CLINICAL Premature ejaculation: A clinical review for the general physician Eric Chung, Brent Gilbert, Marlon Perera, Matthew J Roberts Background remature ejaculation is one of the ejaculatory latency time (IELT). The most common sexual dysfunctions, IELT is defined as the time from vaginal Premature ejaculation is one of the most P affecting up to 21–31% of the penetration to ejaculation. Lifelong common sexual dysfunctions in men. Australian adult male population, premature ejaculation is characterised Recent epidemiological studies suggest irrespective of their age, marital status or by an IELT of <1 minutes since first its prevalence in Australia may range ethnicity.1–5 This sexual condition is likely intercourse, whereas IELT of <3 minutes from 21–31%. to be under-reported and under-treated at any point in a man’s life is considered 12 Objective because of the patients’ perceived shame to be acquired premature ejaculation. and low self-esteem. This is in addition to Premature ejaculation can be further This article will discuss the current many physicians feeling uncomfortable divided into authority-based subtypes definition of premature ejaculation from or uncertain about the management ‘variable’ and ‘subjective’ (Table 1), a urological perspective. It will provide of premature ejaculation.6,7 The impact which describe individuals experiencing an understanding of the pathogenesis of premature ejaculation is mostly felt significant distress and dissatisfaction of premature ejaculation, as well as psychologically and in interpersonal with ejaculation.12 assessment and management options. relationships.8 Men with premature ejaculation often experience significant Pathophysiology and Discussion psychological distress, avoid physical and associations Premature ejaculation can have a emotional intimacy, and become victims Psychological components often significant adverse effect on the quality of false medical advertisings and unproven contribute to acquired premature of life for the patient and his sexual medical management.8 –11 ejaculation. However, it is likely partner’s. It can potentially lead to The aim of this article is to provide that a complex interplay between psychological distress, diminished self- general practitioners (GPs) with an neurophysiological factors predominantly esteem, anxiety, erectile dysfunction, overview to assess and manage patients influence premature ejaculation. In reduced libido and poor interpersonal with premature ejaculation and other particular, genetic predisposition for relationships. Most men feel reluctant associated sexual dysfunction. impairment of inhibitory serotonergic to discuss premature ejaculation with pathways that regulate ejaculation, their general practitioner despite its Definition and classification modulated by 5-HT2c , 5-HT1a, 5-HT1b psychological, emotional and relational Premature ejaculation is defined as the receptors and synaptic serotonin effects. Effective, evidence-based inability to control or delay ejaculation, transporters has been reported for treatment options are available and which results in dissatisfaction or distress lifelong premature ejaculation.13,14 Other physicians should feel confident when for the patient. Recently, the International conditions, such as chronic prostatitis and exploring ways to improve the quality of Society of Sexual Medicine (ISSM) hyperthyroidism, may also be associated life for men with sexual dysfunction. classified premature ejaculation as lifelong with acquired premature ejaculation.15,16 or acquired, and proposed inclusion of an Erectile dysfunction and premature objective, quantifiable time to ejaculation, ejaculation frequently co-exist,5,17 as men which is referred to as the intravaginal with erectile dysfunction might try to © The Royal Australian College of General practitioners 2015 REPRINTED FROM AFP VOL.44, NO.10, OCTOBER 2015 737 CLINICAL PREMATURE EJACULATION ejaculate early, before loss of erection.1 7, 1 8 It is also important to explore the neurological, lower limb and genital Thus, detection of comorbid erectile perceived degree of ejaculatory control, examinations are recommended. Although dysfunction is crucial in guiding therapeutic estimated IELT (precise timing is not examination has a low diagnostic yield, it implementation.19 necessary), previous attempts to correct facilitates important reassurance for the premature ejaculation, and the impact patient that he is anatomically normal. Assessment of premature on interpersonal relationships and quality There are no specific investigations to ejaculation of life. Various screening questionnaires confirm or exclude premature ejaculation. Patients with premature ejaculation may such as the Premature Ejaculation Any additional investigations should present to general practice because Diagnostic Tool (PEDT), when combined investigate suspicion of contributory of personal or partner-initiated reports with clinical assessment, are accurate factors identified during history and of erectile or sexual dysfunction, and in diagnosing premature ejaculation if examination. relationship difficulties. However, when the it is unclear.20–22 It is particularly crucial physician is unsure of the context of the to ascertain whether the diagnosis is Management of premature presenting complaint, or uncertain about lifelong or acquired, and be aware that ejaculation what to ask, an open-ended question, such erectile dysfunction may exacerbate the Ideally, discussions about management as ‘How are things at home?’, may evoke presentation. Simply inquiring about the should involve the patient and his regular disclosure of relevant symptoms. A full loss of an erection before ejaculation can sexual partner. Treatment choice requires evaluation of the patient’s medical, sexual, help to distinguish erectile dysfunction consideration of symptom severity, psychological, social and drug history, from premature ejaculation. reversible causes, psychosocial impact, along with his partner’s sexual history, is Physical examination of patients side effects and patient preferences.23 necessary to identify any factors that may who experience premature ejaculation In clinical practice, management is be potentially reversible. is often unremarkable. Full abdominal, complex and requires a combination Table 1. Summary of the four classifications of premature ejaculation Lifelong (primary) Acquired (secondary) Variable Subjective IELT criteria <1 minute4 <3 minutes4 Short or normal Normal or prolonged Symptoms Ejaculation occurs too New onset of premature PE is inconsistent Subjective, self- early in nearly every ejaculation, usually the and occurs irregularly perception of rapid sexual encounter result of an identifiable and not the result of ejaculation despite source and patient has (psycho)pathology normal ejaculation experienced normal time ejaculations in the past Onset Early, usually from first Can occur at any time in Can occur at any time Can occur at any time sexual encounter a man’s life in a man’s life in a man’s life Prevalence Low Low High High Quality of Ejaculation remains Ability to delay Ability to delay Ability to delay ejaculation rapid throughout ejaculation may be ejaculation may be ejaculation may be control lifetime with no ability diminished or lacking diminished or lacking diminished or lacking to control ejaculation Aetiology • Genetic • Urological (erectile Normal variance of Psychological • Neurobiological dysfunction, prostatitis) sexual performance preoccupation with • Hormonal imagined rapid (hyperthyroidism) ejaculation • Psychological • Relationship problems Treatment • Pharmacotherapy • Medical management • Reassurance • Psychotherapy • Psychotherapy +/– • Pharmacotherapy • Education • Reassurance • Psychotherapy • Behavioural therapy • Education • Education IELT, intravaginal ejaculatory latency time 738 REPRINTED FROM AFP VOL.44, NO.10, OCTOBER 2015 © The Royal Australian College of General practitioners 2015 PREMATURE EJACULATION CLINICAL of pharmacological, psychological and constraints, costs and requirement for related to sexual dysfunctional, or in behavioural treatments (Figure 1). strong compliance from couples. combination with pharmacotherapy.12,27 Inconsistent, randomised evidence Conservative management evaluating psychological therapy suggests Behavioural therapy options its efficacy decreases over time24 and is Various behavioural changes have been inferior to pharmacotherapy.25 However, suggested in the literature. For example, Psychological therapy psychological therapy may be a suitable precoital masturbation is widely thought Initially, psychological therapy was the first-line treatment for patients with to improve IELT, but there is a lack of mainstay of treatment for premature subjective premature ejaculation, or when data to support this practice. Alternative ejaculation. It is used less in current a clear psychological aetiology is present.26 behavioural therapy modalities attempt clinical practice because of time This can also be used to manage distress to attenuate the sensory responses of Patient/partner history – Establish presenting complaint – Estimate intravaginal ejaculatory time Variable PE Treatment – Perceived degree of ejaculatory control - Reassurance – Degree of patient/partner distress - Education – Onset and duration of PE PE unlikely Psychotherapy – Psychosocial history - – Medical history - Behavioural therapy – Physical examination Subjective PE - Follow-up PE likely PE secondary to ED or Yes Manage the primary