The definition for premature ejaculation has been debated over the years but many experts in the field currently rely on the International Society of Sexual Medicine (ISSM) definition which identifies the following criteria:

  • Ejaculation which occurs always or nearly always before or within one minute of vaginal penetration.
  • Failure to delay ejaculation during nearly all episodes of vaginal penetration.
  • Personal distress, bother, frustration and/or the avoidance of sexual encounters.
  • Premature ejaculation may be classified as ‘lifelong’ (primary) or ‘acquired’ (secondary):
    • Lifelong premature ejaculation is characterised by onset from the first sexual experience and remains a problem during life.
    • Acquired premature ejaculation is characterised by a gradual or sudden onset with ejaculation being normal before onset of the problem. Time to ejaculation is short but not usually as fast as in lifelong premature ejaculation.

The European Association of Urology (EAU) points out that the ISSM definition only applies to men with lifelong premature ejaculation who have vaginal intercourse. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) is due to publish a new definition in May 2013.


The prevalence of premature ejaculation varies according to definition and is difficult to assess in view of many men not wanting to seek help or even discuss the problem. The EAU reports a prevalence of 20-30% whilst a Cochrane review quoted a prevalence of 3-20%.

Risk factors

  • Premature ejaculation may be anxiety-related. It is therefore more common in young men and early in a relationship. In these situations, the problem usually resolves with time.
  • Iatrogenic causes include amphetamines, cocaine and dopaminergic drugs. Although effective for the treatment of premature ejaculation in some men, sildenafil may also be a cause of premature ejaculation in others.
  • Urological causes – e.g, prostatitis.
  • Neurological causes – e.g, multiple sclerosis, peripheral neuropathies.


Management should be tailored to the needs of the individual. The condition may be more of an issue in some relationships than others and patient expectation should be explored. Psychosexual counselling may be sufficient.

1. General advice

  • More frequent sex (or masturbation): premature ejaculation is more likely if there is a longer gap between sexual intercourse.
  • Using a condom to decrease sensation.
  • Using a cream with a numbing effect might also help. It should be applied to the head of the penis and especially the frenulum and corona (Your doctor would have pointed those out for you) about 10 minutes prior to penetration. It usually does not affect the sensation of the partner and does not decrease the intensity of the man’s orgasm.
  • Sex with the woman on top reduces the likelihood of premature ejaculation.
  • Squeeze and stop-go techniques: stimulating the penis almost to the point of ejaculation and then stopping. These techniques are often effective but may take a few months to produce any benefit and relapse is common.
  • Behavioural treatments are useful for secondary premature ejaculation but are not recommended first-line for lifelong premature ejaculation. They are time-intensive and require commitment from the partner.

2. Drug therapy

Selective serotonin reuptake inhibitor (SSRI) antidepressants are the most commonly used (off-label use) but need to be taken daily for 12 weeks before the maximum effect is achieved. Paroxetine, clomipramine, sertraline and fluoxetine have all been shown to be effective.

Dr. Rudolph/Serfontein/Aspeling/Govender usually prescribes Paroxetine (there are various brand names but this is the active ingredient). For the first few days you will be asked to use half strength and then you will go up to full strength after that. It might cause slight nausea and a dry mouth in the beginning. Remember: these drugs work in your brain, so you might feel a bit strange in the beginning but it is usually quite easy to get used to it. Please use it EVERY DAY, not only when you want to have intercourse. It is much more effective if used every day and it is not good for you to skip dosages because you will experience withdrawal symptoms. You will not get addicted to the drug, we will just have to taper the dosage if you would like to stop using it. Stopping it abruptly can cause significant side effects and can be dangerous. It is possible that we might be able to use “as necessary” dosing later or even stop the treatment completely, but that will be assessed at your follow-up visit. We usually request a follow-up visit within one month to six weeks. Cheaper alternatives will also be discussed during your follow-up visit.
WARNING: This drug should not be taken if you are trying for a baby – it might damage the DNA of the sperm. You have to be off the drug for at least two months before you start trying for a baby.

  • In patients who cannot tolerate the side-effects of SSRIs, on-demand treatment with clomipramine may be a suitable alternative.
  • Daproxetine is an SSRI which has been specifically developed for the treatment of premature ejaculation. It is proving highly effective but is not yet licensed for use in the South Africa.
  • Sildenafil (Viagra) is an effective alternative, especially in older men and when associated with erectile dysfunction. Studies suggest that it improves intravaginal latency times, reduces performance anxiety and improves sexual satisfaction. It is thought to act by down-regulating the ejaculation threshold. There is some evidence that a combination of sildenafil with SSRI is better than SSRI monotherapy.
  • Anaesthetic creams may be effective and may show an additive effect when combined with sildenafil. Aerosol sprays are proving popular and novel preparations are being developed. Topical preparations may be the preferred therapy for some patients.
  • Tramadol has been found to have beneficial effect in the treatment of premature ejaculation but further studies of long-term safety are required before this treatment can be recommended as a viable option.

3. Psychosexual therapy

The evidence base for the effectiveness of psychological interventions is limited and randomised trials with larger sample sizes are needed.

4. Surgery

One study reported that a short frenulum was found in 43% of individuals affected by lifelong premature ejaculation. Frenulectomy was effective in relieving the problem and the authors recommended excluding short frenulum in all patients with lifelong premature ejaculation.


Premature ejaculation may have a significant adverse effect on both self-confidence and the relationship. One study reported that premature ejaculation can lead to sexual dissatisfaction, a feeling that something is missing from the relationship and an impaired sense of intimacy. If the condition remains untreated it can lead to increased irritability, interpersonal difficulties and deepening of an emotional divide.

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Love Coach: The Sex Doctor Will See You Now

The Sex Doctor Will See You Now

By Dr. Elna Rudolph, published in Women’s Health Magazine, December 2014.

WH’s resident sex doc shares four of her actual cases with advice so real and raunchy, you’ll want to try it tonight!

Read the full article here.

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The ins and outs of a sexologist

When people find out that I’m a “sex doctor”, it is either a great conversation starter or the ultimate convo killer. Yes, I’m a sex therapist – but I’m also a qualified medical doctor. Some think I watch people have sex, others think I just suggest kinky positions or toys and some don’t even allow their minds to go there. Many have mentioned that they would love to be a fly on the wall in my practice. So allow me to share some of what I’ve learnt over my years of getting people naked (once they leave my office). These four cases represent the most common reasons couples and singles book time with me. And the advice I give them will no doubt keep your bedroom fires burning…


The case: Unconsummated marriage

The couple: Erica and Paul, late twenties, married for seven years, both still virgins

Erica and Paul refrained from sex before marriage for religious reasons, but they were excited about finally having sex on their wedding night. They tried, but it felt like he was hitting a wall inside her vagina – it was impossible. Erica knew that the first few times can be uncomfortable, but nothing could have prepared her for the excruciating pain she experienced when Paul tried to insert his penis. She felt like he was cutting her open and after the attempt, the area would burn for hours. They tried lubrication, alcohol, sedatives, foreplay – nothing worked! They saw many doctors who told her that there is nothing wrong with her and psychologists who were convinced that she must have been abused, but she hadn’t been. When they came to see me, she could orgasm through other forms of stimulation, but they desperately wanted a baby.

The treatment: Take control of your vagina.

On examination, I discovered that Erica was born with a condition called Neuroproliferative Provoked Vestibulodynia, where there were too many nerve endings around her vaginal opening (and in her belly button!) The sensitivity made the muscles around her vagina contract, much like an eyelid protects the eye.

This sensitivity and resulting muscle spasm made inserting tampons impossible, never mind a penis! We had to take the sensitivity away, relax the muscles and teach Erica’s brain that something can be inserted into her vagina without causing her pain. In my examination room, she inserted something into her vagina for the first time – an ear bud! A specialist pelvic function physiotherapist taught her relaxation techniques and how to use her pelvic floor muscles. She practiced at home with vaginal dilators every day and applied a special cream around her vagina to help the nerve problem.

Within four weeks, Erica was able to insert a dilator the size of an erect penis into her vagina without any physical or psychological discomfort. Paul then began to help with the dilators and he also attended a few of the physiotherapy sessions. After a follow-up with me, they got the “all-clear” and were able to carefully attempt penetration at home. Success! The better news? Erica popped into my office a few weeks ago – pregnant with their second baby!


The case: He comes early – every time

The patient: Nkosi, 35, single

Every time he had sex, Nkosi ejaculated within less than a minute of penetration. At times it was so bad that he ejaculated even before penetration. He was so embarrassed that he began to avoid relationships. He read about the stop-start and squeeze techniques and had been practising for years, but they didn’t work. He also ejaculated within seconds while masturbating.

The treatment: Pop a pill

This doesn’t mean your sex life needs to come to a shuddering halt! Ejaculation is a learned behaviour and can be controlled. If a guy consistently ejaculates in less than a minute, it’s a genetic problem with a specific receptor. No amount of sex therapy, psychotherapy or exercise will get it right. I prescribed Nkosi with an SSRI – an antidepressant that works on this particular receptor.

Nkosi takes the SSRI every day and now lasts about 10 minutes. He’s seeing someone now and they’re planning to get married next year.


The case: She can’t orgasm

The couple: Lisa and Ben, married for 15 years

Lisa and Ben are happily married, but both feel like they are missing out on something… Despite Ben’s efforts with oral sex, manual stimulation and penetrative sex, Lisa has never been able to have an orgasm. They have also tried using a vibrator together, but to no avail. Lisa comes from a typical Afrikaans household – she found it difficult to embrace her sexuality initially, but now enjoys sex.

The treatment: Take things into your own hands

The first step is always education: only a third of women orgasm from penetration alone and many don’t know that the most sensitive spots are the clitoris and nipples, not the vagina itself. Lisa and Ben were instructed to do erotic massage, sensate focus exercises (where each partner becomes more aware of the sensations they feel) and up their foreplay skills. I changed Lisa’s antidepressant and sorted out her hormones – she was on a Pill that broke down and blocked her testosterone, making orgasms very difficult. She felt better and they enjoyed the exercises, but still no orgasm.

That’s when I suggested masturbation. After all this time, the pressure of losing control in your partner’s presence makes orgasm very unlikely. She had to do it alone. The idea was strange for her, but she gradually became more and more comfortable and eventually had her first orgasm with the help of a small bullet vibrator. By herself. She then did it in his presence and eventually with his help.

When Lisa came for her check-up this year, she mentioned that it is the best thing that she has ever done for herself and for their relationship. Her husband sent me a big bouquet of flowers!


The case: She wants more

The couple: Claire and John, have been together for four years

When Claire and John, who has an extremely demanding job, started dating, they had sex almost daily, but for the last year, it only happens about once a month. Claire cried during the consultation and said she feels completely rejected and it’s influenced her self-esteem. She loves him and didn’t want to leave, but would if the problem wasn’t solved.

The treatment: The two Ts (time and testosterone)

When men don’t want to have sex, there is a good reason for it: either psychological or physical. Being a medical doctor, I always exclude the medical first. John had very low testosterone levels – the hormone he needs for libido. Due to stress, the stimulation of the testis to produce testosterone was shut down. He didn’t make time for any exercise, ate poorly, didn’t sleep enough and was constantly worried about work. He needed to look after himself and de-stress. John was shocked to see how his lifestyle affected his health, and made radical changes. I also advised them to plan for intimacy twice a week, have date nights and do fun things together.

Three months later, they are having sex at least once a week, John’s testosterone is back to normal and Lisa is beaming.


  • All images courtesy of Google.
  • Content courtesy of Women’s Health.
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Bad Sex is a Health Warning

Bad Sex is a Health Warning

By Mary Bradley

Weak erections or premature ejaculation, while a “downer” literally, can also be a sign of serious underlying health issues. If you’re going more than a month with no mojo, you should check it out with a doctor.

Guys are often accused by women of obsessing about sex, including the hardness and staying power of their erections, not to mention how often they get it up and, for that matter, get it on.  The thing is men may be onto something with their focus on their member, …  if for the wrong reasons.

Like the canary in the coal mine, not being able to get it up, keep it up, or shooting too quickly or not quickly enough may be a sign, sometimes the first, of underlying health problems, including cardiovascular disease, hormonal imbalances and neurological problems among others.

Dr. Prithy Ramlachan, co-author of a study on male sexual dysfunction published 2014 in South African Medical Journal   explains that for healthy erections a lot must be working right, including a healthy vascular system, good blood supply, balanced and adequate hormones including testosterone and thyroid hormones, and a satisfying psycho-social world.   According to Ramlachan, a fraught relationship with one’s sexual partner; negative cultural or religious attitudes about sex; depression and anxiety; as well as self-esteem issues including job loss and financial stress can affect a man’s erections for the worse. The last are significant issues for many South African men with the country’s high unemployment rate and economic uncertainty.

When any of the above factors are out of whack or not up to snuff, the result can be problems in the bedroom including weak erections, ejaculation difficulties, low libido and, possibly, serious underlying health problems.

Tellingly, many of the risk factors for male sexual dysfunction are the same for cardiovascular disease (CVD) and include high blood pressure, overweight especially the roll around the belly, high LDL cholesterol, raised blood sugar including diabetes and insulin resistance, smoking, and poor diet, advancing age and stress and depression. You’ve heard ‘em before, when it comes to your heart, but these risks also affect your penis. Talk about cutting close to the bone!

Experts estimate 40% of men will suffer erectile dysfunction (ED) at some point in their lives.  While rates are much higher among older men (52% of men aged 40-70, cited in a 2013 article in The Journal of Royal College of Physicians), 14% to 20% between ages 18 and 40 experience sexual problems, according to a 2011 study of European males.  Dr. Ramlachan, conducting an exploratory study at a primary healthcare clinic in KZN, found a prevalence of 64.9% in a sample of more than 500 men aged 18 and over.  That’s both guys on either side of you at the rugby game suffering ED, excluding yourself of course!

Why the connection between CVD and a happy penis? The answer is a matter of good plumbing. Erections require good blood flow and pressure, and top-notch piping, aka, vascular system. Weak erections can be a first sign of otherwise silent CVD.

Why would CVD show up first in the penis? Penile blood vessels are much narrower at 1-2 mm diameter than vessels elsewhere, including the coronary (3-4 mm) and carotid (5-7 mm) arteries; it follows, the penile artery will exhibit effects of arthrosclerosis – cholesterol-laden fat deposits combined with inflammation – and high blood pressure – sooner than larger blood vessels.  Anything that inhibits healthy blood flow will inhibit erections.

Not surprisingly, ED is an independent risk factor for heart disease, and here’s the kicker; it’s especially indicative of CVD in younger men.

A study published in 2009 Mayo Clinic Proceedings found that men aged 40-49 with erectile dysfunction were twice as likely to develop heart disease as men without ED.  Indeed, ED sufferers have an 80% higher risk of heart disease than dudes who don’t have erection problems. Experts have concluded that a guy with organic, as opposed to psychological, ED is at risk of experiencing a major cardiovascular event within 3-5 years of the onset of ED symptoms.

….so that’s the bad news.

The good news is that, you’ve got a 3-year window, after first experiencing bad sex, to take preventative action, through lifestyle changes and medical treatment. If the side-effects of turning your health around, include avoiding a major CV event and improving your sex life; that’s terrific news!

The bottom line is that the younger you are and experience ED, the more important to take action now, get screened and lower your risk of CVD.

Occasional softness or inability to get it up or keep it up once in a while is generally not a concern. That’s part of life in the 21st century fast-lane.  However, don’t write-off repeated soft erections or bad sex as merely a result of overwork or not enough sleep.  Dr. Elna Rudolph, medical doctor and sexologist at My Sexual Health Clinic, advises that, if symptoms persist a month, get screened by a doctor for underlying health problems. Dr. Ramlachan says that too often men discount symptoms as a result of overwork, stress or aging and delay or avoid seeing a doctor, because they don’t think it’s serious.

Sex problems may not suggest only CVD. They can be a sign of blood sugar imbalances including insulin resistance, which can put you at risk for diabetes. According to a 2007 study in The American Journal of Medicine, diabetic men had more than 2.5 times the rate of ED than non-diabetics.  High blood sugar and insulin levels can damage blood vessels and result in poor penile blood flow, as well as damage nerve function needed for A-1 erections.  Not surprisingly, CVD can be a knock-on effect of untreated insulin resistance, especially when it comes in the form of metabolic syndrome.

Men with metabolic syndrome have a higher incidence of ED. Metabolic syndrome is that constellation of symptoms that include high blood pressure, abdominal obesity, cholesterol abnormalities and insulin resistance.  So, if you’re suffering ED, be on the lookout … Metabolic Syndrome increases your chances of heart disease and diabetes.

As well, diabetes and insulin resistance are linked to lower testosterone in men.   While testosterone levels gradually decrease with age, eating too many refined and sugary foods or being sedentary or over-weight can affect testosterone levels for the worse.  Sometimes it’s not a problem of too little testosterone but too much estrogen, caused by excess body fat, among other factors. Excess estrogen can overwhelm the testosterone you’ve got, leading to signs of low testosterone like weakness, fatigue, low libido and ED.   Dr. Justin Howlett, urologist at UCT Private Academic Hospital, routinely tests testosterone levels in patients with ED.

ED, ejaculation problems and low libido can be a sign of poor thyroid function. The thyroid gland and its hormones   govern metabolism and energy levels. They affect pretty much every system in your body including production of sex, stress and blood pressure hormones. When the thyroid is out of whack, you can suffer a cluster of symptoms including fatigue, weakness, hair loss, ED and, in the case of too much thyroid hormone, anxiety and premature ejaculation.

Depression can also lead to sexual dysfunction and vice versa.   Another side-effect of low testosterone, along with sexual dysfunction, is depression.   The chicken and egg relationship of mood and sexual performance continues; SSRIs, commonly prescribed drugs to combat depression, include ED as a side-effect.

SSRI’s are not the only drugs that may affect a guy’s mojo. Beta-blockers can do the same.  Cape Town cardiologist J.P. Smedema explains that a side-effect of many drugs, including over-the-counter meds, can include sexual dysfunction. The important thing, Smedema says, is to let your doc know immediately of any changes in your sex drive or erections after starting a new medication. Often alternate meds won’t cause symptoms.

Similarly, stress and anxiety can contribute to ED, ejaculation problems and lack of desire.

Conditions like Parkinson’s, kidney disease, brain and spinal cord injury can impact sexual performance including stroke, dementia and prostate and rectal surgery.  A study reported at the 2008 Clinical Congress of the American College of Surgeons found rates of sexual dysfunction among patients under 50 who’d suffered traumatic injury of any kind in the past year was triple the normal population!

Excess porn viewing has been linked to erectile dysfunction. Rudolph suggests that it is not porn itself but the intimacy problems watching too much can reinforce. She notes that porn addiction and resulting sexual dysfunction are some of the toughest problems to treat and can wreak havoc on a man’s sexual relationships.

So, what to do, if you’re unhappy with your sexual performance?


Dr. Rudolph says that, in this day and age with the pharmaceutical advances and expanded knowledge of the effects of lifestyle on sexual health, there is seldom reason for a man to suffer bad erections.

The first step, if you’re noticing poor performance, is to visit your doctor and be screened for health issues that could cause or contribute to the problem.

She’ll ask you what’s up or, as the case may be, what’s not up and want details about the nature of the problem and how and when it began. ED with gradual, as opposed to sudden, onset may suggest different causes.   Whether you experience spontaneous nighttime erections is clue to the cause and resolution of sexual dysfunction.

Howlett explains the initial blood tests for ED include blood sugar, cholesterol and testosterone. Depending on levels, he will check prostate specific antigen (PSA), thyroid hormones, as well as inflammatory markers and kidney and liver function. He routinely checks blood pressure.  If he discovers markers for heart disease, he’ll refer to a cardiologist for treatment and, depending on the severity, begin treating the sexual dysfunction with lifestyle changes and meds, as appropriate.

After addressing lifestyle issues, he explains, the first line of treatment for ED is usually a PDE-5 inhibitor, the most familiar being sildenfal, aka Viagra. If these fail, penile injections are the next treatment of choice and have a high success rate. Nevertheless, their use must be monitored for side-effects like prolonged erections (Priapism) that can cause permanent damage.

The next treatment in South Africa is likely vacuum pumps. These devices draw blood into the penis creating an erection. Should they not work, according to Howlett, penile prostheses are an option. Interestingly, the greatest need for penile implants in his practice stems from patients who’ve bought penile injections on-line and not been adequately supervised by a physician.

Howlett strongly urges men avoid herbal or “natural” remedies to resolve sexual problems. Unlike pharmaceuticals, supplements are unregulated. Some have been found to contain ingredients not on the label, including PDE-5 inhibitors.  “If you are treated with nitrates for chest pain and don’t know you’re on PDE-5 inhibitors, the result could be fatal,” he explains.

Dr. Rudolph’s practice includes clinical psychologists on-site who treat psychological issues that may cause or exacerbate a man’s sexual dysfunction.  Howlett, Rudolph and Ramlachan see psychological factors as key when treating the patient with performance issues and may, or may not, use depression or anxiety meds as part of that.

Bottom line, there is a lot you can do to prevent and resolve penis-performance problems that don’t involve medical treatment or drugs.

  • Healthy Diet. – Make sure you eat heart-healthy food– The Mediterranean Diet is what the 2012 Princeton III Consensus Recommendations for Management of ED and CVD specifically recommends. That diet emphasizes fruits and vegetables, beans and legumes, whole grains, fish, lean meat, poultry and dairy and polyunsaturated oils. Avoid trans and excessive saturated fats and sugary and refined foods.
  • Regular Exercise – Studies have shown improved erectile function for men who are physically active compared to coach potatoes. In one 2012 Journal of Sexual Medicine study of men between 18 and 40, those who were physically active had not only improved erectile function but better orgasms and overall sexual satisfaction.
  • Butt out – Smokers have 1.5 to 2 times greater risk than non-smokers of ED. Smoking damages blood vessels and cigarettes are not the only problem. Howlett has seen recreational drugs, including cannabis, negatively affect patients’ erections.
  • Keep Trim – Being overweight, especially abdominal obesity, is linked to worsening ED. Obese men were found to have ED twice as often as normal weight guys.
  • Manage Stress – Stress and anxiety can lower testosterone as well as your libido and sexual performance. Anxiety can cause PE and ED.
  • Watch the biking – Studies have found that excessive bicycling can cause erection problems, due to chronic friction and pressure in the penile region. Interestingly, studies indicate that horseback riding is not a problem. Go figure!
  • Limit Porn – While studies conflict, there appears a link between excessive porn viewing and sexual problems, especially among younger men, some of whom watch in excess of several hours a day of the hot and horny stuff on-line. A review published in the 2016 issue of Behavioral Sciences observes how men exposed to excess porn may exhibit signs of ED, delayed ejaculation and decreased libido and sexual satisfaction.  The authors speculate that the limitless novelty and extreme nature of some porn eventually desensitize men to sex with real partners and hamper arousal.

Improve your Sex Life

  • Stop Smoking,
  • Do regular vigorous exercise
  • Maintain a normal weight
  • Eat a healthy diet
  • Maintain a healthy LDL/HDL cholesterol ratio

Common Risks for ED

  • High Blood Pressure
  • Cardiovascular Disease
  • Medications including SSRI’s, Beta blockers and many other meds
  • Smoking
  • Overweight especially abdominal obesity
  • Low testosterone (hypogonadism)
  • Blood sugar problems including insulin resistance and diabetes
  • Psycho-social factors including self-esteem issues, depression and anxiety
  • Increasing age