Premature or Delayed Ejaculation

Essentials

• Ejaculation in less than 1-2 minutes from the beginning of intercourse is defined as premature, and ejaculation with a latency time of more than 20 minutes is defined as delayed or inhibited.
• The symptom may cause problems in personal life and couple relationship.
• Non-pharmacological treatments include behavioural therapy and pelvic floor muscle exercises. There is little evidence for their efficacy.
• Pharmacological treatment is based on either local anaesthetics or on selective serotonin reuptake inhibitors (SSRI) to influence brain serotonin levels.

Prevalence and definitions

• Premature (or sensitive) ejaculation (PE) is a common type of male sexual dysfunction.
• The symptom may be lifelong or acquired.
• The symptom is familiar to one man in five but in about 7% of men it is considered to cause a level of distress requiring measures to be taken.
• There are several definitions for the symptom, the common elements being ejaculation occurring before the patient so wishes, inability to control ejaculation, and resulting adverse mental effects.
• IELT (intravaginal ejaculation latency time) means time from vaginal penetration to beginning ejaculation.
• There is significant case-specific and personal variation in IELT but ejaculation is considered premature if the time is less than 1 minute (DSM-5) or 2 minutes (upcoming ICD-11).
• Ejaculation is delayed or inhibited if it takes 20 minutes or more to occur.

Diagnosis

• Below, you will find the definitions published by the International Society of Sexual Medicine (ISSM) in 2016. The specified time limit for the lifelong type of the disorder is also 1 minute in DSM-5. Source: Seksuaalilääketiede [sexual medicine] textbook 1.
• For diagnosis, all 3 criteria (1, 2 and 3) must be met.

1. Male sexual dysfunction in which ejaculation always or almost always occurs prior to or within about 1 minute from penetration (IELT). The condition may be
   • a. lifelong if it has been occurring since the first intercourse (prevalence 3%)
   • b. acquired if the previously normal time to ejaculation decreases clinically significantly and disturbingly to about 3 minutes or less (prevalence 4.2%).
2. The condition involves inability to control ejaculation in all or almost all cases of intercourse.
3. The condition also involves negative personal consequences, such as anxiety, worry, frustration or avoidance of sexual intercourse.

• In addition to the two main types, two other subtypes of premature ejaculation have been suggested.
  • In natural variable premature ejaculation, the time to ejaculation varies but may at times and depending on the situation be disturbingly short (prevalence 10%). This is not considered to represent actual sexual dysfunction but normal variation.
  • In subjective premature ejaculation, the time to ejaculation is normal or even longer than normal (e.g. exceeding 10 minutes) but the patient experiences ejaculation as premature (prevalence 5.8%). Voluntary control of ejaculation may be poor or totally lacking. This does not represent actual sexual dysfunction. This requires sexual counselling and the provision of accurate information.

Aetiology

• The cause often remains open.
• The lifelong type of disorder probably represents a neurobiopsychological condition with a hereditary component.
• In the acquired type of disorder, there may be an underlying disease, such as prostatitis or hyperthyroidism.

Workup

• For an investigation algorithm for premature ejaculation, see Figure 1 in http://academic.oup.com/smoa/article/2/2/60/6956277?login=false.

Drug therapy

• Pharmacological treatment is based on either local anaesthetics or on selective serotonin reuptake inhibitors (SSRI) to influence brain serotonin levels.
• Dapoxetine and a spray containing a combination of lidocaine and prilocaine have marketing authorization for use in premature ejaculation.
• The combination spray is not available in the Nordic countries but in many European countries it is available as an over-the-counter product in pharmacies.
• Ordinary SSRIs
  • Paroxetine at doses of 5-20 mg/day is the most effective drug, and beneficial for nearly all patients. It lengthens the IELT as much as 8.8-fold.
  • Fluoxetine and sertraline prolong the IELT about 5-fold.
  • SSRIs usually remain effective for several years but in rare cases their efficacy may decrease.
  • In the beginning of treatment, fatigue, nausea and sweating may sometimes occur for 1-3 weeks.
  • Long-term SSRI use may be associated with an increased risk of diabetes and weight increase.
  • In contrast with the treatment of depression, loss of sex drive or potency occur surprisingly seldom.
  • All SSRIs taken daily are off-label products.
• Dapoxetine
  • An ultra-short-acting SSRI officially indicated in the treatment of premature ejaculation
  • A dose of 30-60 mg should be taken 1-2 hours before intercourse; the effect will last for about 2-3 hours.
  • It lengthens the IELT 2-3-fold and improves the person's own ability to control ejaculation.
  • Nevertheless, 70-90% of patients stop using the drug rather quickly due to poor efficacy and high cost.
• Local anaesthetic lidocaine-prilocaine spray
  • The product should be sprayed on the glans penis about 5 minutes before intercourse.
  • In comparison to traditional anaesthetic ointments, the spray has the advantage of maximizing the nervous effect in the area of the glans without any local anaesthetic effect on the shaft of the penis.
  • The product lengthens the IELT to as long as 6-7 minutes.
  • There are few adverse effects.
• Other drugs (poor evidence of efficacy)
  • Tramadol, 50 mg 2 hours before sex
  • PDE5 inhibitors
  • Alpha-blockers, particularly silodosin
  • A new SSRI molecule is being developed.
  • Botulinum toxin injections into the bulbospongiosus muscle, oxytocin antagonists, modafinil, caffeine, and lengthening of the penile frenulum have been tried.

Non-pharmacological treatment

• There is no evidence of the efficacy of treatment based on behavioural therapy (start-stop technique and squeeze technique).
• Psychological techniques have been experimentally combined with dapoxetine, with slightly improved efficacy compared to drug therapy alone.
• Rehabilitation of pelvic floor muscles with or without medication has been studied.
• Circumcision has been used to slow down ejaculation but its efficacy has not been proven.
• Medical aids and sex toys have also been tried.

Delayed or inhibited ejaculation

• Delayed and inhibited ejaculation are types of male sexual dysfunction that are least understood and difficult to treat.
• Five to ten per cent of men suffer from some degree of delayed ejaculation, the prevalence increasing with age.
• An IELT exceeding 20-25 minutes can be considered abnormal if the man is not actively trying to lengthen it.
• Any disease, psychological cause, medication or surgical procedure affecting parts of the central or peripheral nervous systems controlling ejaculation may lead to delayed or inhibited ejaculation.
• Drugs potentially preventing ejaculation or orgasm include all SSRIs, tricyclic antidepressants, most antipsychotics, benzodiazepines, naproxen, tramadol, prazosin, and thiazide diuretics, for example.
• Treatment
  • There is no specific treatment available.
  • Modifying lifestyle factors affecting ejaculation, or addressing mental causes, diseases or medication can be attempted.
  • In primary health care, measures can be taken to treat erectile dysfunction or hypothyroidism, to change possibly harmful medication or to try to address alcohol consumption, for example.
  • Experimental medication has not proved useful.