A) BEHAVIOURAL TREATMENT
Semans start-stop method J.H Seman was the first offer treatment for this condition which he called –the start stop technique. Dr Helen Kaplan developed it extensively and used it to treat men with poor ejaculatory control, and who lacked the help of sexual partner. In Indian condition this method is useful as man are often reluctant to involved there partner in sex therapy This exercised are useful if done with some degree of regularity. Mental and physical fatigue will act as constraints and it’s imperative to have proper privacy and leisure time which is rather difficult in today circumstances.
Step 1 - Self-exploration: Here the man learns about his sensual area of the body in an unburdened and unregulated manner. When he is rested and relaxed undressed and lies on the bed. Using the finger tips, he touches different part of his body starting with the face. This touching exercised is then extended to neck, arm, shoulder, chest, abdomen etc. Different stroke are to be tried out and tested for their sensitiveness. The stimulation of the penis and scrotum is done intermittently and with varying degree of pressure using different type of strokes and grips on the penis the man learn to become aware of his pleasurable feelings. As this is only an exploratory test the man is advised not to masturbate to the point of ejaculation on this occasion as sexual turn-on is not what is desired but being aware of the pleasure of touch is crucial.
Step 2 - Self- Stimulation: Here the beginning is like the previous step wherein initially non-genital stimulation is done for about 10-15 minutes after the man feels relaxed and is sufficiently aroused he has to stimulate his genitals. This should be intermittent with other areas of the body also being touched. Being aware of the sensations generated within the body is important and so is the sensory focus on the sensations areas which include the penis, scrotum, perineum, inner thighs etc. As the stimulation is increased, the man will start feeling sufficiently aroused to achieve a good erection. At this stage he has to deliberately slow down the tempo of stimulation for about 10 -15 seconds and then resume. After doing it 2-4 times, he can let go and ejaculate whenever he wants. During the ejaculations process he has to concentrate his attention on the physical sensations just before ejaculations occurs. This is the point of ejaculatory inevitability.
Step 3 - Introducing the Stop-Start method: Following the practice of steps 1 and 2 for a few days, a change in pattern of stimulation is introduced. It involves deliberate total stopping of stimulation for about 10 – 15 seconds much before the level of high arousal is reached. After a slight loss of erection the stimulation is restarted. Slowly he has try to come as near as possible to the point of ejaculations inevitability and then stop – so that the urge to ejaculate disappears. The stop phase may have to be increased in highly sensitive subjects. Some men lose control and ejaculate but this teaches them to stop slightly earlier when they do the exercise next time. If ejaculation does occur the exercise is terminated. He has to be able to control himself for 3-4 such occasions and then the stimulation is continued to the point of ejaculation. At this stage the man has to concentrate on the pleasure aspect rather than trying to time himself as that may act as a distraction during climax. This procedure is to be repeated a number of times and it’s only then the man will slowly learn to control his ejaculation.
Step 4 - Stop- Start Method with lubrication: Some men tend to ejaculate prematurely only during sex. The reason attributed is that this probably occurs due to the enhanced sensitivity as a result of the wetness within the vagina due to lubrication.to enable a man to have this increased sensitivity during masturbation this step of the exercise advocates the use of a non- alcoholic, water-soluble lotion or jelly. These small changes are quite important as they mimic the factors that occur during sexual intercourse.
Step 5 - Stop-Start Method with lubrication and Fantasy: Some men masturbate only by using the physical stimulus and their minds concentrate only on the pleasure aspect that they derive from penile stimulation. During sex, the presence of a partner is excessively stimulating which is sometimes a contributing factor for a premature ejaculation. For such men, adding a fantasy of their choice during the exercise enables them to simulate a real life situation and hence achieve still greater control.
B. SQUEEZE TECHNIQUE
Masters and Johnson advice the innovative squeeze technique to stop the ejaculatory response. Based on detailed history taking, they devised a unique couple therapy where there is a graded increase in sexual stimulation and called it ‘Sensate Focus Method’ According to them many couples are able to cope successfully with reconditioning the man’s sexual response on their own so that sex becomes more relaxed and fulfilling. However in some situations, sex therapy is the best solution rather than trying a self help program.
The squeeze technique demands the involvement of a co-operative partner whose role is to periodically apply a specific type of a non stimulatory pressure to the penis from early stages of sexual arousal to the pre-ejaculatory state. It interrupts the ejaculatory response so that the man slowly learns to achieve control. They state that most men do not benefit from trying to use the squeeze technique on themselves. It works only when the man doesn’t try to direct the action or instruct his partner as to when and how firmly to squeeze.
Step 1- Learning to squeeze: For doing squeeze technique, the woman has to put the pad of her thumb on the frenulum of the penis while placing the first and the second fingers of the same hand on the opposite side of the shaft parallel to each other. These are placed slightly lower the coronal ridge. The woman then firmly squeezes the penis for about four seconds and lets it go.
Factors to be remembered are:-
- Avoid pinching or scratching with fingernails
- Pressure from front to back and not side to side
- Only pads should be used and the complete finger is not to be wrapped around
- Proper pressure is essential. More if it is firm, less if flaccid. Suitable instructions essential
- For early experimenting, it’s better if the man guides the woman by keeping his hand over hers
- Pressure should be firm enough so that erection is lost in the process.
Step 2 - Using the squeeze during sex play where man is passive: Here the couple is advised to purposefully indulge in sex play for about 20-40 minutes. Here the degree of excitement is purposefully allowed to remain low and the squeeze is applied about 3-6 times during the whole encounter. Erection of the penis is not considered important. Some points to be remembered are:
- An excessively sensitive man ejaculate immediately after a woman touches his penis
- The woman should actively play with the penis between two squeezes
- Ejaculating despite the squeeze is considered normal
- Initially it is better to avoid any type of lubrication as it is counterproductive
- The Squeeze is to be kept separate and discreet from other type of foreplay
Step 3 - Using the squeeze during sex play where both are active: Here the variation is that they have to take turns so that degree of stimulation for the man is now greater. Masters and Johnson strongly suggest that couples should do this step for at least three times before they move to the next step.It helps to develop physical and psychological comfort between the couple with prolonged non- coital sexual stimulation. It also aids in annihilating the performance anxiety of the man as the periodic squeeze assist in preventing premature ejaculation.
Step 4 - Genital –to-Genital touching: This is an essential step to make the man feel at ease wherein genital contact is established without a complete intercourse. After going through the initial steps as described above without ejaculation, the woman has to sit astride her partner, apply the squeeze and then get her vagina in close proximity to his penis. She has to use non-genital stimulation along with firm squeeze to the penis. She has to initiate the first direct contact with the vagina lips immediately after a squeeze. Some men tend to lose control at this point. Whether or not this occurs the purpose of this exercise is to allow the man to feel comfortable with direct penis-vagina contact. It proves to be a learning experience for the man. In case he does not ejaculate the couple can proceed to the next step immediately.
Step 5 - Woman in control intercourse position: Now the woman is encouraged to sit astride with the man lying on his back. She has to intermittently use the squeeze on five to six occasions before attempting to insert the penis in her vagina. Use of some lubricant to stimulate the penis is advised. Once erection without ejaculation is achieved for a satisfactory period of time she squeezes the penis and inserts it in her vagina. She has to sit still without any movements and both have to focus on their physical sensations.It’s imperative that the woman be in total control during this process. After the man is able to control ejaculation at the end 15-20 seconds the woman removes the penis and applies the squeeze once again and reinserts the penis. Now after staying still for some more time she begins a slow thrust pattern. Gradually over a period of time the thrusting speed is increased along with the time. It is normal to expect a few failures wherein the man may ejaculate prematurely, but slowly over a period of time he learns to control himself.