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Premature ejaculation

Dr Rajesh Varma

Definition

Intravaginal ejaculatory latency time (IELT): the time period between penile penetration and ejaculation

PE is a male sexual dysfunction characterised by:

  • Lifelong PE (LPE): IELT < 1 minute, from the first sexual experience
    Acquired PE (APE): clinically significant reduction in latency time, IELT< 3 minutes, developing gradually or suddenly

  • Inability to delay ejaculation on all or nearly all vaginal penetrations

  • Negative personal consequences: distress, frustration, and/or avoidance of sexual intimacy.

Two further subtypes:
Natural variable PE: characterised by irregular early ejaculation
Premature-like ejaculatory dysfunction: subjective perception of early ejaculation, where the latency time is in the normal range.

Aetiology

Aetiology is unknown

Favoured hypothesis: hyposensitivity of the 5-HT2C or hypersensitivity of the 5HT1A receptors ejaculation mechanism

Prevalence

31% in the US
14% to 31% in the UK
Globally 30% in men aged 40-80y

Assessment of PE

  • Diagnosis of PE: latency period (<1m, <3m), any ability to delay PE, adverse psychological effect

  • Distinguish LPE (since first sexual experience) from APE (later)

  • Erectile dysfunction (inability to maintain erection or opting to rush intercourse to prevent loss of erection)

  • Impact on relationships

  • Previous treatments

  • Impact on mental health and quality of life 

Assessment of general medical health

Medical History

Screen for chronic illness, endocrinopathy, autoimmune neuropathy, Peyronie's disease and prostatitis

Physical examination 

  • General examination, penis, scrotum, inguinal LN

  • Digital rectal examination to check for prostate pathology

  • Screen for anatomical, infective or neoplastic disorders affecting genitalia

  • Consider urinalysis

Management

Explore patients' expectations before initiating treatment.

Manage co-existing secondary causes as an INITIAL STEP
Erectile dysfunction (treat using PDE-5 inhibitors - shown to increase IELT by 2min)
Genitourinary infection
Prostatits

Treatment options:

  1. Behavioural therapy (+/- psychosexual counselling)

  2. Pharmacological therapy (recommended for LPE as more effective)

Behavioural therapy (+/- psychosexual counselling)

  • More useful in APE, PE that causes few psychological sequelae, patient preference to avoid pharmacological treatment.

  • Overall success rates of 50% to 60%, however, relapse common when treatment ends

  • Behavioural therapies and can be combined with pharmacological treatment.

  • Stop-start technique: the partner stimulates the penis until the patient feels the urge to ejaculate, then stops the stimulus to let the urge pass, after which stimulation is started again.

  • Squeeze technique: the partner applies manual pressure to the glans of the penis just before ejaculation, until the patient loses the urge.

Topical local anaesthetic applied to the glans

Lidocaine and prilocaine, in the form of EMLA cream or spray (not recommded by DTB), can be used up to 20-30 minutes before intercourse (IELT increase 3-6min)

Available over the counter

Disadvantages: glans hypoanaesthesia, vaginal numbness, possible transvaginal absorption and female anorgasmia unless a condom is used.

Daily SSRI (off-license)

Paroxetine is superior SSRI (IELT increase by 5min)

Mechanism: increases synaptic levels of serotonin and desensitises 5HT1A and 5-HT1B receptors, delaying ejaculation.

Consider if co-existent depression or anxiety

Disadvantages: need to be taken for at least 1-2 weeks before the effects are evident (owing to achievement of receptor desensitisation)

RIsk of suicidal ideation in young men with co-existent depressive disorder

Common side-effects include fatigue, nausea, diarrhoea and vomiting.

On-demand short-acting SSRI (licensed for PE)

Dapoxetine + behaviour (IELT increase 5min)

Take dapoxetine 30mg or 60mg taken 1-2hr before sexual intercourse. Start with 30mg dose.

Advantages: fewer side-effects were reported compared with traditional SSRIs.
Side-effects include dizziness, headache, nausea.

No drug interactions have been found between dapoxetine and phosphodiesterase (PDE5) inhibitors.

Local CCG policy

Important to check local CCG guidelines given relatively high-cost of licensed treatments (lidocaine/prilocaine spray, dapoxetine) over similarly effective non-licensed treatments (EMLA cream, SSRIs).