Definition and terminology
The International Society for Sexual Medicine (ISSM) Ad Hoc Committee recently reviewed it’s definition of Premature Ejaculation (PE). Premature ejaculation can be present since the first sexual encounter; (lifelong premature ejaculation, LPE) or can develop after an initially period of ‘normal’ ejaculatory time (acquired premature ejaculation, APE).
The diagnosis of premature ejaculation involves 3 main components:
- Ejaculation that always or nearly always occurs prior to or within about 1 minute of vaginal penetration from the first sexual experience (LPE), OR a clinically significant reduction in latency time, often to about 3 minutes or less (acquired premature ejaculation)
- The man experiences the inability to delay ejaculation on all or nearly all vaginal penetrations
- The man experiences negative personal consequences, such as distress, bother, frustration, and/or the avoidance of sexual intimacy.
Please note that the definition is limited to intra-vaginal sexual activity, as the evidence could not be correlated with other sexual activities. In addition, it does not define PE when men have sex with men. The committee concluded that there was insufficient information available to extend the definition to these other situations or groups.
Other terminology which can be used when describing premature ejaculation include:
Anteportal ejaculation
Is the term applied to men who ejaculate prior to vaginal penetration and is considered the most severe form of PE. It can result in difficulty conceiving children. It is estimated that between 5% and 20% of men with LPE suffer from anteportal PE.
Variable premature ejaculation (VPE)
VPE is characterized by short ejaculatory latency that occurs irregularly and inconsistently with some subjective sense of diminished control of ejaculation. This subtype is not considered a sexual dysfunction but rather a normal variation in sexual performance.
Erectile dysfunction
Premature ejaculation may occur simultaneously with erectile dysfunction, that is, the inability to obtain and/or maintain an erection which is satisfactory for vaginal penetration. There is no evidence however that PE will lead to erectile dysfunction.
Diagnosis and Investigations
Diagnosis is based on history and examination. History includes:
- Sexual history, which will include questions about your erections, ejaculation time and relationship with your partner. It may also include completing a questionnaire like the one below.
- Voiding history and other lower urinary tract symptoms.
- Documenting other medical problems including medications you are taking.
Treatment options
Treatment for PE needs to be tailored to each individual, and sometimes combination therapy is required. Also occasionally PE may be associated with other medical conditions that need treatment as well. It is advisable therefore, that you see a medical professional prior to starting any treatment.
Options for treatment include but are not limited to:
Psychological/ Behavioural therapy
Psychological/Behavioural therapy has two overlapping goals. First, psychological interventions aim to help men develop sexual skills that enable them to delay ejaculation while broadening their sexual scripts, increasing sexual self-confidence, and diminishing performance anxiety. The second goal focuses on resolving psychological and interpersonal issues that may have precipitated or be the consequence of the PE symptom for the man, partner, or couple. Present day psychotherapy for is an integration of psychodynamic, systems, behavioural, and cognitive approaches within a short-term psychotherapy model.
Medication
SSRI
One of the most effective medications for treating PE are selective serotonin reuptake inhibitors (SSRIs). This medications acts on the central nervous system to increase the amount of serotonin in the brain. This has the effect of giving men more control over sexual functions.
SSRI medication includes Dapoxetine (Priligy), which was specifically developed to treat PE and other SSRIs including Sertraline, Paroxetine, clomipramine and fluoxetine. SSRIs are also used to treat depression, anxiety and other medical problems.
SSRIs are effective in both men with LPE and with APE. Men taking medication report increase ejaculatory time, increase ejaculatory control and decreased distress, resulting in increased satisfaction. The medication can be taken either on demand (that is just prior to anticipated sexual activity) or as a daily tablet.
Treatment-related side effects are uncommon and included nausea, diarrhea, headache, and dizziness. If you are on an SSRI you should be advised to avoid sudden cessation or rapid dose reduction as it may cause SSRI withdrawal syndrome.
Men wishing to impregnate their partners should be advised that SSRIs may affect the motility of spermatozoa and therefore should not begin treatment with an SSRI, or if on an SSRI, gradually discontinue taking it . Caution is suggested in prescribing SSRIs to young adolescents with PE aged 18 years or less and to men with PE and depression.
Topical Local Anaesthetics (LA)
The use of topical LA is moderately effective in delaying ejaculation. Diminishing the glans sensitivity may inhibit the spinal reflex arc responsible for ejaculation. Care needs to be taken not to transfer the topical anaesthetic to the vagina during intercourse.