EUROPEAN UROLOGY 59 (2011) 772–774
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Platinum Priority – Editorial
Referring to the article published on pp. 765–771 of this issue
Contribution of Acupuncture to Western Medical Knowledge of
Premature Ejaculation: An Intriguing New Development
Marcel D. Waldinger *
Department of Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Faculty of BetaSciences, Utrecht University, Utrecht, The Netherlands
Department of Psychiatry and Neurosexology, HagaHospital, The Hague, The Netherlands
Recently, the International Society for Sexual Medicine
provided an evidence-based guideline on the various options
currently in existence for the treatment of premature
ejaculation (PE) [1]. The guideline shows that, especially in
the last two decades, enormous progress has been made in
the pharmacologic treatment of PE. This development has led
to new neurobiologic and neurophysiologic knowledge of PE.
In addition, it was shown that there are four PE subtypes that
have different etiologies and pathogenesis. Whereas intra-
vaginal ejaculation latency time (IELT) persistently occurs
within about 1 min in men with lifelong and acquired PE, a
substantial number of men in the general population are not
satisfied with a normal or even a long duration of IELT [2]. One
should be cautious in reaching a diagnosis that these men are
suffering from PE. In line with human research showing the
strong ejaculation-delaying effects of selective serotonin
reuptake inhibitors (SSRIs), animal research has shown
robust evidence that there is involvement of the central
serotonin (5-hydroxytryptamine) system in ejaculation and
the existence of a lumbar spinal (ejaculation) reflex [3]. Data
derived from animal research suggest a major role for the
central serotonergic system in ‘‘modulating’’ the spinal
ejaculatory reflex [4]. This serotonergic modulation of
ejaculation may result in faster or more delayed ejaculation,
whereas ejaculation itself is probably not under the direct
influence of the serotonergic system but rather of other
neurotransmitter systems in the spinal cord. As the
serotonergic system ‘‘only’’ modulates ejaculation, some
men are able to delay their ejaculation in a variety of ways,
whereas others, in which the serotonergic influence is nearly
absent, are completely unable to delay ejaculation [4]. In
DOI of original article: 10.1016/j.eururo.2011.01.019
* Department Psychiatry and Neurosexology, HagaHospital, Leyweg 275, 2545 CH The Hague, The Netherlands. Tel.: +31 70 210 2086;
Fax: +31 70 210 4902.
E-mail address: md@waldinger.demon.nl
0302-2838/$ – see back matter # 2011 European Association of Urology. Published by Elsevier B.V. All rights reserved.
these men, SSRIs are unable to delay ejaculation—a
pharmacologic phenomenon that has been subject to hardly
any investigation [4]. Interestingly, recent genetic research of
PE has shown that the very short IELTs in lifelong PE are
associated with genetic polymorphisms of the central
serotonergic system [5]. Presumably, genetic research may
provide answers to various questions about the pathogenesis
of PE. However, as is the case in drug treatment studies of PE,
there are also various limitations to the methodology and
design of genetic studies of PE [4]. Notably, the aforemen-
tioned brief overview of recent developments in PE is mainly
derived from Western medical research into PE.
In the current issue of European Urology, Sunay et al
present an interesting study showing that, compared to
placebo, acupuncture significantly delays ejaculation in
men with PE [6]. Like other clinical studies of PE, the study
by Sunay et al also has some methodological limitations. For
example, the number of IELT measurements during baseline
and treatment period is thus far very limited. Although less
than paroxetine, the study indicates that the ejaculation-
delaying effect of acupuncture in the current group of men
appears to be significantly stronger compared to sham
acupuncture (needling of nonacupuncture points). That
outcome is an intriguing one that I would like to address
because it may point to some unknown neurobiologic or
other mechanisms underlying PE.
Acupuncture is an ancient Chinese healing method.
Despite its existence for many centuries, many Western
physicians still tend to dismiss its efficacy by arguing that
this is caused by a placebo effect. However, such an
argument is no longer in line with current neuroscientific
doi:10.1016/j.eururo.2011.02.018
 EUROPEAN UROLOGY 59 (2011) 772–774
knowledge of the underlying mechanisms of actions of
acupuncture.
In contrast to Western medicine, traditional Chinese
medicine is built on a system of beliefs and practices that
are alien to Western thought and medicine. Whereas
Western medicine is concerned with cause and effect,
Chinese medicine attends to relationships and patterns
using methods as diverse as observation, five-element
analysis, and pulse- and alarm-point diagnosis. For the
Chinese, illness occurs simultaneously on all levels of a
person’s being, including physical, mental, and energetic.
Traditional Chinese medicine does not distinguish between
these levels or treat them separately, as would their
Western counterparts. All symptoms are observed and
included as part of the diagnostic picture. This holistic view
has remarkable similarities with the concepts and ideas of
Sigmund Freud, who not only thought that illness
simultaneously affects various physical and mental levels
of a person’s being but also developed a holistic method to
treat mental and physical illnesses. His approach, which he
called psychoanalysis, consisted of continuous listening and
analysis of every small detail of a patient’s thoughts and free
associations. In 2000, after a century of controversy, a
number of neuroscientists and psychoanalysts decided that
integration of psychoanalysis and neuroscience was a more
fruitful approach to treat and investigate patients with
emotional problems and to unravel clinical issues that
cannot be explained by merely neuroscientific reasoning. In
only a few years, neuropsychoanalysis has become known
worldwide.
In the last decade, neuroscientists also started to
investigate the neuroscientific underpinnings of the holistic
approach that is so characteristic of traditional Chinese
medicine. For example, acupuncture, which is one of the
methods used in traditional Chinese medicine, focuses on
homeostatic (yin–yang) regulation, a way of thinking that
is rather difficult for Western physicians to understand
and apply. However, today, neuroscientific research has
succeeded in establishing an empirical basis for acupunc-
ture. It has been shown that manipulation of strictly defined
energetic trigger points results in potent sensory stimula-
tion that produces various changes in the central and
peripheral nervous system.
In the event that future research confirms the ejaculation-
delaying effects of acupuncture, as described in the current
study by Sunay et al [6], acupuncture could possibly become a
promising new treatment for PE not only in Asian countries
but also in other parts of the world. In that case, it would
be intriguing to investigate whether acupuncture delays
ejaculation through an effect on central serotonergic
neurotransmission or by another mechanism of action. For
example, although animal research has repeatedly confirmed
the involvement of serotonin neurotransmission in ejacula-
tion, there is a lack of understanding of the role neuropep-
tides play in the ejaculation process. Interestingly, various
studies have shown that acupuncture facilitates the release
of endogenous opioids in the central nervous system and that
several classes of molecules, such as neurotransmitters,
cytokines, and growth factors, are possible mediators
773
for specific acupuncture effects [7]. Particularly interesting
is b-endorphin, an endogenous opioid that influences a
variety of hypothalamic and autonomic functions. It is
important in the regulation of pain perception, stress
response, mood, and immune functions [8].
Why is acupuncture able to delay ejaculation? Is it
because of the release of specific neuropeptides in the brain,
or is it related to a diminished sensitivity for external
stimuli? For example, acupuncture has been reported to
alleviate the sensory discriminative aspect and affective
component of pain [9]. Physiologically, the afferent
stimulation of acupuncture has been attributed to its effect
on A-d and C-fiber sensory nerve fibers and activation of
descending pain-inhibiting pathways. As these nerve fibers
are sensitive to the light touch of mechanoreceptors in the
skin, further research of acupuncture may perhaps lead to
better insight into the still unanswered question of why
some men only ejaculate rapidly intravaginally whereas
their ejaculation time is seemingly undisturbed during
masturbation. Interestingly, neuroimaging studies in
humans have validated that acupuncture modulates a
widely distributed network of brain regions involved in pain
perception and have shown that the amygdala, insula, and
hypothalamus modulation may demonstrate some acu-
puncture specificity [10]. This knowledge of acupuncture
may perhaps contribute to brain imaging studies of PE.
I accordingly encourage the cooperation of Western
clinicians and those scientists who are involved in
traditional Chinese medicine. Research of acupuncture
treatment of PE may benefit from the consistent application
of the rather strict evidence-based methodology of Western
medicine (IELT cut-off point of 1 min, use of a stopwatch) to
the sophisticated and ancient Chinese method of acupunc-
ture. Additional neurobiologic and neuroimaging research
may lead to a better understanding of the underlying
mechanisms of acupuncture and help determine acupunc-
ture’s potential as a treatment for PE.
An important question needs to be answered by further
research: Does acupuncture provide only temporary relief
or does it have the potential for prolonged ejaculation-
delaying effects after acupuncture treatment has been
completed? If the latter is the case, then we should consider
the application of acupuncture for treating PE to be an
intriguing new development.
Conflicts of interest: The author has nothing to disclose.
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