Short-term effect of the prone masturbation training on premature ejaculation

Abstract

Background: Whether conventional behavioral therapies for premature ejaculation can significantly improve the intravaginal ejaculatory latency time is still controversial. Prone masturbation is rare and observed in some patients with delayed ejaculation. Therefore, we tried to verify whether the regular prone masturbation training method had a therapeutic effect on premature ejaculation.

Methods: From July to December 2018, a total of 21 patients met the enrollment criteria and volunteered to participate. Participants were diagnosed with premature ejaculation with an intravaginal ejaculatory latency time of less than 3min and a Premature Ejaculation Diagnostic Tool score greater than 9. Participants performed 12-week prone masturbation training.

Results: Ten patients completed the entire treatment regimen. The mean age of the 10 participants was 30.4 ± 6.1 years, the mean frequency of sexual intercourse was 1.9 ± 0.83 times a week, and the median duration of premature ejaculation was 1.5 years. After 3 months of prone masturbation training, the median self-reported intravaginal ejaculatory latency time significantly increased from 60 to 105 s (p = 0.011), and the mean Premature Ejaculation Diagnostic Tool scores decreased from 15.0 ± 3.7 to 12.7 ± 3.7 points (p = 0.119).

Conclusions: The regular prone masturbation training method, as a novel behavioral therapy, probably has a therapeutic effect on premature ejaculation.

Graphical abstract

Keywords

behavioral therapy / intravaginal ejaculatory latency time / masturbation / premature ejaculation

1 INTRODUCTION

Premature ejaculation (PE) is a common male sexual dysfunction characterized by reduced ejaculatory latency, lack of ejaculation control and negative personal relations[1]. Available treatment options for PE, such as pharmacotherapy, behavioral therapy (BT) and a combination of these two approaches, are still unsatisfactory[2]. The “start–stop” and “squeeze” techniques are the most commonly used BTs in the treatment of PE, and the overall success rates are far lower than the original data; however, the reproducibility is still controversial[3–5]. It is speculated that this may be due to the selected patients and different patient enrollment criteria[6]. Searching for a new BT to improve treatment efficacy has become extremely essential and urgent.

It has been reported that idiosyncratic masturbation, which is not easily duplicated by the partner's hand, mouth, or vagina, can cause delayed ejaculation or anejaculation[1,7]. We wonder whether PE patients can prolong the ejaculation latency if they regularly practice this unusual masturbation style[7]. Prone masturbation is one of the most common idiosyncratic masturbation styles. In this study, we tried to verify whether regular prone masturbation as a new potential BT had a therapeutic effect in patients with PE.

2 CASE DESCRIPTION

All subjects were recruited from the outpatient clinic at the Third Affiliated Hospital of Sun Yat-sen University from July through December 2018. Each patient provided written informed consent before inclusion. The inclusion criteria were as follows: (1) male, aged 18–45 years; (2) subjects who met the 2014 International Society for Sexual Medicine criteria for PE: ejaculation that always or nearly always occurs prior to or within about 1 min of vaginal penetration from the first sexual experience (lifelong PE), or a clinically significant reduction in latency time, often to about 3 min or less (acquired PE); the inability to delay ejaculation on all or nearly all vaginal penetrations; and negative personal consequences, such as distress, bother, frustration, and/or the avoidance of sexual intimacy[1]; (3) heterosexual men with a stable relationship with a single sexually active female partner for at least 6 months; (4) subjects with scores higher than 9 points on the Chinese version of the Premature Ejaculation Diagnostic Tool (PEDT); and (5) subjects with no history of any previous therapies for PE or who had stopped the therapies for at least 3 months.

Patients were excluded if they met any of the following exclusion criteria: (1) patients diagnosed with variable PE or subjective PE; (2) patients diagnosed with erectile dysfunction (ED) based on scores ≤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 using medications for endocrinological, metabolic, chronic systemic, or psychiatric diseases; (4) patients diagnosed with sexual hormone abnormalities, hyperthyroidism, hypothyroidism, Peyronie's disease, prostatitis, urethritis, or urinary tract infection; and (5) patients abusing alcohol or illegal drugs. During the treatment period, the use of any other therapies for PE was prohibited.

All participants completed the questionnaires, including the PEDT and IIEF-5. Genital examinations were performed to check if the participants had urogenital abnormalities. The therapeutic efficacy of the regular prone masturbation training method was evaluated through a comparison of the mean PEDT score and the self-reported IELT value before and after a 3-month regular prone masturbation training.

The prone masturbation training method was performed by each participant alone in a private setting without any audiovisual sexual stimulation. Briefly, patients lay on their bellies with the base of their penis rubbing against the bed sheets, forward or backward, attempting to mainly compress the dorsal root of the penis without stimulating the glans of the penis as much as possible at the time of masturbation (Figure 1). When the patients felt the urge to ejaculate, the stimulation was stopped immediately. When the sensation subsided, the stimulation was resumed. Each training session was required to last 10–15 min. After the training session, ejaculation was permitted. Vaginal intercourse was permitted after the training session. The training was conducted three times a week for 3 months.

Statistical analysis was conducted using IBM SPSS software version 19. Data were normally distributed according to the Shapiro–Wilk test. Differences in the mean PEDT scores in patients before and after the 3- month training were compared using the paired t-test. Differences in the self-reported IELT in patients before and after the 3-month training were compared using the Wilcoxon signed-rank test. Differences were considered statistically significant at p < 0.05.

From July to December 2018, a total of 21 patients met the enrollment criteria and volunteered to participate. During the study period, one individual did not respond, two individuals accepted other treatments (one accepted pelvic-floor muscle rehabilitation and the other accepted acupuncture therapy), and eight individuals could not follow the treatment plan (seven patients quit the study in less than a month and one in the second month). Finally, 10 patients completed the entire treatment regimen.

The characteristics of the participants are listed in Table 1. The mean age of the 10 participants was 30.4 ± 6.1 years, the mean frequency of sexual intercourse was 1.9 ± 0.83 times a week, and the median duration of PE was 1.5 years.

The therapeutic effectiveness of the regular prone masturbation training method was assessed in terms of the mean PEDT score and the self-reported IELT value, as listed in Table 2. Before the regular prone masturbation training, the mean baseline PEDT score in participants was 15.0 ± 3.7 points, and the median self-reported IELT was 60 s, ranging from 20 to 120 s. It should be noted that IELT was recorded as 60 s when the patient said the IELT was less than 1 min without telling the exact time. The levels of serum fasting blood glucose, thyroid hormones, and sex 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. The IIEF-5 scores were normal. No abnormality was found in the genital examinations of the participants. After the 3-month regular prone masturbation training, the median IELT was 105 s (range: 60–420 s), which was significantly longer than the 60 s at baseline (range: 20–120 s, p = 0.011). Six (60%) out of 10 participants reported that the IELT was prolonged by approximately 105 s. The mean PEDT score decreased from 15.0 ± 3.7 points at baseline to 12.7 ± 3.7 points after 3 months of regular prone masturbation training (p = 0.119). No ED or anorgasmia during or after the training was reported.

3 DISCUSSION

In the face of rapid and effective pharmacotherapy, BT is slowly becoming an alternative treatment option rather than a first-line treatment[2]. Stroking up and down the shaft with the hand was described as the “usual” masturbation style by Bernie Zilbergeld, indicating that other ways different from this are “unusual” styles[8]. Among individuals who practice “unusual” masturbation methods (one of typically representative as prone masturbation), delayed ejaculation is very common, and some individuals utilizing this style have ED[7,8]. PE and ED really have interplay[9], but for the accuracy of the experiment, we excluded patients with combined ED by IIEF-5. If it necessary, the Color Duplex Doppler Ultrasonography and RigiScan are used for etiological or differential diagnosis. Why does ED occur with prone masturbation? Presumably, when masturbating in the prone position, the penis ejaculates in a flaccid state, which is completely different from the conditions for ejaculation during vaginal intercourse. Although this ejaculation pattern is associated with the risk of ED, no ED or anorgasmia occurred during or after the training in our study. We think that perhaps the people who perform this unusual masturbation technique when they are very young may have a relatively high risk of ED; for patients who have gradually formed a stable “normal” sexual reaction chain, erectile function is not easily affected by the practice of prone masturbation. This may also be due to the fact that the ejaculation manner in the flaccid state was not the only ejaculation pattern of these trainees.

By carefully analyzing conventional BTs, such as the stop–start technique and the squeeze technique, we find some limitations of these traditional BTs: 1. All of the traditional BTs emphasized the importance of the patient's partner. However, in today's fast-paced life, at least in China, PE patients often come to see a doctor alone rather than together with their partner, and the conservative Eastern culture also amplifies this trend[10]; therefore, it is ideal to find a simple technique that the patient can perform individually and more easily, without involving too many detailed psychogenic/relationship factors that need to be discussed with their partner[3,4]. 2. The stop–start technique is similar to “usual masturbating”, which is performed by stroking up and down the shaft, including the glans, with one hand of the patient or partner. Because the glans is relatively sensitive, it is easy to achieve the feeling of ejaculation. The frequent “stopping” involved in the procedure is, to some extent, relatively uncomfortable, similar to driving a car with frequent brake applications. Switching between stopping and starting means constantly switching between a flaccid and erect penis. 3. Keeping a full erection for 10–15 min for the training is sometimes difficult for some patients.

Our training protocol has some significant advantages over the aforementioned BTs: 1. This method originated from our patients who complained of delayed ejaculation with habits of this unusual masturbation style. Many reports have confirmed that this “atypical masturbatory style” is a frequent cause of male orgasmic disorder (mainly delayed ejaculation)[11]. In a sense, the validity of the methodology has been shown reversely. Another special “atypical masturbatory style” penis-root masturbation training, a novel BT performed by placing the thumb (one hand) or thumbs (two hands) on the root of the fully erected penis (no more than 1/3 of the erect penis) and rubbing the penile root up and down or circularly with a certain degree of friction, has been proven to be effective in the treatment of primary PE[12]. 2. Different from conventional BTs and penis-root procedures, when performing prone masturbation, the penis usually remains flaccid, and there is no pressure to maintain an erection. Of course, this procedure has better privacy and concealment comparing with the above-mentioned BTs, and is suitable for performing under fatigue conditions.

What are the explanations for the mechanism of acquired prolonged IELT? Penile dorsal nerve somatosensory-evoked potential[12,13] and the gradual formation of an autosexual orientation mode through peripheral and central synergy effects have been reported[14]. The underlying mechanism of this new ejaculation mode may involve the changing of neurosignaling pathways, not only psychological factors[15].

Most of the patients who complain about delaying vaginal ejaculation by masturbating in the prone position usually have a course of more than 1 year, but some of our patients reported that delayed ejaculation occurred within 3 months after using the prone masturbation method, this is the partial rational for our 3-month follow-up to observe the effect. Furthermore, < 3 and >6 months reflect short- and long-term efficacy, respectively. Our study focused on evaluating the short-term efficacy of novel behavioral treatments for PE.

There are several methodological weaknesses in our study. Self-estimation rather than a stopwatch was used to measure the IELT in this work, although self-report of ejaculatory latency has a good correlation with the stopwatch method[16]. There was a small sample size and no control group. As we all know, compared to medication, BT is definitely boring and time-consuming, and prone masturbation needs to be done alone. BT cannot be as short-term as drug therapy, and it requires a longer term treatment process. Therefore, the fact that many patients give up the exercise automatically when the cycle is not completed does not mean that the BT is ineffective. This study only included and analyzed the data of patients who completed the cycle, and these data are true and reliable. To compensate for these limitations, a new multicenter, large-scale, randomized, comparative clinical trial should be carried out.

4 CONCLUSION

Regular prone masturbation training, as a novel BT, probably has a therapeutic effect on PE. For patients who have a stable sexual experience and suffer from only PE, this method is safe for short-term training. However, this method still needs to be further verified in randomized controlled trials.

References

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