Premature ejaculation (PE)

Premature ejaculation is said to occur when a man reaches orgasm, and thus ejaculates, too quickly for his sexual partner to achieve enjoyment from the act of love-making

Premature ejaculation (PE) is a common and highly sensitive matter and most men avoid broaching the problem with their GP

• when PE is raised (either by the GP or the patient), a frank and supportive approach goes a long way to opening up conversation and working toward a more satisfying sex life for both the patient and their partner
  
  
• PE may be classified as lifelong (primary) or acquired (secondary)
  • lifelong PE is characterised by onset from the first sexual experience and remains a problem throughout life. Ejaculation occurs too quickly, either before vaginal penetration or <1-2 min afterwards. Acquired PE is characterised by a gradual or sudden onset, with ejaculation being normal before onset of the problem. Time to ejaculation is short but not usually as fast as in lifelong PE
    
    
• PE is a common male sexual dysfunction, with prevalence rates of 20-30% (1)
  • limited data suggest that the prevalence of lifelong PE, defined as intravaginal ejaculatory latency time (IELT) <1-2 min, is about 2-5% (1)
  • aetiology of PE is unknown, with little data to support suggested biological and psychological hypotheses, including anxiety, penile hypersensitivity, and serotonin receptor dysfunction
    • in contrast to ED, the prevalence of PE is not affected by age
    • risk factors for PE are generally unknown. PE has a detrimental effect on self-confidence and on relationship with the partner. It may cause mental distress, anxiety, embarrassment, and depression; however, most men with PE do not seek help

Assessment:

• lifelong (primary) or acquired (secondary) PE is typically diagnosed via a sexual, medical and psychological history
  
  
  • sexual history: onset and duration, ejaculatory latency time, perceived control over ejaculation, frequency of occurrence, past sexual relationships and functioning
    
    
  • medical history: general history, medications, past or current infections, past traumas
    
    
  • psychological history: guilt, inhibitions or misinformation about sex, negative sexual experiences, anxiety, depression, and the impact of PE on the patient and their partner
    
    
• a brief physical examination of the vascular, endocrine and neurologic systems may be undertaken if the patient's history suggests an underlying medical condition, such as chronic illness, genitourinary infection, Peyronie disease, endocrinopathy or autonomic neuropathy

Treatment:

• first line treatment options for the management of primary/lifelong PE include (1):
  • previously the off-label use of daily selective serotonin reuptake inhibitor (SSRI) therapy, which acts to delay ejaculation within 1-2 weeks of therapy commencement, has been used for the treatment of PE. The recommended dosages are paroxetine (20-40 mg/day), sertraline (25-200 mg/day), or fluoxetine (10-60 mg/day) (1)
    • note that a short-acting on demand SSRI has been developed (4) - dapoxetine, as the first drug developed for PE, is an effective and safe treatment for PE (4)
  • the application of topical anaesthetic to reduce penile sensitivity, eg. lidocaine-prilocaine cream (5%) applied 20-30 minutes before sexual activity. (Note: A condom must be used to avoid causing numbness in the partner) (1)
    
    
• second line treatments include behavioural and cognitive techniques - have a short term success rate of around 50-60%, but are less effective in the long term.
  • behavioural techniques are thought to be most effective when combined with pharmacotherapy. 'Stop-start' techniques involve ceasing sexual stimulation before ejaculation, and recommencing when arousal is reduced. Other behavioural techniques focus on reducing sexual stimulation by exploring sexual activities or positions that may be less stimulating or arousing, using double condoms to decrease penile sensitivity, or cognitive distractions to reduce arousal

Concurrent psychological counselling can also be beneficial in increasing the patient's sexual confidence and self esteem (1)

Secondary PE is often seen in patients with ED - a trial of PDE5 inhibitors may be warranted (1)

Notes (2):

• many men are unsure about how long 'normal' sex should last before ejaculation. A study looking at 500 couples from five different countries found the average time between a man putting his penis into his partner's vagina and ejaculation was around five-and-a-half minutes
  
  
• Self-help advice
  • there are a number of self-help techniques that you may want to try before seeking medical help. These include:
    • masturbating an hour or two before having sex
    • using a thick condom to help decrease sensation
    • taking a deep breath to briefly shut down the ejaculatory reflex (an automatic reflex of the body during which ejaculation occurs)
    • having sex with your partner on top (to allow them to pull away when you are close to ejaculating)
    • taking breaks during sex and thinking about something boring
      
      
• Couples therapy advice
  • If you are in a long-term relationship, you may benefit from having couples therapy
    • the purpose of couples therapy is two-fold
      • firstly, couples are encouraged to explore issues that may be affecting their relationship, and given advice about how to resolve them
        
        
      • secondly, couples are shown techniques that can help the man to 'unlearn' the habit of premature ejaculation. The two most popular techniques are the 'squeeze technique' and the 'stop-go technique'
        
        
      • in the squeeze technique, his sexual partner begins masturbating the man. When the man feels that he is almost at the point of ejaculation, he signals to his sexual partner. The sexual partner stops masturbating him, and squeezes the head of his penis for between 10 to 20 seconds. The sexual partner then lets go and waits for another 30 seconds before resuming masturbation. This process is carried out several times before ejaculation is allowed to occur
        
        
      • the stop-go technique is similar to the squeeze technique except that the sexual partner does not squeeze the penis. Once the man feels more confident about delaying ejaculation, the couple can begin to have sexual intercourse, stopping and starting as required
        
        
      • these techniques may sound simple, but they do require a lot of practice

Reference:

• 1) Hatzimouratidis K et al. Guidelines on male sexual dysfunction: erectile dysfunction and premature ejaculation. Eur Urol. 2010 May;57(5):804-14.
• 2) NHS Direct Wales - Erectile Problems (accessed 6/7/2013)
• 3)Wijesinha S, Piterman L, Kirby CN. The male reproductive system - An overview of common problems. Aust Fam Physician. 2013 May;42(5):276-8.
• 4) McMahon CG. Dapoxetine: a new option in the medical management of premature ejaculation. Ther Adv Urol. 2012 Oct;4(5):233-51.