How is premature ejaculation defined, evaluated, and managed?

Definition, Evaluation, and Management of Premature Ejaculation

Definition

Premature ejaculation is ejaculation that occurs sooner than desired, either before or shortly after penetration, causing distress to either one or both partners. 1

PE is subclassified into two forms: 1

• Lifelong (primary) PE: Present since first sexual activity
• Acquired (secondary) PE: Develops later in life after a period of normal ejaculatory function

For context, the median ejaculatory latency time (ELT) in Western countries is 5-6 minutes following intromission. 1

Evaluation

The diagnosis of PE is based on sexual history alone—no laboratory or physiological testing is required unless the history and physical examination reveal indications beyond uncomplicated PE. 1

Key Elements of Sexual History

Obtain explicit details about: 1

• Time to ejaculation (most important feature)
• Frequency and duration of PE
• Whether PE occurs with all partners or specific partners only
• Occurrence with all or only some sexual attempts
• Degree of stimulus resulting in PE
• Nature and frequency of sexual activity (foreplay, masturbation, intercourse)
• Impact on sexual activity and quality of life
• Aggravating or alleviating factors
• Relationship to drug use or abuse
• Partner's perspective on the condition

Critical Evaluation Point: Distinguish PE from Erectile Dysfunction

If concomitant erectile dysfunction (ED) and PE are present, thoroughly evaluate the temporal relationship between the conditions. 1 Some men with lifelong PE develop ED related to performance anxiety, while acquired PE may be secondary to ED. 1

If both ED and PE coexist, treat the ED first—PE may improve when ED is effectively managed. 1, 2

Management

Combining behavioral and pharmacological approaches is more effective than either modality alone and should be the recommended treatment strategy. 1, 3, 2 This combination leads to significantly greater increases in ELT and improved scores on validated PE assessment instruments compared to pharmacological therapy alone. 1

First-Line Pharmacological Treatment

Daily SSRIs are the first-line pharmacologic therapy, with paroxetine showing the strongest effect—increasing ejaculatory latency time by 8.8-fold over baseline. 3

Recommended daily dosing regimens: 3

• Paroxetine 10-40 mg (most effective)
• Sertraline 50-200 mg
• Fluoxetine 20-40 mg
• Citalopram 20-40 mg
• Clomipramine 12.5-50 mg

Topical penile anesthetics (lidocaine/prilocaine cream) applied 20-30 minutes before intercourse are also first-line options with minimal side effects. 3, 2 However, these may cause penile hypoesthesia and transfer to partners; use with a condom or thorough washing to prevent partner numbness. 2

Important Caveats About SSRIs

• All SSRIs for PE are off-label use, as none have FDA approval for this specific indication 1, 3
• Common adverse effects include ejaculation failure, decreased libido, nausea, dry mouth, and insomnia 3, 2
• Up to 40% of patients may refuse to begin or discontinue SSRI treatment within 12 months due to concerns about taking antidepressants, effects below expectations, or cost 2

Behavioral Therapy Component

Psychotherapy for PE represents a legitimate treatment approach and should be integrated with pharmacotherapy. 3 Most psychological therapies integrate psychodynamic, systematic, behavioral, and cognitive approaches within a short-term model. 3

Consider referring men with PE to a mental health professional with expertise in sexual health, particularly when psychological factors (depression, anxiety, decreased self-esteem, relationship conflict) are prominent. 3

Physical behavioral techniques include: 4

• Squeeze and stop-start techniques
• Sensate focus exercises
• Pelvic floor rehabilitation

Second-Line Options

α1-Adrenoreceptor antagonists may be considered for men who have failed first-line therapy, though efficacy data are limited and additional controlled studies are needed. 2

Tramadol should be used with extreme caution due to its opioid-like properties and risk of dependency, particularly concerning in the context of the opioid crisis. 2, 5

Treatment Algorithm

1. Start with daily SSRI (paroxetine preferred) or topical anesthetic 3, 2
2. Add behavioral therapy to pharmacotherapy for enhanced outcomes 1, 3, 2
3. For treatment-resistant cases, consider combining multiple therapeutic approaches or adding α1-adrenoreceptor antagonists 2
4. If ED coexists, treat ED first before addressing PE 1, 2

Treatments to Avoid

Surgical management (including injection of bulking agents, selective dorsal nerve neurotomy, pulsed radiofrequency ablation, or hyaluronic acid gel augmentation) should be considered experimental and only used in the context of an ethical board-approved clinical trial. 1, 2 Invasive treatment may be associated with permanent loss of penile sensation. 1, 2

Safety Considerations

Safety should be a primary consideration, as PE is not a life-threatening condition. 1 The risks of some treatments (neurectomy, penile prosthesis implantation) far outweigh their benefits. 1

Patient and partner satisfaction is the primary target outcome for PE treatment—the patient plays a central role in determining the need for treatment and should be informed of risks and benefits of all therapeutic options. 1