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MALE SEXUAL DYSFUNCTION
PREMATURE EJACULATION


Semir A. S. Al Samarrai

 

1.)Introduction:

Premature ejaculation is a very common male sexual dysfunction, it is poorly understood. Patients are often unwilling to discuss their symptoms and many physicians do not know about effective treatment. As a result, patients may be misdiagnosed or mistreated (1).

2.)Definition

Premature ejaculation is defined in the DSM-IV-TR as a “persistent or recurrent ejaculation with minimal sexual stimulation before, on , or shortly after penetration and before the person wishes it”. 

The clinician must take into account factors that affect duration of the excitement phase, such as age, noretly of the sexual partner or situation, and recent frequency of sexual activity (3).

‘ In the (ICD-IO) premature ejaculation is defined as the inability to delay ejaculation sufficiently to enjoy love-making, which is manifested by either on occurrence of ejaculation before or very soon after the beginning of intercourse (if a time limit is required; before or within 15 seconds of beginning of intercourse) or ejaculation occurs in the absence of sufficient erection to make intercourse possible. The problem is not the result of prolonged absence from sexual activity '(4). 

The International Society of Sexual Medicine (ISSM) have adopted a completely new definition of premature ejaculation which is the first evidence-based definition.

“ Premature ejaculation is a male sexual dysfunction characterized by ejaculation which always or nearly always occurs prior to or within about one minute of vaginal penetration, and 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”.

It must be noted that this definition is limited to men with lifelong premature ejaculation who engage in vaginal intercourse since there are sufficient objective data to propose an evidence-based definition from acquired (6).

All definitions have taken into account the time to ejaculation, the inability to control or delay ejaculation, and negative consequences (bother / distress) from premature ejaculation (7,8,9,10,11)

3.) Classification

Premature ejaculation is classified as 'lifelong' (primary) or 'acquired' (secondary) (12).

The lifelong PE is characterized by onset from the first sexual experience, remains so during life and ejaculation or occurs too to fast before vaginal penetration <1-2minutes after.

Acquired PE is characterized by gradual or sudden onset following normal ejaculation experiences before onset, and time to ejaculation is short (usually not as short as in lifelong premature ejaculation.



4.) Epidemiology of Premature Ejaculation

Epidemiological research has consistently shown that premature ejaculation, at least according to del DSM-IV definition is the most common male sexual dysfunction, with prevalence rate of 20-30% (15,16,17).

5.) Risk factors:

The aetiology of premature ejaculation is unknown, with little data to support suggested biological and psychological hypothesis, including
Anxiety
Penile hypersensitivity
5-HT receptor dysfunction (5)

A significant proportion of men with erectile dysfunction also experience premature ejaculation (15). High levels of performance anxiety related to erectile dysfunction may worsen remature ejaculation, with a risk of misdiagnosing premature ejaculation instead of the underlying erectile dysfunction.

According to the NHLS, the prevalence of premature ejaculation is not affected by age (16,17), unlike erectile dysfunction, which increases with age.

Premature ejaculation is not affected by marital or income status (16), However, premature ejaculation is more common in blacks, Hispanic men and men from Islamic backgrounds (28,29) and may higher in men with a lower educational level (15.16).

Other risk factors may include a genetic predispositions (30)., poor overall health status and obesity (16), Prostate inflammation (31,32), thyroid hormone disorders(33), emotional problems and stress (16,34), and traumatic sexual experience (15.16)

Successful eradication of causative organisms in patients with chronic prostatitis and premature ejaculation produced marked improvements in IELT (Intravaginal Ejaculatory Latence Time) and ejaculatory control compared to untreated patients. 

6.) Diagnosis: 

Diagnosis of PE is based on the patients medical and sexual history (35,36). History should classify PE as lifelong or acquired.

Special attention should be given to the duration time of ejaculation, degree of sexual stimulus, impact on sexual activity and quality of life, and drug use or abuse.

It is also important to distinguish Premature Ejaculation from erectile dysfunction.

The use of intravaginal ejaculatory latency time (IELT) alone is not sufficient to define Premature ejaculation, as there is significant overlap between men with and without PE (24,25). In everyday clinical practice, self-estimated(IELT) is sufficient. Self-estimated and stopwatch-measured IELT are interchangeable and correctly assign PE status with 80% sensitivity and 80% specificity (37).

Specificity can be improved further to 96% by combining IELT with a single-item patient-reported outcome (PRO) an control over ejaculation and satisfaction with sexual intercourse (scale ranging from 0= very poor to 4= very good) and an personal distress and interpersonal difficulty (0= not at all to 4= extremely).

Physical examination and investigation:

Physical examination is a part of the initial assessment of men with premature ejaculation. It includes a brief examination of the vascular, endocrine and neurological systems to identify underlying medical condition associated with PE and other sexual dysfunctions, such as chronic illness, endocrinopathy, autonomic neuropathy, Peyronic disease, urethritis or prostatitis. 

8.) Treatment:

In many relationships, premature ejaculation causes few, if any, problem, in such cases, treatment should be limited to psychosexual counselling.

Before beginning treatment, it is essential to discuss patient expectations thoroughly, erectile dysfunction, in particular, or other sexual dysfunction or genitorurinary infection (e.g. prostatitis), should be treated first or at the same time as the premature premature ejaculation.

Various behavioural techniques have demonstrated benefit in treating PE and are indicated for patients uncomfortable with pharmacological therapy.

In lifelong, PE, behavioural techniques are not recommended for first line treatment.

Pharmacotherapy, is the basis of treatment in lifelong premature ejaculation only chronic selective serotonin reuptake inhibitors (SSRIs) and on demand topical anesthetic agents have consistently shown efficacy in premature ejaculation therapy. 

References

1. Rosenberg MT, Sadovsky R. Identification and diagnosis of premature ejaculation. 
Int J Clin Pract 2007 Jun; 61(6):903-8
http://www.ncbi.nlm.nih.gov/pubmed/17504352

3. American Psychiatric Association. Diagnostic and Statistical manual of Mental Disorders. 4th Ed. Text Revision. Washington, D.C., American Psychiatric Publishing, Inc, 2000 

4. International Classification of Disease and Related Health Problems. 10th Ed. Geneva, World Health Organization, 1994. 

5. McMahon CG, Abdo C, Incrocci L, et al. Disorders of orgasm and ejaculation in men. J. Sex Med 2004 Jul;1(1):58-65.
http://www.ncbi.nlm.nih.gov/pubmed/16422984

6. McMahon CG, Althof SE, Waldinger MD, et al. An evidence-based definition of lifelong premature ejaculation: report of the International Society of Sexual Medicine (ISSM) ad hoc committee for the definition of premature ejaculation. J Sex Med 2008 Jul;5(7):1590-606. 
http:www.ncbi.nlm.nih.gov/pumbed/18466262

7. Balon R, Sagraves RT, Clayton A. Issues for DSM-V: sexual dysfunction, disorder, or variation along normal distribution: toward rethinking DSM criteria of sexual dysfunctions,Am J Psychiatry 2007 Feb; 164(2):198-200. [no abstract available] 
http://www.ncbi.nlmnih.gov/pubmed/17267778

8. Waldinger MD, Schweitzer DH. The DSM-IV-TR is an inadequate diagnostic tool for premature ejaculation. J Sex Med 2007 May;4(3):822-3. [no abstract available] 
http://www.ncbi.nlm.nih.gov/pubmed/17498112

9. Waldinger MD, Schweitzer DH. The use of old and recent DSM definitions of premature ejaculationin observational studies: a contribution to present debate for a new classification of PE in the DSM-V. J Sex Med 2008 May;5(5):1079-87. 
http://www.ncbi.nlm.nih.gov/pubmed/18331260

10. Waldinger MD, Schweitzer DH. Changing paradigms from a historical DSM-IV view toward an evidence-based definition of premature ejaculation. Part I-validity of DSM-IV-TR. J Sex Med 2006 Jul;3(4):682-92. 
http://www.ncbi.nlm.nih.gov/pubmed/16839325

11. Waldinger MD, Schweitzer DH. Changing paradigms from a historical DSM-IV view toward an evidence-based definition of premature ejaculation. Part II-proposal for DSM-V and ICD-11.J Sex Med 2006 Jul;3(4):693-705. 
http://www.ncbi.nlm.nih.gov/pubmed/16839326

12. Godpodinoff ML. Premature ejaculation: clinical subgroups and etiology. J Sex Marital Ther 1989 Summer; 15(2):130-4 
http://www.ncbi.nlm.nih.gov/pubmed/2769774

15. Laumann EO, Nicolosi A, Glasser DB, et al; GSSAB Investigators’ Group. Sexual problems among women and men aged 40-80 y: prevalence and correlates identified in the Global Study of Sexual Attitudes and Behaviors. Int J Impot Res 2005 Jan-Feb; 17 (1):39-57. 
http://www.ncbi.nlm.nih.gov/pubmed/15215881

16.Laumann EO, Paik A, rosen RC. Sexual dysfunction in the United States: prevalence and predictors. JAMA 1999 Feb;281(6):537-44 
http://www.ncbi.nlm.nih.gov/pubmed/11022110

17. Porst H, Montorsi F, Rosen RC, et al. The premature Ejaculation Prevalence and attitudes (PEPA) survey: prevalence, comorbidities, and professional help-seeking. Eur Urol 2007 Mar;51(5):816-23; discussion 824. 
http://www.ncbi.nlm.nih.gov/pubmed/16934919

24.Giuliano f, Patrick DL, Porst H, et al; 3004 Study Group. Premature ejaculation: results from a five-country European observational study. Eur Urol 2008 May;53(5):1048-57. 

25. Patrick DKL, Althof SE, Pryor JL, et al. Premature ejaculation: an observational study of men and their partners. J Sex Med 2005 May; 2(3):358-67 

28. Richardson D, Goldmeier D. Premature ejaculation-does country of origin tell us anything about etiology? J Sex Med 2005 Jul;2(4):508-12 

29. Carson c, Gunn K. Premature ejaculation:definition and prevalence. Int J Impot Res 2006 sep-Oct;18 9Suppl 1):S5-13 

30. Waldinger MD, Rietschel M, Nothen NM, et al. Familial Occurrence of primary premature ejaculation.Psychiatr Genet 1998 Spring; 8(1):37-40. [no abstract available] 
http://www.ncbi.nlm.nih.gov/pubmed/9564687 

31. Screponi E, Carosa E, Di Stasi SM, et al. Prevalence of chronic prostatis in men with premature ejaculation. Urology 2001 Aug;58(2):198-202 
http://www.ncbi.nlm.nih.gov/pubmed/11489699

32. Shamloul R. el-Nashaar A. Chronic prostitis in premature ejaculation: a cohort study in153 men. J Sex Med 2006 Jan;3(1):150-4.

33. Carani C, Isidori AM, Granata A, et al. Multicenter study on the prevalence of sexual symptoms in male hypo-and hyperthyroid patients. J Clin Endocrinol Metab 2005 Dec;90(12):6472-9 

34. Dunn KM, Croft PR, Hackett GI. Association of sexual problems with social,psychological, and physical problems in men and women: a sectional population survey. J Epidemiol Community Health 1999 Mar;53(3):144-8 

35. Sharlip I. Diagnosis and treatment of premature ejaculation: the physician’s perspective. J Sex Med 2005 May;2 (Suppl 2):103-9. 

36. Shabsigh R. Diagnosis of premature ejaculation: a review. J Med 2006 Sep;3(4):318-23. 

37. Rosen RC, McMahon CG, Niederberger C, et al. Correlates to the clinical diagnosis of premature ejaculation: results from a large observational study of men and their partners. J Urol 2007 Mar;177(3):1059-64; discussion 1064. 

Correspondence:
Prof. Dr. SEMIR AHMED SALIM AL SAMARRAI
Professor Doctor of Medicine-Urosurgery, Andrology, and Male Infertility
Dubai Healthcare City, Dubai, United Arab Emirates.
Mailing Address: Dubai Healthcare City, Bldg. No. 64, Al Razi building, Block D,
2nd floor, Dubai, United Arab Emirates, PO box 13576
Email: fmcalsam@emirates.net.ae