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Premature Ejaculation

Review literature: (Althof, 2006) (Montague et al., 2004). EAU Guidelines Sexual Health.

Definition of Premature Ejaculation

Premature ejaculation is one of the most common sexual complaints. It is characterized by an unwanted early ejaculation before or after minimal sexual stimulation, this may interfere with sexual or emotional well-being in patient or partner and may possibly disturbe the (sexual) relationship. There are many different definitions of premature ejaculation. The most frequently cited definitions refer to the following components of the disease:

• Intravaginal ejaculatory latency time (IELT): the average time from the start of vaginal penetration until ejaculation is less than 1–2 minutes.
• Lack of control: the premature ejaculation is unintentionally and it is regularly present (75–100%).
• Distress: premature ejaculation interferes with the sexual or emotional well-being.
• Exclusion criteria: premature ejaculation is not caused by sexual abstinence, new partners, new sexual situations, alcohol, drugs or medication.

Epidemiology of Premature Ejaculation

The prevalence rate of premature ejaculation in sexually active men is around 20%, it varies between studies and due to different definitions of premature ejaculation. Premature ejaculation is equally prevalent in all age groups.

Etiology (Causes) of Premature Ejaculation

Psychogenic causes:

Anxiety, poor communication between partners, lack of ejaculation techniques or psychodynamic causes.

Physical causes:

Penile hypersensitivity, 5-hydroxytryptamine (5-HT) receptor hyper- or hyposensitivity (depending on the receptor subtype), erectile dysfunction.

Signs and Symptoms

The clinical course of the disease is variable. Primary premature ejaculation is usually a lifelong disease and is caused by physical causes (see above). Secondary premature ejaculation is the acquired form, psychogenic causes are more prevalent.

Diagnstik workup of Premature Ejaculation

History:

In addition to a detailed sexual history (vaginal latency time, partners, techniques, ...), further questions aime to exclude erectile dysfunction or to assess other sexual complaints.

Treatment of Premature Ejaculation

Sexual Therapy

The benefits of sexual therapy are the lack of side effects, it improves the communication of sexual partners and may result next to the treatment of premature ejaculation in a more satisfying partnership. Disadvantages are the delayed and inconstant effect of behavioral therapy. In addition, it requires a high human and financial burden to patients (or society), and the cooperation of the sexual partner is mandatory.

Stop-Squeeze Method [Masters and Johnson, 1970]:

The sexual arousal is reduced just before ejaculation by compression of the glans penis, until the sexual arousal decreases. Thereafter, the sexual stimulation is continued.

Stop-Pause Method [Kaplan 1983]:

Shortly before ejaculation, the sexual stimulation is paused, until the decreased sexual arousal allows further stimulation without ejaculation.

Local treatment of premature ejaculation:

Desensitivation of the glans penis is reached by wearing multiple condoms and/or the use of ointments with local anesthetics (such as lidocaine).

Pharmacological Treatment of Premature Ejaculation

Pharmacological therapy of premature ejaculation is possible with the use serotonin reuptake inhibitors (SSRIs) and tricyclic antidepressants. The problem are the side effects of the antidepressants and the lack of approval for the indication premature ejaculation. Since 2009, dapoxetine (a short-acting SSRI) received approval for the treatment of premature ejaculation.

Dapoxetine:

Dapoxetine is a short-acting selective serotonin reuptake inhibitor (SSRI), which is approved for an on-demand therapy. A 30 mg dose is taken 1–3 hours before planned sexual activity. Dapoxetine should be taken only once a day. In the case of inefficiency without side effects, the dose may be increased to 60 mg. Please see section dapoxetine for pharmacology, side effects and contraindications.

Paroxetine:

Paroxetine is a long-acting SSRI. Dosage 20–40 mg daily. Onset of action after 1–2 weeks.

Fluoxetine:

Fluoxetine is a long-acting SSRI. Dosage 20–40 mg daily. Onset of action after 1–2 weeks.

Clomipramine:

Tricyclic antidepressant, which can be used (off-label) as on-demand treatment. Dosage 10–50 mg five hours before sexual intercourse.

Phosphodiesterase inhibitors:

PDE5 inhibitors do not increase IELT, but they do increase confidence in achieving a second erection and thereby improve sexual experience. In addition, PDE5 inhibitors are indicated for the treatment of erectile dysfunction, which may also be the cause for the premature ejaculation.

Tramadol:

Beside the activity on the opioid receptor, tramadol also influences the cholinergic and serotonergic nervous system. Tramadol could increase IELT in a randomized phase-3 study (Bar-Or u.a., 2012): 1,2 min (with 62 mg Tramadol) versus 0,6 min (with placebo). Side effects of tramadol were acceptable.

References

Bar-Or, D.; Salottolo, K. M.; Orlando, A.; Winkler, J. V. & Group, T. O. S. A randomized double-blind, placebo-controlled multicenter study to evaluate the efficacy and safety of two doses of the tramadol orally disintegrating tablet for the treatment of premature ejaculation within less than 2 minutes.
Eur Urol, 2012, 61, 736-743.

Buvat, J.; Tesfaye, F.; Rothman, M.; Rivas, D. A. & Giuliano, F. Dapoxetine for the Treatment of Premature Ejaculation: Results from a Randomized, Double-Blind, Placebo-Controlled Phase 3 Trial in 22 Countries.
Eur Urol, 2009.

Hatzimouratidis, K.; Amar, E.; Eardley, I.; Giuliano, F.; Hatzichristou, D.; Montorsi, F.; Vardi, Y. & Wespes, E. Guidelines on male sexual dysfunction: erectile dysfunction and premature ejaculation.
Eur Urol, 2010, 57, 804-814.

D. K. Montague, J. Jarow, G. A. Broderick, R. R. Dmochowski, J. P. W. Heaton, T. F. Lue, A. Nehra, I. D. Sharlip, und A. U. A. E. D. G. U. Panel. Aua guideline on the pharmacologic management of premature ejaculation.
J Urol, 172 (1): 290–294, Jul 2004.

  Deutsche Version: Vorzeitige Ejakulation