Clinical correlate 9 Premature ejaculation

Study Questions

What is the definition of premature ejaculation? Does the patient in the video scenario have true premature ejaculation?
What are the three major classes of treatments for premature ejaculation?

Reference Texts

A. Summary from: Men’s Sexual Health

Richard Sadovsky, MD , Stanley Althof, PhD Men's sexual issues

Clinics in Family Practice

Volume 6 • Number 4 • December 2004

From the Department of Family Practice, SUNY-Downstate Medical Center, Brooklyn, New York (RS); and the Department of Psychology, Case Western Reserve College of Medicine, Cleveland, Ohio and Center for Marital and Sexual Health of South Florida, West Palm Beach, Florida (SA)

* Full text reprint requests to: Richard Sadovsky, MD Department of Family Practice SUNY-Downstate Medical Center, Box 67 450 Clarkson Avenue Brooklyn, NY 11203

According to the Diagnostic and Statistical Manual of Mental Disorders, premature ejaculation is defined as ejaculation before, on or shortly after penetration and before ejaculation is desired, and this must be a cause of distress. As the author notes, this definition is problematic, since it can mean different things to different people. “ How is “before, on, or shortly after penetration” operationalized? For instance, does a man warrant the diagnosis if he ejaculates in less than 30, 60, 90, 120, or 180 seconds after vaginal penetration? What percentage of coital attempts does he need to evidence this rapidity 25%, 50%, 75%, or 100%?” In clinical practice premature ejaculation is defined as ejaculation within a 2-minute latency period in most sexual encounters. If a patient complains of premature ejaculation and the latency is longer than that, reasons for why he considers this a problem should be explored.

Needless to say, determining prevalence given the difficulty defining the problem is unreliable. Typical estimates are that premature ejaculation affects 225-38% of the population. Ejaculation is a reflex involving efferent and afferent pathways, as well as sensory and motor centers. Neurotransmitters involve primarily serotonergic and dopaminergic neurons interacting with cholinergic, adrenergic, oxytocinergic and GABAergic neurons. There are emission and ejaculation phases of ejaculation, governed by the sympathetic and somatic nervous system respectively.

Dopaminergic drugs generally have a positive effect on ejaculation and serotonergic drugs a negative effect, although some 5-HT receptors have a delaying effect and others an accelerating effect on ejaculation. Surgical trauma damaging the sympathetic nerves and drug withdrawal can also contribute to premature ejaculation.

Both psychologic treatments targeting self-control and performance anxiety and pharmacologic treatments can be helpful.

Pharmacological approaches include antidepressants, topical ointments and PDE5 inhibitors. Selective serotonin reuptake inhibitors have been shown to be effective in well-designed trails, with paroxetine being most effective, followed by fluoxetine and sertraline. These medications increase ejaculatory latency 20-fold. Although stopping these medications will cause the patient to return to baseline, short-acting reuptake inhibitors than can be used on an as-needed basis are under development. Topical anaesthetics applied 1 hour before intercourse to decrease sensitivity of the glans also work well but may have an unpleasant numbing effect on the female partner.

Sildenafil, those not officially indicated for premature ejaculation, or sildenfil combined with paroxetine, is another effective modality.

Psychological approaches include behavioral management and partner work. Distraction exercises may prevent adequate attention being paid to the partner’s satisfaction.