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Received: 16 August 2019    Revised: 3 October 2019    Accepted: 14 October 2019

DOI: 10.1111/and.13473

ORIGINAL ARTICLE

The efficacy of regular penis‐root masturbation, versus Kegel

exercise in the treatment of primary premature ejaculation: A
quasi‐randomised controlled trial

Mingyang Jiang1 | Guanqiang Yan2 | Huachu Deng2 | Hao Liang2 | Yunni Lin2 |

Xun Zhang1

1
Department of Andrology, The First
Affiliated Hospital of Guangxi Medical
University, Nanning, China
2
Guangxi Medical University, Nanning, China
Correspondence
Xun Zhang, Department of Andrology, The
First Affiliated Hospital of Guangxi Medical
University, Nanning, Guangxi, China.
Email: drrzhangxun@126.com
Abstract
To explore the efficacy of regular penis‐root masturbation (PRM) versus Kegel exer‐
cise (KE) in the treatment of primary premature ejaculation (PPE). This study was a
prospective quasi‐randomised controlled trial. Thirty‐seven heterosexual males with
PPE were selected according to the time sequence of outpatient consultations and
the preliminary results of a pre‐experiment and were assigned to an PRM group and a
KE group. Differences in intravaginal ejaculatory latency times (IELTs) and premature
ejaculation diagnostic tool (PEDT) scores were compared between the two groups.
The study was approved by the Ethics Committee of the First Affiliated Hospital of
Guangxi Medical University. Among the 37 PPE patients, 18 performed PRM and 19
patients performed KE. The IELTs of patients who performed PRM and KE were sig‐
nificantly prolonged before treatment, and the difference after treatment was statis‐
tically significant (p < .05). Compared with the KE group, the IELT prolongation effect
in the PRM group was more significant PRM (p < .05). The PEDT scores of patients
after performing PRM and KE were significantly lower than those before performing
these exercises (p < .05). Compared with the KE group, the PEDT scores of the PRM
group exhibited a greater decrease (p < .05). Thus, both PRM and KE have therapeutic
effects on PPE. Compared with KE, PRM is more effective in the treatment of PPE.

KEYWORDS
Kegel exercise, primary premature ejaculation, RCT, regular penis‐root masturbation

1 |  I NTRO D U C TI O N premature ejaculation. Compared with healthy males, PE patients

Premature ejaculation (PE) is the most common sexual dys‐
function in males. In 2014, the International Society of Medical
Sciences (ISSM) updated the definition of PE (Althof et al., 2014).
The prevalence of PE is estimated to be 20%–30% accord‐
ing to the definition of the American Diagnostic and Statistical
Manual of Mental Disorders (DSM‐IV; Laumann, Paik, & Rosen,
1998) and the updated version of the International Society of
Sexual Medicine's Guidelines for the diagnosis and treatment of
have less sexual function and satisfaction as well as more psycho‐
logical disorders and interpersonal relationship difficulties, and
their partners' satisfaction with sexual relationships decreases as
the condition worsens. Treatment for PE may involve a range of
interventions, including systemic medications (such as selective
serotonin reuptake inhibitors [SSRI], tricyclic antidepressants,
phosphodiesterase type 5 inhibitors and analgesics; Smits et al.,
2007), local anaesthetics or sprays, and behavioural therapies
(BTs; Swenson et al., 2015). Among them, selective serotonin

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https://doi.org/10.1111/and.13473
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2 of 6       JIANG et al.
reuptake inhibitors are commonly used drugs. Lifelong PE may be
due to dysfunction of the serotonin pathway of the central sys‐
tem, and SSRI and serotonin agonists can increase the intravaginal
ejaculation latency time (IELT), resulting in a significant benefit
of SSRIs for PE treatment. However, due to the side effects of
these drugs, patient compliance is low (Kilinc, Aydogmus, Yildiz, &
Doluoglu, 2018; Yildiz, Kilinc, & Doluoglu, 2018).
Behaviour therapy and psychotherapy for PE include two
major types of overlapping treatments (Althof et al., 2014). The
first category includes sexual counselling aimed at addressing
the psychological and interpersonal conflicts that cause PE. The
second category includes behavioural therapy, which helps men
develop sexual skills, delay ejaculation and increase sexual self‐
confidence. Common behavioural treatments include the follow‐
ing methods. (a) The “stop‐start” technique, introduced by Simon,
which involves a man or his partner stimulating the penis until
he feels the urge to ejaculate and then stopping until the feeling
disappears. This requires several repetitions to allow ejaculation
(Hidetoshi, 2011). The goal is to learn to recognise the sensation
of impending ejaculation to improve the control of ejaculation.
(b) According to the related “squeeze” technique proposed by
Masters and Johnson, the man's partner stimulates the penis until
he feels the urge to ejaculate and then squeezes the glans of the
penis until the feeling disappears. After several repetitions, he can
ejaculate. The man and his partner first focus on an area outside
of the genitals, excluding the breasts, and sexual intercourse, to
encourage physical sensation and reduce performance anxiety.
Then, genital contact is gradually introduced, and finally, complete
sexual intercourse occurs (Mcmahon et al., 2010). (c) Pelvic floor
muscle rehabilitation training also helps to control ejaculation
(Pastore et al., 2012).
The purpose of this study was to select primary premature ejacu‐
lation (PPE) patients from a clinic to undergo guided penis‐root mas‐
turbation (PRM; Ma, Zou, Lai, Zhang, & Zhang, 2019) and observe the
improvement of vaginal ejaculation latency after 3 months of practice
as well as to compare the efficacy of PRM and Kegel exercise (KE). The
study aimed to provide a new method of treatment for PE.
2 |  M E TH O DS
This trial was carried out according to CONSORT‐revised 2010
guidelines. The trial programme protocol was approved by the
Ethics Committee of the First Affiliated Hospital of Guangxi Medical
University (KY‐E‐069) and registered with the Chinese Clinical Trial
Registry (ChiCTR1900024896). We began recruiting patients in
August 2019. The authors confirm that all related interventions were
registered.
2.1 | Research object
Primary premature ejaculation patients were enrolled accord‐
ing to the order of outpatient visits and the preliminary results of
a pre‐experiment (i.e., patients for whom ejaculation occurred too
quickly after the beginning of sexual intercourse, ejaculation within
the vagina occurred in <1 min, ejaculation could not be controlled
and ejaculation could not be controlled with any sexual partner
under any condition).
2.2 | Inclusion criteria
(a) Men with PPE, including those with rapid initial ejaculation, lack
of control of ejaculation and vaginal ejaculation within <1 min; (b)
Men in a stable heterosexual relationship with sexual partners who
supported the research methods involved in the study; (c) Men with
a duration of PPE longer than 1 year; (d) Men with good compliance
who could receive weekly WeChat follow‐up guidance and undergo
monthly clinical visits.
2.3 | Exclusion criteria
(a) Secondary premature ejaculation (SPE), including acquired PE,
men previously able to achieve sufficient ejaculation time control,
those with vaginal ejaculation occurring in <3 min, men who re‐
ported distressed, troubled, or frustrated feelings and/or those
who avoided sexual intimacy; (b) Homosexual patients or those
with behaviours such as exhibitionism, voyeurism, fetishism and
cross dressing. Such patients typically lack excitement for het‐
erosexual vaginal intercourse, often because of forced fertility
treatment after complaining of PE, and require further psycho‐
logical behavioural counselling or treatment; (c) Patients with a
poor relationship with their sexual partner, which could affect
the performance and implementation of treatment; (d) PPE com‐
bined with erectile dysfunction; (e) PPE combined with obvious
organ disease that may be related to the condition, such as PPE
combined with hypogonadism; and (f) Patients with severe schizo‐
phrenia, anxiety, depression or other neurological symptoms or
poor compliance.
2.4 | Collection of clinical data
We collected the patient's name, age, duration of the disease and
record the intravaginal ejaculation latency time (IELT) and the pre‐
mature ejaculation diagnostic tool (PEDT) score before and after
treatment.
2.5 | Diagnostic criteria
2.5.1 | Diagnostic criteria of the IELT
Waldinger and other scholars introduced the concept of intra‐
vaginal ejaculatory latency (IELT) in 1994, which is the time from
the insertion of the penis into the vagina until the male begins to
ejaculate. The diagnosis of PE can be relatively objectively quanti‐
fied by measuring the IELT, which is the basis for clinical research
in PE.
JIANG et al.
F I G U R E 1   Flow chart
2.5.2 | Diagnostic criteria of the PEDT
The PEDT score measures the following five items: (a) difficulty in
delaying ejaculation; (b) ejaculation before the patient intends; (c)
ejaculation with little stimulation; (d) frustration associated with PE;
and (e) couples' opinions about ejaculation. The retest reliability of
the PEDT was, and all items were significantly different between PE
patients and non‐PE patients based on a diagnostic cutoff score.
2.6 | Statistical analysis
Statistical analysis was performed with the statistical software
IBM SPSS STATISTICS 25.0. First, the data were tested for normal‐
ity and homogeneity of variance. In this trial, the sample size was
limited, the data were not normally distributed and the variance
was not uniform. Therefore, we used the Wilcoxon signed‐rank
test to calculate the differences in IELT and PEDT scores before
and after treatment. The Mann–Whitney U test was used to com‐
pare the differences in the IELT and PEDT scores before and after
treatment between the two groups.
3 | R E S U LT S
3.1 | Overall results
This study was a prospective quasi‐randomised clinical trial that in‐
cluded PPE patients based on the time sequence of outpatient visits
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and the preliminary results of a pre‐experiment. A total of 48 pa‐
tients were contacted, and four were excluded. Among the 44 PPE
patients, 22 patients were assigned to the PRM group, and 22 pa‐
tients were assigned to the KE group. After 3 months of follow‐up,
37 patients completed the trial; of those, 18 practiced PRM and 19
practiced KE as shown in Figure 1. The baseline characteristics are
shown in Table 1. Before treatment, patients who were diagnosed
with PPE according to their medical history and related examinations
were given education and guidance on PRM skills and medication
methods. WeChat communication was established with patients,
and follow‐up was performed once per week. Patients who were in‐
cluded in the trial were asked to visit the clinic once per month until
the end of treatment.
3.2 | Comparison of the IELT before and
after treatment
The median IELT of subjects before performing KE was 1 min, and
the median IELT of these subjects after performing KE was 2 min.
The Wilcoxon signed‐rank test results showed that the IELT of pa‐
tients after treatment was significantly longer than that before KE
treatment (Z = −3.384, p = .001).
The median IELT of subjects before performing PRM was 1 min,
and the median IELT of the subjects after treatment was 5 min. The
Wilcoxon signed‐rank test results showed that the IELT of patients
after treatment was significantly longer than that before performing
PRM (Z = −3.744, p < .001).
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TA B L E 1   Baseline demographic data (mean ± SD) of primary TA B L E 3   Premature ejaculation diagnostic tool (PEDT) during
premature ejaculation patients at all stages of a quasi‐randomised the study
trial
  PRM KE Z p‐Value
  PRM KE p‐Value
PEDT
Number of patients 18 19   Pre‐treatment 16 (2) 17 (2) −0.872 .383
Age (year) 31.39 ± 8.39 29.58 ± 5.75 .164 Post‐treatment 10 (2) 15 (4) −4.395 <.001
Course of disease 11.5 ± 7.23 10.16 ± 5.68 .308 Z −3.744 −3.539    
(month)
p‐Value <.001 <.001    
Course of treat‐ 2.89 ± 0.32 2.68 ± 0.75 .017
ment (month) Difference value −6 (2) −2 (3) −4.472 <.001

Abbreviation: KE, Kegel exercise; PRM, penis‐root masturbation. Abbreviation: KE, Kegel exercise; PRM, penis‐root masturbation.

neuropathological disorders, genes and genetics. We found that a

The Mann–Whitney U test results showed that the IELT prolon‐ portion of patients complaining of nonejaculation in clinical visits
gation effect was more significant in the PRM group than in the KE had a history of masturbation in a prone position. By changing the
group. The difference in IELT between PRM group and KE group was method of masturbation, nonejaculation can be partially reversed.
statistical significance (Z = −4.388, p < .001) as shown in Table 2. Further observations revealed that the prone position masturbation
method can significantly prolong the IELT. Based on this method, we
have developed a new PRM method (Ma et al., 2019).
3.3 | Comparison of PEDT scores before and
The dorsal nerve of the penis root is a sensory nerve that is es‐
after treatment
sential for normal erection and ejaculation (Šedý, Naňka, Špačková,
The median PEDT score of subjects before performing KE was 17, & Jarolím, 2010). Frequent stimulation of the dorsal nerve branches
and the median PEDT score of these subjects after KE treatment was of the penis root can reduce penile sensitivity and central excitabil‐
15. The Wilcoxon signed‐rank test results showed that the PEDT ity to a certain extent, which may help to improve the ejaculation
score of patients after performing KE was significantly lower than threshold and prolong the IETL, thereby effectively treating PE
that before treatment (Z = −3.539, p < .001). (Althof et al., 2010).
The median PEDT score of subjects before performing PRM was The steps for PRM are as follows. One or both thumbs are placed
16, and the median PEDT score of the subjects after PRM treat‐ on the back of the penis root (within one to three of the penis), and
ment was 10. The Wilcoxon signed‐rank test results showed that the penis root is massaged in a circular motion or along the proximal
the PEDT score of patients after performing PRM was significantly end so that the patient experiences sexual pleasure and maintains
lower than that before treatment (Z = −3.744, p < .001). an erection. When the patient feels that they are about to ejaculate,
The results of Mann–Whitney U test showed that the PEDT score stimulation should be stopped immediately. When the feeling sub‐
of the PRM group was significantly lower than that of KE group. The sides, stimulation is continued. During the training, the partner is
difference in PEDT score between PRM group and KE group was allowed to touch and kiss the patient and provide audiovisual stimu‐
statistically significant (Z = −4.472, p < .001), as shown in Table 3. lation. PRM requires 10–15 min. Ejaculation and vaginal intercourse
are allowed after training. The training is conducted three times a
week for a period of 3 months and can be completed by the patient
4 |  D I S CU S S I O N or his partner.
The steps of traditional KE are as follows: (a) at 1 hr after eating,
Recent studies have shown that sexual problems in male patients the patient first empties their bladder and then rests in a supine posi‐
are associated with physical diseases such as metabolic syndrome, tion with a comfortable soft cushion for the head while relaxing their
whole body and mentally concentrating. (b) The feet of the patient
TA B L E 2   Intravaginal ejaculatory latency times (IELT) during the are separated by a shoulder width with the legs bent, and breath‐
study ing remains deep and slow. During inhalation, the muscles should
  PRM KE Z p‐Value be contracted in the anus, and then, the urethra is contracted, sim‐
ilar to the movement of urine. The muscles of the pelvic floor are
IELT
then lifted. Contraction is continued for 3–5 s, and then, the patient
Pre‐treatment 1 (1) 1 (1) −0.233 .816
slowly relaxes as they exhale. As many pelvic floor muscles as possi‐
Post‐treatment 5 (2) 2 (2) −3.559 <.001
ble should be exercised to avoid contraction of the thighs, buttocks
Z −3.744 −3.384    
and muscles. Contraction and relaxation of the pelvic floor muscles
p‐Value <.001 .001     are alternated rhythmically. This should be practiced three times a
Difference value 3 (2) 1 (2) −4.388 <.001 day with 50–100 repetitions each time. Urination should be per‐
Abbreviation: KE, Kegel exercise; PRM, penis‐root masturbation. formed after practice.
JIANG et al.
A recent study evaluated 10 randomised controlled trials (RCTs)
of behaviourally treated PE patients. Four studies suggested that
behavioural therapy can prolong the IELT compared with a control
group. Two studies suggested that behavioural therapy was not ef‐
fective. Four other studies suggested that traditional behavioural
therapy combined with drug therapy was less effective but could
significantly improve the IELT (0.5 min). This evidence revealed that
behavioural therapy could extend the ejaculation latency and that
combination therapy achieved better results than therapy without
drug treatment. However, more RCTs are needed to evaluate the
psychological treatment of PE (Abu & Abdelhamed, 2017; Cooper
et al., 2015; Park, Park, & Moon, 2015). Studies have shown that
approximately 30% of PE patients treated with paroxetine choose to
discontinue the treatment after a relatively short time, and approx‐
imately 20% of people refuse to start medical treatment (Salonia et
al., 2009). Furthermore, 90% of PE patients choose to discontinue
treatment within 1 year (Mondaini et al., 2013). Drug treatment
compliance is not high. Reasons for discontinuation of medication
include the cost of the drug, unsatisfactory efficacy and the need
to take the drug before sexual intercourse. Psychosocial treatment
interventions were once the first‐line treatment option for PE, and
the stop–start technique that Semans (1956) first described and sub‐
sequently used multiple variants of is arguably the most common
treatment. However, a meta‐analysis of psychosocial treatment in‐
tervention studies of PE showed that the results were not sustained.
In particular, for long‐term treatment, the meta‐analysis indicated
that the initial treatment was successful, but relapse occurred at
3 years after treatment (Corona et al., 2017; Glina et al., 2010).
The potential clinical significance of this study is as follows. (a)
Our study systematically proposed PRM for the first time, and the
steps of this new behavioural treatment are easy to implement. (b)
This is the first study to compare the efficacy of PRM and KE in
the treatment of PPE. (c) In the course of the study, no side effects
were observed in the two groups. Compared with drug therapy with
psychosocial intervention therapy, this method has an advantage
because drug side effects are one of the main reasons that patients
stop treatment.
The study had the following limitations. (a) The number of sub‐
jects was small, and some patients were lost to follow‐up or with‐
drew during the follow‐up; (b) Some patients were followed up for
<3 months, which may lead to bias in the results; (c) Differences
in geography, customs, social life, background, economic develop‐
ment and educational level may lead to differences in follow‐up
results, which may lead to potential bias in the results; (d) Since
the patient is not hospitalised, there is no method of monitoring
whether the patient is regularly performing PRM or KE, using
other drugs or undergoing psychosocial intervention, which may
make the results unreliable; (e) The test conditions were lim‐
ited, and only patients' IELT and PEDT scores could be collected.
However, IELT measurement and the PEDT score need to be as‐
sessed through sexual intercourse, and the patient's understand‐
ing of sexual knowledge, as well as the position, physical state,
and mental and psychological factors during sexual intercourse
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will have great influences. The patient's marital relationship and
their partner's cooperation are also factors that are beyond the
control of the study; (f) We could not follow‐up the two groups
after 3 months; therefore, we cannot determine whether there
is a need for continuous training to maintain progress. This issue
is important because it is necessary to assess whether follow‐up
medication or psychosocial intervention are needed; (g) Smoking,
drinking and organic diseases all affect the ejaculation latency of
patients. However, considering that PE patients are generally out‐
patients who do not undergo hospitalisation and follow‐up is dif‐
ficult, we cannot comprehensively complete the medical records;
(h) According to Waldinger, Zwinderman, Olivier, and Schweitzer
(2008), the geometric mean should be used for all studies because
some measurements may be more strongly influenced by outliers.
However, since our sample size was relatively small and was not a
skewed distribution, we used the arithmetic mean.
In summary, the above results need to be further confirmed by
large‐scale, multi‐centre, controlled trials including patients with
different age groups, education and income levels and regions of
residence.
5 | CO N C LU S I O N S
Both PRM and KE have therapeutic effects on PPE. Compared with
KE, PRM is more effective in the treatment of PPE.
AC K N OW L E D G E M E N T S
This work was supported by the First Affiliated Hospital of Guangxi
Medical University.
C O N FL I C T O F I N T E R E S T
All authors declared no competing interests.
AU T H O R C O N T R I B U T I O N S
X.Z. designed the clinical trial. M.J. and G.Y. collected data and per‐
formed data analysis. M.J., G.Y., H.L. and Y.L. wrote the manuscript.
All authors read and approved the final manuscript.
ORCID
Xun Zhang  https://orcid.org/0000-0002-1001-7522
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How to cite this article: Jiang M, Yan G, Deng H, Liang H, Lin
Y, Zhang X. The efficacy of regular penis‐root masturbation,
versus Kegel exercise in the treatment of primary premature
ejaculation: A quasi‐randomised controlled trial. Andrologia.
2019;00:e13473. https​://doi.org/10.1111/and.13473​