PREMATURE EJACULATION

Dr.DINESH
UROLOGY RESIDENT
RGGGH
 Mr A

• 30 year-old man came with c/o

“I ejaculate too early”
Is it Premature Ejaculation (PE)?
Common factors in all definitions
• Time to ejaculation assessed by IELT
• Perceived control
• Distress
• Interpersonal difficulty related to the
ejaculatory dysfunction
 International Society for Sexual
Medicine (ISSM), 2010, 2015
1. Ejaculation that always or nearly always occurs prior
to or within about 1 minute of vaginal penetration
(lifelong PE) or a clinically significant and
bothersome reduction in latency time, often to about
3 minutes or less (acquired PE).
2. The inability to delay ejaculation on all or nearly
all vaginal penetrations.
3. Negative personal consequences, such as
distress, bother, frustration, and/or the avoidance
of sexual intimacy.
4. Occurs in 75%-100% of sexual encounters
 DSM-5 DEFINITION OF PE
⚫ A. A persistent or recurrent pattern of ejaculation occurring during
partnered sexual activity within approximately 1 minute
following vaginal penetration and before the person wishes it
⚫ B. The symptom must have been present for at least six months
and must be experienced on almost all or all (approximately 75%–
100%) occasions of sexual activity
⚫ C. The symptom causes clinically significant distress in the
individual
⚫ D. Mild PE 30-60 sec , Mod PE 15-30 sec, Severe PE <15 sec
 Intravaginal ejaculatory latency time (IELT)
Time taken to ejaculate after
vaginal penetration
Waldinger et al., 2005-
• median IELT 5.4 minutes
(range 0.55–44.1 minutes)
• Distribution- positively
skewed.
• Independent of condom
use or circumcision status
Waldinger et al., 2009-
• median IELT of 6 minutes
(range 0.1–15.2)
 IELT decreases with age
• Waldinger et al., 2005
 IELT in clinical practice
• Significant overlap between
men with PE and without PE
• Self-estimated IELT is
sufficient in clinical practice
(EUA, ISSM, AUA)
• Self-estimated IELT- 80%
sensitive and 80% specific (cf-
stopwatch-measured IELT)
• Stopwatch-measured ILET- for
clinical trial
 Premature-like
Lifelong PE Acquired PE Natural variable PE ejaculatory
dysfunction
In the majority of IELT is short Ejaculation time may be IELT is in the normal range
cases (80%) within (less than 3 min) short or normal or may even be of longer
30–60 s or duration
(20%) 1 and 2 min

From about the first Early ejaculation occurs Early ejaculations are: Subjective perception of
sexual encounter at some point in a man’s • Inconsistent consistent or inconsistent
life • Occur Irregularly rapid ejaculation

With nearly every The man had normal Ability to delay ejaculation Ability to delay ejaculation
woman ejaculation experiences may be diminished or may be diminished or
before lacking lacking

Ejaculation occurs The onset is either The impression of Imagined early ejaculation
too early nearly sudden or gradual diminished control of or
in each ejaculation lack of control of ejaculation
intercourse

Remains rapid The dysfunction may be Psychotherapy should be The preoccupation is not
throughout the the result of considered as first-line better accounted for by
lifetime of the urological/thyroid treatment another mental disorder
subject dysfunctions or
psychological problems
 Diagnostic Dilemma
• Mr D- I ejaculate within 5 minutes. My wife said
her friend’s partner is able to hold for 30
minutes !!!! (overdiagnosis of PE)

• Mr B- I find it difficult to hold my hardness.

Even when I am hard, I cum quickly (ED
misdiagnosed as PE)

• Mr S- I lose hardness immediately after the

discharge (PE misdiagnosed as ED)
 Prevalence of PE
The USA National Health and
Social Life Survey (NHSLS)
study, 1999-
• 31% in men 18-59 years
• 30% (18-29 years)
• 32% (30-39 years)
• 28% (40-49 years)
• 55% (50-59 years).
The Global Study of Sexual
Attitudes and
Behaviors
(GSSAB), 2005-
• prevalence 30% in all age
groups
The Premature Ejaculation
Prevalence and
Attitudes
(PEPA) survey, 2007-
• prevalence 22.7%
• Does not vary with age
Waldinger et al., 2008-
• 2.3% (lifelong PE),
• 3.9% (acquired PE)
• 8.5% (natural variable PE)
• 5.1% (premature-like
ejaculatory dysfunction)
 How many seek treatment
The Global Study of Sexual Attitudes
and Behaviors (GSSAB), 2005-
• 78% men with perceived PE do not
seek professional help
• More likely to seek treatment for ED
The Premature Ejaculation Prevalence and
Attitudes (PEPA) survey, 2007-
• Only 9% men with PE seeks treatment
 Pathophysiology of PE
• Ejaculation is retarded by 5HT2C
receptors
• Ejaculation is facilitated by
5HT1A receptors

PE happens if there are

1. hyposensitivity of the 5-HT2C
2. hypersensitivity of the 5-HT1A
3. low 5-HT neurotransmission
4. spinal command set at lower
threshold
 Risk factors
• Prostate inflammation – 26-77% (Corona et al., 2010)
• Hyperthyroidism- 50% to 15% (Carani et al., 2005)
• Glans penis hypersensitivity
• Varicocele
• Detoxification from prescribed drugs (e.g., raboxetine ,citalopram) or recreational
drugs
• Chronic pelvic pain syndrome
• Varicocele
• ED
• Anxiety, emotional problem, stress
• Traumatic sexual experience
• Ethnicity- common in black men, Hispanic men and men from Islamic backgrounds
• Lower education levels
• Overall health status and obesity
• Family H/O (Waldinger et al., 1998; Finish Twin study, 2007)
• Genetics- the LL genotype ejaculated in a 100% shorter time than SL and SS genotype.
Evaluation
 Limitation of questionnaires
• 40% of men with PEDT-diagnosed PE and 19%
of men with probable PE self-reported the
condition
 Examination and investigations
• Embarrassment
• Attitude of the patient
• Reassuring for the patient
• Urethritis, Peyronie’s disease, phimosis
• Testicular examination in ED
• Prostatitis- routine screening?
• Endocrinopathy- Thyroid
• Neurological examination
• More important in acquired PE than lifelong PE (ISSM)
• Targeted investigations- dictated by H/O and examination
• No role of routine TSH screening
 Effect of PE in QoL
• Low satisfaction with
their sexual relationship
• Low satisfaction with
sexual intercourse
• Difficulty relaxing during
intercourse
• Less frequent intercourse
• Detrimental effect on self-
confidence
• Relationship-conflict
• Mental distress, anxiety,
depression
 Anteportal Ejaculation
• Ejaculation prior to vaginal penetration
• Considered the most severe form of PE
• Typically present when they are having
difficulty conceiving children.
• 5% of lifelong PE men suffer from
anteprotal PE (De Carufel et al., 2006;
Waldinger et al., 1998; Pagani et al., 1996)
 Principles of treatment
• Discuss the patient’s expectations thoroughly.
• Treat them first, if present
1. ED
2. Chronic prostatitis
3. Hyperthyroidism

Lifelong PE
1. Pharmacotherapy is the basis
• Dapoxetine on demand is the ONLY
approved treatment for PE
2. Behavioural therapy
Acquired PE
• Behavioural treatment first
• Add pharmacotherapy
 Physical/ Behavioural
•
Therapy
Hypothesis- PE occurs
because the man fails to
appreciate the sensations
before feelings of
ejaculatory inevitability.
• Re-training- attenuates
stimulus-response
connections by
progressively more intense
and more prolonged
stimulation, just below the
threshold for triggering
the response.
 Stop Start Technique
• Semans, 1956
• The partner stimulates the
penis until the patient feels the
urge to ejaculate.
• At this point, he instructs his
partner to stop, waits for the
sensation to pass
• Then stimulation is resumed
• 3 pauses before orgasm
Squeezing technique
• Masters and Johnson, 1970
• The partner applies manual
pressure to the glans just
before ejaculation until the
patient loses his urge.
• Squeeze for 15-20 sec
• 3 pauses before orgasm
Masturbation before coitus
• For younger men
• The penis is desensitised resulting in greater
ejaculatory delay after the refractory period
is over.
Outcome of behavioural therapy
• Short-term success rates of 50-60% (Grenier et
al., 1995; Metz et al., 1997)
• 8 fold increase in IELT than doing nothing (De
Carufel and Trudel, 2006)
• A double-blind, randomised, crossover study-
pharmacotherapy better IELT prolongation than
physical therapy (Abdel-Hamid et al., 2001)
• Combination with dapoxetine is better than
dapoxetrine alone in lifelong PE (Cormio et al.,
2015)
• Level 2b evidence (ISSM)
 Dapoxetine hydrochloride
• Short-acting SSRI
• Rapid Tmax (1.3 hours) and a short half-life (95% clearance after 24
hours)
• On demand (1-2 hr before coitus)
• Dose 30 mg and 60 mg increases IELT by 2.5- and 3.0-fold
respectively (Macmahon et al., 2011; Porst et al., 2010).
• Effective from the first dose (Porst et al., 2010)
• No increased risk of suicidal ideation or suicide attempts
• Level 1a evidence (ISSM)
 Long acting antidepressants
• To be given for 1-2 weeks before any benefit is seen
• TCA- Clomipramine 12.5-50 mg
• SSRIs- Paroxetine (8.8 fold delay in IELT) > Sertraline.>
fluoxetine > Citalopram
• Tachyphylaxis (decreasing response to a drug following chronic
administration)
• Decreased libido, anorgasmia, anejaculation and ED
• Should not be stopped abruptly
• Avoided in men with depressive disorders and <18 yr age
(suicidal ideation)
• Level 1a evidence (ISSM)
 Desensitising agents
• Local anaesthetic gel- oldest pharmacological
treatment of PE
• Lidocaine-prilocaine cream- 20-30 min before
intercourse
• Prolonged application (30-45 minutes) → loss of
erection due to numbness of the penis
• A condom will prevent diffusion of the topical
anaesthetic agent into the vaginal wall
• Level of evidence 1b (ISSM)
 Tramado
• Atypical opioid l
• Activates opioid (µ) receptors centrally, inhibits
serotonin and noradrenaline uptake
• 62 and 89 mg increases IELT by 2.4 and 2.5 fold
respectively
• US-FDA, 2009- addiction, dyspnoea
• Level of evidence 2d (ISSM)
• Not recommended for PE
 Phosphodiesterase-5 inhibitors
• Sildenafil vs placebo- does not improve IELT, improves
satisfaction and confidence, reduces the refractory time to
achieve a second erection after ejaculation.
• Sildenafil + physical therapy- better than physical therapy
alone
• SSRI+sildenafil- better than monotherapy with
SSRI (paroxetine, sertraline)
• Limited data on other drugs (Vardenafil, Tadalafil)
• Level 4d evidence
• Should NOT be used in PE without any evidence of
ED
 Role of surgery
• In refractory lifelong PE,
• Surgically induced penile hypo-anesthesia
1. Selective dorsal nerve neurotomy
2. Hyaluronic acid gel glans penis
augmentation
• May be associated with permanent loss
of sexual function
• Level 4 evidence (ISSM)
• NOT recommended