History

Fact Explanation
Inability to delay ejaculation on all or nearly all vaginal penetrations Premature ejaculation (PE) is Persistent or recurrent ejaculation with minimal stimulation before, on, or shortly after penetration, and before the person wishes it. Ejaculation which always or nearly always occurs prior to or within about one minute of vaginal penetration. This can be life long or acquired condition. Life long PE occurs from the first sexual encounter and continues on throughout adulthood. It is associated with intravaginal ejaculatory latency time (IELT) less than 1 minute, Inability to delay ejaculation is accompanied with negative personal consequences. It is hypothesized that lifelong PE may have a biological component to its pathophysiology, possibly involving changes in central serotonin receptor sensitivity. [1,2,3,4,5]
Negative personal consequences Distress, bother, frustration and/or the avoidance of sexual intimacy are some features of life long PE. Early sexual experiences such as traumatic sexual episode as a child or teenager, family relationships during childhood and adolescence such as incest or sexual assault, general attitude toward sex and regarding sex as dirty, involvement of the sexual partner, partner failing to support the man or blaming him are aggravating and predisposing causes of life long and acquired PE, that should be explored in the history. [1,3,4]
late onset symptoms Acquired or secondary PE occurs after a period of normal sexual functioning This may be related to performance anxiety, erectile dysfunction or, occasionally, medical problems. Acquired PE is characterized by substantial decrease in time-to-ejaculation compared with previous sexual experience, associated with inability to delay ejaculation and negative personal consequences. Acquired PE also has a physiological component and may be the result of psychological stressors. It may also be ‘situational’, i.e. confined to certain partners or circumstances. Onset of ED can also lead to acquired or compensatory PE. [1,2,3,6]
Erectile dysfunction Erectile dysfunction (ED) or impotence is sexual dysfunction characterized by the inability to develop or maintain an erection of the penis during sexual activity. Erectile dysfunction is one of the more common events which cause performance pressure such as fear of failure to satisfy the partner. Fear of the fact that an erection will not last may also precipitate premature ejaculation. [1,2,5]
History of medical/surgical illnesses Erectile dysfunction associated with PE may have several etiologies that co-exists in the patients. History of vascular causes such as atherosclerosis, peripheral vascular disease, myocardial infarction and arterial hypertension, Systemic diseases such as diabetes mellitus, scleroderma, renal failure and liver cirrhosis, neurologic causes such as epilepsy and stroke, endocrine conditions such as hyperthyroidism and hypothyroidism should be explored. Traumatic injury to urethra is a surgical cause for premature ejaculation. [7,8,9]
Drug history Premature ejaculation can be caused by drugs of addiction such as cocaine and amphetamine. Drug induced causes of erectile dysfunction are common. Beta blockers, selective serotonin reuptake inhibitors (SSRIs), and the uroselective alpha adrenergic receptor antagonists have been associated with the loss of libido or ejaculatory disorders. [1,2,7,8,9]
References
  1. HARRISON C, BAYRAM C, BRITT H. Premature ejaculation. Aust Fam Physician [online] 2013 May, 42(5):265 [viewed 19 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/23781521
  2. XIA JD, HAN YF, ZHOU LH, CHEN Y, DAI YT. Efficacy and safety of local anaesthetics for premature ejaculation: a systematic review and meta-analysis. Asian J Androl [online] 2013 Jul, 15(4):497-502 [viewed 19 July 2014] Available from: doi:10.1038/aja.2012.174
  3. SEREFOGLU EC, SAITZ TR. New insights on premature ejaculation: a review of definition, classification, prevalence and treatment. Asian J Androl [online] 2012 Nov, 14(6):822-9 [viewed 19 July 2014] Available from: doi:10.1038/aja.2012.108
  4. GIULIANO F, CLèMENT P. Pharmacology for the treatment of premature ejaculation. Pharmacol Rev [online] 2012 Jul, 64(3):621-44 [viewed 19 July 2014] Available from: doi:10.1124/pr.111.004952
  5. MOHEE A, EARDLEY I. Medical therapy for premature ejaculation. Ther Adv Urol [online] 2011 Oct, 3(5):211-22 [viewed 19 July 2014] Available from: doi:10.1177/1756287211424172
  6. MCMAHON CG. Dapoxetine: a new option in the medical management of premature ejaculation. Ther Adv Urol [online] 2012 Oct, 4(5):233-51 [viewed 19 July 2014] Available from: doi:10.1177/1756287212453866
  7. VLACHOPOULOS C, JACKSON G, STEFANADIS C, MONTORSI P. Erectile dysfunction in the cardiovascular patient. Eur Heart J [online] 2013 Jul, 34(27):2034-46 [viewed 20 July 2014] Available from: doi:10.1093/eurheartj/eht112
  8. NUNES KP, LABAZI H, WEBB RC. New insights into hypertension-associated erectile dysfunction. Curr Opin Nephrol Hypertens [online] 2012 Mar, 21(2):163-70 [viewed 20 July 2014] Available from: doi:10.1097/MNH.0b013e32835021bd
  9. HEIDELBAUGH JJ. Management of erectile dysfunction. Am Fam Physician [online] 2010 Feb 1, 81(3):305-12 [viewed 20 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/20112889

Examination

Fact Explanation
Signs of medical conditions which results in erectile dysfunction A thorough physical examination is important to detect any related physical cause. Cardiovascular, genitourinary and neurological systems should be well focused. Blood pressure, pulses, sensation, complete examination of external genitalia including abnormalities such as hypospadias and Peyronie plaques should be looked in to. [1,2]
References
  1. HEIDELBAUGH JJ. Management of erectile dysfunction. Am Fam Physician [online] 2010 Feb 1, 81(3):305-12 [viewed 20 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/20112889
  2. NUNES KP, LABAZI H, WEBB RC. New insights into hypertension-associated erectile dysfunction. Curr Opin Nephrol Hypertens [online] 2012 Mar, 21(2):163-70 [viewed 20 July 2014] Available from: doi:10.1097/MNH.0b013e32835021bd

Differential Diagnoses

Fact Explanation
Delayed orgasm in the female partner The symptom of orgasmic dysfunction/ delayed orgasm is being unable to reach orgasm, taking longer than average to reach orgasm, or having only unsatisfying orgasms. This can be so severe that the female partner does not achieve orgasm. These condition can often cause sexual frustration and can be mistaken as due to premature ejaculation. [1,2]
Drug induced sexual dysfunction There is a wide range of drugs that is known to affect the sexual function. notably antidepressants, antipsychotics, and antihypertensives. [1,2]
Pre-ejaculate Pre-ejaculate is the lubricating fluid produced by Cowper glands and other glands during the excitement phase of sexual stimulation. This may be mistaken as ejaculation. [1,3]
Erectile dysfunction Erectile dysfunction is the inability in achieving or maintaining an erection which is sufficient for a satisfactory sexual performance. Drugs such as anti-depressants and nicotine, neurogenic disorders, cavernosal disorders and psychological causes predominate as etiologies of erectile dysfunction. [1,4]
References
  1. AMIDU N, OWIREDU WK, GYASI-SARPONG CK, WOODE E, QUAYE L. Sexual dysfunction among married couples living in Kumasi metropolis, Ghana. BMC Urol [online] 2011 Mar 2:3 [viewed 19 July 2014] Available from: doi:10.1186/1471-2490-11-3
  2. MALVIYA N, JAIN S, GUPTA VB, VYAS S. Management of drug induced sexual dysfunction in male rats by ethyl acetate fraction of onion. Acta Pol Pharm [online] 2013 Mar-Apr, 70(2):317-22 [viewed 19 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/23614288
  3. HARRISON C, BAYRAM C, BRITT H. Premature ejaculation. Aust Fam Physician [online] 2013 May, 42(5):265 [viewed 19 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/23781521
  4. CIOE PA, ANDERSON BJ, STEIN MD. Change in symptoms of erectile dysfunction in depressed men initiating buprenorphine therapy. J Subst Abuse Treat [online] 2013 Nov-Dec, 45(5):451-6 [viewed 19 July 2014] Available from: doi:10.1016/j.jsat.2013.06.004

Management - General Measures

Fact Explanation
Education and Counselling The management should include female partner's support. Both should be educated regarding PE and the possible treatment techniques. Options such as manual stimulation during foreplay, or other means to satisfy the partner should be suggested until the PE is treated. Addressing the fears and anxieties such as underlying performance pressure is important. Any serious primary medical condition such as angina should be treated and fears of getting angina in a healthy individual during a sexual excitement should be addressed. [1,2,3]
References
  1. HARRISON C, BAYRAM C, BRITT H. Premature ejaculation. Aust Fam Physician [online] 2013 May, 42(5):265 [viewed 19 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/23781521
  2. SEREFOGLU EC, SAITZ TR. New insights on premature ejaculation: a review of definition, classification, prevalence and treatment. Asian J Androl [online] 2012 Nov, 14(6):822-9 [viewed 19 July 2014] Available from: doi:10.1038/aja.2012.108
  3. XIA JD, HAN YF, ZHOU LH, CHEN Y, DAI YT. Efficacy and safety of local anaesthetics for premature ejaculation: a systematic review and meta-analysis. Asian J Androl [online] 2013 Jul, 15(4):497-502 [viewed 19 July 2014] Available from: doi:10.1038/aja.2012.174

Management - Specific Treatments

Fact Explanation
Sex therapy Sex therapy aims to develop more self control in the ejaculatory process through exercises, education and talking therapy. It may include cognitive behavioral therapy (CBT), anxiety reduction/desensitization, education, enhance communication and behavioral assignments/homework exercises. [1,2]
Squeeze-pause technique Men are instructed to pay close attention to their arousal pattern and learn to recognize his mid-level excitement, the moment before ejaculation felt imminent and inevitable. Sensing it, they were to signal their partner, who squeezed the head of the penis between thumb and index finger, suppressing the ejaculatory reflex and allowing the man to last longer. [1,2]
Stop-start technique Stop and start technique is probably the most common behavioral therapy for premature ejaculation. It this method, the male recognize his mid-level excitement and simply stops/ refrain himself from the act for few seconds. Stop-start technique does not involve squeezing. [1,2,3]
Second attempt at coitus Male partner is advised to perform masturbation 1-2 hours before sexual relations are planned. [1,2]
Pelvic floor exercise (Kegel exercise) This consists of repeatedly contracting and relaxing the muscles that form part of the pelvic floor. The aim of Kegel exercises is to improve muscle tone by strengthening the pubococcygeus muscles of the pelvic floor. [1,2,3]
Topical desensitizing agents Using lidocaine-prilocaine anesthetic cream might be an effective treatment for PE, possibly by decreasing penile hypersensitivity. This should be applied 20-30 minutes before sexual act.New topical anesthetics with absorption technology enable men to maintain pleasurable sexual sensitivity and practically eliminate transference to this partner. [3,4]
Selective serotonin reuptake inhibitors The most effective pharmacologic therapy for premature ejaculation is SSRI therapy. SSRI are traditional drug of choice for depression, delays orgasm as a common side effect. The downside to most SSRIs is that they must be taken daily in order to achieve the desired effect. Sertraline, paroxetine, fluoxetine, citalopram, or dapoxetine are commonly used SSRIs. Dapoxetine (Priligy) is a highly potent inhibitor of serotonin reuptake transporter which has been specifically developed to treat this condition. It's first dose may be effective when given 1-3 hours before coitus. [3,4,5,6]
Tricyclic antidepressants (TCAs) TCAs, specially clomipramine has been shown to have favorable effects on intravaginal ejaculatory latency time (IELT). Anticholinergic side effects such as drowsiness, dizziness, dry mouth, and fatigue have been reported in clomipramine-treated patients and may necessitate discontinuation of therapy. So usage of clomipramine is implemented on demand regimen than a continuous regimen. Some TCAs with SSRI like activity will have SSRI like effects as well[1,3,4,5]
Phosphodiesterase type 5 (PDE5) inhibitors Combination of phosphodiesterase type 5 (PDE5) inhibitors with SSRIs has been shown to provide better results. PDE5 inhibitors are the treatment of choice for erectile dysfunction. It enables some men to sustain an erection after ejaculation, providing an opportunity to satisfy his partner. Sildenafil, tadalafil and vardenafil are commonly used PDE5 inhibitors. [3,4,5,6]
Tramadol The opioid analgesic tramadol has been found to be effective significantly more than placebo in achieving increased sexual intercourse satisfaction, tolerability and increased time to ejaculation. Tramadol must be taken at least 2 hours before sexual activity in order to be effective. The most common side effects include nausea, somnolence, erectile dysfunction, dyspepsia, headache, vomiting, and dizziness. [7]
Treatment of the medical conditions which predispose to erectile dysfunction (ED) Special concern should be made for treatment and/or control of medical conditions. As an instance, in a diabetic, proper glycemic control plays a major role in prevention/ treatment of ED. In hypertensives, the proper antihypertensive should be carefully chosen as hypertension itself as well as the drug can lead in to the further aggravation of ED and PE. Hyperthyroidism and hypothyroidism should be treated with antithyroid drugs and thyroxine respectively. [8,9,10]
References
  1. HARRISON C, BAYRAM C, BRITT H. Premature ejaculation. Aust Fam Physician [online] 2013 May, 42(5):265 [viewed 19 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/23781521
  2. SEREFOGLU EC, SAITZ TR. New insights on premature ejaculation: a review of definition, classification, prevalence and treatment. Asian J Androl [online] 2012 Nov, 14(6):822-9 [viewed 19 July 2014] Available from: doi:10.1038/aja.2012.108
  3. XIA JD, HAN YF, ZHOU LH, CHEN Y, DAI YT. Efficacy and safety of local anaesthetics for premature ejaculation: a systematic review and meta-analysis. Asian J Androl [online] 2013 Jul, 15(4):497-502 [viewed 19 July 2014] Available from: doi:10.1038/aja.2012.174
  4. GIULIANO F., CLEMENT P.. Pharmacology for the Treatment of Premature Ejaculation. Pharmacological Reviews [online] December, 64(3):621-644 [viewed 19 July 2014] Available from: doi:10.1124/pr.111.004952
  5. MOHEE A, EARDLEY I. Medical therapy for premature ejaculation. Ther Adv Urol [online] 2011 Oct, 3(5):211-22 [viewed 19 July 2014] Available from: doi:10.1177/1756287211424172
  6. MCMAHON CG. Dapoxetine: a new option in the medical management of premature ejaculation. Ther Adv Urol [online] 2012 Oct, 4(5):233-51 [viewed 19 July 2014] Available from: doi:10.1177/1756287212453866
  7. EASSA BI, EL-SHAZLY MA. Safety and efficacy of tramadol hydrochloride on treatment of premature ejaculation. Asian J Androl [online] 2013 Jan, 15(1):138-42 [viewed 19 July 2014] Available from: doi:10.1038/aja.2012.96
  8. VLACHOPOULOS C, JACKSON G, STEFANADIS C, MONTORSI P. Erectile dysfunction in the cardiovascular patient. Eur Heart J [online] 2013 Jul, 34(27):2034-46 [viewed 20 July 2014] Available from: doi:10.1093/eurheartj/eht112
  9. NUNES KP, LABAZI H, WEBB RC. New insights into hypertension-associated erectile dysfunction. Curr Opin Nephrol Hypertens [online] 2012 Mar, 21(2):163-70 [viewed 20 July 2014] Available from: doi:10.1097/MNH.0b013e32835021bd
  10. HEIDELBAUGH JJ. Management of erectile dysfunction. Am Fam Physician [online] 2010 Feb 1, 81(3):305-12 [viewed 20 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/20112889