Guide: Premature ejaculation

Definition
Several imprecise definitions of premature ejaculation (PE) exist. The most recent definition,
developed by the International Society for Sexual Medicine (ISSM), is based on clearly definable
criteria (Althof, 2014):
 Ejaculation that always or nearly always occurs prior to or within about 1 minute of vaginal
penetration from the first sexual experience (lifelong PE)
OR
 A clinically significant reduction in intra-vaginal ejaculatory latency time (IELT), often to
about 3 minutes or less (acquired PE)
AND
 The inability to delay ejaculation on all or nearly all vaginal penetrations
AND
 Negative personal consequences, such as distress, bother, frustration, and/or the avoidance of
sexual intimacy.
Ejaculation occurring prior to vaginal penetration (ante-portal ejaculation) is the most severe form of
PE, typically presenting in men or couples having difficulty conceiving.

Diagnosis
Diagnosis is based on the patient’s medical and sexual history. PE is classified as either primary
(lifelong) or secondary (acquired):

Primary (lifelong) PE
 Tends to present in men in their 20s and 30s
 Patient has never had control of ejaculation
 Underlying disease unlikely to be present
Secondary (acquired) PE
 Tends to present in older men
 Patient was previously able to control ejaculation
 Commonly associated with erectile dysfunction or other underlying disease
ISSM has proposed further diagnostic categories for men who present with distressing ejaculatory
problems but who do not fall within the above criteria:
 Variable PE - short IELT that occurs irregularly and inconsistently with perception of
diminished control of ejaculation. Considered a normal variation in sexual performance

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  Subjective PE – characterised by one or more of the following:
o Perceived short IELT or lack of control over the timing of ejaculation
o IELT in the normal range or even longer duration (i.e., after 5 minutes)
o Diminished ability to control ejaculation (i.e., to withhold ejaculation at the moment
of imminent ejaculation)
o Other pre-occupations that cannot be explained by a mental disorder
ISSM recommended treatments for VPE and SPE focus on reassurance, education, psychotherapy and
behavioral therapy.

Presentation and taking a history

PE may be identified when the man or his partner presents with relationship or sexual difficulties.
Establish sexual and medical histories as a first step (Andrology Australia 2014, Palmer 2008).

Sexual history
 Establish IELT - ask the man or his partner to estimate or use a stopwatch
 Onset and duration of PE
 Precipitating factors (sexual education, masturbation guilt, religious or cultural inhibitions)
 Previous sexual function
 Frequency of sexual relations (infrequent sexual activity can be a factor)
 Perceived degree of ejaculatory control
 Degree of patient/partner distress
 Determine if fertility is an issue
 Distinguish PE from erectile dysfunction
Other factors that may have an influence:
 Novelty of the partner or sexual situation
 Depression, anxiety, stressors
 Taboos or beliefs about sex

Medical history
 General medical history
 Cardiovascular history
 Medications (prescription and non prescription)
 Trauma (urogenital, neurological, surgical)

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  Infections – including STDs
In older men with secondary PE (especially if secondary to erectile dysfunction), investigate risk
factors-
 Cardiovascular disease
 Hypertension
 Hyperlipidaemia
 Diabetes
 Obesity
 Obstructive sleep apnoea
 Peyronie’s disease
 Lower urinary tract symptoms (urethritis or prostatitis)
 Hyperthyroidism (uncommon)
 Endocrine dysfunction, especially gynaecomastia
Common causes of secondary PE (Althof 2014)
 Erectile dysfunction (ED) – Rapid ejaculation becomes a compensatory mechanism for many
men with declining erectile function. Patients may confuse PE and erectile dysfunction where
they are unable to achieve a second erection after ejaculation, or because they rush intercourse
to prevent loss of their erection. High levels of anxiety related to their ED may worsen any PE
symptoms. However, PE and ED may occur independently as co-morbid conditions in some
men.
 Prostatitis – prostatic inflammations and chronic bacterial prostatitis are common findings in
men with secondary PE. Physical and microbiological examination is recommended in men
with painful ejaculation, or prostatic pain, but routine screening for prostate disorder in all
men with PE is not supported by the evidence.
 Psychological factors – psychological or interpersonal factors may cause or exacerbate PE.
The problem may be circular – for example, performance anxiety may lead to PE, which in
turn worsens the original performance anxiety.

Physical examination and investigations (Palmer 2008)

 Physical examination is rarely needed in younger patients with primary PE. Routine
laboratory or neurophysiological tests should be carried out only if indicated by specific
findings from the history or physical examination.
 If investigating suspected secondary PE, it is important to perform a general medical
examination as well as a genital examination, including neurological assessment of the genital
area and a penile and testicular examination. Check gait, muscle strength, sacral reflex arc,
S2-S4 and general reflexes.

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  If PE occurs with painful ejaculation, a rectal examination should also be conducted to
determine presence of prostatic inflammation.
Management
Management involves both the patient and his partner and therapeutic options should suit both
partners. Control over ejaculation and satisfaction with sexual intercourse are the central issues for
men with PE and should be the highest priority when assessing PE and evaluating treatment for this
condition. Before beginning treatment, it is essential to discuss the patient's expectations thoroughly.
Management of PE is guided by the underlying cause (Andrology Australia 2014).
Primary PE:
 1st line: SSRIs, reduction of penile sensation
 2nd line: Behavioural techniques, counselling
 Most men require ongoing treatment to maintain normal function
Secondary PE:
If secondary to ED, investigate and manage the underlying cause of the ED. Treatment of ED with
PDE5 inhibitors is effective.
 1st line: Behavioural techniques, counselling
 2nd line: SSRI, reducing penile sensation
 Many men return to normal function following treatment
Pharmacological treatment
The most effective and well-tolerated treatment for primary PE is pharmacological therapy with
SSRIs, usually given in small doses on a daily basis.
Dapoxetine hydrochloride (30mg, taken 1-3 hours before intercourse) is the only SSRI specifically
approved for treatment of PE in Australia (TGA), with trials demonstrating ≥ 50% increase in IELT
(McCarty 2012). The following alternative regimens have been reported (Andrology Australia 2014):
 Fluoxetine hydrochloride: 20 mg/day
 Paroxetine hydrochloride: 20 mg/day.
 Sertraline hydrochloride: 50 mg/day or 100 mg/day.
 Clomipramine hydrochloride: 25-50 mg/day or 25 mg 4-24 hours before intercourse.
 PDE-5 Inhibitors (if PE is related to ED):30-60 minutes pre-intercourse.
Start with low doses and titrate upwards. Trial for 3-6 months and then slowly titrate down to
cessation. If PE reoccurs, resume treatment with the same drug. Trial an alternative drug if first choice
is not effective.
Take into account the following when prescribing pharmacotherapy (Palmer 2008):
 Time to onset of action and effect on spontaneity of intercourse – paroxetine and sertraline
have a slow onset (5 hours) and long half-life, making them less suitable for on-demand use,
and need to be taken daily to maintain efficacy. Paroxetine (the first SSRI developed
specifically to treat PE) is rapidly absorbed with a short half-life, and can be taken on demand

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 (MJA). Daily treatments may have less effect on spontaneity than pre-intercourse dosing – be
guided by patient preference and sexual habits.
 Side effects, particularly with higher dose tricyclic anti-depressants eg., clomipramine
50mg/day. Commonly reported side effects include dry mouth, constipation, nausea, sleep
disturbances, fatigue, dizziness and hot flushes. Titrate carefully upwards from low starting
doses to minimize side effects.

Reduction of penile sensation (Andrology Australia 2014)

 Topical applications: Local anaesthetic gels or creams can diminish sensitivity and delay
ejaculation. Excess use is associated with loss of pleasure, orgasm and erection. Apply 30
minutes prior to intercourse. Anaesthetic – containing condoms are available to prevent trans-
vaginal absorption.
 Lignocaine ointment: 5% - apply 20-30 minutes before intercourse
 Lignocaine spray: 10%
 Double condoms: Using 2 condoms can diminish sensitivity and delay ejaculation.
The above regimens may be combined for maximum effectiveness. Anaesthetic agents may cause
penile numbness, leading to loss of the erection. Creams may cause local symptoms of irritation and
burning.

Behavioural techniques
The ‘stop-start’ technique:
 Sexual stimulation until just before orgasm – patient recognises their ‘point of no return’ in
order to learn to control the sensations prior to ejaculation.
 Stop and rest for about 30 seconds then resume. Repeat if necessary, then continue
stimulation until orgasm.
The "squeeze" method:
 Sexual stimulation until just before orgasm to lessen the urge to ejaculate. At that point, the
man or his partner gently squeezes the end of the penis (where the glans meets the shaft) for
several seconds. Stop sexual stimulation for about 30 seconds, then repeat. The last time,
continue stimulation until orgasm.
Other techniques/strategies (Althof 2014):
 Extended foreplay
 Pre-intercourse masturbation
 Cognitive distractions
 Alternate sexual positions
 Interval sex
 Increased frequency of sex

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Counselling
Psychological problems are usually a consequence of PE rather than the cause, although the link can
be reciprocal. The main psychological presentation is anxiety (Hatzimouratidis 2015).
 It is important to address the issue that has created the anxiety or psychogenic cause.
 Limited studies indicate that behavioural therapy, as well as functional sexological treatment,
lead to improvement in the duration of intercourse and sexual satisfaction. However, the
evidence for the effectiveness of psychological interventions for the treatment of premature
ejaculation is weak and inconsistent (Melnik 2011).
 Techniques to improve ejaculatory control, including meditation/relaxation, hypnotherapy and
neuro-biofeedback may be helpful.

Referral
General practitioners should be able to diagnose, offer support, and prescribe behavioral exercises for
men suffering from PE. When the situation is complex, there are co-morbidities or patients do not
respond to the initial intervention, consider referral:
 General referral: endocrinologist or urologist
 If lower urinary tract disease: Urologist
 If hormonal problem: Endocrinologist
 Psychosexual issues; Counsellor, psychologist, psychiatrist or sexual therapist
 Fertility issues: fertility specialist

References:
1. Althof, E, McMahon CG, Waldinger MD, et al. An update of the International Society of Sexual
Medicine’s guidelines for the diagnosis and treatment of premature ejaculation (PE). Sex Med
2014;2:60–90 2. Andrology Australia. Premature ejaculation and other ejaculatory disorders –
diagnosis and management. Clinical summary guide 8. 2007, updated February 2014. 3. Palmer NR,
Stuckey BGA. Premature ejaculation: a clinical update MJA 2008; 188: 662–666 4. McCarty E,
Dinsmore W. Dapoxetine: an evidence-based review of its effectiveness in treatment of premature
ejaculation. Core Evidence 2012;7:1–14 5. Hatzimouratidis K, Eardley I, Giuliano F, et al. Guidelines
on male sexual dysfunction: erectile dysfunction and premature ejaculation. European Association of
Urology 2015 6. Melnik T, Althof S, Atallah ÁN, et al. Psychosocial interventions for premature
ejaculation (Review). Cochrane Database of Systematic Reviews 2011, DOI:
10.1002/14651858.CD008195.pub2.

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