Q. I’m a 34-year-old man. I’m in good shape, and I watch my diet. However, I’ve always had a problem of early ejaculation. I used to think it was because I was young, but it has gotten so bad that I am sometimes afraid of having sex because I may not “do the job well.” I don’t talk about it because I sometimes feel it’s just petty, but it has obviously been bothering me for some time. Do you have any suggestions?

A. Let me congratulate you for sharing such a difficult situation with me. You are going to be fine, since you just took the first step — talking about it.

In fact, many men have this problem. It’s called premature ejaculation, and there are many good treatments available. The best treatment starts with telling someone who cares about you. Keeping it a secret only adds to your frustration and stress, generating fear of failure or performance anxiety that only makes the problem worse. On top of that, your own ego is hurt, which can cause embarrassment and guilt. Your partner, on the other hand, may not know what happened and take the blame personally. All of that can be avoided.

Traditionally, premature ejaculation has been seen as a psychological problem — a learned response in which the ejaculatory reflex is activated sooner than desired. It has therefore been treated with a variety of behavioral techniques to help your body learn new patterns.

The two most common approaches are the stop-start technique and the squeeze technique. In the stop-start technique, you and your partner work together to delay ejaculation. Every time you feel like ejaculating, both of you stop; when the sensation subsides, you restart. You can try this on your own or with the help of a behavioral therapist. The squeeze method involves using your hand to squeeze either the head of the penis or the base of the penis anytime you get the urge to ejaculate. Or you can use a constriction band, sold through most pharmacies, called the Actis ring. This squeezes the base of the penis for a more prolonged erection.

Studies have shown a 60-90 percent success rate in overcoming premature ejaculation using such behavioral techniques. However, you must be patient, as these methods may take up to six months to work completely. More important, you can take advantage of this time to develop new approaches to making love and to learn to satisfy your partner in many ways.

The use of medication to treat premature ejaculation is relatively new, but it can provide excellent, immediate responses with minimal side effects. These agents alter the metabolism of serotonin and other neurotransmitters in the brain to inhibit the ejaculatory reflex.

One such medication is clomipramine (Anafranil), an antidepressant. Urologists at Case Western Reserve University found good response to this drug in a carefully selected group of men — specifically, patients who were in stable relationships and who had a lifelong history of premature ejaculation, no evidence of erectile dysfunction, and no evidence of psychological disorders. The researchers noted some side effects, including hot flashes, headaches or nausea. Still, 79 percent of the men in the study were able to tolerate the drug. Later studies found that 25mg of clomipramine, given daily, increased time to ejaculation by 249 percent, and higher doses produced an increase of 517 percent. Because of side effects at those dosages, most doctors advise using the drug less frequently or only in anticipation of intercourse.

Men with a history of psychiatric disorders or who are taking other antidepressants should not be given clomipramine, as it may interact with other medications. One study demonstrated changes in sperm, perhaps affecting fertility, that may reflect such interaction.

Another group of antidepressant medications, the selective serotonin re-uptake inhibitors (SSRIs) also work well, with infrequent side effects (such as loss of appetite and headache). I have prescribed the SSRI sertraline (Trazdone, Zoloft) with excellent results, but only after a careful examination and a medical/social history to make sure the patient really has premature ejaculation; otherwise, the drug might cause priapism (prolonged erection). Two other SSRIs — paroxetine (Paxil) and fluoxetine (Prozac) — are now under investigation for this use.

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