What Does a Sneeze and Premature Ejaculation Have in Common?

He feels it coming and frantically realizes there is nothing he can do about it. Recognizing the inevitable, he grabs for a tissue so he does not spray everywhere. He then blows his nose to reduce the congestion and irritation in the hope that another sneeze does not immediately follow the first one. 

Remind you of anything else? What does a sneeze and premature ejaculation (PE) have in common?

In either situation, if a man waits too long, there is nothing that can be done to prevent it from happening. For a variety of biopsychosocial and cultural reasons, “too long” varies from man to man, and from sneeze to sneeze, as explained by Sexual Tipping Point® (STP) model. But no matter what the predetermining factors, both a sneeze and an ejaculation always happen once the point of inevitability has passed. If a man tries to hold back once it starts, it just happens anyway and often creates a bigger mess. Yet, if a man recognizes that it is about to happen, there are steps to take. A big difference between a sneeze and PE is that most men are taught how to avoid/delay a sneeze early in life.  

Before anyone sneezes, there are premonitory sensations (PS) that must be recognized and attended to, or the sneeze will happen automatically. In other words, generally, a sneeze is a reflex response to external stimulation/irritation of the nasal passage. By recognizing the premonitory sensations to a sneeze and then doing something about it, a sneeze can be postponed or even aborted. Most boys learn over time to notice a dribbling nose, an irritation, and tingling in his nostrils, etc. and the subsequent necessity to blow his nose. Yet for some men who suffer from an autosomal dominant compelling helio-ophthalmic outburst (sneezing when first looking at the bright sun), like a few men with PE, it seems like there is nothing they can do to stop it. For others, when finding themselves in a novel, very stimulating environment such as highly polluted air filled with smoke, nothing will abate that automatic reaction as the sneeze attempts to protect the lungs from such irritants. But for the most part, managing a sneeze is a lesson learned and easily applied. Errors tend to be few over time, with only rare mistakes that usually do not cause any shame.

PE can have a devastating impact on both men and their partners. Source: MAP Education & Research Foundation, used with permission.

PE can have a devastating impact on both men and their partners.
Source: MAP Education & Research Foundation, used with permission.

Juxtapose that with the man with PE, who finds himself feeling helpless to control his ejaculatory process. He is frequently humiliated and ashamed of himself and even ridiculed by others. PE is a very common male sexual dysfunction with millions of men and their partners suffering from its consequences. The condition is characterized by concerns regarding time to ejaculation, distress and most importantly perceived control over ejaculation. PE may be either lifelong (present since sexual maturation) or acquired (developed after a period of normal ejaculatory function). These forms of PE are sometimes referred to as primary and secondary PE, respectively. Additionally, PE may be generalized (happens in all situations, with all partners) or situational (happens in specific situations and/or with specific partners). PE most commonly refers to distress over heterosexual intercourse, but gay men also complain of it. It can have a devastating impact on self-esteem, and can cause avoidance of sexual activity, avoidance of intimacy, and even complete avoidance of socialization with any potential sexual partner(s).  

Why do countless men still regress and/or fail to learn how to delay their ejaculation despite the ready availability of sex therapy, treatments, and over-the-counter remedies? The remainder of this post will focus on the answer, as it characterizes so many of the men suffering from PE, as well as men who fail PE treatments or regress once treatment is withdrawn. All of these men, even when “treated,” may still have difficulty identifying their premonitory sensations (PS) to orgasm and knowing what to do about it. Premonitory sensations are a man’s early warning system that can immediately trigger recognition that an ejaculation is imminent. These signals reflect the mind and body changes in his arousal level, such as testicular elevation, increased muscle tension, increased breathing and heart rate, etc., all of which precede and foreshadow the emission stage. Many men notice these sensations as a “yellow light” that means to relax, slow down and/or interrupt stimulation completely. However, men with PE frequently are unable to identify and/or do not, or cannot respond quickly enough to these early warning signals to delay their ejaculatory process consciously. The reasons for such a difficulty can be caused by psychosocial factors and/or physical ones, as explained by the Sexual Tipping Point®(STP) model. They do not know what to do with their mind and body once PS are recognized in order to delay their reflex until they wish to ejaculate. An ejaculation is a reflex that is delayed (like a sneeze), but not controlled or shut down. While these problems can be related to disease and/or a biological predisposition, it is often a function of ignorance. How so?

Disproportionately, men suffering from PE (and sometimes their healthcare professionals as well) are unaware of important male physiology. A man’s ejaculation is comprised of two stages—emission and expulsion. During the emission stage, the bladder neck closes, and seminal fluid is deposited into the beginning of the passage that is also used for urination called the posterior urethra. The second stage, expulsion or ejection, is triggered “automatically” two to four seconds after the initiation of emission. Men often experience the emission stage as the point of no return or in scientific terminology, “ejaculatory inevitability”(EI). While almost all men recognize their point of EI, by that time it is “too late” to delay ejaculation, as expulsion is automatically seconds away. Often, unaware of these two stages, men presume that the expulsion stage, with its ejection of fluid, feelings of pleasure, and coordinated muscle contractions constitute the entire ejaculatory process. 

When there is a physical (genetic) biological predisposition for such rapid progression from PS to EI, modification of either thought or behavior in sufficient time to delay is essentially impossible. Such men will require a medication such as a serotonin-modifying pharmaceutical (elevating the neurotransmitter serotonin levels helps delay ejaculation). Alternatively, some men prefer a desensitizing ointment or any agent that minimizes sensitivity in order to slow the physiological processes taking him from PS to EI. Regrettably, most men using medical treatments for PE will regress as soon as the medication/device is withdrawn. They never learned how to delay and thus control their ejaculation, but instead, their ejaculation process was delayed pharmaceutically outside of their own direct conscious effort. Consciously delaying the ejaculatory process requires both identification of PS and a cognitive/behavioral response to those signals prior to the initiation of the emission (EI) stage. This is quite similar to what it is necessary to recognize in order to successfully blow one’s nose before a sneeze begins. 

When a man notices that “tingling nasal sensation,” and/or nasal stuffiness, etc, “blowing his nose,” will temporarily postpone (or even abort) the sneeze or sometimes the process repeats itself. However, if a man “waits too long and reaches that “ah… ah,” tipping point, the “choo” will happen even if he is in the middle of blowing his nose. That “waiting too long” until he hits that “ah… ah,” is the sneeze equivalent of EI. 

Many men do not recognize that the physical signals they experience in connection with emission (EI) are what they are mistakenly identifying as signals they are about to “come.” No matter what he does at that point, an ejaculation is going to happen anyway: It is automatic and nothing can be done about it. A few men have a biological predisposition to ejaculate so much more quickly than other men, and so the speed of their arousal and the transition from PS to EI is such a rapid blur that they are unable to discern a difference. When such a man says, "Uh-oh, I am going to come,” what he should be saying is, “Uh-oh, I am coming.” He has failed to identify his PS and is responding instead, albeit too late, to the sensation(s) that characterize his emission phase. 

Most men are able to notice their PS and do something mentally and physically to delay the onset of that automatic reflex. All the successful techniques that men use involve some conscious and sometimes preconscious reduction/adjustment of stimulation whether mental and/or physical. Whether they change their thoughts to something less sexy, modify their breathing, focus in on what they are experiencing in a more Zen-like mindful manner or merely stop, slow down, or move in a different manner, all of the above can take the “edge” away from escalating arousal and imminent ejaculation. Men with PE, however, find that no matter what they seem to do, ejaculation overtakes them. Some experience a partially retarded ejaculation (PRE) as they attempt a last-second “squeeze” of their anal-genital muscles, only to find that their fluids ooze out anyway. All they have done in reality is suppress the muscular contractions that typically accompany ejaculation. 

All men with PE must learn to “dial down” their mental and/or physical arousal in response to PS, to a level below their threshold for emission, in order to truly "control" (delay) their ejaculation. Some men have a naturally longer latency than others and find such control is "automatic,” while others learn this themselves over time through experience or by reading. Identifying PS and learning to slow down and delay ejaculation is the basis for sex therapy of premature ejaculation, and some men find such an approach helpful and sufficient in and of itself.  However, some men do require something external to themselves to slow down the process in order to be able to fully “feel” what is happening in their bodies. Yet many healthcare clinicians are surprised that their patients relapse when medical and "over the counter" treatments do not work once the sprays, pills, barrier methods, etc. are withdrawn. Those healthcare professionals must also learn to teach “stop/start…go fast, go slow" techniques of sex therapy and educate their patients with PE, in order to accomplish long-term treatment success. Even when the PE is more extreme, a physician working together with a sex therapist can make learning to delay an ejaculation as easy as postponing a sneeze.


American Urological Association Premature Ejaculation Guidelines

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Perelman, MA. Why The Sexual Tipping Point is a Variable Switch Model. Current Sexual Health Reports, 10: 38. 2018

Perelman MA. “A New Combination Treatment for Premature Ejaculation: A Sex Therapist's Perspective”. Journal of Sexual Medicine. 2006;3:1004–1012.

Rowland, D., Tuohy, A., & Humpfer, J. (2014). An Integrative Approach to the Treatment of Premature Ejaculation. Current Sexual Health Reports, 6(2), 124–135. 

Perelman M. “Treatment of Premature Ejaculation.” In Principles and Practices of Sex Therapy [Eds. S Leiblum and L Pervin].  New York: Guilford Press, 1980, Chapter 7, pp.199-233.

McMahon C, Abdo C, Incrocci L, Perelman M, Rowland D, Waldinger M, Xin ZC. “Disorders of Orgasm and Ejaculation in Men.”  Journal of Sexual Medicine, 2004:1:1:58-65.