Premature ejaculation

What is premature ejaculation?

The definition for premature ejaculation has been debated over the years but many experts in the field currently rely on the International Society for Sexual Medicine (ISSM) definition which identifies the following criteria, updated in 2013¹ :

• Premature ejaculation which always or nearly always occurs prior to or within about one minute of vaginal penetration from the first sexual experience (lifelong premature ejaculation), OR, a clinically significant reduction in latency time, often to about three minutes or less (acquired premature ejaculation); 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.

This definition incorporates both lifelong and acquired premature ejaculation but only applies to vaginal intercourse, as the committee felt there was not the evidence to extend the definition to other situations or groups.

Other definitions exist but all essentially rely on the three common factors of short ejaculatory latency, lack of ability to delay ejaculation, and negative consequences for the individual and/or their partner.

Epidemiology^{2 3}

• The prevalence of premature ejaculation varies according to definition and is difficult to assess in view of many men not wanting to seek help or even discuss the problem.

• The estimated prevalence is likely to be around 1-3% of men, although some studies have reported it to be up to 30%.

Risk factors

The aetiology and pathophysiology of premature ejaculation are poorly understood. Data about many of the following possible risk factors are sparse and unconvincing.

• Genetic predisposition.

• Obesity.

• Poor general health.

• Emotional problems and stress.

• History of traumatic sexual experiences.

• Medication and recreational drugs. Possible causes include amfetamine, cocaine and dopaminergic medication.

• Prostatitis.

• Neurological causes - eg, multiple sclerosis, peripheral neuropathies.

• Thyroid disorder.

• Varicocele.

• Erectile dysfunction.

Assessment²

History should include:

• An estimate of intravaginal ejaculation latency time.

• Perceived control.

• Degree of distress.

• Impact on sexual activity and relationship and quality of life.

Two questionnaires are available for the assessment of premature ejaculation - the Premature Ejaculation Diagnostic Tool (PEDT) and the Arabic Index of Premature Ejaculation (AIPE).

Examination may be indicated to exclude endocrine, urological or neurological conditions which may be relevant. Further investigation is not routinely indicated, unless suggested by findings on history and/or examination.

Premature ejaculation treatment and management^{1 3}

Premature ejaculation management should be tailored to the needs of the individual. Premature ejaculation may be more of an issue in some relationships than in others and patient expectation should be explored. Psychosexual counselling may be sufficient.

General advice

• More frequent sex (or masturbation): premature ejaculation is more likely if there is a longer gap between sexual intercourse.

• Using a condom may decrease sensation.

• Sex with the woman on top reduces the likelihood of premature ejaculation.

• Squeeze and stop-go techniques: stimulating the penis almost to the point of ejaculation and then stopping. These techniques are often effective but may take a few months to produce any benefit and relapse is common..

• Behavioural treatments are useful for secondary premature ejaculation but are not recommended first-line for lifelong premature ejaculation. They are time-intensive and require commitment from the partner.

• Where present, treat erectile dysfunction and/or prostatitis first.

• Reviews suggest that pharmacological therapy is most effective, particularly for lifelong premature ejaculation.

Pharmacological therapy

• Selective serotonin reuptake inhibitor (SSRI) antidepressants are commonly used off-label but need to be taken daily, as it takes one to two weeks for the effect to be achieved. Paroxetine, fluoxetine, citalopram, escitalopram and sertraline have all been shown to be effective⁴ . The serotonin-noradrenaline reuptake inhibitor (SNRI) duloxetine is also effective. On-demand treatment with clomipramine may be a suitable alternative.

• Dapoxetine - a short-acting SSRI which has been specifically developed for the treatment of premature ejaculation - has been shown to be effective and is approved for use in the UK⁵ . It is taken as required, one to three hours before anticipated sexual activity⁶ . It is not recommended for men over the age of 65.

• Anaesthetic creams may be effective. Options with evidence of efficacy are EMLA® cream and lidocaine gel⁷ . Aerosol sprays are proving popular and novel preparations are being developed but are not available on the NHS. Topical preparations may be the preferred therapy for some patients⁸ .

• Tramadol has been found to have beneficial effect in the treatment of premature ejaculation and may be used "on-demand". The most common adverse effect was sleep disturbance⁹ . Due to its potential for addiction, it is not routinely recommended.

• Phosphodiesterase type 5 (PDE5) inhibitors may be helpful in some cases, although the evidence for this is limited. There is some evidence that a combination of sildenafil with SSRI is better than SSRI monotherapy. It may be that the PDE5 inhibitor allows a second erection within a short space of time with subsequent improvement in intravaginal ejaculatory latency time (IELT)¹⁰ .

Psychosexual therapy¹¹

The evidence base for the effectiveness of psychological interventions is limited for premature ejaculation treatment. Psychological therapy needs compliance from the partner and is time-consuming, expensive and less effective than pharmacotherapy, and its efficiency decreases with time. It is however the first-line therapy in patients with subjective premature ejaculation or where there are underlying psychological problems. Psychotherapy is effective in managing psychological distress. Methods like meditation/relaxation, hypnotherapy and neuro-biofeedback help improve ejaculatory control. .

Surgery

One study reported that a short frenulum was found in 43% of individuals affected by lifelong premature ejaculation. Frenulectomy was effective in relieving the problem and the authors recommended excluding short frenulum in all patients with lifelong premature ejaculation¹² . This option is not reflected in any of the available guidelines.

Complications

Premature ejaculation may have a significant adverse effect on both self-confidence and the relationship. One study reported that premature ejaculation can lead to sexual dissatisfaction, a feeling that something is missing from the relationship and an impaired sense of intimacy. If the premature ejaculation remains untreated it can lead to increased irritability, interpersonal difficulties and deepening of an emotional divide¹³ . Studies report as well as the detrimental effect on sexual function and relationships, premature ejaculation may lead to reduced quality of life, mental distress, anxiety and depression² .