correction or adjustment, the treatment of such an illness is more likely to be effective than otherwise. Most important is, therefore, the understanding by the physician of the nature of the patient’s conflicts or anxieties and evolving proper means for their resolution by careful and well-documented observations, however, painstaking and time-consuming they may be. Mere prescriptions of some fancy or costly drugs or injections are not going to be of any value.
The patient could possibly help himself by learning to relax and to decrease the amount of tension and excitement by assuming a less active role during coitus. He can assign the active role or aggressive position (the woman-super position) to his female partner. He may be advised to recite the alphabet or to count numbers backwards, in his mind, during copulation. This takes away tension and enables him to hold his ejaculation for a longer time. The man may be advised to practice to stop voluntarily, a few times, the flow of urine during the act of micturition, to wait for a short while and then to recommence the flow. Repetition of this exercise, a few times a day for some weeks, helps him to gain muscular control and thus enables him to exert control over the flow of semen. The advice is based on the belief that there exists a connection between the bladder control and premature ejaculation.
Tranquilizers:- They are a versatile group of drugs. They relieve emotions, tensions and anxieties, but their indiscriminate use is beset with grave dangers. Isocarboxide much as Marplan 10 mg three or four times a day, has been used with success in many cases and has enabled them to get over their anxieties and thus to continue sexual relations for a longer time without precipitous ejaculation.
Local hypersensitivity:- If the prepuce is tight, circumcision may be advised. To reduce local sensitivity, the use of anaesthetising ointment such as 1%-2% xylocaine or procaine is recommended. The ointment is applied on the glans penis and a small quantity is left into the external urethral opening, half an hour before the intercourse. In addition, the use of oestrogen such as (Eticyclin linguestradiol) 0.01 mg, twice a day orally, for some days, should be advised. This treatment would help to reduce the local sensitivity of the glans penis and help him to delay his ejaculation for a sufficient time.
Congested posterior urethra:- To remove the congestion and to reduce the irritability of the posterior urethra, the following procedure is recommended. The patient is asked to report with a full bladder. Prostatic massage is given and then he is asked to pass urine. Two ml of freshly prepared silver nitrate solution, 1 in 1000, gradually increased in strength 1 in 500, is instilled into the urethra by means of Utzmann’s canula. The patient is told not to pass urine for half an hour. This treatment is given twice a week for about six to eight weeks. Light transurethral fulguration of the veru montanum is indicated in some cases.
Emotional conditions:- Various procedures in use have already been discussed. However, there is a new approach to this problem. It is based on the theory of desensitization. It does not involve the use of medicines, injections or psychological desensitization. It aims at a permanant cure of the condition by retraining the man’s pattern of sexual response so that a greater and more than usual sexual stimulation is required to trigger his ejaculatory reflex. There are two methods of this retraining technique:-
Both the techniques require the wife’s complete co-operation, utmost patience, tact and sympathy. Neither method will work unless she is willing to help her husband. Throughout the process of retaining, she must always be affectionate, encouraging and devoid of any criticism either in word or action. Of her own, she is not to make demands on him but she must always be ready to respond to his needs and to what he freely desires.
Active Method:- The man and his wife are interviewed separately, at the first session. The technique is explained to them in detail and instructions are given in its use. At the next session, both are invited together for an interview with an object of ascertaining whether the technique and instructions have been properly understood. After a few weeks they are again interviewed to evaluate the progress.
The wife is required to stimulate the male organ manually until the husband becomes aware of the sensation that precedes the ejaculation. He then signals her to stop the stimulation. When the impending sensation has died out, the wife resumes the stimulation till he feels again the pre-ejaculatory sensation. Again he asks her to stop manipulations. Repetition of this procedure, day after day, establishes a new pattern of sexual response in which intense sexual stimulation is tolerated without ejaculation. Thus the man learns to postpone his ejaculation almost indefinitely.
Passive Method:- The man is so fearful and sensitive to any sexual stimulation that a mere close contact with a woman he desires, arouses the fear and triggers the reflex ejaculation, making a successful union impossible. Desensitizing the man to these sensations will enable him to tolerate the situation without precipitous ejaculation. The procedure of interview is similar to one in the previous method. They are told to do nothing at all to increase his sexual excitement. She is to make no sexual demands on him. They are to engage in sexual closeness without either expecting an intercourse. In bed, they indulge in only as much sexual activity as the man can tolerate without anxiety. He is to do only as much as he really feels like doing and no more. He is not to make love except when he freely desires. As there is no set goal he must reach, or no level of sexual performance he must attain, the anxiety he feels about sexual stimulation is considerably lessened. He becomes more and more relaxed and is able to indulge in more intense sexual stimulation or close embraces without being least anxious. He thus learns to tolerate a greater amount of stimulation without ejaculation. His sexual mechanism gets retained to respond in the union with a greater degree of excitement and much less anxiety.
Both the active and passive approaches appear to work exceedingly well in the hands of the authors and cures have been reported in weeks or months. With either technique, premature ejaculation may occur accidentally, at times, and should be expected by the couple. Because they no longer regard it as a sign of failure, it does not create tension or arouse his inferiority complex. If it does accidentally, further efforts of retraining are preferably delayed and the husband then should gently stimulate his wife’s clitoris until she reaches an orgasm. This is to help her to achieve sexual relief and to enlist her continued co-operation in efforts to re-train his pattern of sexual response.