premature%20ejaculation
PREMATURE EJACULATION
Premature ejaculation is a male sexual dysfunction characterized by short, easily stimulated ejaculation that occurs always or nearly always before or within one minute of vaginal penetration.
It is involuntarily controlled and causes negative personal consequences like distress, frustration and avoidance of sexual intimacy.
Exact etiology and risk factors are unknown.

Diagnosis

  • The diagnosis of PE relies mainly on medical and sexual history
    • Intravaginal ejaculatory latency time (IELT), perceived control, distress and interpersonal difficulty due to ejaculatory dysfunction are assessed

Classification

Classification of PE

Lifelong/Primary PE

  • PE with onset from the first sexual experience and remains a problem throughout life
  • Ejaculation occurs too quickly, either before vaginal penetration or within about 1 minute afterwards

Acquired/Secondary PE

  • Onset of PE is gradual or sudden with ejaculation being normal prior to onset
  • Time of ejaculation is short but not as fast as in primary PE, often about ≤3 minutes

Anteportal Ejaculation

  • Men who ejaculate prior to vaginal penetration and is considered the most severe form of PE
    • Such men typically present when they are having difficulty conceiving children

Subclasses

  • Not evidence-based but important as it accurately characterizes men who are not qualified for the diagnosis of PE and these may help health care professionals

Natural Variable PE

  • Characterized by early ejaculations that occur irregularly and inconsistently with some subjective sense of diminished control of ejaculation
  • Not considered as a sexual dysfunction or psychopathology but rather a normal variation in sexual performance

Premature-like Ejaculatory Dysfunction (Subjective PE)

  • An imagined early ejaculation or lack of control of ejaculation while ejaculation latency time is in the normal range or can even last longer
  • Ability to control ejaculation (ie to withhold ejaculation at the moment of imminent ejaculation) may be diminished or lacking
  • Preoccupation is not better accounted for by another mental disorder

Assessment

Assessment of Ejaculatory Latency

Stopwatch Assessment of Ejaculatory Latency

  • Widely used in clinical trials and observational studies but have not been recommended in use in routine clinical management of PE
  • Advantage of objective measurement but disadvantage of being intrusive and potentially disruptive of sexual pleasure or spontaneity

Self Estimation of IELT by the patient and partner

  • Recommended method of determining IELT in clinical practice

History

Sexual History

  • Assess frequency and duration of PE, relationship to specific partners, occurrence with all or some attempts, degree of stimulus resulting in PE, nature and frequency of sexual activity, impact on sexual activity, types and quality of personal relationships and quality of life, aggravating or alleviating factors, and relationship to drug use or abuse
    • Length of time of ejaculation, degree of sexual stimulus, impact on sexual activity and quality of life and drug use or abuse helps in classifying the type of PE the patient has
  • Differentiate PE from erectile dysfunction (ED)
  • IELT alone is not sufficient to define PE because there is significant overlap between men with and without PE
    • But, in everyday clinical practice, self-estimated IELT is sufficient

Questionnaires that can be used to characterize PE and determine treatment effects are:

  • Standardized assessment measures include the use of validated questionnaires, in addition to stopwatch measures of ejaculatory latency
  • Premature Ejaculation Diagnostic Tool (PEDT)
    • Short, psychometrically validated measure that can be easily administered to facilitate the diagnosis of PE
    • Assesses control, frequency, minimal sexual stimulation, distress and interpersonal difficulty
    • A total score of ≥11 suggests a diagnosis of PE, a score of 9 or 10 suggests a probable diagnosis of PE while a score of ≤8 indicates a low likelihood
    • Most widely used questionnaire
  • Arabic Index of Premature Ejaculation (AIPE)
    • Assesses control, hard erections for sufficient intercourse, satisfaction for the patient and partner, sexual desire, time to ejaculation, anxiety or depression
    • Scores range from 7-35 with a cut-off score of 30 suggesting a diagnosis of PE and classified into mild (score of 26-30), moderate (score of 14-19), mild to moderate (score of 20-25), and severe (score of 7-13)
  • Premature Ejaculation Profile (PEP)
    • Contains questions regarding perceived control over ejaculation, satisfaction with sexual intercourse, personal distress related to ejaculation, interpersonal difficulty related to ejaculation
  • Index of Premature Ejaculation (IPE)
    • Contains questions regarding control, sexual satisfaction and distress
  • Male Sexual Health Questionnaire Ejaculatory Dysfunction (MSHQ-EjD)
  • Only PEDT and AIPE can discriminate between patients with or without PE
  • Currently, the role of questionnaires is optional in everyday clinical practice
  • PEP and IPE are currently the preferred questionnaire measures to assess PE, particularly in monitoring responsiveness to treatment
  • These measures may serve as useful adjuncts but should not be used as a substitute for a detailed sexual history performed by a qualified clinician

Physical Examination

  • Brief examination of the vascular, endocrine, and neurologic systems to identify underlying medical conditions associated with PE or other sexual dysfunctions
  • Advisable in lifelong PE and acquired PE to assess for associated/causal diseases such as ED, thyroid dysfunction and prostatitis, risk factors and etiologies

Laboratory Tests

Laboratory or Physiologic Testing

  • Should be directed by specific findings from history or physical exam and is not routinely recommended
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