What is the best course of treatment for a 33-year-old male with low libido and premature ejaculation, with a history of Urinary Tract Infection (UTI) and possible early epididymitis?

Management of Low Libido and Premature Ejaculation in a 33-Year-Old Male

For this 33-year-old male with low libido and premature ejaculation, testosterone testing is appropriate to evaluate low libido, while behavioral techniques and topical anesthetics are recommended for premature ejaculation management. 1, 2

Diagnostic Approach

Low Libido Evaluation

• Early morning total and free testosterone testing is essential as hypogonadism is found in approximately 15.6% of men with sexual dysfunction 3
• Measurement of free testosterone fraction is particularly important as it can prevent unnecessary further endocrine evaluation in 50% of patients with hypogonadism 3
• Assess for other potential causes:
  • Psychological factors (stress, anxiety, depression)
  • Medication side effects (particularly from previous UTI treatment)
  • Relationship issues
  • Lifestyle factors (sleep quality, physical activity, alcohol consumption)

Premature Ejaculation Assessment

• Determine if the condition is lifelong (present since sexual debut) or acquired (developed after a period of normal function) 1
• Assess for ejaculatory control, personal distress, and ejaculation latency time 1
• Evaluate for comorbid erectile dysfunction, as approximately one-third of patients with PE also have ED 4
• Consider relationship to previous UTI/epididymitis, as LUTS can be associated with PE in up to 77% of cases 5

Treatment Recommendations

For Low Libido

1. Testosterone Therapy:

   • If morning total testosterone is <300 ng/dL, consider testosterone replacement therapy 2, 1
   • Testosterone treatment significantly improves sexual desire in hypogonadal men 6, 7
   • Available forms include intramuscular, transdermal, or oral preparations 1

2. Lifestyle Modifications:

   • Regular physical exercise (already recommended)
   • Stress management techniques (already recommended)
   • Adequate sleep (already recommended)
   • Weight management if needed
   • Limiting alcohol consumption

For Premature Ejaculation

1. First-line Behavioral Techniques:

   • Start-stop technique (already recommended) - instruct patient to stop stimulation when approaching climax, then resume after sensation subsides 1
   • Squeeze technique - applying pressure to the glans penis when approaching climax
   • Pelvic floor exercises to improve ejaculatory control

2. Topical Treatments:

   • EMLA cream (lidocaine-prilocaine) applied 20-30 minutes before sexual activity (already recommended) 1
   • Other lidocaine-based sprays or creams as alternatives

3. Pharmacological Options (if behavioral and topical treatments fail):

   • SSRIs (paroxetine, sertraline, fluoxetine) - can be used daily or on-demand 1, 2
   • Dapoxetine (if available) - specifically approved for PE in some countries
   • Clomipramine as an alternative 2

Follow-up Plan

• Evaluate testosterone results and initiate appropriate treatment if levels are low
• Assess response to behavioral techniques and EMLA cream after 4-12 weeks 2
• If no improvement with initial management, consider:
  • Adjusting treatment approach
  • Referral to sexual health specialist
  • Psychological counseling if stress or relationship factors are significant

Important Considerations

• The relationship between PE and ED can create a vicious cycle, where men who attempt to control ejaculation reduce arousal (leading to ED), while those trying to achieve erection increase arousal (leading to PE) 4
• Partner involvement in treatment discussions may improve outcomes 2
• Set realistic expectations about improvement rather than complete resolution 2
• If PE persists despite treatment, consider evaluating for other urological conditions given the patient's history of UTI and epididymitis 5

Pitfalls to Avoid

• Focusing on only one aspect of sexual dysfunction when both low libido and PE are present
• Ignoring the potential relationship between previous UTI/epididymitis and current sexual dysfunction
• Failing to follow up on testosterone results and adjust treatment accordingly
• Not providing adequate instruction on proper use of behavioral techniques or topical treatments
• Overlooking psychological factors that may contribute to sexual dysfunction