Guidelines are most useful when they are available to answer questions at the point of care. A concise yet complete handheld computer version of this guideline is available for download, compliments of FAMILY PRACTICE NEWS, at www.redi-reference.com
Many studies suggest that premature ejaculation is the most common male sexual disorder, and according to the National Health and Social Life Survey, the prevalence of premature ejaculation in the United States is 21% in men aged 18–59. Although there is no universally accepted definition of premature ejaculation, the American Urological Association (AUA), defines it as “ejaculation that occurs sooner than desired, either before or shortly after penetration, causing distress to either one or both partners.”
Clinical Evaluation
The AUA emphasizes that “the diagnosis of premature ejaculation (PE) is based on sexual history alone.” As a result, a detailed history should be obtained from all patients with ejaculatory complaints, with particular attention paid to time to ejaculation. Additional relevant details include frequency and pattern of PE, relationship to specific partners, degree of stimulus resulting in ejaculation, nature and frequency of sexual activity (including masturbation and intercourse), relationship to drug use or abuse, and psychosocial impact of PE. It is valuable to obtain input from sexual partners as well.
It's also imperative to distinguish PE from erectile dysfunction (ED), the inability to sustain a sufficient erection prior to ejaculation, though the conditions often coexist. In patients with concomitant PE and ED, the erectile dysfunction should be treated first, and PE may improve if the ED is effectively treated. It is not necessary to perform laboratory or physiologic testing unless history and physical exam reveal specific indications for doing so.
Recommendations for Treatment
The AUA makes it clear that “patient and partner satisfaction is the primary target outcome for the treatment of PE.” Because PE is not life-threatening, the safety of a treatment should be the most important concern. Certain treatments, such as neurectomy and prosthetic implants, have risks that far outweigh their benefits. It is also important to note that no pharmacologic treatments have FDA-approved indications for PE, but the following agents have been studied:
▸ Serotonin reuptake inhibitors. In clinical trials, SRIs have proven to be more effective than placebo in treating PE. SRI options include fluoxetine, paroxetine, and sertraline (selective SRIs), as well as clomipramine (a nonselective SRI). Many dosages and dosing regimens have been evaluated, and it is unclear whether continuous daily dosing or situational dosing is superior for managing all patients. It is therefore recommended that dosage regimens be based on patient needs, compliance concerns, and frequency of sexual activity. Doses of SRIs used in treating PE tend to be lower than those recommended in the treatment of depression, and duration of therapy has not been established. SRI use will most likely be needed on a continuing basis; experience has shown that PE returns when treatment with SRIs is terminated. Adverse effects from SRI use for PE are similar to those seen in treating depression and are considered acceptable for the benefits seen in patients with PE.
▸ Topical anesthetic agents. According to the AUA, topical anesthetic agents may be applied to the penis prior to intercourse to delay ejaculation. Approximately 2.5 g of lidocaine/prilocaine cream applied 20–30 minutes before intercourse has been shown to increase latency time without significant side effects. It is important to note that topical agents may be used with or without a condom and may be wiped off immediately prior to intercourse to prevent transfer of product to the partner's vaginal wall. One concern when using these products, however, is increased numbness in the penis after prolonged periods of time, leading to loss of erection. This loss in penile sensation may make topical treatment unacceptable to many patients and thereby limit its use.
▸ Other pharmacologic therapies. There have been other agents proposed for the treatment of PE. These involve therapies typically used in the management of erectile dysfunction. There is a small amount of evidence suggesting intracorporal injection of a vasoactive agent, such as alprostadil, or use of sildenafil may increase latency in patients with PE. There is also evidence to suggest that combined use of sildenafil and paroxetine on a situational basis is more effective than paroxetine alone, albeit with an increase in the frequency of headaches and flushing. One other possibility for treatment involves medications that effect adrenergic blockade, as ejaculation is modulated by the sympathetic nervous system. One study using alfuzosin and terazosin showed mild efficacy at increasing ejaculation latency.