ORIGINAL RESEARCHEJACULATORY DISORDERS

Yoga in Premature Ejaculation: A Comparative Trialwith Fluoxetine

Vikas Dhikav, MD,* Girish Karmarkar, MBBS, MD, Mallika Gupta, MBBS,* andKuljeet Singh Anand, DM*All India Institute of Medical Sciences, New Delhi, India; Private Practice, Thane-Mumbai, India; Dr. RML Hospital andPost Graduate Institute of Medical Education and Research-Guru Gobind Singh-Inderprastha UniversityNeurology,Delhi, India

DOI: 10.1111/j.1743-6109.2007.00603.x

A B S T R A C T

Introduction. Yoga is a popular form of complementary and alternative treatment. It is practiced both in developingand developed countries. Use of yoga for various bodily ailments is recommended in ancient ayvurvedic (ayus = life,veda = knowledge) texts and is being increasingly investigated scientically. Many patients and yoga protagonistsclaim that it is useful in sexual disorders. We are interested in knowing if it works for patients with prematureejaculation (PE) and in comparing its efcacy with uoxetine, a known treatment option for PE.Aim. To know if yoga could be tried as a treatment option in PE and to compare it with uoxetine.Methods. A total of 68 patients (38 yoga group; 30 uoxetine group) attending the outpatient department ofpsychiatry of a tertiary care hospital were enrolled in the present study. Both subjective and objective assessment toolswere administered to evaluate the efcacy of the yoga and uoxetine in PE. Three patients dropped out of the studyciting their inability to cope up with the yoga schedule as the reason.Main Outcome Measure. Intravaginal ejaculatory latencies in yoga group and uoxetine control groups.Results. We found that all 38 patients (2565.7% = good, 1334.2% = fair) belonging to yoga and 25 out of 30 of theuoxetine group (82.3%) had statistically signicant improvement in PE.Conclusions. Yoga appears to be a feasible, safe, effective and acceptable nonpharmacological option for PE. Morestudies involving larger patients could be carried out to establish its utility in this condition. Dhikav V, KarmarkarG, Gupta M, and Anand KS. Yoga in premature ejaculation: A comparative trial with fluoxetine. J Sex Med2007;4:17261732.

Key Words. Premature Ejaculation; Yoga; Fluoxetine; Nonpharmacological Treatment; Complementary and Alter-native Treatments

Introduction

Premature ejaculation (PE) is the mostcommon sexual disorder of young males.Normative data suggest that men with an intra-vaginal ejaculatory latency time of less than1 minute have denite PE, while men withintravaginal ejaculatory latency times of between1.0 and 1.5 minutes have probable PE [1].Prevalence rates of 2030% have been reported[2].

PE is generally dened as the occurrence ofejaculation prior to the wishes of both sexual part-ners. This broad denition, thus, avoids specifyinga precise duration for sexual relations and reachinga climax.

An occasional instance of PE may not be causefor concern, but if the problem occurs with morethan 50% of attempted sexual relations, a dysfunc-tional pattern should be suspected and appropriatediagnostic and therapeutic measures must beinitiated.

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A number of treatment options are used for PE.Although selective serotonin reuptake inhibitors(SSRIs) have the potential to improve the qualityof life for men with PE and their partners [35],patients satisfaction and drug side effects mayremain to be a problem. New treatments aretherefore desirable. Because the condition hasstigma and patients may not be aware that medicaltreatment options are available, nonpharmacologi-cal treatment options seem preferable.

Yoga is a popular nonpharmacological inter-vention. There are many types of yoga: hathayoga is an element of raja yoga and deals mainlywith physical postures and breathing. Karma yogaemphasizes spiritual practice to help the indi-vidual unify body, mind, and heart throughcertain practices in daily life and work. Bhaktiyoga, a devotional form, generally encompasseschanting, reading of scriptures and worship prac-tices. We focused mainly on hatha yoga byvarious asanas. An asana is a particular posture ofthe body, which is both steady and comfortable.In yoga, there are more than a hundred classicalposes, and these probably have as many varia-tions. These can be subdivided into two catego-ries: active and passive. Active poses are supposedto tone specic muscle and nerve groups, andbenet organs and the endocrine glands. Thepassive poses are employed primarily in medita-tion, relaxation, and pranayama practices. Weemployed both active and passive poses duringthe present study (see Figure 1).

Each posture, or asana, is held for a period oftime and is synchronized with the breath. Gen-erally, a yoga session begins with gentle asanasand works up to the more vigorous or challeng-ing postures. A full yoga session includes exer-cises of every part of the body, pranayama(prana = life; breath control practices), relaxation,and meditation.

Yoga is a popular nonpharmacological treatmentmethod for a number of conditions, and there areclaims of it being effective in bodily disordersincluding the sexual ones; we thought it worthwhileto investigate its efcacy and to compare it to u-oxetine, a commonly used SSRI for PE.

Materials and Methods

We studied 68 patients (Table 1) attending theoutpatient department of a tertiary care psychiatrichospital in North Delhi. A detailed history of eachpatient was taken. A general physical examinationof all systems was performed. After establishing

the diagnosis using Diagnostic and StatisticalManual IV, the patients were offered to choosebetween pharmacological (capsule uoxetineuoxetine group) and nonpharmacological (yogayoga group) treatments. Three patients opted outof the study citing inability to adhere to the yogaregime. Because these opted out of the yoga groupbefore the study began, we did not include them inthe nal analysis.

The wives of the patients were briefed aboutstarting the stopwatch once the penetration beganand then to stop it once the husbands ejaculated.They was asked to note down the intra-ejaculatorylatencies in seconds in a diary.

Those who opted for drugs were given uoxet-ine capsule (group 1) in dose of 2060 mg/day as asingle dose, while for those who opted for yoga(group 2) the protocol was explained (Table 2).The patients were encouraged to report any sideeffects occurring during the course of treatment inboth groups.

Patients included in the study had PE, wereuoxetine nave, had no history of trauma, dia-betes, hypertension, or any other chronic physi-cal or mental disorder. There was no history ofsubstance abuse. The patients were not on anyconcurrent medications and had unremarkablegeneral physical examinations. The mean age ofonset of PE was 28 years and the mean durationwas 1.7 1.5 years.

The patients were briefed by a sexologist and ayoga expert about the protocol they had to followover 12 weeks (Tables 2 and 3). They were told topractice 12 asnas and 2 pranayanams for 1 hour/day.The patients were examined after 4 and 8 weeks,respectively. Their intravaginal ejaculatory laten-cies were noted and analyzed.

Although the average suggested duration was 1hour, it was not rigidly xed, and the patients weretold to practice yogasanas depending upon theirstamina. This was because in yoga, the advice gen-erally given was that the patients should not exertthemselves. Three repetitions of each asana weresuggested. Differential relaxation was taught to thepatients once they nished their daily yoga proto-col with a breathing technique called as anulom-vilom (breathing via alternative nostrils) and

Table 1 Demographic data38 cases Mean age = 38.9 10.1 years30 controls Mean age = 38.6 9.2 years

Total number = 68; age range = 2258 years; mean duration of prematureejaculation = 1.7 1.5 years.

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shavasan (Sanskritshav = a dead body, lyingdead). That means in the end, the patients per-formed breathing as mentioned and laid still forfew minutes. In this, they were able to relax thosemuscles, which were stretched during yoga. Thatis why this is named as differential relaxation. Allpatients were told to practice mehabhed mudra,which included doing perineal and pubococcygeal

exercises for 1015 seconds at a time and for 1520times a day. They could do it anywhere includingat their workplace, while, e.g., traveling, reading,or watching TV.

Statistical AnalysisStatistical analysis was performed using SPSSversion 10 (SPSS Inc., Chicago, IL, USA). Paired

A

C

F

I

J

K

G H

D E

B

Figure 1 Various yoga postures employed during the study (figures run from A to K from top left).

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t-test was used to calculate the P value. A P value ofless than 0.05 was considered signicant.

Results

We found that all 38 patients in the yoga grouphad subjective (Table 4) and statistically signicant(P < 0.0001) improvement (Table 5). Twenty-veof 30 patients of uoxetine (82.3%) had clinicalimprovement in PE (Table 5, P < 0.001). Thepatients were interviewed at the end of the 4th and8th weeks. Results in both groups at the 4th weekdid not achieve statistical signicance, while thoseof the 8th week were signicant (P < 0.001seeTable 5). A subjective evaluation was carried out byasking the wife to rate the husbands performanceand her satisfaction after the end of the studyperiod (Table 4). A side-effect prole of uoxetinebased upon patients reporting adverse effects wasprepared (Table 6). None of the side effects,however, required drug discontinuation.

Yoga was well tolerated by patients who choseto enroll themselves for this form of treatment.There were no signicant side effects or dropoutsreported during the course of treatment.

Discussion

PE is an extremely common disorder affectingyoung males. SSRI, like uoxetine, is a commonlyused treatment option for PE [6,7]. AlthoughSSRIs offer several advantages like convenienceof administration and acceptable therapeuticresponse, they have disadvantages like failure inmany patients and unacceptable side effects.Moreover, drug prescription requires a visit to asexologist or psychiatrist, an idea with which manypatients of PE may not be fully comfortable. Thisis due to stigma with PE. It has been said that mostpatients remain unaware that PE is a medical con-dition. A nonpharmacological treatment option inPE should, thus, presumably be a welcome idea.

Table 2 Yogasanas followed in the protocolKapal bhati Sanskritkapal = skull, bhati = bright; forehead brightenerVajarasan Sanskritvajra = diamondYog mudra Yog = after Yogis, mudra = posture; symbol of yogaBhujangasan Sanskritbhujang = snake, asana = posture; serpent-like postureDhanurasan Sanskritdhanu = bow, asana = posture; to adopt a bow-like posturePaschimottoansana Sanskritpaschim = working on posteriorGomukasan Sanskritgomukh = cows mouthVeerasan A typical sitting posture of soldiersArdhmatsyendra mudra Sanskritardha = half, matsyenddra = name of a yogic practitioner, mudra = posture;

half spinal twisting exercisesViparita karani mudra Sanskritviprit = opposite, mudra = posture; legs-up-the-wall poseSarvang Asana Shoulder standHalasan Plow postureMehabhed mudra Sanskritgreat secretAgnisar mudra Sanskritagni = heat; a series of rapid abdominal lifts

Table 3 Brief description of yogasanas used in the present study1. Kapalbhati (Figure 1A)Sit straight in squatting posture with eyes closed. Put hands on the knees. Fix the chest and consciously

contract abdominal muscles.2. Pranayama (Figure 1B)Sit comfortably with eyes closed in squatting posture. Deep breathing should be done via alternating

nostrils as shown.3. Yog mudra (Figure 1C)Take hands to the lower back. Catch the right wrist with the left palm and bend forward.4. Vajarasan (Figure 1D)Fold legs at knee joints and sit on the legs, and touch knee caps as shown.5. Bhujangasan (Figure 1E)Lie down in prone position and transfer weight on palms. Attempt should be made to stretch the back

muscles.6. Dhanurasan (Figure 1F)Body gets a bow-like shape.7. Halasan (Figure 1G)Lie down flat; then, turn legs overhead while maintaining hands on the ground firmly.8. Paschimottoasana (Figure 1H)Sit with legs straight, touch toes, and try to bend the head forward and kiss the toes.9. Ardhmatsyendra mudra (Figure 1I)Sit straight, bend right knee, and put it below buttocks. Now cross the left leg and bring it in

front of the right knee.10. Sarvang asana (Figure 1J)Lie down straight and gradually lift legs. Then, once adequate lift is achieved; support pelvis and lower

back with the palms of both hands.11. Shava asana (Figure 1K)It involves lying relaxed, eyes closed with arms placed on both sides of the body. It relaxes muscles that

are stretched during yogic exercises. In practical terms, this means a posture in which patients lay still with superior and inferiorextremities asunder and perform slow deep breathing with a relaxed mind.

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An online medical dictionary denes yoga asa way of life that includes ethical precepts,dietary prescriptions, and physical exercise. Alarge survey shows that about one in every veadults has used at least one such therapy in thelast 1 year [8].

Pranayama is the method of proper breathing.The way we breathe is supposed to have an effecton the nervous system. By regulating the breathand increasing oxygenation to the brain cells, it issupposed to strengthen the voluntary and invol-untary nervous systems. At the beginning of eachof yoga, pranayama practice is performed in orderto prepare patients for the asanas that follow.

The present study is an attempt to explore thetherapeutic potential of yoga as a nonpharmaco-logical treatment in PE and to compare it to u-oxetine, a known treatment option. Fluoxetinehad a response rate of 83.3%, which is in agree-ment with some of the previously reportedstudies [9,10]. Although uoxetine generally pro-duces symptomatic improvement at the end of 3weeks, results of the present study suggest thatimprovement may not be noticeable until theend of 8 weeks, with yoga. Thus, relatively lateimprovement can be an important limitation ofthe present study. It could, however, be compen-sated somewhat by some form of counseling. Anadditional limitation is that the patients were

given the option of choosing between yoga anduoxetine, hence introducing a selection bias.Three patients chose not to participate in thepresent study because of their inability to adhereto yoga regime.

Although we do not know an exact mechanismby which yoga is useful in PE, several postulationscould be made about its putative mechanisms ofusefulness. Yogasanas and breathing exercises havelong been considered in obtaining the optimummental and physical health state. Yoga couldperhaps be causing better anxiety control. Thisassertion is supported by several studies [1114].One of these studies [11] included 175 patients (98males, 77 females) between age group 1976 yearswho belonged to the heterogenous group. Thestudy evaluated anxiety scores using the State TraitAnxiety Inventory and showed that scores dippedsignicantly after yogic exercises. The same studyshowed that a measurable decline in anxiety scorescould be achieved as early as within 10 days if thepatients adopt healthy lifestyle interventions con-sisting mainly of asanas, pranayama and relaxationtechniques [11]. Others have reported that yogapromotes well-being, improves quality of life [12],and has an antidepressant effect [13]. Additionalmechanisms contributing to a state of calm alert-ness include increased parasympathetic drive,calming of stress response systems, neuroendo-crine release of hormones, and thalamic genera-tors [13]. Relaxation induced by meditation helpsto stabilize the autonomic nervous system with atendency toward parasympathetic dominance.Physiological benets, which follow, may helppractitioners become more resilient to stressfulconditions and may reduce a variety of importantrisk factors for various diseases, especially cardio-respiratory diseases [14]. Two published clinicaltrials in obsessive compulsive disorder, an anxietydisorder using a specic form of yoga known askundalini yoga, have been described. This is a formof yogic exercise consisting of yogic kriyas, mantrachanting, following a particular dietary pattern,etc. [15]. A recent meta-analysis, however, hasconcluded that although results of studies involv-ing yoga were positive, the methodology adoptedwas poor; hence, deriving conclusions were dif-cult. It emphasized the need of future well-designed studies in this regard [16].

The yogasanas selected in the present study, inaddition to their general putative health benets,were primarily aimed at improving the muscletone and plasticity of the pelvic and perinealmuscles. Asanas supposedly improve blood ow to

Table 4 Subjective responses of patients with yoga(n = 38)Satisfaction type Number Percentage

Good 25 65.8%Fair 13 34.2%Poor 0 0%

Table 5 Intravaginal ejaculatory latencies of variousstudy groups*Group Before After t value df P value

1 29.9 15.1 64.1 29.4 5.65 58

these muscles and thus aid in their better contrac-tion. This is probably responsible for local effect ofyogasanas in the present study. Studies have shownthat yoga can improve muscular efciency [17,18].In one such study [17], 42 volunteers were takenand their oxygen utilization during yogic and con-ventional exercises were studied. The study con-cluded that a yogic practitioner is likely to performbetter on tasks such as cycling at average pace,walking at average speed, and tailoring, etc.Decreased fatigue and increased endurance wereshown in another study after 6 months of trainingin yogic exercises [18].

It has been observed that a regular practitionerof yoga shows parasympathetic dominance [11].Stimulation of the sympathetic nerves causescontraction of epididymis, ejaculatory ducts, andseminal vesicles, and leads to ejaculation of semen.Increasing parasympathetic stimulation is assum-ably benecial in enhancing ejaculatory control.We report a signicant therapeutic effect of yogain PE. This is in line with earlier studies, whichhave reported the efcacy of yogic exercises in thetreatment of physical disorders [1315].

What are the potential advantages of yoga as atreatment option in PE? It is popular with goodacceptability, nonpharmacological, has no costsinvolved, and patients could be treated withoutmedical or psychiatric intervention. Additionally,it could offer other associated health benets aswell to the patients [19,20]. Studies have shownthat yogic exercises can reduce basal cortisol, cat-echolamines, metabolic rate, sympathetic activity,and oxygen consumption. Parasympathetic activityhas been shown to increase [20].

Physical efciency, autonomic functions, bodyexibility, and biochemical prole have been notedto improve following yogasnas [19]. A study involv-ing 48 Indian soldiers found that performance onisometeric exercises was better after yoga trainingas measured by electromyography and springpulling capacity [19].

Yogic exercises have been found to be useful ina variety of mindbody problems. PE is oftenperceived as a lifestyle problem [21], thus provid-ing a window for such therapeutic interventions.Studies have shown that sufferers of PE havehigher prevalence of lifestyle problems that canaffect the individual at both emotional and physi-cal levels.

Nonpharmacological treatment options, e.g.,behavioral therapy and psychotherapy, have longbeen the mainstay of the treatment of PE [22].These could be cumbersome and can have limited

efcacy indicating that other nonpharmacologicaltreatments could be desirable. Although yoga wasfound to be a well-tolerated and effective treat-ment option for PE, the therapeutic response wasdelayed by 8 weeks. This is in contrast to SSRIs,which produce symptomatic relief by the 3rd or4th week. Some form of counseling on the part ofthe physician and patience on part of patients maybe required for satisfactory results.

The etiology of PE is multifactorial; hence,failure to appreciate this makes the diagnosis dif-cult and the treatment harder. Therefore, treat-ment of PE is undergoing change in recent timesand it is suggested that an integrated approachshould be adopted [23]. This combination therapyhas become more relevant as patients relapse [23]frequently after taking drugs and has side effectslike dry mouth, nausea, drowsiness, and reducedlibido. Its use may also facilitate the developmentof other sexual dysfunctions, such as anejaculationand erectile dysfunction [24]. Furthermore, it hasbeen considered that because PE involves bothpsychosocial [25] and physiological components[26], both should be addressed. It is hoped thatsuch a combination approach would result in pro-longed ejaculatory latency, improved treatmentsatisfaction, and superior long-term outcome. Wehave tried to explore the possibility of yoga as anonpharmacological treatment in PE. This isbecause, as stated earlier [22], nonpharmacologicaltreatments have been important treatment optionsin this condition. A signicant therapeutic benetof yoga is reported in the study.

Conclusions

PE is the most common male sexual disorder thatis both underdetected and undertreated. It is oftendistressing and patients do not come forward fortreatment easily. This is due to shyness, stigma,feeling of inferiority, and shame in front of thepartner. Yoga seems to be a well-tolerated, safe andeffective nonpharmacological treatment option forPE. The present study reinforces that the mindbody interventions could be benecial in stress-related mental and physical disorders. Becauseours is a pilot study with a small sample size, itwould be worthwhile to do more studies involvinga large number of patients in a double-blindmanner to establish yoga as a nonpharmacologicaltreatment option for PE.

Corresponding Author: Vikas Dhikav, Dr. RML Hos-pital and PGIMER, GGS-IP UniversityNeurology,

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E\3, Flat Number-280 Sector-18, Delhi Rohini110085, India. Tel: +91-9910011205; Fax: 011-26865165; E-mail: vikasdhikav@hotmail.com,va212001@yahoo.com

Conict of Interest: None declared.

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