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Guide: Premature Ejaculation

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  • Definition
  • Diagnosis
  • Presentation and taking a history
  • Sexual history
  • Medical history
  • Physical examination and investigations
  • Management
  • Pharmacological treatment
  • Reduction of penile sensation
  • Behavioural techniques
  • Counselling
  • Referral
  • References

  • Definition

    Several imprecise definitions of premature ejaculation (PE) exist. The most recent definition, developed by the International Society for Sexual Medicine (ISSM), is based on clearly definable criteria (Althof, 2014):

    • Ejaculation that always or nearly always occurs prior to or within about 1 minute of vaginal penetration from the first sexual experience (lifelong PE)


    OR

    • A clinically significant reduction in intra-vaginal ejaculatory latency time (IELT), often to about 3 minutes or less (acquired PE)


    AND

    • The inability to delay ejaculation on all or nearly all vaginal penetrations


    AND

    • Negative personal consequences, such as distress, bother, frustration, and/or the avoidance of sexual intimacy.


    Ejaculation occurring prior to vaginal penetration (ante-portal ejaculation) is the most severe form of PE, typically presenting in men or couples having difficulty conceiving.

    Diagnosis

    Diagnosis is based on the patient’s medical and sexual history. PE is classified as either primary (lifelong) or secondary (acquired):

    Primary (lifelong) PE

    • Tends to present in men in their 20s and 30s
    • Patient has never had control of ejaculation
    • Underlying disease unlikely to be present


    Secondary (acquired) PE

    • Tends to present in older men
    • Patient was previously able to control ejaculation
    • Commonly associated with erectile dysfunction or other underlying disease

    ISSM has proposed further diagnostic categories for men who present with distressing ejaculatory problems but who do not fall within the above criteria:

    • Variable PE - short IELT that occurs irregularly and inconsistently with perception of diminished control of ejaculation. Considered a normal variation in sexual performance
    • Subjective PE – characterised by one or more of the following:
      • Perceived short IELT or lack of control over the timing of ejaculation
      • IELT in the normal range or even longer duration (i.e., after 5 minutes)
      • Diminished ability to control ejaculation (i.e., to withhold ejaculation at the moment of imminent ejaculation)
      • Other pre-occupations that cannot be explained by a mental disorder

    ISSM recommended treatments for VPE and SPE focus on reassurance, education, psychotherapy and behavioral therapy.

    Presentation and taking a history

    PE may be identified when the man or his partner presents with relationship or sexual difficulties. Establish sexual and medical histories as a first step (Andrology Australia 2014, Palmer 2008).

    Sexual history

    • Establish IELT - ask the man or his partner to estimate or use a stopwatch
    • Onset and duration of PE
    • Precipitating factors (sexual education, masturbation guilt, religious or cultural inhibitions)
    • Previous sexual function
    • Frequency of sexual relations (infrequent sexual activity can be a factor)
    • Perceived degree of ejaculatory control
    • Degree of patient/partner distress
    • Determine if fertility is an issue
    • Distinguish PE from erectile dysfunction

    Other factors that may have an influence:

    • Novelty of the partner or sexual situation
    • Depression, anxiety, stressors
    • Taboos or beliefs about sex


    Medical history

    • General medical history
    • Cardiovascular history
    • Medications (prescription and non prescription)
    • Trauma (urogenital, neurological, surgical)
    • Infections – including STDs

    In older men with secondary PE (especially if secondary to erectile dysfunction), investigate risk factors-

    • Cardiovascular disease
    • Hypertension
    • Hyperlipidaemia
    • Diabetes
    • Obesity
    • Obstructive sleep apnoea
    • Peyronie’s disease
    • Lower urinary tract symptoms (urethritis or prostatitis)
    • Hyperthyroidism (uncommon)
    • Endocrine dysfunction, especially gynaecomastia

    Common causes of secondary PE (Althof 2014)

    • Erectile dysfunction (ED) – Rapid ejaculation becomes a compensatory mechanism for many men with declining erectile function. Patients may confuse PE and erectile dysfunction where they are unable to achieve a second erection after ejaculation, or because they rush intercourse to prevent loss of their erection. High levels of anxiety related to their ED may worsen any PE symptoms. However, PE and ED may occur independently as co-morbid conditions in some men.
    • Prostatitis – prostatic inflammations and chronic bacterial prostatitis are common findings in men with secondary PE. Physical and microbiological examination is recommended in men with painful ejaculation, or prostatic pain, but routine screening for prostate disorder in all men with PE is not supported by the evidence.
    • Psychological factors – psychological or interpersonal factors may cause or exacerbate PE. The problem may be circular – for example, performance anxiety may lead to PE, which in turn worsens the original performance anxiety.


    Physical examination and investigations (Palmer 2008)

    • Physical examination is rarely needed in younger patients with primary PE. Routine laboratory or neurophysiological tests should be carried out only if indicated by specific findings from the history or physical examination.
    • If investigating suspected secondary PE, it is important to perform a general medical examination as well as a genital examination, including neurological assessment of the genital area and a penile and testicular examination. Check gait, muscle strength, sacral reflex arc, S2-S4 and general reflexes.
    • If PE occurs with painful ejaculation, a rectal examination should also be conducted to determine presence of prostatic inflammation.


    Management

    Management involves both the patient and his partner and therapeutic options should suit both partners. Control over ejaculation and satisfaction with sexual intercourse are the central issues for men with PE and should be the highest priority when assessing PE and evaluating treatment for this condition. Before beginning treatment, it is essential to discuss the patient's expectations thoroughly.

    Management of PE is guided by the underlying cause (Andrology Australia 2014).

    Primary PE:

    • 1st line: SSRIs, reduction of penile sensation
    • 2nd line: Behavioural techniques, counselling
    • Most men require ongoing treatment to maintain normal function

    Secondary PE:

    If secondary to ED, investigate and manage the underlying cause of the ED. Treatment of ED with PDE5 inhibitors is effective.

    • 1st line: Behavioural techniques, counselling
    • 2nd line: SSRI, reducing penile sensation
    • Many men return to normal function following treatment


    Pharmacological treatment

    The most effective and well-tolerated treatment for primary PE is pharmacological therapy with SSRIs, usually given in small doses on a daily basis. Dapoxetine hydrochloride (30mg, taken 1-3 hours before intercourse) is the only SSRI specifically approved for treatment of PE in Australia (TGA), with trials demonstrating ≥ 50% increase in IELT (McCarty 2012). The following alternative regimens have been reported (Andrology Australia 2014):

    • Fluoxetine hydrochloride: 20 mg/day
    • Paroxetine hydrochloride: 20 mg/day.
    • Sertraline hydrochloride: 50 mg/day or 100 mg/day.
    • Clomipramine hydrochloride: 25-50 mg/day or 25 mg 4-24 hours before intercourse.
    • PDE-5 Inhibitors (if PE is related to ED):30-60 minutes pre-intercourse.

    Start with low doses and titrate upwards. Trial for 3-6 months and then slowly titrate down to cessation. If PE reoccurs, resume treatment with the same drug. Trial an alternative drug if first choice is not effective.

    Take into account the following when prescribing pharmacotherapy (Palmer 2008):

    • Time to onset of action and effect on spontaneity of intercourse – paroxetine and sertraline have a slow onset (5 hours) and long half-life, making them less suitable for on-demand use, and need to be taken daily to maintain efficacy. Paroxetine (the first SSRI developed specifically to treat PE) is rapidly absorbed with a short half-life, and can be taken on demand (MJA). Daily treatments may have less effect on spontaneity than pre-intercourse dosing – be guided by patient preference and sexual habits.
    • Side effects, particularly with higher dose tricyclic anti-depressants eg., clomipramine 50mg/day. Commonly reported side effects include dry mouth, constipation, nausea, sleep disturbances, fatigue, dizziness and hot flushes. Titrate carefully upwards from low starting doses to minimize side effects.


    Reduction of penile sensation (Andrology Australia 2014)

    • Topical applications: Local anaesthetic gels or creams can diminish sensitivity and delay ejaculation. Excess use is associated with loss of pleasure, orgasm and erection. Apply 30 minutes prior to intercourse. Anaesthetic – containing condoms are available to prevent trans-vaginal absorption.
    • Lignocaine ointment: 5% - apply 20-30 minutes before intercourse
    • Lignocaine spray: 10%
    • Double condoms: Using 2 condoms can diminish sensitivity and delay ejaculation.

    The above regimens may be combined for maximum effectiveness. Anaesthetic agents may cause penile numbness, leading to loss of the erection. Creams may cause local symptoms of irritation and burning.


    Behavioural techniques

    The ‘stop-start’ technique:

    • Sexual stimulation until just before orgasm – patient recognises their ‘point of no return’ in order to learn to control the sensations prior to ejaculation.
    • Stop and rest for about 30 seconds then resume. Repeat if necessary, then continue stimulation until orgasm.

    The "squeeze" method:

    • Sexual stimulation until just before orgasm to lessen the urge to ejaculate. At that point, the man or his partner gently squeezes the end of the penis (where the glans meets the shaft) for several seconds. Stop sexual stimulation for about 30 seconds, then repeat. The last time, continue stimulation until orgasm.

    Other techniques/strategies (Althof 2014):

    • Extended foreplay
    • Pre-intercourse masturbation
    • Cognitive distractions
    • Alternate sexual positions
    • Interval sex
    • Increased frequency of sex


    Counselling

    Psychological problems are usually a consequence of PE rather than the cause, although the link can be reciprocal. The main psychological presentation is anxiety (Hatzimouratidis 2015).

    • It is important to address the issue that has created the anxiety or psychogenic cause.
    • Limited studies indicate that behavioural therapy, as well as functional sexological treatment, lead to improvement in the duration of intercourse and sexual satisfaction. However, the evidence for the effectiveness of psychological interventions for the treatment of premature ejaculation is weak and inconsistent (Melnik 2011).
    • Techniques to improve ejaculatory control, including meditation/relaxation, hypnotherapy and neuro-biofeedback may be helpful.


    Referral

    General practitioners should be able to diagnose, offer support, and prescribe behavioral exercises for men suffering from PE. When the situation is complex, there are co-morbidities or patients do not respond to the initial intervention, consider referral:

    • General referral: endocrinologist or urologist
    • If lower urinary tract disease: Urologist
    • If hormonal problem: Endocrinologist
    • Psychosexual issues; Counsellor, psychologist, psychiatrist or sexual therapist
    • Fertility issues: fertility specialist


    References

    1. Althof, E, McMahon CG, Waldinger MD, et al. An update of the International Society of Sexual Medicine’s guidelines for the diagnosis and treatment of premature ejaculation (PE). Sex Med 2014;2:60–90
    2. Andrology Australia. Premature ejaculation and other ejaculatory disorders – diagnosis and management. Clinical summary guide 8. 2007, updated February 2014.
    3. Palmer NR, Stuckey BGA. Premature ejaculation: a clinical update MJA 2008; 188: 662–666
    4. McCarty E, Dinsmore W. Dapoxetine: an evidence-based review of its effectiveness in treatment of premature ejaculation. Core Evidence 2012;7:1–14
    5. Hatzimouratidis K, Eardley I, Giuliano F, et al. Guidelines on male sexual dysfunction: erectile dysfunction and premature ejaculation. European Association of Urology 2015
    6. Melnik T, Althof S, Atallah ÁN, et al. Psychosocial interventions for premature ejaculation (Review). Cochrane Database of Systematic Reviews 2011, DOI: 10.1002/14651858.CD008195.pub2.