If, however, the problem is more persistent, doctors may recommend counseling from a therapist specializing in sexual relationships, or "couples therapy. No medications are officially licensed in the United States for treating PE, but some antidepressants have been found to help some men delay ejaculation.
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A doctor will not prescribe any medicines before taking a detailed sexual history to reach a clear diagnosis of PE. Drug treatments can have adverse effects, and patients should always discuss with a doctor before using any medication. Dapoxetine brand name Priligy is used in many countries to treat some types of primary and secondary PE. However, certain criteria must be met. Side-effects from dapoxetine include nausea, diarrhea , dizziness, and headache. Some topical therapies may be applied to the penis before sex, with or without a condom.
These local anesthetic creams reduce stimulation. Examples include lidocaine or prilocaine, which can improve the amount of time before ejaculation. However, longer use of anesthetics can result in numbness and loss of erection. The reduced sensation created by the creams may not be acceptable to the man, and the numbness can affect the woman, too.
Researchers have found that Kegel exercises, which aim to strengthen the pelvic floor muscles, can help men with lifelong PE. Forty men with the condition underwent physical therapy involving:.
Definition of acquired PE
After 12 weeks of treatment, over 80 percent of the participants gained a degree of control over their ejaculation reflex. They increased the time between penetration and ejaculation by at least 60 seconds. Most cases of PE are not related to any disease and are instead due to psychological factors, including:. These common psychological factors can affect men who have previously had normal ejaculation. These cases are often called secondary, or acquired, PE. Most cases of the rarer, more persistent form—primary or lifelong PE—are also believed to be caused by psychological problems.
Medically, the more persistent form of PE, primary or lifelong PE, is defined by the presence of the following three features:. Psychological symptoms are secondary to the physical ejaculatory events. The man, his partner, or both may experience them. Men who ejaculate too soon can experience psychological distress, but results of a study of men and their partners suggest that the partner tend to be less worried about PE than the man who has it.
The manual used by psychiatrists and psychologists for making a clinical diagnosis known as the DSM-V defines PE as a sexual disorder only when the following description is true:. The condition is persistent or occurs frequently and causes significant distress. However, a more loosely defined form of PE is one of the most common kinds of sexual dysfunction.
A doctor will ask certain questions that are intended to help them assess symptoms, such as how long it takes before ejaculation occurs. This is known as latency. Results from surveys suggest that PE affects between 15 percent and 30 percent of men. However, there are far fewer medically diagnosed and diagnosable cases. This statistical disparity does not in any way diminish the discomfort experienced by men who do not meet the strict criteria for diagnosis. Primary or lifelong PE is thought to affect around 2 percent of men.
Article last updated by Yvette Brazier on Mon 11 December Visit our Premature Ejaculation category page for the latest news on this subject, or sign up to our newsletter to receive the latest updates on Premature Ejaculation. All references are available in the References tab. Byers, E. Premature or rapid ejaculation: heterosexual couples' perceptions of men's ejaculatory behavior [Abstract].
Archives of Sexual Behavior. Ejaculation problems. Hatzimouratidis, K.
Premature Ejaculation: From Etiology to Diagnosis and Treatment
Guidelines on male sexual dysfunction. Two paradigms of treatment are presented: the contemporary one, that proposes starting with selective serotonin reuptake inhibitors SSRI , and the conciliatory one, that proposes behavioral therapy and SSRI, especially sertraline, successfully used in our country. PE is recommended not to be treated by the specialists of Integral General Medicine.
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If identified, the cases must be referred to the municipal, provincial or national commission for sexual health care. The pillars of treatment are: learning techniques for ejaculatory control stop and start, among others , anxiety decrease, communication improvement with the couple, and self-esteem improvement. Auxiliary techniques for ejaculatory control are proposed. Emission involves contractions of the seminal vesicles and prostate and results in expulsion of sperm and seminal fluid into the posterior urethra This is mediated by the sympathetic nervous system T10—L2.
Premature ejaculation: challenging new and the | FResearch
Ejection involves the pulsatile contractions of the bulbocavernosus and pelvic floor muscles with relaxation of the external urinary sphincter This is mediated by somatic nerves S2—4 and involves the sympathetic nervous system with limited voluntary control These reflexes are stimulated by sensory input from nerve endings in the glans penis, which are relayed via the sacral spinal cord to the sensory cerebral cortex The pathway involves central serotonergic and dopaminergic neurons with secondary involvement of cholinergic, adrenergic, oxytocinergic, and gamma aminobutyric acid GABA neurons Dopamine and serotonin are essential neurotransmitters; dopamine promotes seminal emission and ejaculation via D2 receptors, while serotonin is inhibitory via the serotonin receptors 5-HT Stimulation of the 5-HT 2c receptor results in ejaculatory delay in rats, whereas stimulation of the post-synaptic 5-HT 1A receptors results in shortening of ejaculatory latency time 8 , The role of oxytocin is less well established and has been found to have a stimulatory effect on ejaculation in rat models and reduces ejaculatory latency times 8 , This may be as a result of modulating the action of the 5-HT 1A receptors The influence of hormones is less clear.
Some animal models have suggested that cerebral dopamine and serotonin may interact with the hypothalamic-pituitary-thyroid axis 22 — Hyperthyroid rats were found to have shorter times to first ejaculation compared with controls A small study by Carani et al. This would support a possible role for the thyroid hormones in ejaculation. However, other studies have suggested that there is a role only in acquired PE and this is a rare cause 27 , A growing area in the aetiology of PE is its possible association with prostatitis.
Sereponi et al. Prostatic inflammation and chronic bacterial prostatitis were found in In addition, This study has been followed by several studies which have reviewed the effect of treating prostatitis on PE 30 , Treatment of prostatitis with a month of antibiotics based on culture sensitivities appears to increase ejaculatory latency times 2.
There was no recurrence of PE at a follow-up of 4 months 30 , Antibiotics appear to be most effective in men with acquired PE and where there are at least 19 pus cells per high-powered field in expressed prostate secretions The mechanism remains poorly understood, but it has been suggested that prostatic inflammation may alter sensation and therefore the ejaculatory reflex Although the evidence may still be growing, the assessment of the prostate appears to be a useful adjunct to the management of PE.
However, as always, we must balance our use of antibiotics with our responsibility as antibiotic stewards in the growing international antibiotic crisis. This has led to heterogeneous studies, adversely affecting both research and valid information regarding prevalence of the condition 33 , This definition Table 1 has been revised several times, and the current, fifth edition has corrected much of the earlier ambiguity Table 1 This definition remains largely contentious with many ongoing criticisms.
The absence of time criteria in the definition opens it up to misinterpretation by clinicians. This leads to inconsistencies in data collection and difficulty making direct comparisons between studies because of heterogeneous patient populations. In the study by Giuliano et al. A further criticism of the definition is that clinicians are asked to consider factors which may affect the excitation phase, such as age However, there is no consistent evidence that age, novelty of partner, or relationship duration has any effect on ejaculatory latency times 41 , In a large global phone and email survey, men younger than 40 were significantly more likely to report PE 2.
However, in a study of sexual behaviours and attitudes in the USA, the reverse was found 4. The last major criticism is the absence of criteria for how frequently or the duration over which rapid ejaculation should occur before it may be defined as problematic A man with frequent sexual engagement who occasionally experiences rapid ejaculation may not be bothered, whereas a man with infrequent sexual opportunity may be bothered by a single episode of rapid ejaculation. The definition does not clarify which subject should be diagnosed as having PE. The ISSM convened a panel of international experts to produce a new evidence-based definition see Table 2 13 , 43 , 44 for the current one which would address most of the inconsistencies of earlier definitions.
The main difficulties with this definition are the method of measuring the latency time and how to define a normal or abnormal time. This is the time from vaginal penetration to ejaculation.
Location & Availability for: Premature ejaculation : from etiology to
It is a useful measurement tool in PE studies and may be either estimated by the male or his partner or measured directly with the use of a stopwatch. Several studies have suggested an acceptable correlation between estimated times 46 , There was a tendency for men to overestimate their IELT 6 , 46 , However, the study by Pryor et al. Two large international population studies have provided useful information on IELT in the general population 5 , 6. Both revealed a positively skewed distribution in IELT, and median times were 5. There was significant variability across the countries involved.
This may suggest that IELT definitions need to be adjusted depending on the ethnic mix of the study population. In addition, it provides a useful counselling tactic to reassure a male patient that he is actually within the normal distribution. However, studies which have analysed IELT in the general population have not included ethnically diverse populations. A study from the UK reported that the highest incidence of PE was in men from Asian and Islamic backgrounds, which may reflect a genetic or a cultural aetiology 7.
More studies are required to define normal IELT in these populations. The use of the 0. These two studies, therefore, have defined an abnormal IELT as being 1 minute 5 , 7 , The use of IELT is not without inherent problems. The data collected using IELT are usually based on either men with lifelong PE LPE or heterosexual men within stable relationships engaging only in vaginal penetrative sexual intercourse This limits its general applicability to clinical populations. In addition, the act of measuring ejaculatory latency itself may affect sexual performance either positively or negatively.
This is a factor which may be difficult to account for or quantify within clinical trials or medical practice. The European Association of Urology EAU guidelines mention both definitions; however, it recommends that the diagnosis of PE include self-estimated IELT, perceived control, and interpersonal difficulty due to ejaculatory dysfunction Several validated questionnaires, which are mainly for use in clinical trials, have been developed 53 — Whilst they are useful adjuncts in clinical assessment and measuring the impact of treatment on PE, they are not without limitations, and they are used to assess LPE and men who have vaginal sexual intercourse This questionnaire, developed by Patrick et al.
Each domain is assessed by using a single question, and the response is rated on a five-point scale from 0—5; higher scores indicate better functioning. Validation was in populations from Europe and the USA It has been used extensively in observational and pharmacological trials 54 , The main advantages are that it is quick to complete and is useful as a measure of response to treatment However, there are no validated cut-off values and it uses a single question to determine the effect within each domain This would seem to be a major limitation when compared with the International Index of Erectile Function, where the erectile dysfunction ED domain score is determined by five questions and the scores are then divided into categories, which determine ED severity This questionnaire, developed by Althof et al.
It was validated in men with an IELT of not more than 1 minute Validation studies revealed that the questionnaire has good validity and reliability Similar to the PEP, it does not have any validated cut-off values. This is a screening questionnaire with five questions and no domains 55 , 57 , Validation revealed good reliability and validity The total score is from 0 to 25 55 , This useful questionnaire allows a quick diagnosis of PE but does not provide objective evidence of response to treatment.
https://de.ydykamypis.cf McMahon et al. This suggests limitations with both the questionnaire and the male definition of what constitutes PE Table 3 11 , 55 , 57 , The current EAU guidelines for the management of PE suggest the use of pharmacotherapy as first-line treatment This includes either the short-acting dapoxetine DPX on demand or other off-label antidepressants such as daily selective serotonin reuptake inhibitors SSRIs. Tramadol and topical local anaesthetics may be used as weak alternatives to SSRIs; phosphodiesterase-5 inhibitors PDE5is should be used only in men with concomitant ED Behavioural therapy should be used with pharmacotherapy Table 4 60 , The aim of behavioural therapy is the development of sexual skills over time, which allows the male to delay ejaculation, increase sexual confidence, and reduce performance anxiety or stress There are two types of behavioural therapy: psychotherapy and physical techniques Psychotherapy uses counselling to identify and correct any interpersonal problems, which may have precipitated or be contributing to PE 8 , Physical therapies involve a variety of exercises to slowly increase the degree of genital stimulation over time, which allows the male to gain control over his ejaculation 8 , The efficacy of these studies is difficult to assess, as their inclusion criteria do not always meet ISSM PE definitions; they include various types of treatments with either unreported or variable treatment duration 8 , In addition, the number of men receiving treatment is small; the method of IELT measurement and follow-up is limited.
Despite these reservations, behavioural therapy appears to improve IELT when compared with placebo in two out of four studies in a recent systematic review However, the picture is more mixed when behavioural therapy was compared with active drugs that is, antidepressants ; there was a trend towards improved IELT with active drugs or no significant differences 8 , 9 , There is a need for more high-quality studies which are appropriately powered to demonstrate an effect using contemporary PE definitions.
The combination of behavioural therapy with drug treatment for example, DPX, chlorpromazine, paroxetine, and citalopram has shown a significant but small improvement in outcome measures that is, IELT compared with the active drug alone in the three studies included in the systematic review The outcome measures included IELT in two studies and a validated questionnaire in one study. The improvement in IELT was 0. Cormio et al. Both groups had a significant improvement in IELT; however, the combination therapy resulted in a further and second increase at 12 and 24 weeks, respectively Topical local anaesthetic agents are the oldest treatments for PE.
However, they are often criticised for not being specifically optimised for PE, for being slow-acting, and for requiring the use of condoms to prevent partner transference and resultant partner hypoanaesthesia 64 , It consists of 7. This results in a localised desensitising effect The efficacy has been evaluated in two phase III placebo-controlled multicentre studies 64 , There was also a significant improvement in the interprofessional education IPE domain scores in both studies 64 , The odds of achieving an IELT of over 1 minute and over 2 minutes were 9 times and This suggests a very strong placebo effect, which again calls into question how much we truly understand about this condition and controversially whether it exists as a true medical condition.
SSRIs inhibit axonal reuptake of serotonin from the synaptic cleft of central and peripheral serotonergic neurons by 5-HT transporters, resulting in enhanced 5-HT transmission and stimulation of post-synaptic membrane 5-HT 2c receptors SSRIs may be used daily or on demand. A recent meta-analysis evaluated long-acting paroxetine, citalopram, fluoxetine, and fluvoxamine and short-acting SSRIs Paroxetine was associated with the best efficacy, with an The use of an on-demand regime has been associated with less ejaculatory delay 67 — Adverse effects are usually mild and include fatigue, yawning, nausea, and loose stools ED and libido reduction have also been reported, though less frequently compared with men using the drugs for depression 61 , Men must be cautioned about SSRI withdrawal syndrome with abrupt drug cessation It has the largest efficacy and safety database, having been studied in over 6, men in a variety of well-conducted, placebo-controlled trials The highest incidence of adverse events was observed in men over 65 using DPX and men 30—39 years old using other therapies The commonest reasons for discontinuation were the following:.
Disappointment that PE was incurable and tablets needed for every sexual encounter. This suggests that more efficacious therapies are still required. Although similar complaints may be expressed by men with ED, ultimately the insertion of a penile prosthesis will allow a man to have sexual intercourse.
Unfortunately, this is not the case with men with PE. PDE5is are the gold-standard first treatment for men with ED. However, their role in PE remains unclear. PDE5 is expressed in the prostate, vas deferens, and seminal vesicles and may have a physiological role in ejaculation 74 — This is not surprising. Men with ED require higher levels of arousal to attain an erection or may attempt to rush sexual intercourse prior to loss of their erection Both of these situations will predispose them to a reduction in ejaculatory control and possible PE.
Conversely, men with PE require a reduction in arousal to control ejaculation, which may worsen erectile function Sexual dysfunction is also associated with performance anxiety, which may worsen erectile function 13 , However, they have been criticised for their poor methodology DA inhibits the expulsion phase of ejaculation by modulating the activity of the bulbospongiosus muscle in male rats 86 , In addition, it is associated with reduced serotonin transporter occupancy, confirmed on positron emission tomography of the rat brain This was recently evaluated in the first human trial to assess safety and tolerability after a single dose in healthy men Men were randomly assigned to receive either the active drug or placebo.
The drug was well tolerated up to the 80 mg dose.