The most common sexual problem among men is premature ejaculation. Premature ejaculation was defined (only at 2014) as ejaculation within a minute of penetration (with no intent and with distress consequences) and it occurs routinely in 0.5% of men (1).
There was a medical debate whether it is a pathology or just like there are tall and short people, there are those who ejaculate earlier and those who ejaculate later, and they are all healthy and it's not a pathology. In other words, it's natural that not everyone will ejaculate at exactly the same time. Therefore, some expert claimed that there was no pathology here and we deal with healthy men at the extreme end of the normal scale. In the end, due to the significant suffering of those who suffer from it, premature ejaculation was recognized as a medical problem.
Whether it is a medical issue or not, many people want to prolong the time of penetration. (By the way, half of men 'cum' within 5:45 minutes (1)). This post is a rare summary of the solutions from a scientific perspective. In this post, I will try to translate for you the scientific understanding into practical steps that you can implement. Below, I will explain the mechanism of ejaculation and how psychology and behavior can change biology in the context of premature ejaculation.
Not all men are the same. Therefore, I do not believe in a one-size-fits-all solution. In this post, you will receive the scientific explanation of "how the brain controls ejaculation" so that you can understand the logic behind the steps and apply them in a specific way that suits you or your patients. In my course, I give a two-hour lecture on the neurobiology of sexual function, and here I will do it briefly and only in the context of male ejaculation.
When there is a problem, many people want medication, to take a pill, close the issue, and move on. The medical debate I've mentioned above, has been preventing FDA-approval of a pill for this problem. However, in Europe, due to the significant suffering of those who suffer from premature ejaculation, the approval was given (it is marketed under the tradename Priligy, see latter). I suggest treating the psychological-behavioral aspect in parallel or even as a first step. From my perspective as a brain researcher, the psychological-behavioral aspect is entirely biological. From my perspective, non-pharmacological treatment - even just talking - can change things biologically in the brain.
So shall we begin? First, a brief introduction about our nervous system, which is important for what follows. You can think of the brain and the spinal cord as the management team of the body: the brain is the CEO (Chief Executive Officer) and the spinal cord is the COO (Chief Operating Officer). They communicate with the body through the rest of the nerve cells that compose the peripheral nervous system. The peripheral nervous system is divided into two parts: the somatic part, which is conscious, and the autonomic nervous system, which is unconscious and involuntary. The autonomic nervous system works all the time in the background without us being aware of it. For example, the control over heart rate or changes in blood pressure that we are not aware of. Erection, for example, is caused by the action of the autonomic nervous system, which causes relaxation of blood vessel muscles in the penis, and men cannot cause an erection or relaxation of the penis voluntarily, just as we cannot contract or dilate our pupils voluntarily.
The autonomous system has 2 branches that usually work in opposite ways, meaning that one activates while the other deactivates.
One branch is called the sympathetic system and it works in states of arousal (Fight, Flight, Freeze), and as we will see shortly also in sex (which, just think about it for a moment, is the fourth F...).
The second branch of the autonomous system works in states of relaxation (Rest and Digest) and is called the parasympathetic system.
This is a somewhat simplified description, in a following post (here) I explain this deeper.
Bottom line: we have a conscious somatic system and two unconscious systems: the sympathetic system for arousal states and the parasympathetic system for relaxation.
After this background on the structure of the nervous system, we can move on and talk about ejaculation! Ejaculation has two stages, both of which are caused by activation of the sympathetic nervous system.
In the first stage, the sympathetic nervous system causes two things: a) emission of semen from the Epididymis gland which sits just on top of each testicle into the sperm duct (which is called Vas Deferens). b) contractions of the sperm duct, which push the semen up the tube until it joins with the urethra in an area enveloped by the prostate gland. At the bottom of this area, there is a ring-muscle that closes the tube and prevents the semen from continuing. Therefore, the semen accumulates there until the second stage of ejaculation.
In the second stage, the ring muscle receives a nerve command to relax, this opens the way for the sperm, the pressure in the tube is released, and the semen bursts out with the help of contractions of other muscles that push it along the urethra. This stage is also controlled by the sympathetic nervous system.
The opening of the ring muscle (allowing the semen to burst out) is controlled, in addition to the involuntary sympathetic system, by the voluntary somatic system (we relax it to pee).
All nervous information - sympathetic, parasympathetic, and somatic (conscious) - passes between the penis and the spinal cord through 3 nerves: somatic, sympathetic, and para-sympathetic. In the spinal cord, there is a nerve center that controls all the nervous symphony that leads to erection and ejaculation. This center, discovered in humans only in 2017 (!), can make autonomous decisions, but it is also under the control of the brain (the CEO).
So far I explained that ejaculation is caused by the involuntary sympathetic system, which also has a voluntary component - the somatic. The spinal cord (the deputy director) manages the operation and receives instructions from the brain, the CEO.
Now, in short about the CEO: the mechanisms within the brain that control male sexual activity. In the past decades, neural networks were found in a part of the brain called the hypothalamus that control male sexual behavior. In a previous post (here), I showed how their discovery made it possible to activate them artificially and cause a male mouse to stop fighting and try to mate (with whatever is around even with another male), or cause a female to mount a male and try to mate with him as if she were the male and he was the female!
What activates and deactivates this center, which is the highest control center in the brain for erection and ejaculation? The substance dopamine activates the neural networks there, so that an increase in dopamine raises sexual desire. (This explains the action of plant-based dietary supplements that increase dopamine and speed up erection and ejaculation, and increase sexual desire, such as Mucuna pruriens, Magic Velvet Bean). Activation of the center enhances male sexual activity, and therefore increasing dopamine may be a solution for men who suffer from delayed ejaculation. In contrast, the substance serotonin inhibits this center in the brain and thus slows down the progression of sexual activity. In other words, increasing serotonin will delay ejaculation. At the end, after all brain calculations, the electrical signal from the brain (the CEO) reaches the spinal cord, (the COO), where it is translated into a chemical signal. A chemical signal such as oxytocin, vasopressin, and noradrenaline instructs the spinal center to activate the sympathetic system and progressing to ejaculation. In contrast, serotonin, in addition to its former activity in the brain, in the spinal cord it instructs the spinal center to inhibit ejaculation.
Therefore, the spinal cord, the COO, can direct ejaculation and the CEO, the brain, can either stand by or intervene. If the brain intervenes, it can either delay or accelerate ejaculation.
This is the background information you need to understand the following:
How can ejaculation be controlled with pharmaceutical and non-pharmaceutical treatments?
So now, let's get down to it. After we understand how it works, let's see what we can do to delay ejaculation. I'll start with pharmacological intervention, and then I'll write about non-pharmacological treatments.
In fact, there is only one drug approved for use for premature ejaculation and only in Europe: Priligy (Dapoxetine). This drug increases the amount of serotonin in the synapses, which delays sexual activity. This is similar to how antidepressants of the SSRIs family work, so people who take SSRIs often experience suppression of sexual drive and delay in ejaculation. However, unlike SSRIs, Priligy is not taken every day. It increases serotonin strongly and quickly, but for a relatively short time.
In summary, Priligy increases the amount of serotonin - both in the brain itself and from the brain to the spinal cord - and thereby enhances the delay in ejaculation, meaning it delays premature ejaculation.
Another drug, Silodosin, inhibits the activation of the sympathetic system in the pathway from the spinal cord to the reproductive organ. It does so by inhibiting norepinephrine activity in a relatively specific manner in the Epididymis and sperm duct, thereby preventing the semen from exiting. It also prevents the prostate contractions that propel the semen out afterwards.
This drug has shown good efficacy in treating premature ejaculation in humans (2). It has few side effects, but has not yet received (as of now?) approval for preventing premature ejaculation. Researchers noted that it is used off-label for delaying premature ejaculation, meaning that it does not have an approved indication for this purpose. Since Silodosin inhibits contraction of the prostate it's used in men suffering from enlarged prostate.
Since unlike Priligy, Silodosin does not act on the brain at all but only on the level of the spinal cord-reproductive organ, the question arises of what happens in the brain when it gives the signal for ejaculation but no semen comes out. Is the brain aware of this or is it considered an ejaculation from its perspective? From the brain's perspective, it would make sense that if there was ejaculation, serotonin and prolactin would be released within the brain to suppress sexual drive. I haven't seen an answer to this in the literature. It's possible that this medication could delay ejaculation and leave sexual desire intact (meaning there wouldn't be a release of prolactin and serotonin) in the case where the instruction for ejaculation starts from the spinal cord and the brain doesn't intervene. There are definitely interesting questions regarding this medication. If you have used Silodosin, I would be interested in hearing about your experience so that I can share the information with others.
In general, this field does not receive enough scientific attention, and in my opinion, it is because of shame, guilt, and fear on the part of scientists to deal with it. Another example of this is that my course is unique and does not exist, to the best of my knowledge, anywhere else. In contrast to this scientific neglect, erectile dysfunction drugs are best sellers, which shows that there is definitely a demand from consumers for improving sexual function.
Important note: serotonin and norepinephrine serve many other important functions in the body, and therefore, a drug that changes their levels in the body can have a negative impact on other things in the body. Using them together with other drugs/substances can be very problematic (for example, the combination of ecstasy, MDMA, with SSRI-type serotonin-raising drugs is very dangerous). Therefore, these drugs require a doctor's prescription. There is no shame in consulting with a doctor. What about Viagra? Viagra (and similar medications, all of which contain the active ingredient known as PDE5i), primarily works on the smooth muscle cells in the walls of blood vessels in the penis (and clitoris), causing them to relax and dilate, which leads to an erection. This effect has no connection to ejaculation what so ever. However, beyond its effects on blood vessels in the penis, the active ingredient in Viagra has other effects in the body (side effects) that could explain findings from several studies showing that Viagra prolongs ejaculation time in men with premature ejaculation (3).
For those seeking a deeper understanding, these additional effects occur at the level of smooth muscle cells and even in the brain: At the level of muscle cells, just as Viagra relaxes smooth muscle in the walls of blood vessels, it also relaxes smooth muscle cells in the sperm duct (the vas deferens) which reduces sperm movement, it also relaxes smooth muscle in the seminal vesicles meaning less addition of fluids to semen and lastly it relaxes smooth muscles cells in the prostate which inhibits expulsion of the semen (4). It is intriguing to consider whether these effects on muscle cells might also delay the brain’s experience of orgasm.
Additionally, the active ingredient in the drug, PDE5i, crosses from the blood into the brain and has various effects on the brain (4), potentially even directly influencing nerve cells and by that prolonging the brain command to ejaculate but the mechanism is unclear (5).
Furthermore, for some men, there might be a psychological connection where achieving an erection translates into increased confidence. This confidence can reduce the activity of the sympathetic nervous system, meaning it delays ejaculation. That is, if the man feels performance anxiety and lack of confidence, Viagra may help by increasing confidence. If you are trying this direction, I would be happy to hear feedback from you!
In conclusion of the medical part, there are creams designed to reduce sensation in the penis by locally anesthetizing its sensory nerves. At least some of them are based on the substance Lidocaine, which prevents nerve cell activation. This can help men who have increased sensitivity in their penis skin. However, it will not help when the trigger for ejaculation is not over-sensitivity in the penis but psychological factors, as we will see shortly. Now I will refer to non-pharmacological treatments. Since the sympathetic system is responsible for ejaculation, slowing it down delays ejaculation. What increases the activity of the sympathetic system? Fear, stress, anxiety - all of these intensify the sympathetic system and therefore accelerate the arrival of ejaculation. Why might someone feel fear, anxiety, or tension during sex? There could be many reasons, and each man is a unique case. For example: the man feels in a test, he is afraid of commitment, he is afraid of the overwhelming feminine sensuality, he is afraid of losing control over himself or his partner, etc. Any intense emotion can activate the sympathetic system. Even a pleasant emotion, for example, when we fall in love.
In-depth psychological work allows the man to identify the psychological factors that activate his sympathetic system. Identifying these factors may allow him to remove the sting from them so that in future sexual situations, he will not enter an such emotional excitment that activates the sympathetic system, or he will learn to reduce the emotional response.
A popular theory of emotion states that emotions, such as fear and anxiety, are the brain's interpretation of a situation, and another interpretation will lead to a different emotion (see previous post on this model). That is, the first solution is not to reach the emotional state that triggers the sympathetic system. This is not something that can be decided easily but rather requires therapeutic work. We will move on to the second solution based on the following fact: when the sympathetic system is active, breathing becomes shorter. There are findings that also show the opposite: slow and deep breathing weakens the function of the sympathetic system (probably through oxygen receptors in the brain steam). Tantric techniques indeed emphasize the importance of breathing in sexuality. That is, the solution is deep breathing and inhaling a lot of air to reduce the activity of the sympathetic system. This is a way to consciously slow down the approach to ejaculation through behavior (breathing).
The third solution is behavioral-physical, using the pelvic floor muscles. As mentioned, a ring-muscle opens in the second stage of ejaculation, causing the semen to burst out with the help of other muscles. This ring-muscle is controlled both voluntarily and involuntarily by the somatic and sympathetic systems. It is possible to learn to strengthen the muscle and its voluntary control to delay ejaculation. The idea is to contract and relax the muscle repeatedly, slowly gaining more specific and increased control over it.
The fourth solution is called "Stop and Start," initially proposed in 1956 by the urologist Dr. James Semans.
The idea is to sense the moment of approaching ejaculation, the “point of no return,” and then stop.
This pause reduces arousal and the activity of the sympathetic nervous system. Once the excitement subsides, stimulation can resume. Over time, an association forms between rising arousal and the act of reducing excitement, making this process increasingly automatic.. According to Dr. Semans, the stimulation is provided by the partner, initially with a dry penis, and once successful, transitioning to a lubricated penis.
The sex researchers Masters and Johnson added to this technique by including a "squeeze" on the head of the penis during the pause. The squeeze is maintained until arousal decreases. The basis for their addition, however, is unclear to me.
The next solution, the sixth on this list, is to use biofeedback to learn to control the unconscious system. But wait, didn't I write earlier that it's impossible to control the autonomous system? so what's happening here? The (amazing) answer is that sometimes, it is possible to voluntary control the involuntary muscles. In biofeedback, the ability to control things that are not normally under conscious control is acquired. People learn with biofeedback to control their heart rate, reduce the activity of the sympathetic system to reduce migraines and urinary incontinence (7). People can even learn to control their brain waves!
In biofeedback, the disabled can, by changing their brain waves, give instructions to a mechanical arm to hand them a cup of coffee! In another application, by consciously controlling the brain waves of disabled people who have lost the ability to speak, they can communicate with the world for the first time by moving the computer cursor. This is actually done by focusing the mind in a certain way (!), electrodes on the head detect brain waves (!) and different types of waves move the computer mouse differently. Even mice can learn to activate certain cells in their brains and silence other specific nerve cells in order to receive a reward (9)!
All of this is amazing to me and sounds like science fiction, but it is already happening. Not everything is possible with biofeedback, and the biological mechanism of biofeedback is still not clear. However, the treatment for premature ejaculation with biofeedback is much more conventional than controlling brain waves or heart rate. The treatment takes several months and is quite effective (50% effectiveness and prolongation of penetration time from 2 minutes to over 10). In patients under the age of 35, the effectiveness was higher - 65% (9). I believe this is a promising direction that has not been sufficiently investigated.
The current treatment for premature ejaculation using biofeedback aims to activate the voluntary ring-muscle just before ejaculation in men so that the urethra remains blocked. In other words, this is an addition to the start-stop strategy. Initially, men cannot activate the muscle, but gradually they learn to do so at the right time. In addition, they learn not to miss the point of no return with a focus on their physical-emotional state (6).
A less conventional biofeedback treatment for premature ejaculation might provide voluntary access to the neural pathway that controls the autonomic system in order to reduce the activity of the sympathetic system. This is because the brain controls the spinal cord that sends commands to the autonomic system for erection and ejaculation. Information from the body and the environment reaches the conscious part of the brain, which interprets this information and translates it into activation instructions for the autonomic system. This learning process is like learning a language. People have difficulty describing in words what they are exactly doing in their mind to change the waves of their brain or the pace of their heart. In any case, as far as I have seen, such a treatment has not yet been done. If you're still counting, I'm moving on to solution number 7. :) In certain cases, early ejaculation may occur because the man learned to ejaculate quickly. For example, if a man had no privacy during childhood and hurried to 'cum' before being caught. Learning is a possible reason for premature ejaculation based on research in lab animals: when a female is repeatedly placed in a cage with a male for a short time, the male learns to ejaculate quickly, and this habit remains with him afterwards (8). Therefore, the idea is to create a new habit. That is, a new learning process that will compete with the previous learning. So, the man learns that there is time! Again, the experience of "not having time" is an experience of pressure that may increase the activity of the sympathetic nervous system. Apparently, the previous learning never disappears, but the new learning competes with it in influencing behavior. This is generally what happens with learning. By the way, it's fascinating (in my opinion) that in lab animals, males who chronically ejaculate quickly do not enjoy sex, but they continue to want it! This is another example that the two systems of wanting and enjoying are separate systems in the brain, and I'll write on it in a separate post. This is the end... I have examined the existing treatments from a practical perspective and their scientific basis. I make a great effort to bring the most up-to-date and accurate scientific knowledge and make it accessible in simple language. If I missed something, I would be happy to hear and add/correct it. You can contact me at doctoramosg@gmail.com .
I work hard to make high-quality, in-depth, and FREE content on the science of sexuality accessible. If you'd like to support me with a coffee (4$), I'd greatly appreciate it, and it would help me continue. Thank you in advance!
I delved into the subject because premature ejaculation is the most common sexual problem among men. In my opinion, this post is a rare summary of the biological perspective and I hope it was interesting and helpful. I would appreciate if you could spread it further.
In my course, I talk about everything sex, both broadly and in-depth. I bring the most up-to-date science in an interesting and accessible way to everyone. It's worth reading more posts on the blog, and of course, signing up for the upcoming course!
Sources (this is a limited list, this post is based on dozens more)
Proposal for a definition of lifelong premature ejaculation based on epidemiological stopwatch data. Waldinger et al. (2005). Journal of Sexual Medicine.
Effectiveness of 'on demand' silodosin in the treatment of premature ejaculation in patients dissatisfied with dapoxetine: a randomized control study. Bhat et al. (2016). Central European Journal of Urology free reading here https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5057054/
The role of phosphodiesterase type 5 inhibitors in the management of premature ejaculation: a critical analysis of basic science and clinical data, (2007), Juza Chen, Gal Keren-Paz, Yuval Bar-Yosef, Haim Matzkin, European Urology. Review.
Current and emerging treatment options for premature ejaculation, (2022), Murat Gul,
Kadir Bocu, Ege Can Serefoglu, Nature Reviews Urology
PDE5 Exists in Human Neurons and is a Viable Therapeutic Target for Neurologic Disease, (2016), Andrew F Teich, Mikako Sakurai, Mitesh Patel, Cameron Holman, Faisal Saeed, Jole Fiorito, Ottavio Arancio, Journal of Alzheimer's Disease.
Biofeedback for treating pre-mature ejaculation - Awareness and timing of pelvic floor muscle contraction, pelvic exercises and rehabilitation of pelvic floor in lifelong premature ejaculation: 5 years experience (2014). Archivio Italiano di Urologia e Andrologia https://pubmed.ncbi.nlm.nih.gov/25017593/
Efficacy of Biofeedback for Medical Conditions: an Evidence Map, (2019), Journal of General Internal Medicine. Here
Context-Dependent Acquisition of Copulatory Behavior in the Male Rat: Role of Female Availability, Pfaus, (2008), Behavioral Neuroscience Here
Biofeedback in lab-animals:
7. Closed-loop brain training: the science of neurofeedback, (2016) Nature Reviews Neuroscience Here
8. A comprehensive review of EEG-brain–computer interface paradigms, (2019), Journal of Neural Engineering And Brain Computer Interfaces, a Review (2012) Sensors. link
Comments