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.

Pharmacotherapy

  • Basis of treatment in lifelong PE, but all medical treatments (except for Dapoxetine) are off-label indications
  • Chronic antidepressants including selective serotonin reuptake inhibitors (SSRIs) and Clomipramine and on-demand topical anesthetic agents have consistently shown efficacy in PE

Selective Serotonin Reuptake Inhibitors (SSRIs)

  • Daily SSRIs are the first choice of treatment but are use off-label
  • Eg Paroxetine, Sertraline, Fluoxetine, Citalopram
  • Ejaculation delay may start 5-10 days after drug intake, but it is more evident after 2-3 weeks and may be maintained for several years
  • Blocks axonal reuptake of serotonin from the synaptic cleft of central serotonergic neurons by 5-HT transporters, resulting in enhanced 5-HT neurotransmission and stimulation of post-synaptic membrane 5-HT autoreceptors
  • In most studies, on-demand administration 3-6 hours prior to intercourse is modestly efficacious and well tolerated but is associated with substantially less ejaculatory delay than daily treatment
  • For SSRIs or TCAs, PE returns when the medication is discontinued

Dapoxetine

  • Potent SSRI that has been specially designed as an on-demand oral treatment for PE
  • Improves IELT significantly
  • Approved in over 50 countries
  • Clinical trials have shown that if taken 1-2 hours before intercourse, it was effective from the first dose on IELT with increased ejaculatory control, decreased distress, and increased satisfaction
  • Comparably effective on both lifelong and acquired PE
  • No drug-drug interactions associated with Dapoxetine including phosphodiesterase (PDE) inhibitor drugs
    • Generally well tolerated when co-administered with PDE inhibitors but may increase the risk of possible prodromal symptoms that may progress to syncope as compared to when either drugs are administered alone

Clomipramine

  • Serotonergic tricyclic antidepressant
  • Effective in delaying ejaculation but use off-label for the treatment of acquired and lifelong PE
  • A controlled-trial has shown that on-demand use of Clomipramine 3-5 hours before intercourse, was less efficacious compared to daily dosing

Topical Anesthetic Agents

  • Eg, Lidocaine-Prilocaine cream
  • Diminishes the sensitivity of the glans penis that may inhibit the spinal reflex arc responsible for ejaculation
  • Use is well established and is moderately effective in delaying ejaculation
  • There are evidences of efficacy and effectiveness as off-label on-demand treatment for lifelong PE
  • Lidocaine-Prilocaine cream applied 20-30 minutes prior to intercourse
    • Prolonged application (eg 30-45 minutes) may result in the loss of erection due to numbness of the penis
    • Condom should be worn to avoid diffusion of the topical agent to the vaginal wall that can cause numbness in the partner

Tramadol

  • Has been investigated as a potential off-label therapy for PE with several studies demonstrating efficacy
  • Should be considered only when other therapies are not effective due to potential risk of addiction and side effects
  • Further well-controlled studies is needed to assess the efficacy and safety in the treatment of PE

Phosphodiesterase type 5 Inhibitors

  • Eg Sildenafil, Tadalafil, Vardenafil
  • Several recent studies supported its therapeutic role but there is only one clinical trial that shows Sildenafil’s role in the treatment of PE
  • IELT was not significantly improved but Sildenafil increased confidence, perception of ejaculatory control, and overall sexual satisfaction as well as reduced anxiety and decreased refractory time to achieve a second erection after ejaculation
  • Treatment in men with lifelong PE with normal erectile function is not recommended and further evidence-based research is encouraged to understand conflicting data
COMBINATION THERAPY
  • Studies have shown that combination therapy (ie pharmacological therapy was given in conjunction with a behavioural treatment) was better than pharmacological therapy alone on either IELT index
  • Combining a medical and psychological approach may be especially useful in men with acquired PE where there is a clear psychosocial precipitant, or lifelong cases where the individual or couple’s issues interfere with the medical treatment and success of therapy
    • Similarly, in men with PE and comorbid erectile dysfunction, combination therapy may also be helpful to manage the psychosocial aspects of the sexual dysfunctions
  • Modern approach to PE treatment

Non-Pharmacological Therapy

  • Indicated in patients uncomfortable with pharmacological therapy
  • Behavioural techniques are not recommended for first line treatment of lifelong PE
  • Goals of psychotherapy in men and couples suffering from PE are:
    • Help men develop sexual skills that will enable them to delay ejaculation while broadening their sexual scripts, increasing sexual self-confidence and diminishing performance anxiety
    • Focus on resolving psychological and interpersonal issues that may have precipitated, maintained or be the consequence of the PE symptom for the man, partner or couple
  • Psychotherapy offers men, women and couples benefit, including the development of sexual skills, delay of ejaculation improving relationship concerns and sexual self-confidence
  • Efficacy of psychological and behavioral interventions have some supporting evidence although future well designed studies on the efficacy of psychotherapy are needed
  • Men with natural variable PE should be educated and reassured
  • Men with premature-like ejaculatory dysfunction may require a referral for psychotherapy

Behavioural Strategies

  • Stop-Start maneuver involves the partner stimulating the man’s penis until the sensation of almost climaxing (inevitable orgasm) is felt and at which time stimulation is abruptly stopped until this feeling disappeared
    • The partner must repeat this cycle until the ejaculation can be controlled voluntarily
  • In the Squeeze technique, the partner is advised to squeeze the penile frenulum or glans, just on cessation of penile stimulation at the time of inevitable orgasm, and then the female partner restarts the stimulation at least 30 seconds later
  • Stop-Start and Squeeze techniques are typically applied in a cycle of three pauses proceeding to orgasm
    • They focus on distraction and a reduction of excitement or stimulation, that may also detract from overall sexual satisfaction, and are based on the theory that the reason PE occurs is that the man fails to appreciate the sensations of heightened arousal and to recognize the feelings of ejaculatory inevitability
    • The main goal of traditional psychosexual treatment for PE is to help men identify the premonitory sense of ejaculation/orgasm and work with the patient to improve self-control
  • Masturbation before anticipation of sexual intercourse is the behavioral technique usually used by many younger men
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