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Archivio Italiano di Urologia e Andrologia 2014; 86, 2
ORIGINAL PAPER
Awareness and timing of pelvic floor muscle contraction,
pelvic exercises and rehabilitation of pelvic floor
in lifelong premature ejaculation: 5 years experience
Giuseppe La Pera
Department of Urology, San Camillo Forlanini Hospital, Rome, Italy.
Objectives: To assess the cure rate of
patients with premature ejaculation who
underwent a treatment involving: 1) awareness of the pelvic
floor muscles 2) learning the timing of execution and main-
tenance of contraction of the pelvic floor muscles during
the sensation of the pre-orgasmic phase 3) pelvic floor
rehabilitation (bio feed back, pelvic exercises and electro-
stimulation).
Materials and methods: We recruited 78 patients with life-
long premature ejaculation who completed the training.
The patients were informed of the role of the pelvic floor.
They were taught to carry out the execution and mainte-
nance of contraction of the pelvic floor muscles during the
sensation of the pre-orgasmic phase to control the ejacula-
tory reflex. In order to improve the awareness, the tone and
the endurance of the pelvic floor muscles, patients were
treated with the rehabilitation of pelvic floor (RPF) consist-
ing mainly in biofeedback, pelvic exercises and in some
cases also in electro-stimulation (ES). The training was car-
ried out for a period of about 2-6 months with an average
of 2-5 visits per cycle.
Results: 54% of patients who completed the training were
cured of premature ejaculation and learned over time to be
able to postpone the ejaculation reflex. In a subgroup of 26
patients was also measured the IELT which on the average
increased from < 2 minutes to >10 minutes. The best results
occurred mainly in patients aged less than 35 where the
cure rate was 65%. There were no side effects.
Conclusions: In this study, approximately half of patients
with premature ejaculation were cured after applying the
above treatment.This therapy, necessitates a fairly long
period of time (2-6 months) and a great commitment on the
part of the patient, nevertheless it can be a valid and effec-
tive treatment for patients with premature ejaculation. This
treatment makes the patient independent in that he is not
bound to specific times for taking medication. Furthermore
there are no side effects and this therapy is particularly
effective in young males.
KEY WORDS: Premature ejaculation; Awareness; Timing;
Pelvic floor muscles; Pre-orgasmic sensation.
Submitted 26 May 2014; Accepted 16 June 2014
Summary
No conflict of interest declared.
DOI: 10.4081/aiua.2014.2.123
INTRODUCTION
The pelvic floor rehabilitation (PFR) consisting in biofeed-
back, pelvic exercises (kinesis-therapy) and pelvic floor
electrical stimulation in the treatment of lifelong prema-
ture ejaculation has been introduced since 1996 (1) and
was later confirmed by other authors (2).
Since then, from 2008, compared to the previously
described technique, I introduced some changes in the
therapeutic protocol:
1. adopting the new definition of premature ejaculation
(PE) of the ESSM (3);
2. introducing into the protocol the awareness of the
pelvic floor muscles (4);
3. teaching patients when to execute and maintain the
contraction of the pelvic floor muscles. In order to
inhibit the ejaculatory reflex this contraction must
occur during the sensation of the pre-orgasmic phase.
As regards the changes to the protocol of training, these
are based on the observation that patients with prema-
ture ejaculation very often are not aware of the role of the
pelvic floor muscles (4). Therefore some patients may
suffer premature ejaculation simply because they do not
know what to do or are not able to make a selective effec-
tive contraction of the pelvic floor and not because of an
early arrival of the stimulus. The purpose of this study
was to evaluate the cure rates in an unselected popula-
tion of patients with lifelong premature ejaculation
undergoing rehabilitation treatment of the pelvic floor
who have been taught the role of the pelvic floor and the
timing of contraction of these muscles.
MATERIALS AND METHODS
Recruitment of patients
We retrospectively reviewed the charts of 108 patients with
lifelong premature ejaculation. Out of them 78 patients
(72%) completed the protocol training. Patients with erec-
tile dysfunction and patients with signs of prostatitis were
excluded. The majority of patients excluded from treat-
ment or who did not complete the protocol preferred an
immediate drug treatment instead of a treatment that
Archivio Italiano di Urologia e Andrologia 2014; 86, 2
G. La Pera
124
required numerous sessions spread over a period of sever-
al months. The average age was 41 +/- 8 and a median age
of 40 (range 18 to 64).
Definition of a patient with premature ejaculation
The definition of a patient with premature ejaculation
refers to the definition adopted by the ESSM 2008 (3); all
patients had the IELT (5) in less than one minute and a
PEDT (6) test > 11. In the hormone screening was found
only one patient with hyperthyroidism; in all the other
patients, the hormonal values of the thyroid function
were always found normal. Eight patients had a signifi-
cantly low testosterone. In all these cases of hormonal
alteration, the hormonal treatment implemented to cor-
rect hypogonadism or hyperthyroidism did not change
the symptoms of premature ejaculation.
Description of the technique
The technique to inhibit the ejaculatory reflex and to
teach the patient how to take greater control consists of
four steps. The 4 steps are:
1) Have the patient become aware of the existence of the
pelvic floor muscles;
2) Teach the patient the selective contraction of the mus-
cles of the pelvic floor;
3) Teach the patient and have him try out the timing of
the execution and maintenance of contraction of the
muscles of the pelvic floor during the sensation of the
pre-orgasmic phase;
4) Reinforcement of the pelvic floor muscles.
Awareness of the role of pelvic floor muscles
At the beginning of treatment, all patients were made
aware of the role of the pelvic floor through a test
described in 2012 (4). In practice, the patient lying
down is asked to contract his pelvic floor muscles while
performing a digital rectal examination. At the end of
this procedure the patient is asked whether he is aware
that the contraction of the muscles of the pelvic floor is
able to inhibit the ejaculatory reflex. A more accurate
description of this technique and the demonstration of
its validation was previously published (4)
Pelvic floor rehabilitation (PFR)
To learn how to selectively use the muscles of the pelvic
floor, i.e. without activating antagonist muscles such as
the abdominal muscles, we used the technique of PFR
that involves biofeedback, pelvic exercises and in some
cases electro-stimulation. This technique has already
been described for fecal and urinary incontinence and in
the treatment of premature ejaculation (1). The PFR not
only reinforces the tone and strength of contraction of
the pelvic floor muscles but at the same time allows the
patient to better understand the role of these muscles
and acquire the capacity to perform the contraction
selectively. A more detailed description of the technique
was previously published in 1996 (1).
Nearing the orgasmic phase and timing
of the contraction of the pelvic floor muscles
One of the techniques used up to now for the treatment
of premature ejaculation has historically been that of
“stop and start” proposed by Masters and Johnson since
the 1960’s (7). Basically it consists in stopping the stim-
ulation when the excitation reaches the pre-orgasmic
p
hase and and when the ejaculation is about to arrive.
The innovation we have brought to our technique is that
of adding, during the sensation of the pre-orgasmic
phase, the execution and maintenance of contraction of
the muscles of the pelvic floor until the sensation of
upcoming orgasm has passed.
To obtain this result obviously the first step is to be
informed of the existence and the role of the pelvic floor
muscles. The second moment is to be able to carry out the
contraction of the muscles of the pelvic floor in a selective
manner and this can be obtained through biofeedback.
The third element consists of the selective and coordinat-
ed contraction of the pelvic floor muscles to be carried
out at the very pre-orgasmic moment before ejaculation
becomes irreversible. This technique starts from the
assumption that the contraction, performed in a coordi-
nated and timely way, would be able to inhibit the ejacu-
latory reflex similarly to what happens in the bladder
where the contraction of the pelvic floor muscles if done
at a certain moment is capable of delaying the urge of uri-
nation through inhibition of detrusor contraction (8).
In order to teach the patient the “timing” of the contrac-
tion and have him figure out at what moment of pre-
orgasmic sensation it is still possible to inhibit the ejacu-
latory reflex, exercises of masturbation are assigned to do
at home. In these focusing exercises the patient begins to
masturbate and gets to a stage of pre-orgasmic excite-
ment; through “trial and error” he must learn to be able
to recognize in what moment during the sensation of
pre-orgasmic excitement it is still possible to inhibit the
ejaculatory reflex in stopping masturbation, contracting
the muscles of the pelvic floor and maintaining the con-
traction until the sensation of imminent orgasm ceases.
Once the patient has achieved inhibition of the ejaculato-
ry reflex and the sensation of imminent orgasm ceases the
patient resumes masturbation and in the same session
repeats this cycle 3 or 4 times. After 4 or 5 cycles the
patient can let himself reach ejaculation. The results of this
training and in particular the way the contraction is per-
formed and its effectiveness in postponing the ejaculatory
reflex are discussed with the patient once a month; any
doubts are cleared up and further improvements made.
Measurement of results and definition of healing
Patients were considered cured if able to control their
ejaculatory reflex and when they pass from a PDET score
above 10 to one equal or less than 8. Furthermore in one
group of patients was evaluated the IELT (5) both before
and at the end the training.
RESULTS
All patients at the end of the training due to awareness
tests (4) have become conscious of the role of the pelvic
floor in the control of ejaculation; 43 patients or 55% of
all those who completed the training were cured of pre-
mature ejaculation and learned to be able to postpone
the moment of ejaculation. In a subgroup of 26 patients
was also measured the IELT which on the average went
from < 2 minutes to > 10 minutes. The best results
occurred mainly in patients aged less than 35 where the
cure rate was 65%. In the course of more than five years,
t
here were no side effects in the whole sample involved.
Thirty-five patients (45%) after a minimum period of
three months did not demonstrate any benefit from the
technique proposed here and drug therapy was begun
with them. The non-response to treatment was mainly
due to the fact that the patient was not able to selective-
ly contract the pelvic floor muscles or could not recog-
nize the moment to make the contraction. Among these
35 patients, however, there were 12 in which the patient,
even though making a regular and effective contraction
of the muscles of the pelvic floor and even recognizing
the moment when it was necessary to perform the con-
traction, had no beneficial effect on the length of ejacu-
latory latency. Probably this subset of patients is that in
which premature ejaculation is the consequence of the
early arrival of the ejaculatory stimulus.
DISCUSSION
Awareness of the role of the pelvic floor muscles, the PFR
and learning to recognize the timing of the execution and
maintenance of contraction of the pelvic floor muscles
are the crucial elements of this technique in order to
inhibit and improve control over the ejaculatory reflex.
The limit of this method is that it takes a few months for
the patient to understand the dynamics of the sequence
of events, learn control over the ejaculatory reflex and
naturally carry it during sexual intercourse. In many
family and clinical situations there is not always a long
time available and thus the patient may request some-
thing faster such as drug therapy available today.
Another limitation of this technique is that not all
patients are able to perform a selective contraction of the
pelvic floor muscles without activating other antagonist
muscles or are not able to recognize the sensation that
precedes the inevitability of ejaculatory reflex in order to
perform the contraction of the muscles of the pelvic floor
to block and inhibit ejaculation.
In the course of this experience, we observed that
although some patients were able to correctly perform the
contraction of the muscles of the pelvic floor this tech-
nique did not prove effective. This percentage of patients
is typically around 15%. These limits are, however, large-
ly offset by the fact that recovery from premature ejacula-
tion with this technique brings the patient around to be
“independent”, not influencing his sexual activity by taking
a drug and not exposing him to potential side effects or
drug interactions. These results confirm moreover the fact
that the population of patients with premature ejaculation
is a heterogeneous population with different etiological
factors. There are not only patients in whom there is an
early arrival of the ejaculatory reflex.
The positive results of this technique, which does not act
on the arrival of the ejaculatory reflex but only on the con-
trol, suggest the hypothesis that premature ejaculation, in
some cases, may be due to another four causes:
– lack of knowledge of the fact that is necessary to con-
tract the pelvic floor muscles;
– inability to contract these muscles;
– inability to know how to recognize at what moment
during the sensation of the pre-orgasmic phase it is
still possible to block the ejaculatory reflex;
–
result of a disease of the muscles of the pelvic floor.
These data raise therefore the urgent need not only to
reassess the definition of premature ejaculation or at least
redefine the concepts that define it but to re-evaluate the
criteria for inclusion or exclusion in therapeutic trials on
premature ejaculation taking into consideration the vari-
ables of awareness and neuromuscular coordination of
the pelvic floor, the perception of the arrival of the ejac-
ulatory reflex and diseases of the pelvic floor muscles.
CONCLUSIONS
In this study, approximately half of the patients with pre-
mature ejaculation were cured after they learned role and
use of the muscles of the pelvic floor, having learned the
timing of execution and maintenance of contraction of the
pelvic floor muscles during the sensation of the pre-orgas-
mic phase and having undergone PFR. Despite the fact that
this therapy in order to achieve positive results requires a
fairly long period of time (2-6 months) and a greater com-
mitment on the patient’s part, it can be a valid and effective
treatment to offer a patient with premature ejaculation.
This treatment makes the patient independent in that he is
not bound to specific times for taking medication.
Furthermore there are no side effects and this therapy is
particularly effective in young males.
REFERENCES
1. La Pera G, Nicastro A. A new treatment for premature ejacula-
tion: the rehabilitation of the pelvic floor. J Sex Marital Ther. 1996;
22:22-6.
2. Pastore AL, Palleschi G, Leto A, et al. A prospective randomized
study to compare pelvic floor rehabilitation and dapoxetine for treat-
ment of lifelong premature ejaculation. Int J Androl. 2012; 35:528-33.
3. McMahon CG, Althof SE, Waldinger MD, et al. An evidence-based
definition of lifelong premature ejaculation: report of the International
Society for Sexual Medicine (ISSM) ad hoc committee for the definition
of premature ejaculation. J Sex Med. 2008; 5:1590-606.
4. La Pera G. Awareness of the role of the pelvic floor muscles in
controlling the ejaculatory reflex: preliminary results. Arch Ital Urol
Androl. 2012; 84:74-8.
5. Waldinger MD, Hengeveld MW, Zwinderman AH, Olivier B. An
empirical operationalization study of DSM-IV diagnostic criteria for
premature ejaculation. Int J Psychiatry Clin Pract 1998; 2:287-293.
6. Symonds T, Perelman MA, Althof S, et al. Development and val-
idation of a premature ejaculation diagnostic tool. Eur Urol. 2007;
52:565-73.
7. Masters WH, Johnson VE. Premature ejaculation. In: Human
Sexual Inadequacy. Boston, Mass: Little Brown & Company. 1970;
92-115.
8. Burgio KL, et al. Behavioral vs drug treatment for urge urinary
incontinence in older women. JAMA 1998; 280:1995-2000.
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Archivio Italiano di Urologia e Andrologia 2014; 86, 2
Awareness and timing of pelvic floor muscle contraction, pelvic exercises and rehabilitation of pelvic floor in lifelong premature ejaculation
Correspondence
Giuseppe La Pera, MD (Corresponding Author)
lapera@libero.it
Dept of Urology, San Camillo Forlanini Hospital, Rome, Italy
