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Premature ejaculation: A common and treatable concern
Journal o f the American Psychiatric Nurses Association
Psychobiology Perspectives Premature Ejaculation: A Common and Treatable Concern
from ejaculation outside of the vagina to having an erection that lasted for less than 2 minutes. Duration of sexual intercourse or the number of thrusts required to satChristi Carver, RN, ANP, CNS, MSN isfy the criteria of PE varied from study to study (McCarthy, 1989). The fourth edition of the Diagnostic a n d Statistical remature ejaculation (PE) is the most common sexual complaint of adult heterosexual and M a n u a l o f M e n t a l Disorders (DSM IV) of the American homosexual men (Spector & Carey, 1990). Mthough PE Psychiatric Association (1994) provides a definition of is highly amenable to treatment, w h e n left untreated it PE that does not include arbitrary times or percentages. The DSM IV describes PE as persistent or recurcan cause low self-esteem, relationship problems, and rent ejaculation with minimal sexual stimulation before even secondary impotence. Clients with this disorder or shortly after penetration and before the person seek help in both outpatient psychiatric settings and wishes it. Furthermore, the disturbance must cause primary care settings. Advanced practice nurses can marked distress or interpersonal difficulty (American offer comprehensive treatment for patients with PE. Psychiatric Association, 1994). DEFINITION McCarthy (1989) suggested that the definition of PE The definition of PE and even the name of the diagnofocus on a couple's subjective evaluation and elements sis itself are controversial. Some writers have preferred of pleasure rather than on performance criteria. In makto use less value-laden terms such as rapid ejaculation ing an assessment of PE, the clinician would be best served by incorporating both the objective and subjecor early ejaculation rather than PE (McCarthy, 1989). tive criteria along with being In the past, definitions have sensitive to the meaning the focused on specific perfordisorder has for the patient mance criteria. More recently, Although PE is highly amenable to and his partner. those criteria have seemed treatment, when left untreated it arbitrary and culturally biased. can cause low self-esteem, ETIOLOGY For example, Masters and Two types of PE exist: Johnson (1970) defined PE as relationship problems, and even an inability to control ejacula- secondary impotence. primary and secondary. Section for a sufficient period of ondary PE occurs in a man time during intercourse to satwho previously had ejaculaisfy a partner at least 50% of the time. Satisfaction of a tory control. Trauma to the sympathetic nervous system partner is not always possible despite the duration of the from abdominal aortic aneurysm surgery or pelvic fractures, prostatic hypertrophy, prostatitis, and urethritis erection. Other descriptions focused on the duration of can cause PE (Metz, Pryor, & Nevacil, 1997). Withdrawal intercourse (Grenier & Byers, 1995). The range varied from narcotics and trifluoperazine (Stelazine) can also cause PE (Althof, 1995). Of course, relationship stressors should not be overlooked as a source of secondary Christi Carver is self-employed in private practice as a psyPE. It has been determined that hormones play no part chiatric nurse practitioner in Fredericksburg, Virginia, and in the etiology of early ejaculation (Grenier & Byers, is an adult nurse practitioner in an internal medicine practice at Pratt Medical Center in Fredericksburg, Virginia. 1995). Primary PE occurs in men w h o have not yet learned ejaculatory control or possibly have a biologic Reprints not available f r o m the author. susceptibility. Several theoretic causes of primary PE J A m Psychiatr Nurses Assoc (1998). 4, 199-204. have been proposed. Copyright © 1998 by the American Psychiatric Nurses Grenier and Byers (1995) suggested that biologic Association. factors such as greater penile sensitivity and an easily 1078-3903/98/$5.00 + 0 66/1/94295
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J o u r n a l o f the American Psychiatric N u r s e s Association
Case Study A 23-year-old married man came to the clinic with the chief complaint of premature ejaculation, He had been married for 2 years and was developing an almost phobic avoidance of sex. He was anxious to solve theproblem, which was interfering with his relationship with his wife and was a source of self-condemnation. The client was assessed during the first session, and he was given an assignment to practice sensate-focused exercises with his wife. He reported at the second visit that the exercises were enjoyable and that he did not uphold the prohibition against sexual intercourse. (The prohibition was given to decrease performance anxiety.) During coitus he was able to sustain an erection for 8 minutes, which was a big improvement over his previous self-reported duration of 2 minutes or less. Because the client's level of anxiety was quite high even during the sensate-focused exercise, the next assignment was to practice relaxation exercises. Pairing touching with relaxation techniques proved to be an effective type of desensitization. He was also taught the stop and start exercises, which he was practicing on his own. Unfortunately, his wife refused to attend any sessions or to practice techniques together, saying it was his problem. By the third visit the client had a level of ejaculatory control he had not previously achieved. He was able to sustain an erection for 15 minutes. He was more cognizant of the sexual response cycle, and we had begun talking about ways to expand his sexual repertoire. In spite of his improvement, he and his wife were not satisfied with his sexual performance, and at this time he requested and received medication treatment. Drug treatment was helpful and he continued to improve, although not as much as he had hoped. He subsequently moved and was lost to follow-up. Had we been able to enlist the partner's cooperation, this case would likely have had a more successful outcome.
triggered bulbocaverosus reflex contribute to early ejaculation. The combination of a biologic predisposition and early conditioning to ejaculate quickly or high levels of anxiety may aid in the development of PE (Grenier & Byers, 1995). An example of early conditioning is evidenced in sexual experiences that are rushed toward culmination because of feelings of guilt or an uncomfortable setting. An unawareness of the premonitory sensations leading to ejaculation can also cause PE (O'Donohue & Geer, 1993). Sexual excitation is viewed on a continuum. A major treatment for PE focuses on intervening at a time on the continuum before ejaculation is inevitable.
When a client with PE does not respond to treatment or when the partner will not participate M treatment, the clinician should suspect that a relationship problem might be underlying the resistance. Whether sexual performance anxiety is a cause or consequence of sexual difficulty is uncertain (Rosen, Leiblum, & Spector, 1994). However, increased sympathetic nervous system activity combined with biologic vulnerability can precipitate the development of PE (Strassberg, Mahoney, Schaugaard, & Hale, 1990). 200 APNA website: www.apna.org
H. Kaplan (1983) posited that although sexual problems often stem from poor communication or technical difficulties, they could also express deeper hostilities or anxieties. Power struggles or ambivalence about intimacy can get acted out in the sexual arena. When a client with PE does not respond to treatment or when the partner will not participate in treatment; the clinician should suspect that a relationship problem might be underlying the resistance. Psychopathology in one or both partners can also be a barrier to effective resolution.
COMPLICATIONS FROM UNTREATED PREMATURE EJACULATION Left untreated, persons with PE may experience low self-esteem and, because of an almost phobic avoidance of sexual encounters, may withdraw from relationships. Fear and avoidance prolong problem resolution. In fact, infrequent intercourse often precipitates PE (O'Donohue & Geer, 1993). Isolation and low selfesteem can breed depression. Isolation, self-condemnation, and depression all reinforce one another. If untreated, PE can lead to erection problems and inhibited sexual desire (McCarthy, 1989). Furthermore, PE can be a major source of conflict and misunderstanding in a couple's relationship (McCarthy, 1989). The use of "do-it-yourself' distraction techniques, such as thinking of aversive thoughts during intercourse or using numbing creams to decrease sensation, bring with them their own problems. Trying to distract oneself during intercourse leads to "spectatoring" and puts more distance between the man and his partner (Rosen
Vol. 4, No. 6
J o u r n a l o f the American P s y c h i a t r i c N u r s e s Association
Carver
a partner. Maintaining ejaculatory control is most difficult for a man w h e n he is on top of his partner. Therefore the client's partner assumes the superior position, and by verbal and nonverbal communication the couple works together to delay ejaculation by TREATMENT stopping movement and withdrawing the penis until he is ready to resume intercourse. Masters and Although success rates vary from study to study, all studies of PE indicate a high rate of success with treatJohnson (1970) added the "squeeze" technique. After ment. Treatment usually includes education, cognitive withdrawing the penis to postpone ejaculation, the and behavioral interventions, and performance partner squeezes the head of the penis with the thumb and forefinger on the dorsal and ventral side anxiety reduction and relationship enhancement. More recently drug treatment has played an of the frenulum, applying firm pressure for 3 to 4 secimportant role. For some persons, education and reasonds. The squeeze can be used at any time during surance alone can be curative. Information about anaoral or manual stimulation or during intercourse to reestablish shaky ejaculatory control. Semans' techtomy and physiology and the sexual response cycle can be helpful. The realization that one is not totally responnique, as well as the squeeze, will help the client sible for the partner's sexual satisfaction can be liberatestablish ejaculatory control. By working together, the ing. Mso helpful is abandoning the notion that the only couples' communication skills are strengthened and legitimate sexual outlet is penis-focused, orgasm-orientconfidence grows both in their ability to problem solve and in their ability to trust each other. ed intercourse. Sexuality education that stresses awareness, comfort, and a nondemand pleasure orientation As confidence grows, the couple may move from quiet penile containment to slow pelvic thrusting would benefit both partners (McCarthy, 1989). The mainstay of behavioral treatment is the "stop (Masters & Johnson, 1970). As sexual tensions build, the start" technique of Semans (1956). Semans' technique, "stop-start" or squeeze technique can be used if that is mentioned in most all studies and treatments, is a the mutual desire, or the couple may allow themselves series of graduated exercises designed to improve to continue toward culmination. Many couples eventuejaculatory control. The "stop start" technique begins ally prefer the lateral coital position because it allows with masturbation that progresses toward but stops greatest movement for both people, as well as ejaculashort of ejaculation. In this way the man becomes tory control (Masters & Johnson, 1970). more familiar with sensaSensate focus exercises tions that p r e c e d e orgasm, also d e v e l o p e d by Masters and by stopping the stimu- Treatment usually includes and J o h n s o n (1970) are lation, he learns to post- education, cognitive and behavioral designed to improve the p o n e ejaculation. In the sexual interaction of the next step the man's partner interventions, and performance couple. The c o u p l e is inmanually stimulates his anxiety reduction and relationship structed to familiarize thempenis but stops w h e n ejacuselves with the type of enhancement. lation is imminent. Next this touching they enjoy but to is accomplished with the refrain from intercourse. In addition of lubrication to enhance sensations. Each of this way the couple is exposed to increasing levels of these steps is practiced three to four times, up to 15 sexual stimulation while performance demands are minutes in duration, over the course of several days minimized (Rosen et al., 1994). These exercises can or weeks. The "practice" c o m p o n e n t cannot be improve the couple's communication skills and help overemphasized. Although the idea is to learn to them b e c o m e less goal and orgasm oriented. delay ejaculation, these sessions should not be On the cognitive from, Rosen et al. (1994) believed viewed as tests but rather opportunities to practice. that cognitive distortions perpetuate the demand, fear, Some clinicians insert a paradox here and instruct the and failure cycle. Identifying and challenging the disclient to ejaculate early in an attempt to help the tortions is the w o r k of the clinician and client. client feel more in control (O'Donohue & Geer, 1993). Examples of cognitive distortions are overgeneralizaThe third step in Semans' technique is practice with tion and fortune telling. Overgeneralization causes et al., 1994). The topical anesthetic creams promoted to sustain erections are not very satisfactory either because sensations are diminished for both the partner and the client.
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the person to see a single negative event as a neverP. Kaplan (1994) noted immediate improvement in ending pattern, such as "Because I ejaculated early patients treated with selective serotonin reuptake last night, I will never be able to satisfy a partner." inhibitors. The following prescribing recommendations have been derived from many small studies. A Predicting a negative future and then seeing the prediction as fact is an example of fortune telling. dosage of between 25 and 50 mg of clomipramine per Emotional reasoning refers to the false assumption day resulted in significant and rapid improvement in that feelings are facts. An example of someone with the ability to delay ejaculation (Althof, 1995). The PE using this type of reasoning might be, "I feel less dosing schedule remains unclear. Some clients take it manly because of this sexual problem. Other people daily; others use it on the day they expect to have know I am less manly too." Having the client monisexual intercourse. Patients return to baseline after tor, identify, and replace the distortions with realistic withdrawal from the drug (Althof, 1995). Side effects convictions can be helpful. can include loss of libido and genital anesthesia Expanding a couple's sexual activity repertoire will (Balon, 1996). not only help them in recovery from PE but will inocuThe recommended dose of paroxetine is 20 mg a day. Immediate slight imlate them against relapse as they face inevitable change, p r o v e m e n t can be seen in the first week. Side effects aging, or illness (McCarthy, The very side effects, such as can include fatigue, frequent 1989). By exploring a wide delayed orgasm, that often cause range of intimate and erotic intense yawning, and failed people to discontinue drug therapy ways to connect, the focus on ejaculation (Walinger & duration of sexual intercourse with the serotonin reuptake Zwinderman, 1997). diminishes, along with perSertraline is started at 50 mg inhibitors make these drugs and titrated up to 200 mg over formance anxiety (Rosen et al., 1994). Communication desirable for the treatment of PE. a period of 3 weeks, based on skills are strengthened, as is the patient's response. Side effects include dry mouth, the couple's bond. diarrhea, and fatigue (Balon, 1996). Fluoxetine was prescribed in one study at 20 mg a day or every other day DRUG TREATMENT for 8 weeks followed by 20 mg every other day for a A final approach to treatment is medication. Drug treatment is particularly helpful to men with a physimonth and finally every 2 days for 6 months (Balon, 1996). The most frequently cited side effect was anxiety ologic predisposition to PE (Metz et al., 1997). The (Balon, 1996). Larger clinical studies with medications more recent categories of drugs that have been used for the treatment of PE include the dopamine antagoneed to be completed (Grenier & Byers, 1995). Much more remains to be learned about dosage, nists, agents that enhance gamma-amino butyric acid, and antidepressants. Of these, antidepressants have scheduling, and duration of treatment. It should also be remembered that drugs cannot replace a sensitive been the most effective treatment because of the sideassessment of a couple's sexual equilibrium. Medication effect profile, lack of abuse potential, and consistent is not a panacea, and one should be careful that medreports of delayed ejaculation (Balon, 1996). The very side effects, such as delayed orgasm, that often cause ications are not provided in a way that would collude unwittingly with a man's unresolved fear of inadequapeople to discontinue drug therapy with the serotonin cy (Althof, 1996). A careful assessment would avoid reuptake inhibitors make these drugs desirable for the unnecessary use of medication. treatment of PE. An increased level of serotonin is thought to be one of the mechanisms that inhibits NURSING IMPLICATIONS ejaculation (Metz et al., 1997). The drugs sertraline The public expects nurses to have a certain comfort (Zoloft), paroxetine (Paxil), fluoxetine (Prozac), and level with bodily functions. The mind-set that includes clomipramine (Anafranil) have all been used in small a matter-of-fact acceptance of all things human can be studies as well as clinically and have been remarkably a great comfort to clients who are gathering courage effective (Balon, 1996; Grenier & Byers, 1995; to ask for help with sexual problems. Because sexual Mendels, 1995; Metz et al., 1997; Walinger & Zwinderman, 1997). issues are often difficult topics for patients to broach, 202 APNA webs#e: www.apna.org
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routinely asking about any sexual concerns should be part of obtaining a history of the patient and included in the review of systems. The nurse's comfort level with sensitive issues can either pave or block the path to further communication. The second step after eliciting the problem in the history is to make an assessment. The DSM IV (1994) offers the most objective diagnostic criteria. Some men may mistakenly believe they have PE. In many of these cases, education and reassurance may be e n o u g h to help them overcome their problem. Once the disorder is diagnosed, the next step is to let the client k n o w that treatment is nearly always successful. Good reason exists to be hopeful and expectant of success. Education is key. Providing the client and his partner with information about the h u m a n sexual response cycle and whatever anatomy and physiology lessons seem pertinent is helpful. As McCarthy (1989) points out, education should emphasize comfort and a nondemand pleasure orientation. Bibliotherapy is a useful
for individual therapy. If the couple has severe marital problems, they should be referred for marital counseling. Sexual problems usually will not remit unless the underlying-issues are addressed. If they do happen to remit, the remittance will not satisfy the client, and the likelihood of relapse is high. If medication is being considered and you are n o t comfortable with the use of the medication or are unable to prescribe it, identify a practitioner w h o is skilled in the use of medication for this disorder.
Because sexual issues are often difficult topics for patients to broach, routinely asking about any sexual concerns should be part of obtaining a history of the patient and included in the review of systems.
SUMMARY
Providing the client and his partner with information about the human sexual response cycle and whatever anatomy and physiology lessons seem pertinent is helpful. Clients w h o do not respond to the treatments outlined should be referred to a qualified sex therapist.
The complaint of PE is seen both in primary care settings and psychiatric settings. Fortunately, PE is highly amenable to treatment. Education and cognitivebehavioral interventions are key to successful treatment. Helping a client overcome premature ejaculation can make a dramatic difference in h o w a man views his sexuality and, concomitantly, himself.
REFERENCES adjunct. The patient may choose from many available books about sexuality. Providing detailed cognitive and behavioral techniques for the client to practice at home is an important link in the treatment. Follow-up appointments are made to assess progress, refine the treatment plan, and deal with relapse. Even after the patient seems "cured," an additional follow-up appointment should be made some months hence to reinforce the teaching, new perspective, and behavior. Medication is best used as part of the treatment, not instead of treatment. Follow-up visits for medication checks can also be opportunities to reinforce teaching about cognitive and behavioral changes.
REFERRALS If a serious underlying psychopathology is present in one or both of the partners, they should be referred December 1998
Alrhof, S. (1995). Pharmacologictreatment of rapid ejaculation. The Psychiatric Clinics of North America, 18, 85-95. American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.) Washington, DC: Author. Balon, R. (1996). Antidepressants in the treatment of premature ejaculation. Journal of Sex and Marital Therapy, 22, 85-96. Grenier, G., & Byers, S. (1995). Rapid ejaculation: A review of conceptual, etiological and treatment issues. Archives of Sexual Behavior, 24, 447-472. Kaplan, H. (1983). The evaluation of sexual disorders.. New York: Bmnner/Mazel. Kaplan, 17.(1994). The use of serontonergic uptake inhibitors in the treatment of premature ejaculation. Journal of Sex and Marital Therapy, 20, 321-325. Masters, W., & Johnson, V. (1970). Human sexual inadequacy. Boston: Little, Brown. McCarthy, B. (1989). Cognitive-behavioralstrategies and techniques in the treatment of early ejaculation. In S. R. Lieblum & R. Rosen (£ds.), Principles and practice of sex therapy (pp.141-166). New York: The Guilford Press. Mendels, J. (1995). Sertraline for premature ejaculation. Journal of Clinical Psychiatry, 56, 591. APNA website: w w w . a p n a . o r g 203
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Metz, M., Pryor, J., & Nevacil, L. (1997). Premature ejaculation: A psychophysiological review. Journal of Sex and Marital Therapy, 23, 3-23. O'Donohue, W., & Geer, J. (1993). Handbook of sexual dysfunctions.. Assessment and treatment. Boston: AUyn and Bacon. Rosen, R., Leiblum, S., & Spector, I. (1994). Psychologically based treatment for male erectile disorder: A cognitive interpersonal model. Journal of Sex and Marital Therapy, 20, 67-85. Semans, J. H. (1956). Premature ejaculation: A new approach. Southern MedicalJournal, 49, 353-357.
Spector, I., & Carey, M. (1990). Incidence and prevalence of the sexual dysfunctions: A critical review of the empirical literature. Archives of Sexual Behavior, l g 389-403. Strassberg, D., Mahoney, J., Schaugaard, M., & Hale, V. (1990). The role of anxiety in premature ejaculation: A psychophysiologicai model. Archives of Sexual Behavior, 19, 251-253. Walinger, M. D., & Zwinderman, A. H. (1997). Ejaculation-retarding properties of paroxetine in patients with primary premature ejaculation: A double-blind, randomized, dose-response study. British Journal of Urology, 79, 592-595.
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204 APNA website: w w w . a p n a . o r g
Vol. 4, No. 6
Psychobiology Perspectives Premature Ejaculation: A Common and Treatable Concern
from ejaculation outside of the vagina to having an erection that lasted for less than 2 minutes. Duration of sexual intercourse or the number of thrusts required to satChristi Carver, RN, ANP, CNS, MSN isfy the criteria of PE varied from study to study (McCarthy, 1989). The fourth edition of the Diagnostic a n d Statistical remature ejaculation (PE) is the most common sexual complaint of adult heterosexual and M a n u a l o f M e n t a l Disorders (DSM IV) of the American homosexual men (Spector & Carey, 1990). Mthough PE Psychiatric Association (1994) provides a definition of is highly amenable to treatment, w h e n left untreated it PE that does not include arbitrary times or percentages. The DSM IV describes PE as persistent or recurcan cause low self-esteem, relationship problems, and rent ejaculation with minimal sexual stimulation before even secondary impotence. Clients with this disorder or shortly after penetration and before the person seek help in both outpatient psychiatric settings and wishes it. Furthermore, the disturbance must cause primary care settings. Advanced practice nurses can marked distress or interpersonal difficulty (American offer comprehensive treatment for patients with PE. Psychiatric Association, 1994). DEFINITION McCarthy (1989) suggested that the definition of PE The definition of PE and even the name of the diagnofocus on a couple's subjective evaluation and elements sis itself are controversial. Some writers have preferred of pleasure rather than on performance criteria. In makto use less value-laden terms such as rapid ejaculation ing an assessment of PE, the clinician would be best served by incorporating both the objective and subjecor early ejaculation rather than PE (McCarthy, 1989). tive criteria along with being In the past, definitions have sensitive to the meaning the focused on specific perfordisorder has for the patient mance criteria. More recently, Although PE is highly amenable to and his partner. those criteria have seemed treatment, when left untreated it arbitrary and culturally biased. can cause low self-esteem, ETIOLOGY For example, Masters and Two types of PE exist: Johnson (1970) defined PE as relationship problems, and even an inability to control ejacula- secondary impotence. primary and secondary. Section for a sufficient period of ondary PE occurs in a man time during intercourse to satwho previously had ejaculaisfy a partner at least 50% of the time. Satisfaction of a tory control. Trauma to the sympathetic nervous system partner is not always possible despite the duration of the from abdominal aortic aneurysm surgery or pelvic fractures, prostatic hypertrophy, prostatitis, and urethritis erection. Other descriptions focused on the duration of can cause PE (Metz, Pryor, & Nevacil, 1997). Withdrawal intercourse (Grenier & Byers, 1995). The range varied from narcotics and trifluoperazine (Stelazine) can also cause PE (Althof, 1995). Of course, relationship stressors should not be overlooked as a source of secondary Christi Carver is self-employed in private practice as a psyPE. It has been determined that hormones play no part chiatric nurse practitioner in Fredericksburg, Virginia, and in the etiology of early ejaculation (Grenier & Byers, is an adult nurse practitioner in an internal medicine practice at Pratt Medical Center in Fredericksburg, Virginia. 1995). Primary PE occurs in men w h o have not yet learned ejaculatory control or possibly have a biologic Reprints not available f r o m the author. susceptibility. Several theoretic causes of primary PE J A m Psychiatr Nurses Assoc (1998). 4, 199-204. have been proposed. Copyright © 1998 by the American Psychiatric Nurses Grenier and Byers (1995) suggested that biologic Association. factors such as greater penile sensitivity and an easily 1078-3903/98/$5.00 + 0 66/1/94295
p
December 1998
A P N A webs#e: w w w . a p n a . o r g
199
Carver
J o u r n a l o f the American Psychiatric N u r s e s Association
Case Study A 23-year-old married man came to the clinic with the chief complaint of premature ejaculation, He had been married for 2 years and was developing an almost phobic avoidance of sex. He was anxious to solve theproblem, which was interfering with his relationship with his wife and was a source of self-condemnation. The client was assessed during the first session, and he was given an assignment to practice sensate-focused exercises with his wife. He reported at the second visit that the exercises were enjoyable and that he did not uphold the prohibition against sexual intercourse. (The prohibition was given to decrease performance anxiety.) During coitus he was able to sustain an erection for 8 minutes, which was a big improvement over his previous self-reported duration of 2 minutes or less. Because the client's level of anxiety was quite high even during the sensate-focused exercise, the next assignment was to practice relaxation exercises. Pairing touching with relaxation techniques proved to be an effective type of desensitization. He was also taught the stop and start exercises, which he was practicing on his own. Unfortunately, his wife refused to attend any sessions or to practice techniques together, saying it was his problem. By the third visit the client had a level of ejaculatory control he had not previously achieved. He was able to sustain an erection for 15 minutes. He was more cognizant of the sexual response cycle, and we had begun talking about ways to expand his sexual repertoire. In spite of his improvement, he and his wife were not satisfied with his sexual performance, and at this time he requested and received medication treatment. Drug treatment was helpful and he continued to improve, although not as much as he had hoped. He subsequently moved and was lost to follow-up. Had we been able to enlist the partner's cooperation, this case would likely have had a more successful outcome.
triggered bulbocaverosus reflex contribute to early ejaculation. The combination of a biologic predisposition and early conditioning to ejaculate quickly or high levels of anxiety may aid in the development of PE (Grenier & Byers, 1995). An example of early conditioning is evidenced in sexual experiences that are rushed toward culmination because of feelings of guilt or an uncomfortable setting. An unawareness of the premonitory sensations leading to ejaculation can also cause PE (O'Donohue & Geer, 1993). Sexual excitation is viewed on a continuum. A major treatment for PE focuses on intervening at a time on the continuum before ejaculation is inevitable.
When a client with PE does not respond to treatment or when the partner will not participate M treatment, the clinician should suspect that a relationship problem might be underlying the resistance. Whether sexual performance anxiety is a cause or consequence of sexual difficulty is uncertain (Rosen, Leiblum, & Spector, 1994). However, increased sympathetic nervous system activity combined with biologic vulnerability can precipitate the development of PE (Strassberg, Mahoney, Schaugaard, & Hale, 1990). 200 APNA website: www.apna.org
H. Kaplan (1983) posited that although sexual problems often stem from poor communication or technical difficulties, they could also express deeper hostilities or anxieties. Power struggles or ambivalence about intimacy can get acted out in the sexual arena. When a client with PE does not respond to treatment or when the partner will not participate in treatment; the clinician should suspect that a relationship problem might be underlying the resistance. Psychopathology in one or both partners can also be a barrier to effective resolution.
COMPLICATIONS FROM UNTREATED PREMATURE EJACULATION Left untreated, persons with PE may experience low self-esteem and, because of an almost phobic avoidance of sexual encounters, may withdraw from relationships. Fear and avoidance prolong problem resolution. In fact, infrequent intercourse often precipitates PE (O'Donohue & Geer, 1993). Isolation and low selfesteem can breed depression. Isolation, self-condemnation, and depression all reinforce one another. If untreated, PE can lead to erection problems and inhibited sexual desire (McCarthy, 1989). Furthermore, PE can be a major source of conflict and misunderstanding in a couple's relationship (McCarthy, 1989). The use of "do-it-yourself' distraction techniques, such as thinking of aversive thoughts during intercourse or using numbing creams to decrease sensation, bring with them their own problems. Trying to distract oneself during intercourse leads to "spectatoring" and puts more distance between the man and his partner (Rosen
Vol. 4, No. 6
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Carver
a partner. Maintaining ejaculatory control is most difficult for a man w h e n he is on top of his partner. Therefore the client's partner assumes the superior position, and by verbal and nonverbal communication the couple works together to delay ejaculation by TREATMENT stopping movement and withdrawing the penis until he is ready to resume intercourse. Masters and Although success rates vary from study to study, all studies of PE indicate a high rate of success with treatJohnson (1970) added the "squeeze" technique. After ment. Treatment usually includes education, cognitive withdrawing the penis to postpone ejaculation, the and behavioral interventions, and performance partner squeezes the head of the penis with the thumb and forefinger on the dorsal and ventral side anxiety reduction and relationship enhancement. More recently drug treatment has played an of the frenulum, applying firm pressure for 3 to 4 secimportant role. For some persons, education and reasonds. The squeeze can be used at any time during surance alone can be curative. Information about anaoral or manual stimulation or during intercourse to reestablish shaky ejaculatory control. Semans' techtomy and physiology and the sexual response cycle can be helpful. The realization that one is not totally responnique, as well as the squeeze, will help the client sible for the partner's sexual satisfaction can be liberatestablish ejaculatory control. By working together, the ing. Mso helpful is abandoning the notion that the only couples' communication skills are strengthened and legitimate sexual outlet is penis-focused, orgasm-orientconfidence grows both in their ability to problem solve and in their ability to trust each other. ed intercourse. Sexuality education that stresses awareness, comfort, and a nondemand pleasure orientation As confidence grows, the couple may move from quiet penile containment to slow pelvic thrusting would benefit both partners (McCarthy, 1989). The mainstay of behavioral treatment is the "stop (Masters & Johnson, 1970). As sexual tensions build, the start" technique of Semans (1956). Semans' technique, "stop-start" or squeeze technique can be used if that is mentioned in most all studies and treatments, is a the mutual desire, or the couple may allow themselves series of graduated exercises designed to improve to continue toward culmination. Many couples eventuejaculatory control. The "stop start" technique begins ally prefer the lateral coital position because it allows with masturbation that progresses toward but stops greatest movement for both people, as well as ejaculashort of ejaculation. In this way the man becomes tory control (Masters & Johnson, 1970). more familiar with sensaSensate focus exercises tions that p r e c e d e orgasm, also d e v e l o p e d by Masters and by stopping the stimu- Treatment usually includes and J o h n s o n (1970) are lation, he learns to post- education, cognitive and behavioral designed to improve the p o n e ejaculation. In the sexual interaction of the next step the man's partner interventions, and performance couple. The c o u p l e is inmanually stimulates his anxiety reduction and relationship structed to familiarize thempenis but stops w h e n ejacuselves with the type of enhancement. lation is imminent. Next this touching they enjoy but to is accomplished with the refrain from intercourse. In addition of lubrication to enhance sensations. Each of this way the couple is exposed to increasing levels of these steps is practiced three to four times, up to 15 sexual stimulation while performance demands are minutes in duration, over the course of several days minimized (Rosen et al., 1994). These exercises can or weeks. The "practice" c o m p o n e n t cannot be improve the couple's communication skills and help overemphasized. Although the idea is to learn to them b e c o m e less goal and orgasm oriented. delay ejaculation, these sessions should not be On the cognitive from, Rosen et al. (1994) believed viewed as tests but rather opportunities to practice. that cognitive distortions perpetuate the demand, fear, Some clinicians insert a paradox here and instruct the and failure cycle. Identifying and challenging the disclient to ejaculate early in an attempt to help the tortions is the w o r k of the clinician and client. client feel more in control (O'Donohue & Geer, 1993). Examples of cognitive distortions are overgeneralizaThe third step in Semans' technique is practice with tion and fortune telling. Overgeneralization causes et al., 1994). The topical anesthetic creams promoted to sustain erections are not very satisfactory either because sensations are diminished for both the partner and the client.
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the person to see a single negative event as a neverP. Kaplan (1994) noted immediate improvement in ending pattern, such as "Because I ejaculated early patients treated with selective serotonin reuptake last night, I will never be able to satisfy a partner." inhibitors. The following prescribing recommendations have been derived from many small studies. A Predicting a negative future and then seeing the prediction as fact is an example of fortune telling. dosage of between 25 and 50 mg of clomipramine per Emotional reasoning refers to the false assumption day resulted in significant and rapid improvement in that feelings are facts. An example of someone with the ability to delay ejaculation (Althof, 1995). The PE using this type of reasoning might be, "I feel less dosing schedule remains unclear. Some clients take it manly because of this sexual problem. Other people daily; others use it on the day they expect to have know I am less manly too." Having the client monisexual intercourse. Patients return to baseline after tor, identify, and replace the distortions with realistic withdrawal from the drug (Althof, 1995). Side effects convictions can be helpful. can include loss of libido and genital anesthesia Expanding a couple's sexual activity repertoire will (Balon, 1996). not only help them in recovery from PE but will inocuThe recommended dose of paroxetine is 20 mg a day. Immediate slight imlate them against relapse as they face inevitable change, p r o v e m e n t can be seen in the first week. Side effects aging, or illness (McCarthy, The very side effects, such as can include fatigue, frequent 1989). By exploring a wide delayed orgasm, that often cause range of intimate and erotic intense yawning, and failed people to discontinue drug therapy ways to connect, the focus on ejaculation (Walinger & duration of sexual intercourse with the serotonin reuptake Zwinderman, 1997). diminishes, along with perSertraline is started at 50 mg inhibitors make these drugs and titrated up to 200 mg over formance anxiety (Rosen et al., 1994). Communication desirable for the treatment of PE. a period of 3 weeks, based on skills are strengthened, as is the patient's response. Side effects include dry mouth, the couple's bond. diarrhea, and fatigue (Balon, 1996). Fluoxetine was prescribed in one study at 20 mg a day or every other day DRUG TREATMENT for 8 weeks followed by 20 mg every other day for a A final approach to treatment is medication. Drug treatment is particularly helpful to men with a physimonth and finally every 2 days for 6 months (Balon, 1996). The most frequently cited side effect was anxiety ologic predisposition to PE (Metz et al., 1997). The (Balon, 1996). Larger clinical studies with medications more recent categories of drugs that have been used for the treatment of PE include the dopamine antagoneed to be completed (Grenier & Byers, 1995). Much more remains to be learned about dosage, nists, agents that enhance gamma-amino butyric acid, and antidepressants. Of these, antidepressants have scheduling, and duration of treatment. It should also be remembered that drugs cannot replace a sensitive been the most effective treatment because of the sideassessment of a couple's sexual equilibrium. Medication effect profile, lack of abuse potential, and consistent is not a panacea, and one should be careful that medreports of delayed ejaculation (Balon, 1996). The very side effects, such as delayed orgasm, that often cause ications are not provided in a way that would collude unwittingly with a man's unresolved fear of inadequapeople to discontinue drug therapy with the serotonin cy (Althof, 1996). A careful assessment would avoid reuptake inhibitors make these drugs desirable for the unnecessary use of medication. treatment of PE. An increased level of serotonin is thought to be one of the mechanisms that inhibits NURSING IMPLICATIONS ejaculation (Metz et al., 1997). The drugs sertraline The public expects nurses to have a certain comfort (Zoloft), paroxetine (Paxil), fluoxetine (Prozac), and level with bodily functions. The mind-set that includes clomipramine (Anafranil) have all been used in small a matter-of-fact acceptance of all things human can be studies as well as clinically and have been remarkably a great comfort to clients who are gathering courage effective (Balon, 1996; Grenier & Byers, 1995; to ask for help with sexual problems. Because sexual Mendels, 1995; Metz et al., 1997; Walinger & Zwinderman, 1997). issues are often difficult topics for patients to broach, 202 APNA webs#e: www.apna.org
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routinely asking about any sexual concerns should be part of obtaining a history of the patient and included in the review of systems. The nurse's comfort level with sensitive issues can either pave or block the path to further communication. The second step after eliciting the problem in the history is to make an assessment. The DSM IV (1994) offers the most objective diagnostic criteria. Some men may mistakenly believe they have PE. In many of these cases, education and reassurance may be e n o u g h to help them overcome their problem. Once the disorder is diagnosed, the next step is to let the client k n o w that treatment is nearly always successful. Good reason exists to be hopeful and expectant of success. Education is key. Providing the client and his partner with information about the h u m a n sexual response cycle and whatever anatomy and physiology lessons seem pertinent is helpful. As McCarthy (1989) points out, education should emphasize comfort and a nondemand pleasure orientation. Bibliotherapy is a useful
for individual therapy. If the couple has severe marital problems, they should be referred for marital counseling. Sexual problems usually will not remit unless the underlying-issues are addressed. If they do happen to remit, the remittance will not satisfy the client, and the likelihood of relapse is high. If medication is being considered and you are n o t comfortable with the use of the medication or are unable to prescribe it, identify a practitioner w h o is skilled in the use of medication for this disorder.
Because sexual issues are often difficult topics for patients to broach, routinely asking about any sexual concerns should be part of obtaining a history of the patient and included in the review of systems.
SUMMARY
Providing the client and his partner with information about the human sexual response cycle and whatever anatomy and physiology lessons seem pertinent is helpful. Clients w h o do not respond to the treatments outlined should be referred to a qualified sex therapist.
The complaint of PE is seen both in primary care settings and psychiatric settings. Fortunately, PE is highly amenable to treatment. Education and cognitivebehavioral interventions are key to successful treatment. Helping a client overcome premature ejaculation can make a dramatic difference in h o w a man views his sexuality and, concomitantly, himself.
REFERENCES adjunct. The patient may choose from many available books about sexuality. Providing detailed cognitive and behavioral techniques for the client to practice at home is an important link in the treatment. Follow-up appointments are made to assess progress, refine the treatment plan, and deal with relapse. Even after the patient seems "cured," an additional follow-up appointment should be made some months hence to reinforce the teaching, new perspective, and behavior. Medication is best used as part of the treatment, not instead of treatment. Follow-up visits for medication checks can also be opportunities to reinforce teaching about cognitive and behavioral changes.
REFERRALS If a serious underlying psychopathology is present in one or both of the partners, they should be referred December 1998
Alrhof, S. (1995). Pharmacologictreatment of rapid ejaculation. The Psychiatric Clinics of North America, 18, 85-95. American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.) Washington, DC: Author. Balon, R. (1996). Antidepressants in the treatment of premature ejaculation. Journal of Sex and Marital Therapy, 22, 85-96. Grenier, G., & Byers, S. (1995). Rapid ejaculation: A review of conceptual, etiological and treatment issues. Archives of Sexual Behavior, 24, 447-472. Kaplan, H. (1983). The evaluation of sexual disorders.. New York: Bmnner/Mazel. Kaplan, 17.(1994). The use of serontonergic uptake inhibitors in the treatment of premature ejaculation. Journal of Sex and Marital Therapy, 20, 321-325. Masters, W., & Johnson, V. (1970). Human sexual inadequacy. Boston: Little, Brown. McCarthy, B. (1989). Cognitive-behavioralstrategies and techniques in the treatment of early ejaculation. In S. R. Lieblum & R. Rosen (£ds.), Principles and practice of sex therapy (pp.141-166). New York: The Guilford Press. Mendels, J. (1995). Sertraline for premature ejaculation. Journal of Clinical Psychiatry, 56, 591. APNA website: w w w . a p n a . o r g 203
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Metz, M., Pryor, J., & Nevacil, L. (1997). Premature ejaculation: A psychophysiological review. Journal of Sex and Marital Therapy, 23, 3-23. O'Donohue, W., & Geer, J. (1993). Handbook of sexual dysfunctions.. Assessment and treatment. Boston: AUyn and Bacon. Rosen, R., Leiblum, S., & Spector, I. (1994). Psychologically based treatment for male erectile disorder: A cognitive interpersonal model. Journal of Sex and Marital Therapy, 20, 67-85. Semans, J. H. (1956). Premature ejaculation: A new approach. Southern MedicalJournal, 49, 353-357.
Spector, I., & Carey, M. (1990). Incidence and prevalence of the sexual dysfunctions: A critical review of the empirical literature. Archives of Sexual Behavior, l g 389-403. Strassberg, D., Mahoney, J., Schaugaard, M., & Hale, V. (1990). The role of anxiety in premature ejaculation: A psychophysiologicai model. Archives of Sexual Behavior, 19, 251-253. Walinger, M. D., & Zwinderman, A. H. (1997). Ejaculation-retarding properties of paroxetine in patients with primary premature ejaculation: A double-blind, randomized, dose-response study. British Journal of Urology, 79, 592-595.
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