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Premature Ejaculation (PE) : Definition, Causes, & Treatment

Premature Ejaculation (PE) : Definition, Etiology, Signs, Symptoms, Diagnosis, Management, & Prevention

Definition

  • Premature ejaculation refers to the inability to delay ejaculation sufficiently to enjoy love making, manifest as either occurrence of ejaculation before or very soon after vaginal entry (if a time limit is required: before or within 15 s of vaginal entry), or ejaculation in absence of sufficient erection to make vaginal entry possible.
  • Not due to prolonged abstinence of sexual activity.

Etiology

  1. Psychiatric conditions e.g. depression
  2. Medical conditions

Types

1. Lifelong premature ejaculation

  • Early ejaculation exists from the first (or nearly first) sexual experiences, usually starting in puberty or adolescence.
  • It occurs with every (or nearly every) female partner in most of events of intercourse.
  • Prevalence: 2-3%
  • Intravaginal ejaculation latency time (IELT): Very short (<1 min)
  • Ejaculation time: 30-60 sec i.e. ejaculation occurs within 30–60 s after vaginal penetration with nearly every coitus in most cases.
  • Complains: Very short IELTs and/or easily triggered (early) erections and immediate complete detumescence of the penis after ejaculation.
  • Neurobiologically and genetically induced ejaculatory disorder.
  • Treatment:

 

Oral medication and/or topical anesthetics x very long time

+

Psycho-education & counselling in case of psychological and/or relationship problems

  • Complications: Irritability, annoyance, embarrassment, a decreased feeling of masculinity and sometimes depression.

2. Acquired premature ejaculation

  • Men experience early ejaculations at some point in their life having previously had normal ejaculation experiences.
  • Prevalence: 4-5%
  • Onset: Either sudden or gradual.
  • IELT: 1-3 min.
  • Causes: As a  result of a medical and/or psychological disorder e.g. sexual performance anxiety, psychological or relationship problems, prostatitis, hyperthyroidism or erectile difficulties.
  • Treatment: Medical and/or psychological treatment of the underlying disorder, including temporarily oral medication and/or topical anesthetics.

3. Subjective premature ejaculation

  • Men experience or complain of early ejaculation while their ejaculation time, the IELT, is in the normal range of
    around 2–6 min and sometimes even between 5 and 25 min.
  • IELT: Normal (2-6 min or more)
  • Thus, although the semen have a normal or even long IELT duration, they still perceive themselves as having PE. As the duration of the IELT in the semen is normal, the experience of PE is not related to a medical or neurobiological disturbance.
  • There is either a misperception of the actual IELT, for various psychological reasons, or the IELT is too short for the female partner to attain an orgasm.
  • Prevalence: 5–7%
  • Treatment: Psychotherapy and/or topical anesthetics.

4. Variable premature ejaculation

  • Men experience short IELTs only sometimes and only in certain situations.
  • Variable PE is not regarded as a symptom of underlying psychopathology but of normal variation in sexual performance.
  • Prevalence: 8–11%
  • Treatment: Reassurance and education that this pattern of ejaculatory response is normal and does not require drug treatment or psychotherapy.

Diagnosis

Diagnosis of the PE type is essential for a proper treatment.

Questions to establish the PE subtype

  1. When did you first experience PE?
  2. Have you experienced early ejaculation since your first sexual intercourse?
  3. Did you experience it with most of your sexual partners?
  4. What is the time between penetration and ejaculation?
  5. How often do you have an early ejaculation with your current partner?
  6. Do you feel bothered, annoyed and/or frustrated by your early ejaculation?
  7. Is your erection hard enough to penetrate?
  8. Do you ever rush intercourse to prevent loss of erection?
  9. What is your partner opinion or attitude towards your complaint?

An approach to diagnose the PE subtypes

Management

1.  Psychotherapy, Psycho-education & counselling

2. Drug Therapy: Drug treatment is preferably combined with psycho-education, counselling and should always include information about potential drug-induced side effects.

Oral treatment: SSRI’s (Selective serotonin reuptake inhibitors): Takes around 3 weeks to show effect.

On-demand Daily (off-label)
1. Dapoxetine

  • Dose: 30–60 mg
  • Taken 1–3 h before intercourse
  • Side effects: Nausea, dizziness
1. Paroxetine hemihydrate 20 mg
2. Sertraline 50–100 mg
3. Citalopram 20 mg
4. Fluoxetine 20 mg

  • Side-effects
    On short term (first 3 weeks): Fatigue, yawning, slight nausea, perspiration, loose stools
    On long term: Increased weight, sometimes decreased libido or erectile difficulties
2. Clomipramine (off-label)

  • Dose: 20–30 mg
  • Taken 4–6 h before intercourse
  • Side effects: Nausea, dry mouth, blurred vision, constipation

Topical treatment:  Anesthetics

On-demand (off-label)
1. Cream with lidocaine and prilocaine

  • Side-effects: Erectile difficulties, numbness penis
2. Spray lidocaine

Thus, Dapoxetine is the only officially registered drug to treat PE. However, treatment may be performed
by off-label use of other SSRI’s or anesthetics.

Note: 

  • Very rarely SSRIs may cause penile anaesthesia or hypoesthesia. The patient should be informed that in case of penile anaesthesia the SSRI should be discontinued.
  • In case the patient want to stop taking an SSRI, this should occur very gradually in 4–6weeks in order to prevent the occurrence of an SSRI discontinuation syndrome.
  • In case of a wish for pregnancy, it is better to postpone SSRI treatment or to discontinue the use of an SSRI as there are some indications that SSRI treatment of a male may affect spermatozoa.

3. Squeeze therapy
4. Double sex therapy
5. Pelvic floor exercises e.g. Kegel maneuvers

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