Elizabeth K. Peacock, MD
James S. Rosoff, MD
BASICS
DESCRIPTION
• Definition of premature ejaculation (PE) remains controversial:
– ISSM (2008): Ejaculation within about a minute and inability to delay ejaculation with all or nearly all vaginal penetrations causing negative personal consequences (1)
– WHO (2004): Inability to delay ejaculation with ejaculation before/soon after starting intercourse (15 s)
– AUA (2004): Ejaculation sooner than desired, before or shortly after penetration that causes distress to 1/both partners
– EAU (2001): Inability to control ejaculation for sufficient time before vaginal penetration
– APA (2001): Persistent or recurrent ejaculation with minimal sexual stimulation
• May also be classified as primary (lifelong PE) or secondary (acquired PE)
• ICD-10 uses 15 s of intravaginal ejaculatory latency time (IELT) as a cutoff
EPIDEMIOLOGY
Incidence
Unknown
Prevalence
• PE is the most common sexual dysfunction in men <40
• Approximately 20–30% in this group
RISK FACTORS
• Increased levels of arousal due to new partner or situation
• Low frequency of sexual activity
Genetics
Polymorphism in the serotonin transporter promoter region (5-HTTLPR) may play a genetic role in the etiology and/or treatment of PE, though this is controversial.
PATHOPHYSIOLOGY
• Serotonin receptor stimulation (5-hydroxytryptamine):
– Serotonin 5-HT2c receptors inhibit ejaculation, 5-HT1a receptors facilitate ejaculation
– Hyposensitivity of 5-HT2c or hypersensitivity of 5-HT1a may cause PE
– Increase in serotonin transporter (5-HTT) may play a genetic role in PE
• Consider psychological factors, hormone alterations, penile sensitivity, circumcision status, chronic prostatitis as potential causes though with limited evidence supporting these
ASSOCIATED CONDITIONS
• Erectile dysfunction
• General anxiety
• Situational anxiety
• Depression
• Substance abuse
• Relationship distress
• Prostatitis
GENERAL PREVENTION
N/A
DIAGNOSIS
HISTORY
• Time to ejaculation is essential
– Duration/frequency of PE
– Rate of occurrence of PE
– Degree of sexual stimulation causing PE
– Nature/frequency of sexual activity including foreplay, masturbation, and intercourse
• Discuss length of time experiencing PE, perceived lack of control, and resultant sexual dissatisfaction
• Any indication of ED
• Issues with the partner, such as dyspareunia or other medical problems
• Rule out symptoms consistent with cystitis or prostatitis
• Medication history: Consider PE due to withdrawal from narcotics or trifluoperazine (Stelazine)
• Sexual History
– Global to all sexual encounters, or with specific situations and/or partners
– Religious upbringing
– Early sexual experiences
– Sexual relationships, past and present
– Conflicts or concerns within current relationship
– Traumatic sexual experiences
PHYSICAL EXAM
• Complete physical exam with focus to rule out biologic causes including recent pelvic surgery or infectious source
• Rectal exam to assess for prostatitis
• Rare to have findings on exam that would define etiology or change management
DIAGNOSTIC TESTS & INTERPRETATION
Lab
Usually unnecessary
Imaging
N/A
Diagnostic Procedures/Surgery
N/A
Pathologic Findings
N/A
DIFFERENTIAL DIAGNOSIS
• Erectile dysfunction
• Generalized anxiety disorder
• Other anxiety states
• Substance abuse
TREATMENT
GENERAL MEASURES
• Behavioral treatment:
– Stop–squeeze method (Masters and Johnson) involves removal of penis at point of ejaculation with squeezing of glans or frenulum
– Start–stop method (Seman) involves a pause in intercourse at point of ejaculation
– High initial success rates are reported, but poor long-term rates are present due to the time-consuming nature of treatment
• Psychotherapy may be beneficial
• Combination of pharmacotherapy and psychotherapy is suggested as current model for treatment
MEDICATION
First Line
• No medications are approved for treatment of PE in the United States
– SSRIs:
Elevates level of serotonin in synapse that results in prolongation of ejaculatory latency time
1st-line pharmacotherapeutic approach (off-label)
Daily treatment with PO paroxetine 20–40 mg (greatest evidence), sertraline 25–200 mg, fluoxetine 5–20 mg
Newer agents have not been effective (fluvoxamine/venlafaxine)
Dapoxetine approved in Europe only for on-demand dosing for PE
– Topical agents:
EMLA: Lidocaine–prilocaine 2.5% cream
TEMPE: Metered-dose aerosol spray with lidocaine 7.5 mg and prilocaine 2.5 mg per spray
Second Line
• Clomipramine:
– Tricyclic antidepressant
– Daily treatment with 25–50 mg or on-demand treatment with 50 mg 5 hrs prior to intercourse
• Tramadol (synthetic opioid analgesic) with potential treatment role in PE (little evidence) (2)
SURGERY/OTHER PROCEDURES
CT-guided cryoablation of unilateral dorsal penile nerve (single study, 24 patients) (3)
ADDITIONAL TREATMENT
Radiation Therapy
N/A
Additional Therapies
European Medicines Agency’s Committee for Medicinal Products for Human Use (CHMP) has recommended authorization of a cutaneous spray containing a mixture of 150 mg lidocaine and 50 mg prilocaine per milliliter applied to the glans
Complementary & Alternative Therapies
N/A
ONGOING CARE
PROGNOSIS
Varies by treatment modality. May have up to 80% success rate with medication and/or behavioral modification
COMPLICATIONS
• Medications carry side effects, but complications of PE are limited
• Rarely, a problem with fertility may exist due to inability to complete intercourse
• May provoke anxiety or depression if PE is severe
• May interfere with development of sexual relationship
FOLLOW-UP
Patient Monitoring
N/A
Patient Resources
Urology Care Foundation. http://www.urologyhealth.org/urology/index.cfm?article=122
REFERENCES
1. McMahon CG, Althof S, Waldinger MD, et al. An evidence-based definition of lifelong premature ejaculation: Report of the International Society for Sexual Medicine Ad Hoc Committee for the Definition of Premature Ejaculation. BJU Int. 2008;102(3):338–350.
2. Montague DK, Jarow J, Broderick GA, et al. AUA guideline on the pharmacologic management of premature ejaculation. J Urol. 2004;172(1):290–294.
3. David Prologo J, Snyder LL, Cherullo E, et al. Percutaneous CT-guided cryoablation of the dorsal penile nerve for treatment of symptomatic premature ejaculation. J Vasc Interv Radiol. 2013;24(2):214–219.
ADDITIONAL READING
Bejma JP, Hellstrom WJG. Premature ejaculation. AUA Update Series. 2007;26:366–372.
See Also (Topic, Algorithm, Media)
• Dysorgasmia (Painful Orgasm), Male
• Ejaculatory Disturbances (Delayed, Decreased, or Absent)
• Ejaculation Premature Algorithm 
CODES
ICD9
302.75 Premature ejaculation
ICD10
F52.4 Premature ejaculation
CLINICAL/SURGICAL PEARLS
• Exact definition of PE remains controversial.
• Combination of pharmacotherapy (off-label use) and psychotherapy is likely the most beneficial treatment.