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INTRODUCTION
Premature ejaculation (PE) is a common male sexual dysfunction that can have significant effects on a couple's relationship [1]. The prevalence of PE is as high as 20% to 30%, but few affected individuals seek medical help [23]. According to a previous study, approximately 25% to 40% of adult men may develop PE at certain stages in their lives [4].
However, no widely accepted definition and assessment tool exists for evidence-based clinical studies of patients with PE [5]. At present, methods for the treatment of PE include nonmedical therapy (behavioral therapy and psychotherapy), medical therapy (pharmacology and surgery), and combination therapy. Of these options, nonmedical therapy is both safe and effective [6].
Fangzhongshu (sexual skills and methods), zhuyou (spell-casting), and yijing (Chinese medicine) were the important branches of traditional Chinese medicine (TCM) in ancient China [7]. Fangzhongshu, which mainly deals with sexual skills and techniques in intercourse between men and women, is an important summary of the experience of experts on sexology and contains valuable information regarding interventional treatments for various types of sexual dysfunction [8]. Fangzhongshu (Fig .1) contains many treatments for erectile dysfunction, PE, anejaculation, and other types of sexual dysfunction. Fangzhongshu is quite similar to the concepts of behavioral therapy and psychotherapy that are employed in modern medicine. In a work entitled Yufangmijue (Sexual Secrets), 7 harmful and 8 beneficial sexual behaviors are described, of which “drainage” is similar to the concept of PE in modern medicine. A series of 10 movements mimicking the sexual movements of 10 types of animals can be found in the Mawangdui [a place name] Medical Book of Sexual Activity, which reflects a combination of yin and yang. A work entitled Sheshengzongyao (Summary of Nourishing of Life), which was written during the Ming dynasty, is a comprehensive document of fangzhongshu that impressively describes the art of sexual activity.
Through clinical observation, we found that the intravaginal ejaculatory latency time of primary PE patients was dramatically prolonged after treatment for 4 weeks (0.93±0.28 minutes), 8 weeks (1.20±0.33 minutes), and 12 weeks (1.90±0.65 minutes) in comparison with baseline values (0.60±0.14 minutes) (p<0.05) using the Touching Three Peaks and Foreplay therapy (a type of fangzhongshu therapy). In these patients, scores on a Chinese index of sexual function for PE known as the PECI-5 (Chinese index for premature ejaculation-5) also dramatically improved after treatment for 4 weeks (14.57±1.94 points), 8 weeks (16.37±1.97 points), and 12 weeks (18.53±1.67 points) in comparison with the baseline (13.20±2.51 points) (p<0.05). This method showed clear efficacy, and adverse reactions were rare [9].
To promote understanding between TCM and modern medicine, representative therapies of ancient Chinese medicine, such as fangzhongshu for PE, must be introduced.
LATEST DEFINITION OF PREMATURE EJACULATION
The International Society of Sexual Medicine updated the definition of PE in 2013. The characteristics of PE as currently defined are as follows: (1) Ejaculation that always or nearly always occurs prior to or within 1 minute of vaginal penetration; (2) A clinically significant and bothersome reduction in ejaculatory latency, often to about 3 minutes or less, regardless of whether the PE was present from the first sexual experience or acquired later; (3) The inability to delay ejaculation on all or nearly all vaginal penetrations; (4) Negative personal consequences, such as distress, bother, frustration, and/or the avoidance of sexual intimacy.
Common elements of this definition with earlier definitions include a short ejaculatory latency time and lack of control over ejaculation and sexual satisfaction.
BEHAVIORAL THERAPY AND PSYCHOTHERAPY
Behavioral therapy includes the stop-start program, which was first described in 1956 by Semans [10]. In 1970, Masters and Johnson [11] reported a similar maneuver, the squeeze technique, which was slightly different from the technique described by Semans [10]. These methods were designed to help men recognize moderate levels of excitement, and are postulated to attenuate various stimuli and responses to prolong stimulation by gradual exposure of patients to more intense stimuli. The progress attained gradually leads to sexual confidence, self-esteem, and an increase in intravaginal ejaculatory latency time, although this parameter has only been evaluated in few controlled studies [12]. Although short-term benefits of behavioral therapy have been reported (success rate, 45%~65%), the problem typically reoccurs [1314].
Psychotherapy for patients with PE has 2 main goals. First, psychological interventions can help men develop sexual skills for delaying ejaculation by increasing their sexual confidence and diminishing their performance anxiety. Second, it can resolve psychological and interpersonal issues, which may have precipitated, maintained, or been consequences of PE symptoms for the man, his partner, or the couple [61516]. However, the outcomes in a majority of psychotherapy studies are not well controlled or randomized, and few of them meet the requirements of evidence-based studies. Moreover, similar to behavioral therapy, such studies generally only have short follow-up periods [17].
NONMEDICAL THERAPIES OF ANCIENT CHINESE ANCIENT FANGZHONGSHU
1. Idea transferring
Yufangzhiyao (The Main Purpose of Sexual Activity) points out that “semen will cease activity after raising one's head immediately, opening one's eyes, looking around, shrinking the lower abdomen belly and holding one's breath when the sperm appear to be fluctuating rapidly.” Yulingyanfang (Effective Prescription for Sexual Activity) records a method stating that “the penis will be firm and sexual intercourse will last for a long time if one holds a pill of tianwanbuxin dan (a compound used in Chinese medicine; a type of tranquilizer) in the right hand with serious intent and puts one's heart and soul into it when sexual intercourse occurs.”
Mental anxiety and stress result in sexual intercourse that is dependent on strong psychological stimulation, and consequently, sexual arousal increases rapidly. Hence, anxiety and stress can greatly speed up the ejaculation process and become a cause of PE [1118]. These 2 methods can help men control ejaculation and prolong sexual intercourse by shifting their attention and relieving their stress. A man's attention is shifted visually by raising his head, opening his eyes, and looking around in the first method, whereas the tactile method of clenching a pill in the hand is used in the second method. Moreover, tianwangbuxin dan is considered a tranquilizer in TCM. By clenching it in the hand, it can stimulate the Laogong (PC8, a type of acupuncture point), which belongs to the hand (Jueyin) pericardium meridian and has the function of sedation. This method has the joint effects of pharmacology and massage and can reduce anxiety and stress in patients.
2. Suppressing Yin and Raising Qi
The Categorized Collection of Benefit for Suxual Activity Medical Formulas states that “semenwill not come out for a long time if one presses the meridian behind the scrotum using the index finger and the middle finger of the left hand, taking long exhalations and chattering one's teeth 10 times when the sperm are fluctuating rapidly and on the verge of coming out.”
According to a previous study, increased penile sensitivity and a reduced ejaculation threshold can shorten ejaculatory latency and cause PE [19]. Pressing the lower abdomen can raise the ejaculation threshold and achieve the goal of PE treatments [20]. The technique of “pressing the meridian behind the scrotum,” which means pressing the Huiyin meridian (RN 1, a type of acupuncture point), can postpone the ejaculation reflex and raise the ejaculation threshold to delay ejaculation. In addition, “taking long exhalations” and “chattering one's teeth” are used to divert one's attention and stabilize one's mood to delay ejaculation. The key point of this method is to be mindful of time. The phrase “sperm is fluctuating rapidly and on the verge of coming out” means that the feeling of ejaculation has just started. This technique will fail to raise the ejaculation threshold if used too early or it will fail to control ejaculation if used too late.
3. Interruptions or intermissions in sex
The Sheshengzongyao (Summary of Nourishing of Life) states that “the penis must be removed when ejaculation is felt. Hold down the glans, press on the front of the anus with 3 fingers of the right hand and raise a breath to Dantian [a type of acupuncture point]. Then the mind is controlled and excitement is suppressed by breathing deeply. Do not perform any action. The penile erection can be restored again after some time, and the sexual intercourse can be resumed. PE will not occur if the penis is removed and sexual desire is endured to raise Qi movement.” It also states that “the penis must be moved slowly, without hurry, fatigue, or panting during sexual intercourse. A rest is needed after a long period of sexual intercourse and then one can perform again after calming down. The whole penis or half of the penis can be moved out quickly when ejaculation is about to take place. Never do this in a hurry.”
Controlling or interrupting ejaculation can depress the excitability of the nervous system and thus achieve a therapeutic effect for PE [172122]. The first method involves the interruption of sexual intercourse, and the source points out that the penis should be moved out immediately when imminent ejaculation is felt. This technique involves pressing the front of the anus (Huiyin [RN 1] in the perineum) and breathing deeply to control the mind and suppress excitement. The method of controlling ejaculation after continuing sexual intercourse involves repeating the suppression of sexual excitement by interrupting it again, breathing in, and contracting the anus as when one controls urine. The key point of this method is to interrupt sexual intercourse immediately when imminent ejaculation is felt by shifting one's attention and suppressing yin while raising qi.
The second method involves suspending or discontinuing sexual intercourse. The text states that patience is essential in sexual intercourse; rest is needed to calm down and restore one's energy before continuing sexual intercourse. Patients with high sensitivity can remove the entire penis or half of the penis if slight activity results in ejaculation. The difference between the 2 methods lies in whether it is necessary to remove the penis. Only patients with high sensitivity require removing half of the penis or the whole penis.
4. Special posture
The Dongxuanzi (a book named after its author) introduced a method of “flying seagull sex” that involves “the man standing by the bed, raising the woman's feet, and inserting the penis into the vagina.”
Changing sexual positions or body posture can have a therapeutic effect on impotence, PE, and other disorders of sexual function, thereby improving the quality of sexual intercourse [23]. This method states that a man should stand next to the bed, raise the woman's feet, and insert the penis into the vagina. This method received its name because the woman's legs are held outward and resemble flying seagulls. The positions of standing and lying in this method are easy to implement and are especially suitable for men without a firm erection or much sexual experience. For the man, the standing position, which is comfortable and conserves physical strength in comparison to clinostatis, makes it easier for the penis to enter the vagina. This may alleviate patients' mental stress, prolonging the duration of sexual intercourse and delaying the ejaculation. For women, this position makes it easier to stimulate the G-spot located in the anterior vaginal wall, approximately halfway between the pubic bone and the cervix [24]. Hence, this position improves sexual satisfaction for both men and women.
5. Touching three peaks and foreplay
The Sheshengzongyao (Summary of Nourishing of Life) states that “the three peaks, which are the tongue above, the breasts in the middle, and the vaginal orifice below, can cause high sexual desire in women, with increased secretions in the vagina when touched. Thus, men can hold and fondle women gently, close their mouth and grit their teeth, place their thoughts elsewhere, insert the penis into the vagina and perform sexual intercourse following the method of 9 shallow thrusts followed by 1 deep thrust."
This method suggests that the “three peaks” (tongue, breasts, and vaginal orifice) should be stimulated before sex. Sexual intercourse is performed using the method of 9 shallow thrusts and one deep thrust, in which the penis repeatedly stimulates the vagina in a shallow position and slowly moves deep after adaptation, when both the man and the woman have a high degree of sexual desire and increased secretions. In this method, the sexual organs are first stimulated and then sexual intercourse is performed after a high degree of sexual desire is attained. This can relieve the patient's stress to some extent. In addition, the method of 9 shallow thrusts and 1 deep thrust, which progressively and gradually strengthens the stimulation of the penis, reduces the sensitivity of the penis and improves the stimulation threshold for ejaculation. The combined action of these two techniques delays ejaculation and improves the quality of sexual life.
CONCLUSIONS
Fangzhongshu is a set of ancient sexual techniques based on Taoist thought. The main concepts of sexual harmony, attention paid to flirting and foreplay before sex, and artistry in sexual behavior are important guiding principles in this approach to treatment. Fangzhongshu contains some outdated feudal elements and magical components. However, it should be integrated into modern clinical practice after critical analysis, and its scientific aspects should be promoted to benefit individuals' reproductive health and to promote traditional Chinese culture [25].
Although fangzhongshu has a long history in ancient China, it is only a summary of the experiences of individual experts, and it has not been evaluated through the clinical observation of large samples. Hence, its effects need further study. Studies incorporating scientific observations and research methods need to be designed, and suitable treatment methods should be explored for different groups of people. This will truly reflect the idea of “treatment chosen according to different conditions in terms of locality,time and people concerned” advocated by TCM.
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