Continuing Education Activity
Premature ejaculation describes the phenomenon which occurs when ejaculation happens sooner than a man or his partner would like during sexual activity. It is considered to be the most common sexual disorder in the male population. This activity describes the evaluation and management of premature ejaculation and highlights the role of the interprofessional team in managing patients with this condition.
- Identify the typical diagnostic criteria for a patient with premature ejaculation.
- Summarize the epidemiology of premature ejaculation.
- Review the treatment considerations for patients with premature ejaculation.
- Outline the importance of collaboration and communication amongst interprofessional team members to improve outcomes for patients affected by premature ejaculation.
Ejaculation occurs when the semen gets released from the male reproductive system. The term premature ejaculation describes the phenomenon which occurs when ejaculation happens sooner than a man or his partner would like during sexual activity. About 30% of men are affected but possibly up to 75% in some reviews. Thus it is considered to be the most common sexual disorder in the male population. Occasional premature ejaculation is not a cause for concern; however, for those individuals who meet diagnostic criteria, this condition can cause significant distress and impairment as the sexual activity may be less enjoyable, and relationships may suffer negative consequences.
There are several different definitions of premature ejaculation. It has been defined simply as an inability to exert voluntary control over the ejaculatory reflex or as the condition where a man reaches orgasm and ejaculates before he desires to do so. Masters and Johnson defined it as "the inability of the male to control ejaculation sufficiently to satisfy his female partner in more than 50% of coital episodes provided that she is not anorgasmic" while Strassberg et al. defines it as "the condition where the male has little voluntary control over ejaculation and ejaculates within 2 minutes or less after intromission in at least 50% of coital attempts." The World Health Organization (WHO) describes premature ejaculation as "the inability to delay ejaculation sufficient to enjoy lovemaking, which is manifested by either an occurrence of ejaculation before or very soon after the beginning of intercourse or ejaculation occurring in the absence of sufficient erection to make intercourse possible." Some have suggested that any ejaculation which occurs less than 1 minute after vaginal penetration is automatically "premature" while others suggest that this intravaginal time should normally be at least 4 minutes long with anything less considered pathological.
The DSM-5 defines premature ejaculation as follows:
- Ejaculation occurs during partnered sexual activity within approximately 1 minute following vaginal penetration and before the individual wishes it, during all or almost all sexual activity (75% to 100% of the time)
- Symptoms must persist for at minimum 6 months and cause clinically significant distress to the individual
- The dysfunction is not explainable by a nonsexual mental disorder, medical conditions, the effects of a drug or medication, or severe relationship distress or other significant stressors
The severity of premature ejaculation ranges from mild to severe as follows:
- Mild (occurs within approximately 30 seconds to 1 minute of penetration)
- Moderate (occurs within approximately 15 to 30 seconds of penetration)
- Severe (occurs before sexual activity, at the start of sexual activity, or within approximately 15 seconds of penetration)
Additional specifiers in regards to duration and context are as follows:
- Lifelong - (present since first sexual experience)
- Acquired - (developing after a period of relative normal sexual functioning)
- Generalized - (not limited to specific types of stimulation, situation, or partners)
- Situational - (limited to certain types of stimulation, situations, or partners)
Approximately 30% of men ages 18 to 59 years old have problems with premature ejaculation; however, shame and embarrassment prevent many men from discussing this sensitive topic with their provider. As premature ejaculation has both psychological and biological origins, there are a variety of medications, therapeutic options, and sexual techniques available to delay ejaculation, which may improve sexual satisfaction and intimacy.
A precise cause for premature ejaculation remains undetermined; however, several risk factors are possible. Biological factors including:
- Abnormal levels of the brain neurotransmitter serotonin - low serotonin levels are thought to shorten the time to ejaculation
- Abnormal hormonal levels, e.g., LH, prolactin, and TSH
- Inflammation and/or infection of the prostate or urethra
Several psychological factors are considered to contribute, including:
- Unrealistic expectations about sexual performance
- History of sexual repression
- Overall lack of confidence/poor body image
- Sexual abuse
- Relationship problems
Overall, it appears that premature ejaculation is psychological in nature.
Premature ejaculation is the most frequently encountered sexual dysfunction worldwide. Approximately 30% of adult men aged 18 to 59 years old report having problems with premature ejaculation but some reports put the prevalence as high as 75%. Additionally, 30% of men with premature ejaculation also report experiencing erectile dysfunction; in this case, early ejaculation occurs in the absence of a full erection.
Ejaculation is under the control of spinal ejaculatory generator (SEG) center, located at L1-L2 level. This center receives parasympathetic and sympathetic inputs from the penile nerves and communicates via sensory and motor nerves. In addition to SEG, central, spinal, and peripheral nervous systems also work together for emission and ejaculation.
Normal ejaculation is a complicated but well-coordinated series of physiological events typically involving three phases: emission, expulsion, and orgasm.
Emission involves the introduction of seminal fluid from the seminal vesicles, prostate, and vas into the posterior urethra. This action coordinates with tightening of the internal sphincter which closes the bladder neck and prevents retrograde ejaculation of semen into the bladder. This phase of ejaculation is dependent on smooth muscle contraction but generally has voluntary control. Neurological control is primarily via sympathetic nerves from the pelvic plexus (inferior hypogastric plexus), hypogastric nerves and the caudal paravertebral sympathetic chain, which is located in the retroperitoneum on either side of the rectum and postero-lateral to the seminal vesicles. There is substantial central cerebral control of this phase of ejaculation.
Expulsion describes antegrade ejaculation where the seminal fluid travels from the posterior urethra to the urethral meatus. This function is primarily a spinal reflex and occurs as the process reaches the "point of no return." The pressure for this comes from pelvic floor musculature contractions as well as activity of the ischiocavernosus and bulbospongiosus muscles. The contractions typically occur at about 0.8-second intervals. Neurological control is still basically a sympathetic reflex, but the exact mechanism is not well defined. One theory is that the expulsion reflex initiates by the presence of semen in the bulbar urethra, but clinical and experimental data on this is conflicting.
Orgasm is involved in both ejaculation and the human sexual response cycle (desire, arousal, orgasm, and resolution). While extremely pleasurable, it is also quite short. It is primarily a brain or cerebral process that is associated with various physical events, including contractions of accessory sexual organs. Interestingly, the feeling of orgasm can occur even after radical prostatectomy and can occur without any genital sensory input or ejaculation.
History and Physical
The clinician needs to obtain a thorough history when assessing a male patient for any sexual dysfunction. A detailed history includes inquiring about sexual history, libido, and erectile function. If erectile dysfunction is present, it is crucial to determine the timing of onset of the erectile dysfunction, possible performance anxiety as a contributing factor, and assess for any additional potential risk factors or reversible causes of erectile dysfunction if present.
Also, it is crucial to obtain a thorough health history and perform a regular physical exam. Some helpful questions to ask a patient to assess for potential psychological causes might include:
- How often do you experience premature ejaculation?
- How long have you had this problem?
- Have you ever had a bad sexual experience before the development of the premature ejaculation?
- Does this happen with only one partner or with every partner?
- Does it happen with masturbation?
- Do you experience premature ejaculation with every sexual encounter?
- What type of sexual activity (i.e., masturbation, foreplay, intercourse, use of visual cues, etc.) do you engage in and how often?
- How has this affected your sexual activity?
- How are your personal relationships?
- Is there anything that makes it worse or better? (i.e., drugs, alcohol, etc.)
It is crucial to obtain a detailed history of the patient to diagnose premature ejaculation. The history should focus on his medical complaints and sexual activities. The cause of premature ejaculation can be organic in some cases, and that requires emphasis. No specific laboratory or radiographic tests are necessary to evaluate for premature ejaculation. Some tests such as serum testosterone and prolactin may be appropriate if there is erectile dysfunction or loss of libido with a clinical picture resembling that of someone who suffers from a hormonal imbalance.
Treatment / Management
Treating premature ejaculation often requires a multimodal approach which incorporates a combination of pharmacological, psychological, and behavioral therapies. In the United States, there are no drugs specifically approved for the treatment of premature ejaculation, but SSRIs such as fluoxetine, paroxetine, sertraline, citalopram, and escitalopram, and the TCA clomipramine have been commonly used off-label to treat primary premature ejaculation. These drugs delay ejaculation by inhibiting the serotonin transporter, thereby increasing serotonin’s action at the post-synaptic cleft.
SSRIs are considered as first-line treatment in most cases. Typical dosage ranges include fluoxetine 20 to 40mg/day, paroxetine 10 to 40mg/day, sertraline 50 to 200mg/day, citalopram 20 to 40mg/day, and escitalopram 10-20mg/day. SSRIs should be initiated at the lowest possible dose and titrated up accordingly over 3- to 4-week intervals. Patients have reported 6 to 20 times greater ejaculatory delay with the medication and improvement is seen in as little as one week. However, full therapeutic effects are typically observable after 2 to 3 weeks of therapy. Premature ejaculation can return upon discontinuation, so most men need to take these drugs on an ongoing basis. Unfortunately, SSRIs need to be taken daily for appreciable efficacy and carry the potential for side effects, including decreased libido, anorgasmia, and erectile dysfunction. Sometimes the patient is instructed to take the medication on an “as needed” basis about 3 to 5 hours before sexual activity to decrease the side effects experienced with daily use. However, this method does not seem to be as effective.
A new SSRI developed just for premature ejaculation is dapoxetine, and it is effective when taken 1 to -3 hours prior to the sexual activity. However, the drug has not yet received approval for use in the US. European data indicate that its side effect profile is poor and discontinuation rates are high.
An alternative to SSRIs would be the TCA clomipramine, which is considered second-line therapy and can be dosed daily between 12.5 to 50mg/day. As with SSRIs, clomipramine should be initiated at the lowest possible dose and titrated up accordingly over 3- to 4-week intervals. Full therapeutic benefits are typically apparent after 2 to 3 weeks of therapy. Potential side effects include ejaculatory dysfunction, impotence, and decreased libido. As with the SSRIs, so too can clomipramine be taken in an "as needed" fashion 3 to 5 hours prior to sexual activity, mitigating the potential side effects of daily use, however, this does not seem to be as efficient.
Men can apply topical desensitizing medications such as lidocaine sprays/creams to the tip and shaft of the penis 10 to 15 minutes before initiation of sexual activity; this avoids potential systemic side effects compared to the SSRIs. However, many patients report temporary loss of sensitivity and decreased sexual pleasure; their female partners have also reported similar symptoms. Condoms may also be used to decrease sensation and to minimize loss of sensitivity in female partners when using topical male penile therapies.
Psychotherapy may be used to address the negative thoughts and emotions that can lead to problems with sexual relationships. It can help the patient become less anxious about sexual performance and give them enhanced sexual confidence.
Several behavioral therapies may be options to increase tolerance and delay ejaculation; in essence, training the patient to learn how to recognize that ejaculation is imminent and teaching them through habituation how to delay ejaculation. Two of the most cited examples include the squeeze method and the stop-start method. The squeeze method requires the patient to get close to ejaculation and then have their partner firmly squeeze the intersection of the glans and shaft of the penis, so the erection diminishes. The stop-start technique involves stopping sexual activity just before ejaculation and waiting until the level of arousal has diminished before starting again. Both of these approaches are repeatable as necessary.
Combined pharmacologic and behavioral treatment is more efficient than pharmacotherapy alone.
Today, many clinicians advocate the combined use of phosphodiesterase type 5 inhibitors with SSRIs. Numerous case reports indicate that this combination therapy is far more effective than solo therapy for premature ejaculation.
Nonselective beta-adrenergic blockers have also been tried out with partial success in patients who have failed to respond to SSRIs.
Exercise for both men and women has been reported to help prevent premature ejaculation.
It is important to note that there is no surgery for premature ejaculation. In the past, penile implants were empirically inserted in men with premature ejaculation leading to disastrous results.
Other conditions require consideration before a diagnosis of premature ejaculation can be made, including severely delayed orgasm in the female partner. The average time to climax in females varies between 12 to 25 minutes, in extreme cases of delayed female orgasm, almost any male would be considered to have premature ejaculation, so the partner’s sexual response is a factor that merits evaluation. Adverse effects of psychotropic drugs must also be a consideration as a contributing factor.
Current guidelines by the American Urological Association:
- The diagnosis comes from sexual history.
- If a patient has concomitant premature ejaculation with erectile dysfunction, the latter should receive treatment first.
- Before initiating any therapy, the patient should receive information regarding all the options, risks, and success. The clinician should provide a realistic view.
- The SSRIs remain the drugs of choice. All SSRIs have equal efficacy.
- In some men, local anesthetics and antidepressants may be effective.
- The dose of antidepressant must be the lowest possible to avoid side effects and have the highest chance of success.
- The patient should be supported and offered sexual counseling.
Lifelong premature ejaculation has no cure. However, management of the condition can be successful via a multimodal treatment approach in the majority of cases. Acquired premature ejaculation can often be corrected by treating the underlying cause. For example, if a man has erectile dysfunction and ejaculates prematurely to compensate for his inability to maintain an erection, treating the erectile dysfunction may also treat premature ejaculation. Also, as previously mentioned, upon initiation of pharmacological therapy, it must be continued indefinitely as discontinuation often leads to recurrence of symptoms.
Success rates after treatment vary from 30 to 70%, but relapses are common. Some men need life long therapy. Finally, premature ejaculation has an enormous toll on self-esteem and leads to marital difficulties and depression.
Premature ejaculation can potentially cause couples to have difficulty conceiving if ejaculation does not occur intravaginally. It can also lead to increased stress, anxiety, and relationship issues.
Deterrence and Patient Education
Patients should receive counseling that premature ejaculation is the most common sexual dysfunction in men. Without treatment, it can lead to significant psychological distress, poor self-esteem, anxiety, erectile dysfunction, decreased libido, and poor interpersonal relationships. Patients should understand that there are effective, evidence-based treatments available.
Enhancing Healthcare Team Outcomes
Premature ejaculation describes the phenomenon which occurs when ejaculation happens sooner than a man or his partner would like during sexual activity. Even though premature ejaculation is the most prevalent sexual dysfunction in men, shame and embarrassment prevent many men from addressing their symptoms with their healthcare providers, and as a result, their self-esteem and intimate relationships unnecessarily suffer.
An interprofessional approach to treatment and management might include involving primary care physicians, psychiatrists, urologists, and psychotherapists. Pharmacists also play a significant role in monitoring medication regimens for drug-drug interactions, verifying doses, and providing medication counsel to the patient. Nursing also plays a role but may have only limited access depending on the patient's willingness to share (particularly with a female nurse), but can verify medication compliance. As premature ejaculation has both psychological and biological origins, there are a variety of medications, therapeutic options, and sexual techniques available to delay ejaculation which may improve sexual satisfaction and intimacy and improve the patient’s quality of life.
Premature ejaculation cases require an interprofessional team approach, including physicians, specialists, mental health professionals, specialty-trained nurses, and pharmacists, all collaborating across disciplines to achieve optimal patient results. [Level 5]