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Treatment of almost all medical conditions has been affected by the COVID-19 pandemic. NICE has issued rapid update guidelines in relation to many of these. This guidance is changing frequently. Please visit https://www.nice.org.uk/covid-19 to see if there is temporary guidance issued by NICE in relation to the management of this condition, which may vary from the information given below.
What is premature ejaculation?
The definition for premature ejaculation has been debated over the years but many experts in the field currently rely on the International Society for Sexual Medicine (ISSM) definition which identifies the following criteria, updated in 2013 :
- Premature ejaculation which always or nearly always occurs prior to or within about one minute of vaginal penetration from the first sexual experience (lifelong premature ejaculation), OR, a clinically significant reduction in latency time, often to about three minutes or less (acquired premature ejaculation); and
- The inability to delay ejaculation on all or nearly all vaginal penetrations; and
- Negative personal consequences, such as distress, bother, frustration and/or the avoidance of sexual intimacy.
This definition incorporates both lifelong and acquired premature ejaculation but only applies to vaginal intercourse, as the committee felt there was not the evidence to extend the definition to other situations or groups.
Other definitions exist but all essentially rely on the three common factors of short ejaculatory latency, lack of ability to delay ejaculation, and negative consequences for the individual and/or their partner.
- The prevalence of premature ejaculation varies according to definition and is difficult to assess in view of many men not wanting to seek help or even discuss the problem.
- The estimated prevalence is likely to be around 1-3% of men, although some studies have reported it to be up to 30%.
The aetiology and pathophysiology of premature ejaculation are poorly understood. Data about many of the following possible risk factors are sparse and unconvincing.
- Genetic predisposition.
- Poor general health.
- Emotional problems and stress.
- History of traumatic sexual experiences.
- Medication and recreational drugs. Possible causes include amfetamine, cocaine and dopaminergic medication.
- Neurological causes - eg, multiple sclerosis, peripheral neuropathies.
- Thyroid disorder.
- Erectile dysfunction.
History should include:
- An estimate of intravaginal ejaculation latency time.
- Perceived control.
- Degree of distress.
- Impact on sexual activity and relationship and quality of life.
Two questionnaires are available for the assessment of premature ejaculation - the Premature Ejaculation Diagnostic Tool (PEDT) and the Arabic Index of Premature Ejaculation (AIPE).
Examination may be indicated to exclude endocrine, urological or neurological conditions which may be relevant. Further investigation is not routinely indicated, unless suggested by findings on history and/or examination.
Premature ejaculation management should be tailored to the needs of the individual. Premature ejaculation may be more of an issue in some relationships than in others and patient expectation should be explored. Psychosexual counselling may be sufficient.
- More frequent sex (or masturbation): premature ejaculation is more likely if there is a longer gap between sexual intercourse.
- Using a condom may decrease sensation.
- Sex with the woman on top reduces the likelihood of premature ejaculation.
- Squeeze and stop-go techniques: stimulating the penis almost to the point of ejaculation and then stopping. These techniques are often effective but may take a few months to produce any benefit and relapse is common..
- Behavioural treatments are useful for secondary premature ejaculation but are not recommended first-line for lifelong premature ejaculation. They are time-intensive and require commitment from the partner.
- Where present, treat erectile dysfunction and/or prostatitis first.
- Reviews suggest that pharmacological therapy is most effective, particularly for lifelong premature ejaculation.
- Selective serotonin reuptake inhibitor (SSRI) antidepressants are commonly used off-label but need to be taken daily, as it takes one to two weeks for the effect to be achieved. Paroxetine, fluoxetine, citalopram, escitalopram and sertraline have all been shown to be effective . The serotonin-noradrenaline reuptake inhibitor (SNRI) duloxetine is also effective. On-demand treatment with clomipramine may be a suitable alternative.
- Dapoxetine - a short-acting SSRI which has been specifically developed for the treatment of premature ejaculation - has been shown to be effective and is approved for use in the UK . It is taken as required, one to three hours before anticipated sexual activity . It is not recommended for men over the age of 65.
- Anaesthetic creams may be effective. Options with evidence of efficacy are EMLA® cream and lidocaine gel . Aerosol sprays are proving popular and novel preparations are being developed but are not available on the NHS. Topical preparations may be the preferred therapy for some patients .
- Tramadol has been found to have beneficial effect in the treatment of premature ejaculation and may be used "on-demand". The most common adverse effect was sleep disturbance . Due to its potential for addiction, it is not routinely recommended.
- Phosphodiesterase type 5 (PDE5) inhibitors may be helpful in some cases, although the evidence for this is limited. There is some evidence that a combination of sildenafil with SSRI is better than SSRI monotherapy. It may be that the PDE5 inhibitor allows a second erection within a short space of time with subsequent improvement in intravaginal ejaculatory latency time (IELT) .
The evidence base for the effectiveness of psychological interventions is limited for premature ejaculation treatment. Psychological therapy needs compliance from the partner and is time-consuming, expensive and less effective than pharmacotherapy, and its efficiency decreases with time. It is however the first-line therapy in patients with subjective premature ejaculation or where there are underlying psychological problems. Psychotherapy is effective in managing psychological distress. Methods like meditation/relaxation, hypnotherapy and neuro-biofeedback help improve ejaculatory control. .
One study reported that a short frenulum was found in 43% of individuals affected by lifelong premature ejaculation. Frenulectomy was effective in relieving the problem and the authors recommended excluding short frenulum in all patients with lifelong premature ejaculation . This option is not reflected in any of the available guidelines.
Premature ejaculation may have a significant adverse effect on both self-confidence and the relationship. One study reported that premature ejaculation can lead to sexual dissatisfaction, a feeling that something is missing from the relationship and an impaired sense of intimacy. If the premature ejaculation remains untreated it can lead to increased irritability, interpersonal difficulties and deepening of an emotional divide . Studies report as well as the detrimental effect on sexual function and relationships, premature ejaculation may lead to reduced quality of life, mental distress, anxiety and depression .
Further reading and references
Saleh R, Majzoub A, Abu El-Hamd M; An update on the treatment of premature ejaculation: A systematic review. Arab J Urol. 2021 Aug 419(3):281-302. doi: 10.1080/2090598X.2021.1943273. eCollection 2021.
Althof SE, McMahon CG, Waldinger MD, et al; An Update of the International Society of Sexual Medicine's Guidelines for the Diagnosis and Treatment of Premature Ejaculation (PE). Sex Med. 2014 Jun2(2):60-90. doi: 10.1002/sm2.28.
Guidelines on Male Sexual Dysfunction; European Association of Urology, 2018
Premature ejaculation (PE) Guidelines Update November 2012; British Association for Sexual Health and HIV (BASHH)
Cooper K, Martyn-St James M, Kaltenthaler E, et al; Interventions to treat premature ejaculation: a systematic review short report. Health Technol Assess. 2015 Mar19(21):1-180, v-vi. doi: 10.3310/hta19210.
Premature ejaculation: Dapoxetine; NICE advice, May 2014
British National Formulary (BNF); NICE Evidence Services (UK access only)
Martyn-St James M, Cooper K, Ren K, et al; Topical anaesthetics for premature ejaculation: a systematic review and meta-analysis. Sex Health. 2015 Nov 25. doi: 10.1071/SH15042.
Wyllie MG, Powell JA; The role of local anaesthetics in premature ejaculation. BJU Int. 2012 Dec110(11 Pt C):E943-8. doi: 10.1111/j.1464-410X.2012.11323.x. Epub 2012 Jul 3.
Tan H, Zhou Z, Cui Y, et al; A systematic review and meta-analysis of randomized controlled trials of "on-demand" use of tramadol vs "on-demand" use of paroxetine in the management of patients with premature ejaculation. Int J Clin Pract. 2021 Nov75(11):e14825. doi: 10.1111/ijcp.14825. Epub 2021 Sep 16.
Martyn-St James M, Cooper K, Ren S, et al; Phosphodiesterase Type 5 Inhibitors for Premature Ejaculation: A Systematic Review and Meta-analysis. Eur Urol Focus. 2017 Feb3(1):119-129. doi: 10.1016/j.euf.2016.02.001. Epub 2016 Feb 19.
Raveendran AV, Agarwal A; Premature ejaculation - current concepts in the management: A narrative review. Int J Reprod Biomed. 2021 Jan 2519(1):5-22. doi: 10.18502/ijrm.v19i1.8176. eCollection 2021 Jan.
Gallo L, Perdona S, Gallo A; The role of short frenulum and the effects of frenulectomy on premature ejaculation. J Sex Med. 2010 Mar7(3):1269-76. doi: 10.1111/j.1743-6109.2009.01661.x. Epub 2010 Jan 14.
Graziottin A, Althof S; What does premature ejaculation mean to the man, the woman, and the couple? J Sex Med. 2011 Oct8 Suppl 4:304-9. doi: 10.1111/j.1743-6109.2011.02426.x.