The patient’s unmet needs (PUNs)
A very embarrassed-looking man of 24 years attends your evening surgery and explains that his problem is premature ejaculation. This has been going on since he met his most recent partner, who he has been with for over a year. She is keen to start a family and he is concerned that his condition may cause problems because, as he explains, he usually ejaculates before full penetration. ‘Is there something you can give me for this? We’ve tried those self-help things like the squeeze test’ he asks. ‘And can we be referred to a clinic to help her fall pregnant?’
The doctor’s educational needs (DENs)
How is premature ejaculation defined? How common is it?
Premature ejaculation is one of the most common male sexual problems, found in numerous studies to affect 5-40% of sexually active men, most commonly in the adolescent or early adult period. It is more frequently reported by men of Asian origin.
The epidemiology is confounded by a lack of consensus on the definition of premature ejaculation.
The World Health Organization’s ICD-10 defines premature ejaculation as ‘an inability to delay ejaculation sufficiently to enjoy love making.’1 However, the intravaginal ejaculation and latency time (IELT) provides a more helpful definition. An IELT of 0.9 minutes or less suggests definite premature ejaculation and 0.9-1.3 minutes suggests a probable case.2
It is helpful to differentiate between lifelong premature ejaculation and acquired premature ejaculation, because the former is more challenging to treat.
Premature-like ejaculatory dysfunction characterises men who worry and complain about the condition, but show a normal ejaculatory latency of 3-6 minutes.
What underlying conditions can cause it, or is it inevitably just a variation of normal?
A permanently short IELT is the key characteristic of premature ejaculation. In a recent multinational study of men with normal sexual function the mean IELT was 8.5 minutes.3
Ejaculation is under the control of the sympathetic nervous system and is divided into two phases:
- Emission – when semen is deposited into the posterior urethra and at the same time the internal sphincter of the urinary bladder is closed.
- Expulsion – this emission into the posterior urethra is immediately followed by expulsion forced by contractions of striated muscles in the pelvic floor. The central control is mediated by both serotonergic and dopaminergic systems, which is why SSRIs can be helpful in this situation.
The young man in the case scenario clearly has acquired premature ejaculation, which is causing him much distress. It has taken him more than a year to have the courage to come and talk about it, and the inability to conceive is clearly an issue.
Evaluation should involve a careful and detailed medical and sexual history, and a physical examination to exclude urologic causes such as prostatitis, endocrine causes such as thyroid dysfunction (particularly hyperthyroidism), and neurologic causes.
A detailed physical examination is not essential, but there is a general consensus that it is useful to perform a genital examination to check for penile abnormalities such as phimosis or a short frenulum. In acquired PE, a history of urinary symptoms should lead to a prostate and urine check. Hormonal check are not necessary unless the history dictates it.
How effective are self-help measures such as the ‘squeeze technique’? Do other practical manoeuvres help, such as using anaesthetic creams or wearing a condom?
It seems likely that there may be a genetic background for men with lifelong premature ejaculation, and asking about a family history may provide helpful information. For this patient the aim should be to prolong the ejaculatory latency time.
Behavioural treatments include the ‘stop-start’ technique and the ‘squeeze’, based on the background that premature ejaculation occurs because the man fails to be aware of the sensations of heightened arousal and to recognise the feelings of ejaculatory inevitability. The couple have already tried this approach, although a careful explanation of the correct technique may be helpful.
The use of topical anaesthetics such as lidocaine or prilocaine can be very helpful but may be associated with significant penile hypoanaesthesia and possible transvaginal absorption. Condoms can also be used and are effective, particularly when combined with local anaesthesia.
In the majority of patients research has shown that in head-to-head studies, pharmacotherapy is generally superior to behavioural therapy even in acquired premature ejaculation.
There is a consensus that behavioural therapy is ineffective in lifelong premature ejaculation due to the fact that it is genetic with neurobiological causes.
Long-term studies have shown poor results after initial success.
Combination therapy however has been shown to be superior to either approach as monotherapy.
Therefore the optimum approach is a combination of stop-start technique – a cognitive approach to get control of ejaculation and short-term pharmacotherapy.
Some doctors prescribe SSRIs in this situation. Are they helpful? Are they used regularly or only prior to intercourse?
The introduction of SSRIs has revolutionised the management of premature ejaculation. Daily treatment has been shown to be effective after 56 days but benefit may occur earlier. On-demand treatment is less effective than daily treatment but has fewer side effects. None of the long acting SSRIs are licensed for this indication, but they are commonly used.
Dapoxetine is a short-acting SSRI developed principally for the treatment of premature ejaculation. It can be used on demand, taken a few hours before expected sexual activity and is the first drug to be licensed for this indication. It is most effective at a dose of 60mg and is well tolerated.4
It is unlikely that phosphodiesterase type 5 (PDE-5) inhibitors will significantly delay ejaculation without erectile dysfunction. However, they are useful in erectile dysfunction and secondary premature ejaculation, where men ejaculate quickly because they are not confident they can maintain their erection.
At what point in the process is it reasonable to refer to the local infertility clinic if the couple have problems conceiving? What approach would the clinic be likely to take?
It is important to enquire about and manage ED if it coexists.
This young man needs a multidimensional treatment plan using drug treatment and sexual counselling involving his partner. It is unlikely that they would need to be referred to an infertility treatment. But both artificial insemination and IVF would be possible.
|Daily treatment with SSRIs (off label use) results in the following increases in IELT:|
|Paroxetine 20mg X 8|
|Sertraline 50-200mg X 5|
|Fluoxetine 20-40mg X 5|
|Citalopram 20-40mgX 2|
Professor Mike Kirby is a GP in Radlett and visiting professor at the University of Hertfordshire and The Prostate Centre, London.
1. World Health Organization. International classification of diseases and related health problems. 10th Edn. Geneva: World Health Organization. 1994.
2. McMahon CG. Defining premature ejaculation. European Urological Review 2008;3(2):78-8.
3. Waldinger MD, McIntosh J and Schweitzer DH. A five-nation survey to assess the distribution of the intravaginal ejaculatory latency time among the general male population. The Journal of Sexual Medicine 2009;6(10): 2888–2895.
4. Hutchinson K, Cruickshank K, Wylie K,. (2012) A benefit-risk assessment of dapoxetine in the treatment of premature ejaculation. Drug Safety, 35 (5) 359-72.
- Standard practice in sexual medicine, Edited by Hartmut Porst and Jacques Buvat. Blackwell Publishing. On behalf of the International Society for Sexual Medicine.
- NHS choices. Your health, your choices, premature ejaculation.
- The ESSM Syllabus of Sexual Medicine. Medix publishers