It is evident from the examination of the criteria of ICD-10 and DSM-IV that rapid ejaculation can be diagnosed by two different dimensions: ejaculatory latency or voluntary control. According to ICD-10, ejaculation must occur 'within 15 seconds of the beginning of intercourse,' while DSM-IV is equivocal on duration, stating that 'ejaculation occurs with minimal sexual stimulation before, on, or shortly after penetration'. ICD-10 makes no mention of voluntary control, while DSM-IV notes that ejaculation occurs 'before the person wishes'. Both nosologies, however, require the man to be distressed for at least 6 months, and both require the clinician to make a judgement regarding the independence of this condition from other mental, behavioural, or physiological disorders.
Treatment research has been hampered by the lack of a scientifically sound and universally acceptable definition as to which criterion, ejaculatory latency or voluntary control, should be used to diagnose rapid ejaculation. Thus, one finds 'noncomparability across studies, uninterpretability of studies which do not provide their operational definition, inability to generalize from research results,...and lack of data on rapid ejaculation among homosexual couples. (58> The most frequently cited variable is ejaculatory latency, defined as the time from intromission to orgasm, but these studies use very different operational definitions of time, ranging from less than 1 min to 5 min; similar problems exist when the number of coital thrusts are counted. Those who oppose defining rapid ejaculation in quantitative terms argue that the salient parameter should be voluntary control.(5 6°) They contend that men who make no attempt to control ejaculation may be considered selfish but are not necessarily dysfunctional. The problem in using this definition lies in deciding what is meant by voluntary control.
The prevailing opinions regarding the aetiology of rapid ejaculation have typically assumed that the dysfunction was either psychological or learned, depending upon the theorists' assumptions about how the mind operates. Some believe that a lowered ejaculatory threshold stems from anxiety, general hostility toward women, interpersonal conflicts with a particular partner, or conditioning patterned on furtive masturbation practices, early hurried sexual experiences with prostitutes, or hasty lovemaking in the backseat of a car. Once established, performance anxiety was thought to maintain the rapid ejaculatory pattern.
Anxiety is not a singular concept, however. Anxiety may refer to a phobic response such as being fearful of the dark wet unseen vagina. It may also refer to affect, such as the end result of conflict resolution where two contradictory urges are at play, for example the man is angry at his partner but feels guilty about directly expressing his hostility. Anxiety may refer as well to a preoccupation with sexual failure and poor performance. As the man contemplates another sexual experience, his anxiety leads to an avoidance of any future sexual opportunity. McCarthy (69 suggests that this performance anxiety has two discrete dimensions: a cognitive component where the man watches himself, thus removing himself from awareness of his arousal level, as well as an emotional component consisting of fear of failure.
Strassberg et al.(6 6,2) and Gospodinoff(63) independently speculate that a subgroup of men who rapidly ejaculate may have an underlying neurophysiological vulnerability that explains some of the failures of psychological treatment. They argue that increased penile sensitivity (64) and a constitutionally more rapid bulbocavernousnes reflex create the biological vulnerability. Rowland et al.,(65> however, were unable to find evidence of increased penile sensitivity in rapid ejaculators.
Separating rapid ejaculation into lifelong and acquired groups may prove helpful in clarifying the aetiology of the dysfunction. A subgroup of lifelong rapid ejaculators may have a biological vulnerability, while those with acquired symptoms may not. The development of rapid ejaculation requires an examination of recent psychosocial stressors, medication, or surgery. It is often a consequence of erectile failure. Men develop performance anxiety regarding their erectile reliability and rush intercourse thinking that they have limited time to 'complete the act'. With these thoughts, this additional dysfunction appears and men become even more anxious about sexual interactions.
Rapid ejaculation is best assessed along both dimensions of ejaculatory latency following vaginal penetration and degree of voluntary control. Questions are asked about how long it takes the man to reach orgasm under each of the following circumstances: with masturbation, partner hand and/or mouth stimulation, and intercourse. Some men have inordinately high expectations, for instance 'I should be able to last 45 minutes', and falsely label themselves as rapid ejaculators. Education often reverses this misattribution. The man's level of sexual experience is reviewed, as is the duration of his current relationship. Young inexperienced men routinely ejaculate quickly, while men anxious to please new partners often encounter transient problems. Factors that improve and worsen performance are noted, such as coital positions. Next, the man's degree of voluntary control is examined, and which factors improve or worsen it are noted, such as distraction. The clinician reviews whether the dysfunction occurs under all circumstances or only with specific partners. If this is an acquired disorder it is important to ascertain the life events temporally related to the onset of the problem, for example mother-in-law coming to live with the family. It is also necessary to gauge whether rapid ejaculation is the primary problem or is secondary to erectile dysfunction, in other words whether it occurred after the man began having difficulty achieving an erection. The quality of the non-sexual relationship is also studied, with particular attention to the partner's response to the dysfunction and her level of expectation. Finally, it is worthwhile enquiring about the partner's sexual functioning because sometimes rapid ejaculation disguises a partner's dysfunction, that is to say it is an adaptive response to the partner's sexual aversion.
Organic factors are seldom implicated; however, trauma to the sympathetic nervous system during surgery for aortic aneurysm, pelvic fracture, prostatitis, and urethritis can induce rapid ejaculation. Additionally, drug withdrawal from narcotics or trifluoperazine have been associated with this symptom. (66)
Since the early 1970s, an array of individual, conjoint, and group therapy approaches employing behavioural strategies, such as the stop- start, squeeze technique, progressive sensate focus exercises, masturbatory exercises, and 'quiet vagina' with the female astride, have evolved as the treatments of choice for rapid ejaculation (1W5,,59.,6MZ,6M9.and 70)
Behavioural treatment often begins with the man alone, having him repeatedly stimulate himself to midrange levels of excitement before pausing. After several repetitions he is permitted to ejaculate. The aim of this exercise is to help him learn intermediate levels of excitement and begin to slow down his arousal.
The stop-start procedure involves the man repeatedly being brought to high levels of excitement, initially through stimulation by his partner's hand or mouth and later by vaginal thrusting, but stopping prior to ejaculation. (69> This pause allows the man's arousal to decrease and thereby delays orgasm. This behavioural sequence is repeated several times, after which the man is permitted to ejaculate. Subsequently, Masters and Johnson (10> modified the procedure by introducing a squeeze technique. At the point when stimulation is stopped, the man's glans penis is squeezed firmly but quickly by the partner, which is thought to lower arousal more effectively. Often a partial loss of erection occurs.
Sensate focus exercises are designed to allow the man to develop an awareness of his arousal level by lessening the demand characteristics of the sexual experience. In a slow graduated fashion the man and his partner take turns giving and receiving pleasure. Initially, the touching is restricted to non-genital/non-breast stimulation; upon achieving ejaculatory control these areas are also pleasured.
'Quiet vagina' is an extension of the stop-start manoeuvre to include intercourse. After successful hand stimulation the woman sits astride or lies on top of the man and, without any thrusting or rhythmic movement, envelopes his penis in her vagina. The aim of this exercise is to desensitize the man to the wet warm sensations of the vagina. After the man masters the 'quiet vagina' for a prolonged period of time, movement by the woman is slowly introduced. The man directs her to stop when his excitement has increased. The couple sit/lie quietly until his arousal decreases, whereupon they resume the exercise. This is repeated several times before the man is eventually allowed to ejaculate.
It is crucial for the therapist to monitor the partners' needs and responses during therapy. The female partner may feel used and unimportant. This must be acknowledged, while helping her to focus on the ultimate goal of pleasurable sex for both partners. Also, the therapist must monitor both patient and partner for the emergence of any resistances that will sabotage treatment.
McCarthy(60) delineates three foci of a cognitive-behavioural psychotherapeutic approach:
1. challenging self-defeating ideas about sexuality or women, while replacing them with facilitating thoughts about ejaculatory control, sexuality, and intimacy;
2. learning the behavioural skill of identifying the point of ejaculatory inevitability through the use of the stop-start technique and alternating intercourse positions or thrusting movements;
3. establishing a co-operative, intimate, and satisfying relationship.
Levine(59> advocates an integrated approach where the man or couple seek to understand the hidden meaning(s) of the rapid ejaculation, appreciate the interference of performance anxiety, and, when ready, embark on a series of behavioural tasks. He cautions clinicians to be aware of the man or couple's need for a symptom and how rare it is to find 'simple cases' of rapid ejaculation.
It has been found that the impressive treatment success rates of 60 to 95 per cent reported by Masters and Johnson can not be replicated and are not sustainable/.1. ,2.9,31) Success rates dwindle to 25 per cent 3 years after behavioural treatment.(3 i31) These data suggest that behavioural clinicians may have failed to recognize psychodynamic causes of the disorder, or to develop long-term strategies that allow patients to maintain their initial therapeutic gains. The efficacy of using periodic booster or maintenance sessions after the termination of the original treatment has not been investigated.
Clinicians have long been aware that several classes of drugs impede or eliminate orgasm. These include monoamine oxidase inhibitors, tricyclic and serotonergic antidepressants (phenelzine, pargyline, mebanazine, imipramine, amitripyline, fluoxetine, clomipramine, desipramine), antipsychotics (amoxapine, thioridazine, chlorpromazine, chlorprothizine, mesoridazine, perphenazine, trifluoperazine, and haloperidol), and a-adrenoceptor blocking agents such as phenoxybenzamine and guanethidine/71»
Several investigators have conducted double-blind randomized placebo-controlled studies using strict dosages in a carefully selected population to determine whether clomipramine and the serotonin-selective reuptake inhibitors (fluoxetine, fluvoxamine, paroxetine, and sertraline) are biologically and psychologically efficacious in delaying ejaculation/6,6,7 Z3> All these studies have confirmed the efficacy of these drugs in significantly delaying ejaculation. However, the medication improvements were lost when the men discontinued treatment and, in general, their ejaculatory latencies returned to baseline. One exception has been reported by McMahon (72) who used a novel method of dosing and withdrawing sertraline. After 7 months two-thirds of the sample population maintained their treatment gains. Side-effects were generally mild, dose-related, and tended to diminish with time; dry mouth, headache, drowsiness, and gastrointestinal upset were most frequently observed.
Although criteria for deciding which patients to provide with psychological, pharmacotherapy, or combined treatment do not yet exist, several points are relevant to this clinical decision. (74> The ideal candidate for initial drug therapy would be a man with several years of sexual experience and a lifelong pattern of rapid ejaculation who is free of substance abuse, depression, and psychosis and who is capable of developing stable, satisfying, non-sexual relationships. Drug therapy can also be considered for those patients who have not profited from a competently conducted psychological treatment. In contrast, men/couples with a relatively recent onset of acquired rapid ejaculation and some degree of psychological mindedness might do better with a psychological intervention in the long run. Also, pharmacotherapy should not be a first-line consideration for the young or inexperienced man who, in his first few sexual encounters, experiences rapid ejaculation. Reassurance and education are likely to be more worthwhile. In time, and with more experience, these men can be expected to develop increased confidence and learn to control ejaculation. Caution is warranted in offering drug therapy alone to men where the symptom clearly reflects intrapsychic or interpersonal conflict. Rapid symptom removal may disrupt the individual's or couple's emotional equilibrium.
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