What causes premature ejaculation and what can be done to treat it? | Peter Attia & Mohit Khera

okay so let's let's pivot now and talk a little bit about uh the sort of states of ejaculation so so inorgasmia delayed orgasm Etc um how does the prevalence of this differ by age yeah so ejaculatory dysfunctions are important we know that 30 percent of men 30 of men are likely to have some type degree of ejaculatory dysfunction more prominent is premature ejaculation right so premature ejaculation uh 30 of men up to 30 will have it only nine percent of that 30 percent will seek therapy it's really small and that's really because many men are

embarrassed to seek therapy about this so basically 30 of men have this only three percent of men in total are doing anything about it nine percent of the nine percent that's exactly right which is very small but in you know two years ago the guidelines came out the new guidelines came out so what is a premature ejaculation two ways to think about it this is really important how you break it up at the beginning it's either lifelong or acquired that's your first step has this patient had it ever ever since they remember having sex and

they can always have premature ejaculation or was this acquired in either case you have to have three variables you must have these three one you have to have a decrease ejaculatory time now when it's lifelong it's typically now less than two minutes right so it's less than two minutes it used to be less than one now it's less than two but it has to have a sense of loss of control I couldn't control it and number three they have to be bothered by it if a guy comes in and says I ejaculate in 30 seconds

and I'm happy look great he doesn't have the problem he gets me bothered by it right so it's important what if he's not bothered by it but his partner is well it's he has to be bothered by it right so if he's bothered that she's bothered fine but he has to be bothered by the condition right now acquire it's a little bit different so look things were great till I hit 40 and all of a sudden I developed premature ejaculation same principles you have to be bothered by the condition you have to have a sense

of loss of control and you have to have a decrease in time now how do you define time that's a little bit tricky on this one because it's anywhere from two to three minutes or it's 50 percent of your typical time so let's say I used to ejaculate in 10 minutes and now it's five okay that qualifies it's fifty percent of what man so these are the two definitions of so you want to break it down now why is that important because how I treat somebody is very different right if someone's acquired we start looking

at hormones that's important we look at prolactin we look at thyroid we look at testosterone we look at some more diagnostic if it's lifelong we don't do a lot of diagnostic work up you're not supposed to it's the acquired where you start figuring out you know the four reasons for this premature ejaculation one is the biological the theory that there's increased sensitivity of the glands right so if they're born with increased sensitivity that's why one of the therapies is using lidocaine or some of these numbing agents on the glands they're over the counter there's sprays

that actually lidocaine on the penis 10 minutes prior to engaging sexual activity but doesn't that then put lidocaine onto the partner you wipe it off before you engage in sexual activity I see and so and and but be careful because if you spray too much it causes Ed right so that's one so it's the biological there's a but there's a neurobiological essentially meaning the neurotransmitters so essentially that there's too little serotonin um the neurotransmitters are causing an impairment for the ejaculation there's some belief on genetic uh we don't have an assay right now but they're

four four genes that have been implicated um the sum Gene but these genes are only implicated in lifelong or in acquired uh and acquired that's sorry it should be lifelong I'm sorry and there's polymorphism of the the and they're they're they they're the receptor neurosteroid receptor genes right and they're four of them but we don't use this clinically we don't look for the assay we just know that more studies need to be done and uh the last one's important it's psychological right if you have um a new relationship stress um any kind of uh they

causes some psychological impairment that can actually cause premium do you have a sense of why stress can have opposite effects why is it that in one man stress us might result in Ed and in another man it might result in no difficulty with an erection but premature ejaculation yeah I think it's how you interpret I don't I can't answer that I don't know the answer I don't do know that stress though significantly in effect you in all sexual function I call it sad it's stress anxiety and depression patients suffer from those so stress it can

have a significant impact on all forms of sexual dysfunction right and so but stress stress has a huge impact when it comes to sexual dysfunction a lot of men when the stress have difficulty getting an erection um and so it but it does affect premature ejaculation as well so these are the reasons why men have it so how do you treat it there's some treatment options and the first line therapy typically is the spray I was talking about lidocaine spray that you can use we use promescent it's over the counter it's easy to get the

second one you can use typically is ssris so antidepressants but some men say I don't want to take an antidepressant um I say okay you don't have to take it every day although it works best if you take it every day but you can take it on demand the problem with On Demand is you got to take it six to eight hours ahead of time which is counter-intuitive right because one of the side effects of an SSRI is reduction in libido right and Ed both anorexia libido so you're right uh so so you just have

to realize that those are and then first line therapy should always be Sex Therapy this is one area where Sex Therapy is very effective and sex therapists are what what is the formality of training to be a sexist they are certified you have to have a certification so basically a psychologists or psychiatrist a typically psychologist not psychiatrist but psychiatrists can be uh certified in Sex Therapy but um these uh they're very helpful because there's two techniques the start stop technique The Squeeze technique that teach patients how to prolong the ejaculate but again A lot of

times patients say just give me the pill I say fine I mean but if they did the work that's secure right that's a cure for PE um so so those are the first line therapies they're our second line therapies the two second line therapies are Tramadol a narcotic right it actually has been shown if you look at the ejaculator time less than one minute a lot of studies so up to seven minutes the problem is a narcotic yes and it's been used quite often as a treatment and it's in the guidelines as as what's the

risk of addiction or exacerbation of very high yeah and so that's why I had a patient once that started using you know five a month then you're asking for 10 a month and then once he called for 30 a month and I said this is ridiculous he goes well I'm having sex every day I want it every and I could tell he's getting addicted right and I said I can't do this anymore you know so so you just have to be careful on the tram at all uh and then actually uh alpha blockers Flomax premature

ejaculation yeah right so now does that sometimes convert premature into retrograde you can so right that's one of the risk factors for the alphablock retrograde but it prolongs the ejaculatory time you know so so these are the treatment options that we use for patients and they're quite effective you just kind of go through the algorithm uh for PE explain what a retrograde ejaculation is so think about what happens when the uh so as I mentioned earlier in the prostate there's something called the ejaculatory ducts so think of it like a t Okay so the ejaculatory

ducts are coming up moving forward is the urethra and it's coming out the urethra moving backward is the bladder so when the sperm comes up and the seminal fluid comes up the tendency is for the fluid to go back into the bladder but as the man has an ejaculate he closes off the bladder neck so the fluid cannot get into the bladder it's forced to go out but when you take a medication like an alpha blocker or certain other medications it can actually open the bladder neck so what happens is the sperm comes up seminal

fluid then goes into the bladder and so nothing comes out of the urethra and when the man urinates or voids then the seminal fluid will come out is there any harm of a retrograde ejaculation no harm at all just some patients find it annoying yeah obviously it would impair reproduction so for sure so if someone's trying to have a child yeah [Music]