Premature Ejaculation: Practice Essentials, Background, Pathophysiology
Total Page:16
File Type:pdf, Size:1020Kb
2017617 Premature Ejaculation: Practice Essentials, Background, Pathophysiology This site is intended for healthcare professionals Premature Ejaculation Updated: Mar 15, 2016 Author: Samuel G Deem, DO; Chief Editor: Edward David Kim, MD, FACS more... OVERVIEW Practice Essentials Premature (early) ejaculation is the most common sexual disorder in men younger than 40 years, with 3070% of males in the United States affected to some degree at one time or another. It has historically been considered a psychological disease with no identified organic cause. Signs and symptoms Premature ejaculation can be lifelong or acquired. With lifelong premature ejaculation, the patient has experienced premature ejaculation since first beginning coitus. With acquired premature ejaculation, the patient previously had successful coital relationships and only now has developed premature ejaculation. Patient characteristics in lifelong premature ejaculation can include the following: Psychological difficulties Deep anxiety about sex that relates to 1 or more traumatic experiences encountered during development In patients with lifelong premature ejaculation, inquire about the following: Previous psychological difficulties Early sexual experiences Family relationships during childhood and adolescence Peer relationships Work or school General attitude toward sex Context of the event (eg, marital versus nonmarital) Sexual attitude and response of the female partner Nonsexual aspects of the current relationship level of involvement of the sexual partner in treatment Clues from these and similar questions usually point toward causative factors that may be addressed specifically with therapy. Patient characteristics in cases of acquired premature ejaculation can include the following: Erectile dysfunction Performance anxiety Psychotropic drug use In patients with acquired premature ejaculation, inquire about the following: Previous relationships Current relationship http://emedicine.medscape.com/article/435884overview 1/12 2017617 Premature Ejaculation: Practice Essentials, Background, Pathophysiology Nonsexual aspects of the current relationship level of involvement of the sexual partner in treatment Impotence problems Capacity for coitus Sexual context Sexual response of partner See Presentation for more detail. Diagnosis In males with premature (early) ejaculation and no other medical problems, no specific conventional laboratory tests aid or affect treatment. Checking the patient’s levels of serum testosterone (free and total) and prolactin may be appropriate if premature ejaculation is observed in conjunction with an impotence problem. If depression or other conditions coexist, laboratory studies specific to depression or to another medical or psychological problem are appropriate. Other conditions that should be considered in making the diagnosis of premature ejaculation include the following: Severely delayed orgasm in the female partner Adverse effect from a psychotropic drug Presence of preejaculate Erectile dysfunction See Workup and DDx for more detail. Management Medical treatment for premature (early) ejaculation includes several options. Any serious primary medical condition (eg, angina) should be treated, as should any accompanying erection problem (eg, erectile dysfunction). To achieve the best outcome, the female partner should be included as fully as possible in the treatment and counseling sessions. Outpatient care can be scheduled as appropriate for the clinical circumstances. Nonpharmacologic therapy may include the following: Efforts to relief of underlying performance pressure on the male Sex therapy (eg, instruction in the stopstart or squeezepause technique popularized by Masters and Johnson [1] ) Second attempt at coitus – If another erection can achieve be achieved shortly after an episode of premature ejaculation, ejaculatory control may be much better the second time Pharmacologic therapy may include the following: Topical desensitizing agents (eg, lidocaine and prilocaine) for the male Selective serotonin reuptake inhibitor (SSRI) therapy (eg, sertraline, paroxetine, fluoxetine, citalopram, or dapoxetine); alternatively, use of an agent with SSRIlike effect Phosphodiesterase type 5 (PDE5) inhibitor therapy (eg, sildenafil, tadalafil, or possibly vardenafil) Other agents (eg, pindolol or tramadol) No recommended surgical therapy exists. See Treatment and Medication for more detail. Background http://emedicine.medscape.com/article/435884overview 2/12 2017617 Premature Ejaculation: Practice Essentials, Background, Pathophysiology Premature (early) ejaculation—also referred to as rapid ejaculation—is the most common type of sexual dysfunction in men younger than 40 years. An occasional instance of premature ejaculation might not be cause for concern, but, if the problem occurs with more than 50% of attempted sexual relations, a dysfunctional pattern usually exists for which treatment may be appropriate. Most professionals who treat premature ejaculation define this condition as the occurrence of ejaculation earlier than both sexual partners wish. This broad definition thus avoids specifying a precise “normal” duration for sexual relations and reaching a climax. The duration of intimate relations is highly variable and depends on many factors specific to the individuals involved. For example, a male may reach climax after 8 minutes of sexual intercourse, but if his partner regularly climaxes in 5 minutes and both are satisfied with the timing, this is not premature ejaculation. Alternatively, a male might delay his ejaculation for up to 20 minutes of sexual intercourse, but if his partner, even with foreplay, requires 35 minutes of stimulation before reaching climax, he may still consider his ejaculation and subsequent loss of erection premature because his partner will not have been satisfied (at least, not through intercourse). Because many females are unable to reach climax at all with vaginal intercourse, no matter how prolonged, the second situation described may actually represent delayed orgasm in the female partner rather than premature ejaculation in the male; the problem can be either or both, depending on the point of view. Such differences in perspective highlight the importance of obtaining a thorough sexual history from the patient (and preferably from the couple). Premature ejaculation may be lifelong or acquired. Lifelong premature ejaculation applies to individuals who have had the condition since they became capable of functioning sexually (ie, post puberty). Acquired premature ejaculation means that the condition began in an individual who previously experienced an acceptable level of ejaculatory control and, for unknown reasons, began experiencing premature ejaculation later in life. Acquired premature ejaculation is not related to a general medical disorder and usually is not related to substance inducement, though in rare cases, hyperexcitability might be associated with a psychotropic drug and resolve when the drug is withdrawn. Diagnostic criteria In 2014, the International Society for Sexual Medicine published an evidencebased unified definition of premature ejaculation that comprised the following criteria [45] : 1. Ejaculation that always or nearly always occurs before, or within about 1 minute of, vaginal penetration from the first sexual experience (lifelong premature ejaculation) or a clinically significant and bothersome reduction in latency time, often to about 3 minutes or less (acquired premature ejaculation) 2. Inability to delay ejaculation on all or nearly all vaginal penetrations 3. Negative personal consequences, such as distress, bother, frustration, and/or the avoidance of sexual intimacy DSM5 criteria The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM5), classifies premature (early) ejaculation as belonging to a group of sexual dysfunction disorders that are typically characterized by a clinically significant inability to respond sexually or to experience sexual pleasure. [2] Sexual functioning involves a complex interaction among biologic, sociocultural, and psychological factors, and the complexity of this interaction makes it difficult to ascertain the clinical etiology of sexual dysfunction. Before any diagnosis of sexual dysfunction is made, problems that are http://emedicine.medscape.com/article/435884overview 3/12 2017617 Premature Ejaculation: Practice Essentials, Background, Pathophysiology explained by a nonsexual mental disorder or other stressors must first be addressed. Thus, in addition to the criteria for premature (early) ejaculation, the following must be considered: Partner factors (eg, partner sexual problems or health issues) Relationship factors (eg, communication problems and differing levels of desire for sexual activity) Individual vulnerability factors (eg, history of sexual or emotional abuse, existing psychiatric conditions such as depression, or stressors such as job loss) Cultural or religious factors (eg, inhibitions or conflicted attitudes regarding sexuality) Medical factors (eg, an existing medical condition or the effects of drugs or medications) The specific DSM5 criteria for premature (early) ejaculation are as follows [2] : In almost all or all (75100%) sexual activity, the experience of a pattern of ejaculation occurring during partnered sexual activity within 1 minute after vaginal penetration and before the individual wishes it The symptoms above have persisted for at least 6 months The symptoms