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ORIGINAL RESEARCHEJACULATORY DISORDERS


Yoga in Premature Ejaculation: A Comparative Trial
with Fluoxetine
Vikas Dhikav, MD,* Girish Karmarkar, MBBS, MD, Mallika Gupta, MBBS,* and
Kuljeet Singh Anand, DM
*All India Institute of Medical Sciences, New Delhi, India; Private Practice, Thane-Mumbai, India; Dr. RML Hospital and
Post Graduate Institute of Medical Education and Research-Guru Gobind Singh-Inderprastha UniversityNeurology,
Delhi, India
DOI: 10.1111/j.1743-6109.2007.00603.x

ABSTRACT

Introduction. Yoga is a popular form of complementary and alternative treatment. It is practiced both in developing
and 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 protagonists
claim that it is useful in sexual disorders. We are interested in knowing if it works for patients with premature
ejaculation (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 of
psychiatry of a tertiary care hospital were enrolled in the present study. Both subjective and objective assessment tools
were administered to evaluate the efcacy of the yoga and uoxetine in PE. Three patients dropped out of the study
citing 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 the
uoxetine group (82.3%) had statistically signicant improvement in PE.
Conclusions. Yoga appears to be a feasible, safe, effective and acceptable nonpharmacological option for PE. More
studies involving larger patients could be carried out to establish its utility in this condition. Dhikav V, Karmarkar
G, Gupta M, and Anand KS. Yoga in premature ejaculation: A comparative trial with fluoxetine. J Sex Med
2007;4:17261732.
Key Words. Premature Ejaculation; Yoga; Fluoxetine; Nonpharmacological Treatment; Complementary and Alternative Treatments

Introduction

remature ejaculation (PE) is the most


common sexual disorder of young males.
Normative data suggest that men with an intravaginal ejaculatory latency time of less than
1 minute have denite PE, while men with
intravaginal ejaculatory latency times of between
1.0 and 1.5 minutes have probable PE [1].
Prevalence rates of 2030% have been reported
[2].

J Sex Med 2007;4:17261732

PE is generally dened as the occurrence of


ejaculation prior to the wishes of both sexual partners. This broad denition, thus, avoids specifying
a precise duration for sexual relations and reaching
a climax.
An occasional instance of PE may not be cause
for concern, but if the problem occurs with more
than 50% of attempted sexual relations, a dysfunctional pattern should be suspected and appropriate
diagnostic and therapeutic measures must be
initiated.
2007 International Society for Sexual Medicine

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Yoga in Premature Ejaculation


A number of treatment options are used for PE.
Although selective serotonin reuptake inhibitors
(SSRIs) have the potential to improve the quality
of life for men with PE and their partners [35],
patients satisfaction and drug side effects may
remain to be a problem. New treatments are
therefore desirable. Because the condition has
stigma and patients may not be aware that medical
treatment options are available, nonpharmacological treatment options seem preferable.
Yoga is a popular nonpharmacological intervention. There are many types of yoga: hatha
yoga is an element of raja yoga and deals mainly
with physical postures and breathing. Karma yoga
emphasizes spiritual practice to help the individual unify body, mind, and heart through
certain practices in daily life and work. Bhakti
yoga, a devotional form, generally encompasses
chanting, reading of scriptures and worship practices. We focused mainly on hatha yoga by
various asanas. An asana is a particular posture of
the body, which is both steady and comfortable.
In yoga, there are more than a hundred classical
poses, and these probably have as many variations. These can be subdivided into two categories: active and passive. Active poses are supposed
to tone specic muscle and nerve groups, and
benet organs and the endocrine glands. The
passive poses are employed primarily in meditation, relaxation, and pranayama practices. We
employed both active and passive poses during
the present study (see Figure 1).
Each posture, or asana, is held for a period of
time and is synchronized with the breath. Generally, a yoga session begins with gentle asanas
and works up to the more vigorous or challenging postures. A full yoga session includes exercises of every part of the body, pranayama
(prana = life; breath control practices), relaxation,
and meditation.
Yoga is a popular nonpharmacological treatment
method for a number of conditions, and there are
claims of it being effective in bodily disorders
including the sexual ones; we thought it worthwhile
to investigate its efcacy and to compare it to uoxetine, a commonly used SSRI for PE.
Materials and Methods

We studied 68 patients (Table 1) attending the


outpatient department of a tertiary care psychiatric
hospital in North Delhi. A detailed history of each
patient was taken. A general physical examination
of all systems was performed. After establishing

Table 1
38 cases
30 controls

Demographic data
Mean age = 38.9 10.1 years
Mean age = 38.6 9.2 years

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

the diagnosis using Diagnostic and Statistical


Manual IV, the patients were offered to choose
between pharmacological (capsule uoxetine
uoxetine group) and nonpharmacological (yoga
yoga group) treatments. Three patients opted out
of the study citing inability to adhere to the yoga
regime. Because these opted out of the yoga group
before the study began, we did not include them in
the nal analysis.
The wives of the patients were briefed about
starting the stopwatch once the penetration began
and then to stop it once the husbands ejaculated.
They was asked to note down the intra-ejaculatory
latencies in seconds in a diary.
Those who opted for drugs were given uoxetine capsule (group 1) in dose of 2060 mg/day as a
single dose, while for those who opted for yoga
(group 2) the protocol was explained (Table 2).
The patients were encouraged to report any side
effects occurring during the course of treatment in
both groups.
Patients included in the study had PE, were
uoxetine nave, had no history of trauma, diabetes, hypertension, or any other chronic physical or mental disorder. There was no history of
substance abuse. The patients were not on any
concurrent medications and had unremarkable
general physical examinations. The mean age of
onset of PE was 28 years and the mean duration
was 1.7 1.5 years.
The patients were briefed by a sexologist and a
yoga expert about the protocol they had to follow
over 12 weeks (Tables 2 and 3). They were told to
practice 12 asnas and 2 pranayanams for 1 hour/day.
The patients were examined after 4 and 8 weeks,
respectively. Their intravaginal ejaculatory latencies were noted and analyzed.
Although the average suggested duration was 1
hour, it was not rigidly xed, and the patients were
told to practice yogasanas depending upon their
stamina. This was because in yoga, the advice generally given was that the patients should not exert
themselves. Three repetitions of each asana were
suggested. Differential relaxation was taught to the
patients once they nished their daily yoga protocol with a breathing technique called as anulomvilom (breathing via alternative nostrils) and
J Sex Med 2007;4:17261732

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Dhikav et al.

J
I
K

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

shavasan (Sanskritshav = a dead body, lying


dead). That means in the end, the patients performed breathing as mentioned and laid still for
few minutes. In this, they were able to relax those
muscles, which were stretched during yoga. That
is why this is named as differential relaxation. All
patients were told to practice mehabhed mudra,
which included doing perineal and pubococcygeal
J Sex Med 2007;4:17261732

exercises for 1015 seconds at a time and for 1520


times a day. They could do it anywhere including
at their workplace, while, e.g., traveling, reading,
or watching TV.

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

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Yoga in Premature Ejaculation


Table 2

Yogasanas followed in the protocol

Kapal bhati
Vajarasan
Yog mudra
Bhujangasan
Dhanurasan
Paschimottoansana
Gomukasan
Veerasan
Ardhmatsyendra mudra
Viparita karani mudra
Sarvang Asana
Halasan
Mehabhed mudra
Agnisar mudra

Sanskritkapal = skull, bhati = bright; forehead brightener


Sanskritvajra = diamond
Yog = after Yogis, mudra = posture; symbol of yoga
Sanskritbhujang = snake, asana = posture; serpent-like posture
Sanskritdhanu = bow, asana = posture; to adopt a bow-like posture
Sanskritpaschim = working on posterior
Sanskritgomukh = cows mouth
A typical sitting posture of soldiers
Sanskritardha = half, matsyenddra = name of a yogic practitioner, mudra = posture;
half spinal twisting exercises
Sanskritviprit = opposite, mudra = posture; legs-up-the-wall pose
Shoulder stand
Plow posture
Sanskritgreat secret
Sanskritagni = heat; a series of rapid abdominal lifts

t-test was used to calculate the P value. A P value of


less than 0.05 was considered signicant.
Results

We found that all 38 patients in the yoga group


had subjective (Table 4) and statistically signicant
(P < 0.0001) improvement (Table 5). Twenty-ve
of 30 patients of uoxetine (82.3%) had clinical
improvement in PE (Table 5, P < 0.001). The
patients were interviewed at the end of the 4th and
8th weeks. Results in both groups at the 4th week
did not achieve statistical signicance, while those
of the 8th week were signicant (P < 0.001see
Table 5). A subjective evaluation was carried out by
asking the wife to rate the husbands performance
and her satisfaction after the end of the study
period (Table 4). A side-effect prole of uoxetine
based upon patients reporting adverse effects was
prepared (Table 6). None of the side effects,
however, required drug discontinuation.
Table 3

Yoga was well tolerated by patients who chose


to enroll themselves for this form of treatment.
There were no signicant side effects or dropouts
reported during the course of treatment.
Discussion

PE is an extremely common disorder affecting


young males. SSRI, like uoxetine, is a commonly
used treatment option for PE [6,7]. Although
SSRIs offer several advantages like convenience
of administration and acceptable therapeutic
response, they have disadvantages like failure in
many patients and unacceptable side effects.
Moreover, drug prescription requires a visit to a
sexologist or psychiatrist, an idea with which many
patients of PE may not be fully comfortable. This
is due to stigma with PE. It has been said that most
patients remain unaware that PE is a medical condition. A nonpharmacological treatment option in
PE should, thus, presumably be a welcome idea.

Brief description of yogasanas used in the present study

1. 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 inferior
extremities asunder and perform slow deep breathing with a relaxed mind.

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Dhikav et al.

Table 4 Subjective responses of patients with yoga


(n = 38)
Satisfaction type

Number

Percentage

Good
Fair
Poor

25
13
0

65.8%
34.2%
0%

An online medical dictionary denes yoga as


a way of life that includes ethical precepts,
dietary prescriptions, and physical exercise. A
large survey shows that about one in every ve
adults has used at least one such therapy in the
last 1 year [8].
Pranayama is the method of proper breathing.
The way we breathe is supposed to have an effect
on the nervous system. By regulating the breath
and increasing oxygenation to the brain cells, it is
supposed to strengthen the voluntary and involuntary nervous systems. At the beginning of each
of yoga, pranayama practice is performed in order
to prepare patients for the asanas that follow.
The present study is an attempt to explore the
therapeutic potential of yoga as a nonpharmacological treatment in PE and to compare it to uoxetine, a known treatment option. Fluoxetine
had a response rate of 83.3%, which is in agreement with some of the previously reported
studies [9,10]. Although uoxetine generally produces symptomatic improvement at the end of 3
weeks, results of the present study suggest that
improvement may not be noticeable until the
end of 8 weeks, with yoga. Thus, relatively late
improvement can be an important limitation of
the present study. It could, however, be compensated somewhat by some form of counseling. An
additional limitation is that the patients were
Table 5 Intravaginal ejaculatory latencies of various
study groups*
Group

Before

After

t value

df

P value

1
2

29.9 15.1
33.2 17.9

64.1 29.4
112.8 35.6

5.65
12.29

58
74

<0.0001
<0.0001

*Scores are expressed as mean standard deviation.

Table 6 Adverse effects of fluoxetine in the present


study (N = 30)
Adverse drug reaction

Number of patients (N)

Percentage (%)

Nausea
Vomiting
Anxiety
Insomnia

14
4
4
8

46.6
13.3
13.3
26.6

J Sex Med 2007;4:17261732

given the option of choosing between yoga and


uoxetine, hence introducing a selection bias.
Three patients chose not to participate in the
present study because of their inability to adhere
to yoga regime.
Although we do not know an exact mechanism
by which yoga is useful in PE, several postulations
could be made about its putative mechanisms of
usefulness. Yogasanas and breathing exercises have
long been considered in obtaining the optimum
mental and physical health state. Yoga could
perhaps be causing better anxiety control. This
assertion is supported by several studies [1114].
One of these studies [11] included 175 patients (98
males, 77 females) between age group 1976 years
who belonged to the heterogenous group. The
study evaluated anxiety scores using the State Trait
Anxiety Inventory and showed that scores dipped
signicantly after yogic exercises. The same study
showed that a measurable decline in anxiety scores
could be achieved as early as within 10 days if the
patients adopt healthy lifestyle interventions consisting mainly of asanas, pranayama and relaxation
techniques [11]. Others have reported that yoga
promotes well-being, improves quality of life [12],
and has an antidepressant effect [13]. Additional
mechanisms contributing to a state of calm alertness include increased parasympathetic drive,
calming of stress response systems, neuroendocrine release of hormones, and thalamic generators [13]. Relaxation induced by meditation helps
to stabilize the autonomic nervous system with a
tendency toward parasympathetic dominance.
Physiological benets, which follow, may help
practitioners become more resilient to stressful
conditions and may reduce a variety of important
risk factors for various diseases, especially cardiorespiratory diseases [14]. Two published clinical
trials in obsessive compulsive disorder, an anxiety
disorder using a specic form of yoga known as
kundalini yoga, have been described. This is a form
of yogic exercise consisting of yogic kriyas, mantra
chanting, following a particular dietary pattern,
etc. [15]. A recent meta-analysis, however, has
concluded that although results of studies involving yoga were positive, the methodology adopted
was poor; hence, deriving conclusions were difcult. It emphasized the need of future welldesigned studies in this regard [16].
The yogasanas selected in the present study, in
addition to their general putative health benets,
were primarily aimed at improving the muscle
tone and plasticity of the pelvic and perineal
muscles. Asanas supposedly improve blood ow to

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these muscles and thus aid in their better contraction. This is probably responsible for local effect of
yogasanas in the present study. Studies have shown
that yoga can improve muscular efciency [17,18].
In one such study [17], 42 volunteers were taken
and their oxygen utilization during yogic and conventional exercises were studied. The study concluded that a yogic practitioner is likely to perform
better on tasks such as cycling at average pace,
walking at average speed, and tailoring, etc.
Decreased fatigue and increased endurance were
shown in another study after 6 months of training
in yogic exercises [18].
It has been observed that a regular practitioner
of yoga shows parasympathetic dominance [11].
Stimulation of the sympathetic nerves causes
contraction of epididymis, ejaculatory ducts, and
seminal vesicles, and leads to ejaculation of semen.
Increasing parasympathetic stimulation is assumably benecial in enhancing ejaculatory control.
We report a signicant therapeutic effect of yoga
in PE. This is in line with earlier studies, which
have reported the efcacy of yogic exercises in the
treatment of physical disorders [1315].
What are the potential advantages of yoga as a
treatment option in PE? It is popular with good
acceptability, nonpharmacological, has no costs
involved, and patients could be treated without
medical or psychiatric intervention. Additionally,
it could offer other associated health benets as
well to the patients [19,20]. Studies have shown
that yogic exercises can reduce basal cortisol, catecholamines, metabolic rate, sympathetic activity,
and oxygen consumption. Parasympathetic activity
has been shown to increase [20].
Physical efciency, autonomic functions, body
exibility, and biochemical prole have been noted
to improve following yogasnas [19]. A study involving 48 Indian soldiers found that performance on
isometeric exercises was better after yoga training
as measured by electromyography and spring
pulling capacity [19].
Yogic exercises have been found to be useful in
a variety of mindbody problems. PE is often
perceived as a lifestyle problem [21], thus providing a window for such therapeutic interventions.
Studies have shown that sufferers of PE have
higher prevalence of lifestyle problems that can
affect the individual at both emotional and physical levels.
Nonpharmacological treatment options, e.g.,
behavioral therapy and psychotherapy, have long
been the mainstay of the treatment of PE [22].
These could be cumbersome and can have limited

efcacy indicating that other nonpharmacological


treatments could be desirable. Although yoga was
found to be a well-tolerated and effective treatment option for PE, the therapeutic response was
delayed by 8 weeks. This is in contrast to SSRIs,
which produce symptomatic relief by the 3rd or
4th week. Some form of counseling on the part of
the physician and patience on part of patients may
be required for satisfactory results.
The etiology of PE is multifactorial; hence,
failure to appreciate this makes the diagnosis difcult and the treatment harder. Therefore, treatment of PE is undergoing change in recent times
and it is suggested that an integrated approach
should be adopted [23]. This combination therapy
has become more relevant as patients relapse [23]
frequently after taking drugs and has side effects
like dry mouth, nausea, drowsiness, and reduced
libido. Its use may also facilitate the development
of other sexual dysfunctions, such as anejaculation
and erectile dysfunction [24]. Furthermore, it has
been considered that because PE involves both
psychosocial [25] and physiological components
[26], both should be addressed. It is hoped that
such a combination approach would result in prolonged ejaculatory latency, improved treatment
satisfaction, and superior long-term outcome. We
have tried to explore the possibility of yoga as a
nonpharmacological treatment in PE. This is
because, as stated earlier [22], nonpharmacological
treatments have been important treatment options
in this condition. A signicant therapeutic benet
of yoga is reported in the study.
Conclusions

PE is the most common male sexual disorder that


is both underdetected and undertreated. It is often
distressing and patients do not come forward for
treatment easily. This is due to shyness, stigma,
feeling of inferiority, and shame in front of the
partner. Yoga seems to be a well-tolerated, safe and
effective nonpharmacological treatment option for
PE. The present study reinforces that the mind
body interventions could be benecial in stressrelated mental and physical disorders. Because
ours is a pilot study with a small sample size, it
would be worthwhile to do more studies involving
a large number of patients in a double-blind
manner to establish yoga as a nonpharmacological
treatment option for PE.
Corresponding Author: Vikas Dhikav, Dr. RML Hospital and PGIMER, GGS-IP UniversityNeurology,
J Sex Med 2007;4:17261732

1732
E\3, Flat Number-280 Sector-18, Delhi Rohini
110085, India. Tel: +91-9910011205; Fax: 01126865165;
E-mail:
vikasdhikav@hotmail.com,
va212001@yahoo.com
Conict of Interest: None declared.

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