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Asian Journal of Andrology (2019) 21, 1–4
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Male Sexual Function
The primary premature ejaculation (PPE)
is a common male sexual disorder. We
proposed a novel behavioral therapy for PPE
through regular penis-root masturbation
(PRM). Nine heterosexual men with PPE
completed the self-controlled study. Aer
a 3-month PRM training, the median
intravaginal ejaculatory latency time (IELT)
increased from 60 s to 180 s (P = 0.018), and
the mean Premature Ejaculation Diagnostic
Tool (PEDT) score decreased from 14.8
± 3.7 to 12.8 ± 4.1 (P = 0.074). Five out of
eight patients had the prolonged dorsal
nerve somatosensory evoked potential
(DNSEP). e results suggest that PRM has
a short-term therapeutic eect. Randomized
controlled trials are needed to validate the
e cacy.
Premature ejaculation (PE) is a common
male sexual disorder characterized by
short ejaculatory latency, weak ability to
control ejaculation, and PE-associated
negative psychological and relational
consequences.1 A variety of treatments have
been recommended in the management
of PE, such as pharmacotherapy,
behavioral therapy (BT), and a combined
behavioral and drug therapy.2 A lthough
the pharmacotherapy is considered as a
rst-line treatment for primary PE (PPE),
the associated deciencies, including the
side effects, variable effectiveness, and
relatively high dropout rate, have hindered
CLINICIAN’S WORKSHOP
Regular penis-root masturbation, a novel behavioral
therapy in the treatment of primary premature
ejaculation
Gong-Chao Ma1,*, Zi-Jun Zou1,*, Yu-Fen Lai1, Xun Zhang2, Yan Zhang1
Asian Journal of Andrology (2019) 21, 1–4; doi: 10.4103/aja.aja_34_19; published online: 21 May 2018
1Department of Infertility and Sexual Medicine, The
Third Affiliated Hospital of Sun Yat-sen University,
Guangzhou 510630, China; 2Department of
Andrology, The First Affiliated Hospital of Guangxi
Medical University, Nanning 530021, China.
*These authors contributed equally to this work.
Correspondence: Dr. Y Zhang (zhxml@sina.com)
Received: 26 January 2019; Accepted: 25 February 2019
Open Access
the adoption of this therapy.3 For patients
who are unwilling to accept or do not
respond to pharmacotherapy, BT is a viable
therapeutic option. e typical techniques
in behavioral therapy include the stop–
start technique developed by Semans
and the squeeze technique proposed by
Masters and Johnson.4 Pelvic oor muscle
rehabilitation exercises may also be helpful
in treating PE.5 Although the overall success
rates are reported to reach 50%–60%, the
conventional BTs in the treatment of PPE are
still controversial in terms of the intravaginal
ejaculatory latency time (IELT).6 Maybe we
need to nd a new BT technique to improve
the curative eect.
In a sense, the stop–start technique is
thought to be a “typical” masturbatory style
because the front two-thirds of the penis
receives stimulation in the vagina, and it
has limited effect on prolongation of the
IELT.7 In addition, delayed ejaculation (DE)
can be caused by “atypical” (idiosyncratic)
masturbation that is a masturbation
technique not easily duplicated by the
partner’s hand, mouth, or vagina.8 PE and
DE are seemingly unrelated two extremities
of ejaculatory disorder; however, there
is a relationship between them that the
idiosyncratic masturbatory style can cause DE,
thereby suggesting that this kind of unusual
masturbation has the potential to treat PE. e
specic mode of idiosyncratic masturbation
is prone masturbation.9 In our clinic, we
also found that some patients complained
the delayed ejaculation during penis-root
masturbation. Therefore, we attempted to
verify the hypothesis that regular penis-root
masturbation as a behavior therapy had a
therapeutic eect in patients with primary PE.
PATIENTS AND TECHNIQUE
e protocol and written informed consent
used in this study were reviewed and approved
by the Institutional Review Board of the ird
Aliated Hospital of Sun Yat-sen University,
Guangzhou, China (trial registration number:
(2018)02-209-01).
Male patients with PE were recruited
from the outpatient clinic at the Third
Aliated Hospital of Sun Yat-sen University
according to the following inclusion criteria:
(1) patients’ age varied from 18 to 45 years;
(2) patients met the 2014 International
Society for Sexual Medicine (ISSM)
denition criteria for PPE;1 (3) patients had
a stable, heterosexual relationship with a
single sexually active female partner for at
least 6 months and with at least two sexual
intercourses a week and kept stable during
the study period; (4) patients were identied
if their scores were higher than 9 on the
Chinese version of Premature Ejaculation
Diagnostic Tool (PEDT); and (5) patients
had no history of any previous therapies for
PE or had recently stopped the therapies for
at least 3 months.
Patients were not permitted to enroll in
the study if they met any of the following
exclusion criteria: (1) patients were diagnosed
with secondary PE, variable PE, and subjective
PE; (2) patients were diagnosed with erectile
dysfunction (ED) if their scores were <21
on the abridged five-item International
Index of Erectile Function (IIEF-5), unless
the low IIEF-5 score was completely related
to symptoms of PE; (3) patients were using
medications for endocrinological, metabolic,
chronic systemic, or psychiatric diseases;
(4) patients were diagnosed with sexual
hormone abnormalities, hyperthyroidism,
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Asian Journal of Andrology
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hypothyroidism, Peyronie’s disease, prostatitis,
urethritis, or urinary tract infection; and (5)
patients were abusing alcohol or illegal drugs.
During the treatment period, the use of any
other therapies for PE was inhibited.
Upon enrollment, all participants
completed the questionnaires including PEDT
and IIEF-5. e genital examinations were
performed to check if the participants had
urogenital abnormality. Penile dorsal nerve
somatosensory evoked potential (DNSEP)
that is an electroencephalographic response
aer stimulating the somatic sensory area
of penile dorsal nerve was measured.10 e
therapeutic ecacy of PRM was evaluated
through comparison of the mean PEDT score
and self-reported IELT value before and aer a
3-month PRM training. DNSEP was retested
aer 3 months of PRM.
PRM was performed in a private
setting. Briey, the penis was fully erected
through various sexual stimuli instead of
directly stimulating the glans, frenulum,
and distal penile sha. It is required to avoid
stimulating the distal penile sha because the
stimulation could probably aect the frenulum
simultaneously. Then, one thumb or two
thumbs were placed on the dorsal surface of
the penile root (within the rear one-third of
the penis) (Figure 1), and the penile root was
massaged circularly or along the proximal
penile sha rmly to allow the patients to
feel sexual pleasure and keep erection. When
the patients felt the urge to ejaculate, the
stimulation was stopped immediately. When
the sensation subsided, the stimulation was
resumed. During the training session, the
partner’s touch, kiss, and audiovisual sexual
stimulation were permitted. Each training
Figure 1: Diagram of regular PRM: the PRM was
performed by placing the thumb (one hand) or
thumbs (two hands) on the root of the penis
(no more than 1/3 of the erect penis) and rubbing
the penile root up and down (straight arrow) or
circularly (curve arrow) with a certain degree of
friction. PRM: penis-root masturbation.
session was required to last 10–15 min. Aer
the training session, ejaculation was permitted.
Unlike precoital masturbation that requires
ejaculation before a formal intercourse, PRM
was not prepared for a formal intercourse. e
vaginal intercourse was permitted aer the
training session. e training was conducted
three times a week for 3 months and could
be done by the patient himself or his partner.
Statistical analysis was conducted using
IBM SPSS soware version 19 (SPSS, Inc.,
Chicago, IL, USA). Data were normally
distributed according to the Shapiro–Wilk
test. Dierences of the mean PEDT scores
and mean DNSEP in patients before and aer
a 3-month training were compared using the
paired t-test. Dierences of the self-reported
IELT in patients before and aer a 3-month
training were compared using the Wilcoxon
signed-rank test. Dierences were considered
statistically signicant at P < 0.05.
During the period of May through
November 2018, a total of 16 patients met
the enrollment criteria and volunteered to
participate. During the study period, four
patients declined to continue the treatment
without any reasons, and three could not
stick to the treatment plan. All of these seven
patients quitted the study in less than a month.
Finally, nine patients completed the entire
treatment regimen. e characteristics of the
participants are listed in Table 1. e mean
age of nine participants was 30.2 ± 5.1 years,
the mean frequency of sexual intercourse was
3.0 ± 1.3 times a week, and the mean duration
of PE was 6.3 ± 5.2 years.
The therapeutic effectiveness of PRM
was assessed in terms of the mean PEDT
score, self-reported IELT value, and DNSEP,
as listed in Tab le 2. Before the penis-root
masturbatory training, the mean baseline
PEDT score in participants was 14.8 ± 3.7,
and the median self-reported IELT was 60
s ranging from 30 s to 60 s. Here, it is noted
that the IELT was recorded as 60 s when the
patient just said the IELT was <1 min without
telling the exact time. The mean baseline
latency time of DNSEP was 38.73 ± 2.63 ms in
nine participants. e levels of serum fasting
blood glucose, thyroid hormones, and sexual
hormones in the blood samples obtained from
patients were tested, and all of the values were
within the normal range (data not shown). No
symptom of urinary tract infection was found
in participants by urinalysis. e IIEF-5 scores
were normal. No abnormality was found in
participants by genital examinations.
After the 3-month penis-root
masturbatory training, the median IELT was
180 s (range: 60–300 s) that was signicantly
longer than 60 s at baseline (range: 30–60 s, P =
0.018). Seven (77.8%) out of nine participants
reported that the IELT was prolonged by
about 120 s. e mean PEDT score decreased
from 14.8 ± 3.7 at baseline to 12.8 ± 4.1 aer
3-month PRM (P = 0.074). Eight participants
were retested for DNSEP aer 3-month PRM,
and the mean latency time was 38.56 ± 2.80
ms that was longer than 38.31 ± 2.47 ms at
baseline, but the dierence was not statistically
signicant (P = 0.734).
COMMENTS
Ejaculation is a complex physiological process
involving a variety of biological, psychological,
and social factors, and it is challenging to
understand the neurophysiopharmacology
of ejaculatory disorders.11 Many researches
have focused on the pathophysiology and
pharmacological treatments of PE, but
little attention was paid to BT, as well as
its underlying mechanism.12 The ultimate
goal of BT is to develop sexual skills over
time to control or delay ejaculation, thereby
improving sexual confidence.6,13 Although
BT has also been used to treat PE, the
mechanism underlying the treatment of PE
remains to be elucidated. The mechanism
of delayed ejaculation (DE) includes both
psychogenic and physical factors. Xia et al.14
reported that patients with primary DE have
penile sha rather than glans hyposensitivity,
though it is not stated if the patients have
unusual masturbation. Through unusual
masturbation, patients with DE may develop
the autosexual patterns that produce dierent
types of orgasm from what they experience
with a partner.15
In this study, we found that ve out of
eight patients had prolonged ejaculation
time when they were retested for DNSEP
after regular PRM. There are multiple
possible mechanisms for the acquired
prolonged IELT, however, the most plausible
mechanism might be attributed to autosexual
orientation that could enable the patients to
develop a specialized synergistic ability of
the peripheral and central nervous systems
to control the ejaculation.8,11,15,16 It can be
described as follows: (1) the sensate focus
is shifted to the penile root which might
reduce the feeling of irritation to the glans
or decrease glans sensitivity during vaginal
intercourse, and (2) the patients are getting
used to this uncommon stimulation style that
cannot be easily duplicated by their partner’s
vagina.
Despite the prospective nature of the
study, there are still some limitations. Self-
estimation rather than a stopwatch was used
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Asian Journal of Andrology
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to measure the IELT in this work. Although
the self-estimation may be an inaccurate
measure of actual IELT, some studies have
demonstrated that patient self-report of
ejaculatory latency has a good correlation
with objective stopwatch latency.17 Compared
to a rapid-acting pharmacological treatment,
most BTs require a willingness of the patients
to engage in practicing the relatively dull
techniques, which may explain the higher
attrition rate in our study. e current study
only evaluated the short-term therapeutic
eect of regular PRM in patients with primary
PE immediately after a 3-month training
session, and little is known about the long-term
eects. In addition, we had a relatively small
sample size and uncontrolled and nonblinded
assessment of primary outcome. erefore,
it is needed to conduct a new multicenter,
large-scale, randomized, comparative clinical
trial to validate the ecacy and explore the
underlying mechanism of regular PRM as a
novel BT.
Table 1: Characteristics of nine participants in the study
Case Age
(year)
Weight
(kg)
Height
(cm)
BMI
(kg m−2)
Smoking
history
Drinking
history
Educational
background
PE history
(year)
Frequency of intercourse
(time per week)
1 31 56 165 20.6 No Yes TSS 8 4
2 28 68 172 23.0 No Yes TSS 13 3
3 41 52 150 23.1 No Yes JHS 15 2
4 28 68 170 23.5 No Yes Undergraduate 5 2
5 28 62 173 20.7 No No SHS 1 2
6 26 62 172 21.0 No Yes SHS 1 3
7 29 78 173 26.1 Yes Yes TSS 5 2
8 36 60 165 22.0 No Yes JHS 1 6
9 25 55 160 21.5 No No JHS 8 3
Mean±s.d. 30.2±5.1 62.3±8.0 166.7±7.7 22.4±1.8 - - - 6.3±5.2 3.0±1.3
BMI: body mass index; JHS: junior high school; s.d.: standard deviation; SHS: senior high school; TSS: technical secondary school; PE: premature ejaculation; -: not applicable
Table 2: Results of premature ejaculation evaluation using Premature Ejaculation Diagnostic Tool, intravaginal ejaculatory latency time, and dorsal
nerve somatosensory evoked potential at baseline and after 3 months of the penis‑root masturbatory training
Case PEDT score IELT (s) DNSEP (ms)
Baseline 3 months Baseline 3 months Baseline 3 months
1 10 10 60 300 37.4 39.5
2 14 10 60 240 39.0 40.0
3 19 18 30 60 34.4 34.6
4 16 17 60 60 37.0 37.6
5 13 16 60 60 42.9 42.1
6 20 14 60 300 37.6 34.9
7 17 14 60 180 40.0 38.2
8 15 11 60 120 42.1 NA
9 9 5 60 240 38.2 41.6
Mean±s.d. 14.8±3.7 12.8±4.1 56.7±10.0 173.3±101.5 38.31±2.47 (8 cases)
38.73±2.63 (9 cases)
38.56±2.80
Median (range) 15 (9–20) 14 (5–18) 60 (30–60) 180 (60–300) 38.20 (34.40–42.90) 38.85 (34.60–42.10)
P0.074 0.018 0.734
Differences in the mean PEDT scores and DNSEP in patients before and after a 3-month training were compared using the paired t-test. Differences in the self-reported IELT in patients
before and after a 3-month training were compared using the Wilcoxon signed-rank test. Differences were considered statistically significant at P<0.05. DNSEP: dorsal nerve somatosensory
evoked potential; IELT: intravaginal ejaculation latency time; PEDT: Premature Ejaculation Diagnostic Tool; NA: not available; s.d.: standard deviation
CONCLUSION
Regular PRM, as a novel BT, is a promising
therapeutic approach for PPE. However,
it is still required to be further verified
in randomized controlled trials, and the
underlying mechanism is also needed to be
elucidated.
AUTHOR CONTRIBUTIONS
YZ developed the original content and
drafted the manuscript. GCM contributed
to the clinical trial design, data acquisition,
and data interpretation. ZJZ contributed
to data acquisition, statistical analysis,
and data interpretation and drafted the
manuscript. YFL and XZ contributed to data
acquisition. YZ, ZJZ, and GCM contributed
to the critical revision of the manuscript.
All authors read and approved the final
manuscript.
COMPETING INTERESTS
All authors declared no competing interests.
ACKNOWLEDGMENTS
is work was supported by the National Natural
Science Foundation of China (Grant No. 81571424
and No. 81771565).
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