Premature Ejaculation

Background

• Premature ejaculation is characterized by a perceived inability to control ejaculation that occurs sooner than desired, or expected, either before or shortly after vaginal penetration, and causes emotional distress for the patient and/or sexual partner.
• Current definitions do not incorporate premature ejaculation resulting from sexual activities other than vaginal intercourse or premature ejaculation amongst men who have sex with men.
• Premature ejaculation can be classified as:
  • lifelong - present since the onset of sexual maturity
  • acquired - patient has a history of normal ejaculatory function prior to onset of premature ejaculation symptoms and is usually due to a secondary medical condition
• Variable and subjective premature ejaculation are subtypes which do not meet criteria of the International Society for Sexual Medicine (ISSM) definition of lifelong premature ejaculation, but may cause distress and professional help-seeking.
• Erectile dysfunction, depression, and anxiety may be comorbid conditions in patients with premature ejaculation.

Evaluation

• Diagnose premature ejaculation based on a patient history of ejaculation within about 1 minute of vaginal penetration, inability to control or delay ejaculation, and a high level of distress associated with these symptoms (Strong recommendation).
• Self-estimated intravaginal ejaculatory latency time (IELT) is adequate for clinical diagnosis of premature ejaculation. Other diagnostic tools include:
  • Premature Ejaculation Diagnostic Tool (PEDT)
  • Premature Ejaculation Profile (PEP)
  • Index of Premature Ejaculation (IPE)
• Determine the onset, frequency, and duration of symptoms.
• Assess for comorbid erectile dysfunction as well as for other acquired causes of premature ejaculation.
• Consider a physical exam in the initial assessment of premature ejaculation to identify anatomical associated abnormalities or other sexual dysfunctions, particularly erectile dysfunction (Strong recommendation).
• Obtain tests such as a urinalysis and urine culture if prostatitis is suspected or thyroid studies (thyroid-stimulating hormone [TSH], free thyroxine [FT4], free tri-iodothyronine [FT3]) if hyperthyroidism is suspected (Strong recommendation).

Management

• Treatment should be based on patient preference after the risks and benefits of each option have been discussed.
• Consider including the patient's partner in the decision-making process.
• Treat potentially contributing comorbidities or underlying illnesses such as erectile dysfunction, hyperthyroidism, and chronic bacterial prostatitis first (Strong recommendation).
• Consider psychological or behavioral interventions, especially in combination with pharmacologic treatment, which may improve intravaginal ejaculatory latency time (IELT) (Weak recommendation).
• Consider daily or precoital antidepressants to increase IELT as well as patient and partner satisfaction with sexual experience.
• Consider topical anesthetics applied to the glans penis to increase IELT and patient satisfaction with sexual experience.
• Phosphodiesterase-5 (PDE-5) inhibitors, alone or in combination with other therapies, are recommended for treatment of premature ejaculation (even in men without erectile dysfunction) (Strong recommendation), with evidence suggesting on-demand or daily dosing may be safe and effective.
• Combination medication therapy of PDE-5 and selective serotonin reuptake inhibitors may be better than either monotherapy for increasing IELT in men with premature ejaculation.
• Combined medication and psychological or behavioral intervention may be especially useful for (Weak recommendation):
  • men with acquired premature ejaculation when there is a clear psychological precipitant
  • men with lifelong premature ejaculation where individual or couple issues may inhibit success of medical therapy
• Surgical procedures for premature ejaculation have limited evidence for efficacy, have known adverse effects, and are not generally recommended.