Definition
A.Premature ejaculation (PE) is defined as the inability to control or delay ejaculation, which causes personal distress for the male. Two subtypes exist, based on intravaginal ejaculation latency time (IELT):
1.Lifelong PE is an IELT of less than 1 minute. Onset is typically from the first sexual encounter. Males have no ability to control the ejaculation.
2.Acquired PE is an IELT of less than 3 minutes. Onset is at any point in sexual history. The ability to delay ejaculation is decreased or absent.
B.Two subtypes of PE exist based on personal experience; neither is a true sexual dysfunction:
1.Variable PE is irregular and not the result of psychogenic cause. Onset is at any point in sexual history. The ability to delay ejaculation is decreased or absent.
2.Subjective PE is self-reported rapid ejaculation despite normal ejaculation time. Onset is at any point in sexual history. The ability to delay ejaculation is decreased or absent.
Incidence
A.PE is reported in approximately 21% to 31% of males. It is the most common type of sexual dysfunction. Erectile dysfunction (ED) commonly coexists.
B.Approximately 31% of men report problems with sexual function.
Pathogenesis
A.The exact cause is unknown.
B.Organic: Chronic prostatitis, hyperthyroidism, genetic disorders.
C.Psychogenic: Relationship problems, psychological preoccupation with performance.
D.Iatrogenic: Nerve damage from surgery or trauma.
Predisposing Factors
A.Depression.
B.Consumption of alcohol.
C.Obesity.
D.High blood pressure (BP).
E.High cholesterol.
F.Diabetes.
G.Smoking.
H.Depression and anxiety medication use.
Common Complaints
A.Men:
1.Inability to achieve or sustain erection.
2.Absent or delayed ejaculation.
3.Inability to control the timing of ejaculation.
B.Both sexes:
1.Lack of interest or desire (most common).
2.Inability to become aroused.
3.Pain with intercourse.
Other Signs and Symptoms
A.Diminished self-esteem.
B.Depression.
C.Anxiety.
D.ED.
E.Reduced libido.
F.Relationship difficulties.
Subjective Data
A.Include full medical history, sexual history, and psychological, social, and drug history using open-ended questions.
B.Ask:
1.Partner(s)’ sexual history.
2.Perceived ejaculatory control.
3.Estimated IELT.
4.Previous interventions used to correct the issue.
5.Impact on personal life and relationships.
6.If the issue has been lifelong or acquired.
7.If a loss of erection occurs before ejaculation, to distinguish ED from PE.
C.Screening tools:
1.The online Premature Ejaculation Diagnostic Tool (PEDT) is available at www.sexhealthmatters.org/resources/premature-ejaculation-diagnostic-tool. The PEDT is a five-item screen for PE in men.
2.The Index of Premature Ejaculation (IPE) is available at www.pfizerpatientreportedoutcomes.com/therapeutic-areas/sexual-health/male-sexual-dysfunction. The IPE is a 10-item questionnaire to assess changes in control over ejaculation, sexual satisfaction, and distress in men with PE. The questionnaires are available in several translations. Charges may apply for commercial use.
Physical Examination
A.Vital signs: Check BP, pulse, and respiration.
B.Inspect:
1.Thyroid for nodules.
2.Abdomen for surgical scars.
3.Neurologic examination for deficiencies.
4.Lower extremities for hair distribution pattern, lesions, or trauma.
5.Genitalia for abnormalities.
6.Any additional examination should be based on history and previous examination findings.
C.Palpate:
1.Thyroid for nodules.
2.Abdomen for masses or tenderness.
3.Lower extremities for pain and pulses.
4.Neurologic examination of lower extremities.
5.Genitalia for lesions, masses, or pain.
Diagnostic Tests
A.Should be based on individual history and physical findings.
Differential Diagnoses
A.ED.
B.Testosterone deficiency.
Plan
A.General interventions:
1.The treatment plan should include the patient and sexual partner.
2.The patient and partner should be educated about the possible interventions outlined as follows:
a.Both should be educated in treatment options.
b.Patient and partner satisfaction is the desired outcome.
B.Patient teaching:
1.Consider the impact of the severity of the issue on the patient, any treatable causes, and patient wishes.
2.Effectiveness of psychotherapy may diminish over time.
3.Behavioral therapy: Stop-and-start
method of ceasing genital stimulation until arousal sensation diminishes, or the squeeze
method of squeezing the glans prepuce at heightened arousal.
C.Psychotherapy: Recommended for lifelong, acquired, or variable PE, and is the first-line treatment for subjective PE.
D.Pharmaceutical therapy:
1.In 2014, the International Society of Sexual Medicine (ISSM) updated the Guideline for Premature Ejaculation with pharmacotherapy recommendations for both acquired PE and lifelong PE. Off-label medications include serotonergic tricyclic antidepressants and selective serotonin reuptake inhibitors (SSRIs). The gold standard is SSRIs including dapoxetine or paroxetine.
a.Serotonergic tricyclic antidepressants:
1.Dapoxetine 30 mg, taken as needed approximately 1 to 3 hours prior to sexual activity. The maximum recommended dosing frequency is once every 24 hours.
2.Clomipramine 25 to 50 mg/d.
b.SSRIs:
1.Paroxetine 10, 20, or 40 mg/d or 20 mg 3 to 4 hours preintercourse is the strongest among SSRIs in delaying ejaculation.
2.Fluoxetine 5 to 20 mg/d.
3.Sertraline 25 to 200 mg/d or 50 mg 4 to 8 hours preintercourse.
4.Citalopram 20 to 40 mg/d.
2.Off-label medications also include eutectic mixture of local anesthetics (EMLA).
a.Lidocaine 2.5%/prilocaine 2.5% cream: Apply to glans penis 20 to 30 minutes preintercourse.
Follow-Up
A.The patient should be seen in 2 to 4 weeks if medication was started to assess for efficacy. SSRIs typically achieve maximum effect after 1 to 2 weeks.
B.Taper to discontinue any SSRIs is required. The SSRI withdrawal syndrome is characterized by dizziness, headache, nausea, vomiting, and diarrhea and occasionally agitation, impaired concentration, vivid dreams, depersonalization, irritability, and suicidal ideation.
Consultation/Referral
A.May refer to urologist or sexual health specialist/counselor, particularly if there is provider discomfort with this topic.
B.Psychotherapy: Recommended for lifelong, acquired, or variable PE, and is the first-line treatment for subjective PE. Referral to a practitioner who specializes in sexual therapy is recommended.
Individual Considerations
A.Adults:
1.Off-label SSRIs should be used with caution for the increased risk of serotonin syndrome.
2.Off-label EMLA cream used without a condom may result in vaginal wall numbness in the sexual partner.
3.Prolonged application of EMLA may result in loss of erection if used for 30 to 45 minutes.
B.Geriatric syndrome assessments:
1.Delirium/behavioral disturbance: SSRI-related neurocognitive side effects include changes in mood, anxiety, and akathisia.
2.Falls: Consistently assess for falls. Antidepressants, alone or in combination, are highly anticholinergic, sedating, and cause orthostatic hypotension. Safety measures to reduce falls in the home include removing small area carpets, keeping night lights along the path to the bathroom, and installing a toilet seat with grab bars or nearby grab bars.
C.Pharmacologic caution in geriatrics: Renal and hepatitis dosing of paroxetine is required. Hepatic dosing of fluoxetine and sertraline is required.
D.Beers list caution: SSRIs should be used with caution in older adults. Avoid total of more than three central nervous system (CNS)-active drugs; minimize number of CNS-active drugs. (Refer to Appendix C, Table C.4.)