What causes premature ejaculation in adults?

Causes of Premature Ejaculation in Adults

Premature ejaculation (PE) is caused by a complex interplay of psychological, biological, and pharmacological factors, with the most common causes being anxiety, relationship issues, and neurobiological factors related to serotonin dysregulation. 1

Types of Premature Ejaculation

PE is classified into two main categories:

Lifelong PE

• Present from first sexual experiences
• Primarily associated with:
  • Genetic predisposition 2
  • Psychological factors (anxiety, early sexual experiences) 1
  • Neurobiological factors (serotonin receptor sensitivity) 3

Acquired PE

• Develops after a period of normal ejaculatory function
• More likely to have identifiable organic causes:
  • Hyperthyroidism 2
  • Prostatic inflammation/prostatitis 2, 1
  • Erectile dysfunction (secondary PE) 1
  • Medication withdrawal (particularly opioids) 2

Psychological Factors

Psychological factors play a significant role in both lifelong and acquired PE:

• Anxiety: Performance anxiety creates a cycle of worry about ejaculating too quickly, which paradoxically leads to PE 1
• Depression: Associated with lower self-esteem and confidence 1
• Relationship issues: Decreased emotional intimacy and relationship conflict 1
• Early sexual experiences: Conditioning from hurried sexual encounters 2
• History of sexual abuse: May contribute to sexual dysfunction 1

Biological/Organic Factors

Several biological mechanisms contribute to PE:

• Serotonergic neurotransmission: Disturbances in serotonin pathways and certain 5-HT receptors 3
• Hypersensitivity of the glans penis: Increased penile sensitivity 4
• Pelvic floor dysfunction: Altered muscle tone and control 4
• Hormonal factors:
  • Hyperthyroidism 2
  • Low testosterone (less common) 5
• Prostate conditions: Prostatitis or prostatovesiculitis 4
• Neurological conditions:
  • Multiple sclerosis
  • Peripheral neuropathies
  • Spinal cord injuries 6
• Anatomical factors: Frenulum breve (short frenulum) 4

Pharmacological/Substance-Related Causes

Certain substances can induce or worsen PE:

• Recreational drugs:
  • Amphetamines 4
  • Cocaine 4
• Prescription medications:
  • Dopaminergic drugs 4
  • Some antipsychotics 5
  • Certain antihypertensives 5
• Substance withdrawal: Particularly opioid withdrawal 2

Comorbid Conditions

PE frequently coexists with other sexual dysfunctions:

• Erectile dysfunction (ED): Many patients with ED develop secondary PE due to:
  • Anxiety about maintaining erection 1
  • Need for intense stimulation to maintain erection 1
  • ED should be treated first when both conditions coexist 1

Evaluation Considerations

The American Urological Association recommends:

• A detailed sexual history focusing on:
  • Onset and progression of symptoms 1
  • Relationship to specific partners or situations 1
  • Ejaculatory control and latency time 1
  • Personal distress and relationship impact 1
• Physical examination (though rarely changes management) 1
• No additional testing for lifelong PE 1
• Selective testing for acquired PE as clinically indicated 1

Clinical Pearls and Pitfalls

• Common pitfall: Focusing only on psychological causes while missing underlying medical conditions like hyperthyroidism or prostatitis
• Important consideration: PE and ED frequently coexist, and when they do, the ED should be treated first 1
• Diagnostic challenge: Many men are reluctant to discuss sexual problems, leading to underreporting 7
• Treatment consideration: The causes of PE are often multifactorial, requiring a combination of approaches 2
• Age factor: Ejaculatory dysfunction becomes increasingly common with age and may require more comprehensive management 5

Understanding the specific causes in each individual case is essential for developing an effective treatment approach that addresses both the underlying factors and the sexual dysfunction itself.