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 of Sexual Medicine (ISSM) definition which identifies the following criteria:

• Ejaculation which occurs always or nearly always before or within one minute of vaginal penetration.
• Failure to delay ejaculation during nearly all episodes of vaginal penetration.
• Personal distress, bother, frustration and/or the avoidance of sexual encounters.
• Premature ejaculation may be classified as 'lifelong' (primary) or 'acquired' (secondary):
  • Lifelong premature ejaculation is characterised by onset from the first sexual experience and remains a problem during life.
  • Acquired premature ejaculation is characterised by a gradual or sudden onset with ejaculation being normal before onset of the problem. Time to ejaculation is short but not usually as fast as in lifelong premature ejaculation.

The European Association of Urology (EAU) points out that the ISSM definition only applies to men with lifelong premature ejaculation who have vaginal intercourse. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) is due to publish a new definition in May 2013.

Epidemiology

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 EAU reports a prevalence of 20-30% whilst a Cochrane review quoted a prevalence of 3-20%.

Risk factors

• Premature ejaculation may be anxiety-related. It is therefore more common in young men and early in a relationship. In these situations, the problem usually resolves with time.
• Iatrogenic causes include amphetamines, cocaine and dopaminergic drugs. Although effective for the treatment of premature ejaculation in some men, sildenafil may also be a cause of premature ejaculation in others.
• Urological causes – e.g, prostatitis.
• Neurological causes – e.g, multiple sclerosis, peripheral neuropathies.

Management

Management should be tailored to the needs of the individual. The condition may be more of an issue in some relationships than others and patient expectation should be explored. Psychosexual counselling may be sufficient. 1. General advice

• More frequent sex (or masturbation): premature ejaculation is more likely if there is a longer gap between sexual intercourse.
• Using a condom to decrease sensation.
• Using a cream with a numbing effect might also help. It should be applied to the head of the penis and especially the frenulum and corona (Your doctor would have pointed those out for you) about 10 minutes prior to penetration. It usually does not affect the sensation of the partner and does not decrease the intensity of the man’s orgasm.
• 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.

2. Drug therapy Selective serotonin reuptake inhibitor (SSRI) antidepressants are the most commonly used (off-label use) but need to be taken daily for 12 weeks before the maximum effect is achieved. Paroxetine, clomipramine, sertraline and fluoxetine have all been shown to be effective. Dr. Rudolph/Serfontein/Aspeling/Govender usually prescribes Paroxetine (there are various brand names but this is the active ingredient). For the first few days you will be asked to use half strength and then you will go up to full strength after that. It might cause slight nausea and a dry mouth in the beginning. Remember: these drugs work in your brain, so you might feel a bit strange in the beginning but it is usually quite easy to get used to it. Please use it EVERY DAY, not only when you want to have intercourse. It is much more effective if used every day and it is not good for you to skip dosages because you will experience withdrawal symptoms. You will not get addicted to the drug, we will just have to taper the dosage if you would like to stop using it. Stopping it abruptly can cause significant side effects and can be dangerous. It is possible that we might be able to use "as necessary” dosing later or even stop the treatment completely, but that will be assessed at your follow-up visit. We usually request a follow-up visit within one month to six weeks. Cheaper alternatives will also be discussed during your follow-up visit. WARNING: This drug should not be taken if you are trying for a baby – it might damage the DNA of the sperm. You have to be off the drug for at least two months before you start trying for a baby.

• In patients who cannot tolerate the side-effects of SSRIs, on-demand treatment with clomipramine may be a suitable alternative.
• Daproxetine is an SSRI which has been specifically developed for the treatment of premature ejaculation. It is proving highly effective but is not yet licensed for use in the South Africa.
• Sildenafil (Viagra) is an effective alternative, especially in older men and when associated with erectile dysfunction. Studies suggest that it improves intravaginal latency times, reduces performance anxiety and improves sexual satisfaction. It is thought to act by down-regulating the ejaculation threshold. There is some evidence that a combination of sildenafil with SSRI is better than SSRI monotherapy.
• Anaesthetic creams may be effective and may show an additive effect when combined with sildenafil. Aerosol sprays are proving popular and novel preparations are being developed. Topical preparations may be the preferred therapy for some patients.
• Tramadol has been found to have beneficial effect in the treatment of premature ejaculation but further studies of long-term safety are required before this treatment can be recommended as a viable option.

3. Psychosexual therapy The evidence base for the effectiveness of psychological interventions is limited and randomised trials with larger sample sizes are needed. 4. Surgery 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.

Complications

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 condition remains untreated it can lead to increased irritability, interpersonal difficulties and deepening of an emotional divide.