There has been medical controversy regarding the definition, classification and prevalence of premature ejaculation. The first evidence-based definition of premature ejaculation was limited to heterosexual men who had lifelong premature ejaculation during intercourse. Unfortunately, many patients who present with premature ejaculation do not meet these criteria. These men may be diagnosed with one of the subtypes of premature ejaculation, namely secondary premature ejaculation, situational premature ejaculation, or ejaculatory dysfunction. However, there is also a lack of evidence for a valid classification of these subtypes. The prevalence of premature ejaculation in reported studies is controversial due to the lack of a widely accepted definition of premature ejaculation and criteria for data collection. the high prevalence of 20-30% may be due to the vague definition of premature ejaculation at the time of the questionnaire survey.
Many of the men in the study reported symptoms of premature ejaculation, and many of these patients had symptoms identical to those of premature ejaculation, but only a minority would actively seek treatment. Patients with secondary premature ejaculation appear to have more severe symptoms, while patients who have experienced ejaculatory dysfunction appear to have the least severe of the various types of premature ejaculation. Although many forms of treatment have been proposed for premature ejaculation, only antidepressants and local anesthetics and creams have been shown to be effective. However, no form of treatment has yet been approved by regulatory agencies, and further research is needed to develop effective strategies for the treatment of premature ejaculation.
INTRODUCTION
Although the first reported case of premature ejaculation was published more than 100 years ago, we still do not fully understand the etiology of premature ejaculation onset. Given the high prevalence of premature ejaculation and the rapidly changing pharmaceutical technology, premature ejaculation has become a hot topic of interest in the field of male science and the pharmaceutical industry. Research in this direction has increased over the past two years, and our understanding of premature ejaculation is constantly being updated. However, there are still controversies in the definition, classification, epidemiology and effective treatment of premature ejaculation, and the purpose of this article is to review some of the relevant recent developments.
Definition of premature ejaculation
The etiological study of premature ejaculation has been in a state of incomplete clarity, which poses a great difficulty in defining premature ejaculation. Historically, premature ejaculation has been defined in different ways by numerous academic organizations and renowned scholars. However, most of the definitions have been developed according to the experience of the formulators rather than being defined from an evidence-based perspective. Moreover, these definitions lacked adequate surgical indications and were controversial in terms of surgical specificity, and they relied on subjective statements by clinicians to define premature ejaculation.
To remedy the deficiencies of past definitions of premature ejaculation, the International Committee of Ad Hoc Premature Ejaculation Specialists of the International Medical Association concluded that new qualifications should be added to the definition of premature ejaculation, such as the time from erection to ejaculation, the inability to prolong ejaculation, and the poor personal outcomes associated with premature ejaculation. They also emphasized that objective evidence for evaluating premature ejaculation comes primarily from the population of heterosexual men with lifelong premature ejaculation. Accordingly, they defined lifelong premature ejaculation in heterosexual men as.
1. ejaculation occurs before or within one minute of vaginal penetration during all or almost all vaginal intercourse
2. Inability to prolong ejaculation spontaneously during all or almost all vaginal intercourse.
3. Adverse personal consequences, such as depression, boredom, anxiety, or/and avoidance of sexual contact.
Unfortunately, this definition still covers all aspects of premature ejaculation. First, it does not include premature ejaculation that occurs during sexual encounters other than vaginal intercourse and among homosexual men. Second, the committee’s definition does not take into account men who have a complaint of premature ejaculation but do not meet the criteria for a lifetime definition of premature ejaculation, such as men who have a subjective report of premature ejaculation but ejaculate one minute after penetration; men who have occasional premature ejaculation; and men who have premature ejaculation after a certain time in their lives. Therefore, further research is needed to develop an evidence-based medical definition of premature ejaculation and to provide treatment for men who have a primary report of premature ejaculation but do not meet the criteria.
Classification of premature ejaculation
The depression associated with premature ejaculation varies in severity among patients with premature ejaculation. Some men may simply answer on an epidemiological questionnaire that they have symptoms of premature ejaculation, but they do not seek medical attention for premature ejaculation. On the other hand, other patients may actively seek medication for the negative personal outcomes associated with premature ejaculation.
Waldinger emphasized that premature ejaculation has always been perceived not as a disease but as a sexual dysfunction, which has kept the diagnosis, classification, epidemiology and treatment of premature ejaculation controversial. To clarify misconceptions in all areas, he suggests that we distinguish between the complaints of premature ejaculation and the symptoms of premature ejaculation. Some men may complain of occasional premature ejaculation, but they simply treat this phenomenon as an occasional sexual malfunction. On the other hand, some men may have complaints of premature ejaculation but still have a range of other manifestations, such as ejaculation occurring one minute after vaginal penetration, premature ejaculation in all vaginal intercourse experiences from the first sexual encounter, and lifelong symptoms of premature ejaculation, i.e., as described by the definition recommended by the ISSM Ad Hoc Committee.
Bernard Schapiro made the first attempt to classify premature ejaculation into type A and type B in 1943. This classification has since been renamed by Godpodinoff, who referred to type A as primary premature ejaculation and type B as secondary premature ejaculation. Because these two evaluation methods were not well recognized at the time, they were not widely used, and it took even 20 years before relatively objective diagnostic criteria for lifelong premature ejaculation were developed. The recent ISSM guidelines on the diagnosis and treatment of premature ejaculation state that the diagnostic criteria used to diagnose primary premature ejaculation are also applicable to secondary premature ejaculation. However, the relevant level of evidence is very low.
Since men with secondary premature ejaculation are older and have more severe sexual complaints and more comorbidities, we believe further research is necessary to define secondary premature ejaculation according to evidence-based medical criteria, rather than simply applying the diagnostic criteria for primary premature ejaculation. For patients with secondary premature ejaculation, their intravaginal ejaculatory latency (IELT) must be measured by a closely designed observational test, and in addition to this, the relationship between IELT and ejaculatory control, depression and personal difficulties needs to be confirmed.
In addition to the above classification, there are two other premature ejaculation syndromes for which patients also seek medical help. These two subtypes are named “natural variant premature ejaculation” and “premature ejaculation-like ejaculation disorder” (the characteristics of the four types of premature ejaculation are listed in Table 2). While natural variant premature ejaculation occurs in occasional or specific circumstances, premature ejaculation dysfunction refers to the objective sensation of rapid ejaculation during sexual intercourse, either sequentially or intermittently, while the IELT is in the normal range or even longer. Since the above classifications are based solely on empirical evidence and lack evidence-based medical evidence, scholars suggest that they should be used only on a “provisional” basis, although they may be useful for patients who do not yet meet the diagnostic criteria for premature ejaculation and for voluntary workers to answer questions for these patients.
Recent studies by Waldinger have demonstrated that the medical needs of patients with different types of premature ejaculation vary, with the majority of patients seeking medical help suffering from primary or secondary premature ejaculation. Considering the results of these studies, it can be assumed that patients with primary and secondary premature ejaculation have more severe complaints than those with natural variant premature ejaculation or premature ejaculation-like ejaculatory disorders.
Serefoglu et al. conducted a study using the PRO scoring system and found that patients with secondary premature ejaculation had the most severe complaints, while those with premature ejaculation-like ejaculatory disorder had the least severe complaints.The PRO score was derived from the premature ejaculation patient profile, which was developed to evaluate four aspects of premature ejaculation in a large sample of observational trials and pharmacological studies. Although comparisons of mean premature ejaculation P scores were not statistically significant across all four measures, the four types of premature ejaculation appeared to be ranked in order of severity, with secondary premature ejaculation having the most severe subjective reports, primary premature ejaculation the next most severe, natural variant premature ejaculation the next most severe, and patients with premature-like ejaculatory disorders having the least severe subjective reports.
In a similar study, Porst et al. analyzed premature ejaculation P results in patients with primary and secondary premature ejaculation and concluded that the basic characteristics of patients with secondary and primary premature ejaculation were close to each other, but they did not perform any statistical analysis of PROs. The divergence between the aforementioned trials can be explained by the different methods of calculating premature ejaculation P results used in each study. porst et al. compared the percentage of patients with primary and secondary premature ejaculation who were considered to have worse sexual function based on the four questions of premature ejaculation P, while serefoglu et al. compared the mean scores obtained from each premature ejaculation P measure, an approach that is methodologically similar to the American and European observational pilot studies.
Using a similar approach to the data from Porst et al. found that secondary premature ejaculation was worse in sexual function scores (1.14+0.83 vs. 1.22+0.93; p=0.162) and was able to detect more pronounced difficulties with intercourse (2.09+1.07 vs. 1.89+1.17, p<0.001), whereas patients with primary premature ejaculation were worse in perceptual control (0.61 +0.64 vs. 0.77+0.66; p<0.001) and personal stress (2.83+0.87 vs. 2.80+0.88; p=0.7), while primary premature ejaculation patients showed more severe performance in terms of perceptual control (0.61+0.64 vs. 0.77+0.66; p<0.001) and personal stress.
Whether primary or secondary premature ejaculation is more severe is inconclusive, but it is clear that the two premature ejaculation syndromes have different characteristics and should be managed according to different principles of management. Furthermore, future research needs to be devoted to confirming whether there are differences in the level of severity of the complaints between the various types of patients.
Epidemiology of premature ejaculation
Many studies have been conducted by national and international scholars to understand the epidemiological characteristics of premature ejaculation. However, because there is no clear definition of this disorder, it is impossible to conduct a precise epidemiological study room. Since there is no consensus among academics on the definition of premature ejaculation, most studies have applied theories that have been controversial in past reports. In addition, differences in sampling methods, methods of data extraction, and data analysis methods have contributed to the lack of consistency in results.
According to clinical studies conducted using the definition of premature ejaculation in the DSM-IV-TR, premature ejaculation is the most common male sexual dysfunction with a prevalence of between 20% and 30%. However, the results of these epidemiological studies have been controversial due to the DSM-IV-TR’s use of ambiguous terms in the definition of premature ejaculation, such as “complaints” and “significant depression,” and whether the prevalence of premature ejaculation in the population obtained from the studies is correct. The prevalence of premature ejaculation in the population is also questionable. According to the most recent ISSM definition, the prevalence of primary premature ejaculation ranges from 1% to 5%, whereas the higher prevalence reported in previous studies is due to the inclusion of patients with natural variant premature ejaculation and ejaculation-like syndrome, who may not have a medical need but are still included in epidemiological investigations, a phenomenon caused by the generality and uncertainty of the definition.
Unfortunately, most recent epidemiologic studies have not addressed this issue; McMahon et al. surveyed 4997 Asian-Pacific men (68% of whom were younger than 46 years) and found that more men reported having premature ejaculation than erectile dysfunction (13% vs. 8%). However, McMahon did not report the overall response rate and the demographic characteristics of the non-participants.
In this report, it is important to consider the effect of subject bias, as those who volunteer for health surveys tend to be among the “very worried about themselves” segment of the population, and these individuals tend to believe that they would benefit from participating in such health surveys. Moreover, selection bias must be taken into account. In this study, the majority of respondents were highly educated men between the ages of 18-35.
An online survey conducted in the Middle East collected questionnaires from 804 male Internet users in Arab language countries and found that a total of 82.6% of respondents reported varying degrees of premature ejaculation, although among this group the mean IELT was 5 minutes. As in previous epidemiological studies, the investigators of this study included respondents who ejaculated occasionally (45.9%), most of the time (21.4%), and all the time (15.3%) in the “premature ejaculation” population, without taking into account the previous definition of premature ejaculation Frequency criteria.
As the authors point out, there are many advantages of online questionnaires over in-person surveys, such as wide audience, protection of privacy, and less pressure to discuss sensitive topics. However, online questionnaires also have many problems, such as low response rates, many over-performing volunteers (volunteer bias), and sampling bias (people who participate in online questionnaires can afford computers, access the Internet, check e-mail, and therefore generally have higher social status, higher income levels, and higher education).
In a study of 522 urban Greeks, 58.43% of the respondents reported “early ejaculation disorder” and the prevalence of primary premature ejaculation according to ISSM criteria was 17.7%. This study obtained a significantly higher prevalence rate than the previous study, which may be due to confusion between the definitions of primary premature ejaculation and early ejaculation disorder. In addition, this investigator also did not report IELT, which would have helped make their findings more meaningful if they had reported it.
Another recent cross-sectional study chose a primary care clinic in Malaysia as the study site, and they used the Premature Ejaculation Diagnostic Tool (Premature Ejaculation DT) questionnaire, and they found that the prevalence of premature ejaculation was particularly high (40.6%) across medical conditions. However, the results of this survey are not representative of the general population, as all respondents were patients suffering from various diseases. Moreover, the results of this study need to be treated with caution, as although the sensitivity of the premature ejaculation DT questionnaire is high, its specificity is poor.
A number of studies have come in to try to further elucidate the definition of premature ejaculation and to confirm the true prevalence of premature ejaculation. An epidemiological study conducted in Turkey used a different approach than previous studies in that they determined the proportion of men who were dissatisfied with their ejaculation time (with complaints of premature ejaculation), and then they meticulously analyzed the cooking of these subjects before placing these patients under one of the four premature ejaculation syndromes mentioned above one diagnosis. They randomly selected subjects through stratified random sampling rather than recruiting subjects through advertisements or online resources. Thus, unlike previously reported studies, this study was more representative of urban and rural population distribution, population geography distribution, and all levels of education, income, and age.
Their findings showed that 20.0% of patients reported complaints of “rapid ejaculation,” which is consistent with the previously reported prevalence of premature ejaculation. The prevalence of primary premature ejaculation, secondary premature ejaculation, natural variant premature ejaculation, and rapid ejaculation disorder was 2.3%, 3.9%, 8.5%, and 5.1%, respectively. To our knowledge, this is the first study to report the prevalence of each of these syndromes, and this study establishes that the majority of men reporting premature ejaculation in epidemiological studies are patients with natural variant premature ejaculation and premature ejaculation-like ejaculatory disorders. The low prevalence of primary and secondary premature ejaculation suggests that less than 8% of the male population is truly premature.
In fact, in previous epidemiological studies, few men with premature ejaculation reported seeking medical help, suggesting that in fact physicians are treating far fewer patients than the epidemiological studies suggest. The majority of those who sought medical help were patients with secondary premature ejaculation. It was also clinically demonstrated that the majority of outpatients with premature ejaculation complaints were either primary or secondary premature ejaculation patients, a finding that corroborates the epidemiological findings.
Because the definition of premature ejaculation is now limited to those who engage in vaginal intercourse, there are limited reports of studies examining premature ejaculation in homosexual populations. A North American cohort study of 2640 men explored premature ejaculation in the homosexual population. They used the Premature Ejaculation DT questionnaire and found that premature ejaculation diagnosed by premature ejaculation DT varied with age. The researchers demonstrated that people who were younger, had lower urinary tract symptoms, and had fewer sexual partners were more likely to have premature ejaculation.
Treatment of premature ejaculation
A survey of urology residents showed that although greater than 15% of patients had a primary report of premature ejaculation, the majority of residents failed to treat these patients according to current treatment guidelines. This phenomenon suggests that there is a lack of training for premature ejaculation in urology residency training. It is clear that there is a large unmet need for treatment of premature ejaculation and that there are many treatments available for premature ejaculation that may be effective. For example, local anesthetics, selective 5-HT reuptake inhibitors, and PDE-5 inhibitors have been studied for their effectiveness. In addition, there are newer medications, such as transaminophenol and anesthetic sprays containing small amounts, but further evidence is needed to support the effectiveness of these new treatments. Other treatments include behavioral therapy, psychotherapy, acupuncture, surgery, and a combination of treatments.
Psychotherapy may be beneficial, and these treatments are now considered first-line treatment for patients with natural variant premature ejaculation and premature ejaculation-like ejaculation disorders. Although earlier studies reported high success rates for psychotherapy, it has recently been reported that most previously published articles examining psychotherapy for premature ejaculation did not do well with the principles of control and randomization, and lacked long-term follow-up. Several studies have even provided weak and contradictory evidence. Some advocate that psychotherapy should be used in conjunction with medication to enhance efficacy and that some psychotherapy, including sexual counseling, can even replace medication for some patients.
For example, pharmacotherapy combined with psychotherapy can be particularly effective in patients with secondary premature ejaculation who have a clear psychological disorder; in patients with premature ejaculation combined with ED, a combination of treatments can manage the psychological stress of sexual dysfunction and improve the patient’s quality of life. To evaluate the effects of pharmacotherapy and psychotherapy, a randomized controlled two-stage clinical trial was conducted in which patients received paroxetine and lidocaine spray for the first two months, and after two months the pharmacotherapy was discontinued and patients received behavioral therapy for the next two months. Through this study, the scholars found that after two months of drug treatment, the patients’ IELT was prolonged eight times, and after two months of behavioral treatment, the IELT was shortened again to 1.7 times of the original. The available evidence suggests that, when applied alone, pharmacotherapy is more effective than psychotherapy in improving symptoms in patients with premature ejaculation; however, when dealing with patient troubles, the associated psychological issues cannot be ignored.
Behavioral therapies include the stop-start program proposed by Semans and the squeeze technique developed by Masters and Johnson. These treatments are based on the hypothesis that by gradually applying more intense and prolonged stimulation to the patient, the patient’s stimulus-reflex connection can be weakened, thereby prolonging ejaculation. Masturbation before intercourse has a similar effect to the “stop-and-go” method. Another potentially effective treatment is pelvic floor rehabilitation exercise (lvic floor rehabilitation exercise for premature ejaculation). A small randomized observational trial found that pelvic floor rehabilitation exercise was similar to dapoxetine when needed in the treatment of primary premature ejaculation. These behavioral and pharmacological treatments may improve outcomes when applied together, but further research is needed to validate their effects.
Topical therapy is a simple in situ treatment, and of the topical treatments, lidocaine-proparacaine ointment has received the most attention. In a randomized, double-blind, placebo-controlled clinical trial, lidocaine-proparacaine ointment was found to significantly prolong IELT in 5% of subjects when applied for 20 minutes. in another placebo-controlled trial that included 84 patients with premature ejaculation, lidocaine-proparacaine ointment mixed with sildenafil was not only more effective than placebo, but the combination was also more effective than placebo. but the combined treatment was also superior to the two drugs alone. Recently, a new lidocaine/proparacaine spray (topical dissolution mixture for the treatment of premature ejaculation, TEM Premature Ejaculation Plethora Plethora solutions Ltd, London, UK) has been developed by a UK pharmaceutical company.
Clinical studies have shown that this agent prolongs IELT by 6.3 times, while patients show improvements in self-control and sexual satisfaction in PRO scores. In the near future, it is possible that local anesthetics could be approved for the treatment of premature ejaculation, a treatment with minimal local and systemic side effects. SS ointment, made with nine herbal extracts, is another commonly used local anesthetic. In a double-blind, randomized, placebo-controlled study, SS ointment was able to extend IELT from 1.37 to 10.92 minutes, and 82% of patients reported an improvement in their sexual satisfaction. Topical treatment is also an option in the current treatment guidelines for premature ejaculation.
Among oral medications, antidepressants targeting 5-HT are considered to be the basis of treatment for premature ejaculation. It was found that 5-HT is able to inhibit ejaculation through different downstream pathways, a process that may be able to be enhanced by SSRIs. Moreover, further studies have found huge differences between corticosteroid levels in patients with premature ejaculation and the normal population. It is worth pointing out that after regular administration of SSRIs, it takes some time before a prolongation of ejaculation time is observed and the longest ejaculation prolongation time is observed only 1-2 weeks after treatment. Several well-designed placebo-controlled, double-blind trials have validated the efficacy of routinely administered SSRIs. Therefore, treatment guidelines have consistently identified oral pharmacotherapy as the first-line treatment for primary premature ejaculation.
Among the various SSRIs, paroxetine was found to be more effective than fluoxetine, chlorpromazine, and sertraline. Large-scale clinical studies are needed to better understand the side effects of these routinely administered SSRIs, such as paroxetine. Furthermore, the side effects of SSRIs leading to infertility are clear, and for patients who wish to maintain their fertility, it is best to use other drugs instead of SSRIs. it has been reported that long-term SSRI treatment can cause significant damage to spermatogenesis, affecting sperm transport, disrupting sperm membranes, altering sperm DNA and/or affecting the homeostasis of hormone metabolism. The mechanisms by which sperm are damaged by routine administration of SSRIs have not been fully investigated, but further research is needed to determine whether immediate SSRI treatment also causes sperm damage.
In addition to the risk of infertility, several animal studies have found effects of SSRIs on erectile function, and Angulo et al. suggested that paroxetine could affect erectile function by reducing NO production and expression of neurogenic nitric oxide synthase. Similarly, Kadioglu et al. hypothesized that fluoxetine and sertraline promote the release of smooth muscle relaxing factors, whereas paroxetine has a different nitric oxide synthase inhibitory activity, which may act by inhibiting neurogenic nitric oxide synthase and possibly by inhibiting endothelial-derived nitric oxide synthase. In addition, serotonin antidepressants have several other side effects related to sexual function, such as decreased libido, sensual dysphoria, impotence, and male erectile dysfunction, and it is worth pointing out that these symptoms may persist after treatment with an SSRI has been discontinued.
Dapoxetine is a recently developed drug with fast absorption and clearance, which has been shown to prolong IELT by 2-3.5 minutes and has relatively mild side effects, so it may be an immediate treatment option for premature ejaculation. An analysis of five phase 3 trials found that dapoxetine 30 mg extended the IELT to 3.1 minutes at week 12 when the baseline IELT was 1.9 minutes, and to 3.6 minutes at 60 mg, while placebo extended the IELT to 1.9 minutes. Dapoxetine is more effective in patients with primary and secondary premature ejaculation. No interactions between dapoxetine and other drugs, including PDE-5 inhibitors, have been identified. The Dapoxetine Development Project demonstrated an association between dapoxetine and vasomediated vagal syncope. Immediate treatment may be more convenient than routine administration, and Waldinger et al. demonstrated that a group of patients with primary premature ejaculation benefited from an uninterrupted daily medication regimen that ensured that the effects of treatment were not interfered with by casual sexual behavior. The field of premature ejaculation pharmacotherapy research is still evolving, and there is much debate about the effectiveness of dapoxetine in treating premature ejaculation, especially when there are multiple studies sponsored by pharmaceutical companies.
PDE-5 inhibitors may also be able to be used in the treatment of premature ejaculation. In a well-designed, randomized, double-blind, placebo-controlled study, sildenafil improved patients’ self-confidence, perception of ejaculatory control, and overall satisfaction, and resulted in a shorter period of inactivity after a single ejaculation, as well as a significant improvement in patients’ IELT. Another randomized, double-blind, placebo-controlled study found that sildenafil was similar to placebo. In another randomized, double-blind, parallel-controlled trial, sildenafil significantly improved IELT and sexual satisfaction, and significantly reduced patients’ general anxiety symptoms compared to several SSRIs and “stop-start” techniques.
However, there are few reports in the literature examining the efficacy of other PDE-5 inhibitors (e.g., tadalafil, vardenafil) in the treatment of premature ejaculation. In trials comparing sildenafil, tadalafil, and vardenafil, it was found that only subjects using vardenafil had significantly longer median lengths of vibrationally stimulated ejaculation times than the control group. Evidence suggests that PDE-5 inhibitors alone or in combination with an SSRI are beneficial in patients with secondary premature ejaculation in combination with ED. Another recent META analysis reported similar results, and PDE-5 inhibitors are relatively new, but if the role of NO and PDE5 in ejaculation is further investigated, the place of PDE-5 in the treatment of premature ejaculation will become clearer.
Alpha-1 adrenaline therapy is another new idea for the treatment of premature ejaculation. Currently, there are few studies supporting the therapeutic effects of Alpha-1 adrenergic antagonists, such as terazosin and alfuzosin. However, these drugs have a theoretical ability to treat premature ejaculation. A study investigating eight patients showed that IELT was significantly longer (from 3.4 to 10.1 minutes) in patients treated with Alpha-1 epinephrine compared to pre-treatment, and all patients reported improvement in their premature ejaculation problems. These findings could provide theoretical support for further randomized controlled trials in the future.
Tramadol is an opioid used for analgesia, and immediate administration of tramadol has been shown to be effective in the treatment of premature ejaculation in several placebo-controlled trials. In two of these studies, tramadol 50 mg significantly prolonged IELT in patients, while also improving sexual satisfaction and ejaculatory control. In addition to this, immediate administration of 25 mg of tramadol has been confirmed to prolong IELT from 1.17 minutes to 7.37 minutes. The effectiveness of tramadol was also demonstrated in another single-blind randomized controlled trial that included 60 patients. More recently, a double-blind placebo-controlled clinical trial of 600 patients from 62 research institutions in 11 countries, in which some patients were treated with oral tramadol enteric tablets and others with a placebo control, found that treatment with 62 mg of tramadol significantly improved the patients’ IELT with few side effects or tolerability problems.
This effect was more pronounced in patients with baseline levels of IELT <1 min (approximately 300 patients), and in this subgroup, 62 mg of tramadol treatment significantly prolonged the IELT by 2.4-fold. Further studies sought to include patients with comorbid male erectile dysfunction in the trial. Because tramadol is an opioid, its drug dependence needs to be further investigated, and the interaction of tramadol oral enteric tablets with PDE-5 inhibitors needs to be further explored. Although the mechanism by which tramadol delays ejaculation is not known, it is necessary to inform patients who are taking tramadol with complaints of delayed ejaculation that discontinuing tramadol can improve their sexual function.
In addition, there are a number of other treatments that have not been widely used in addition to those mentioned above. Chinese medicine has always tried to address the occurrence of premature ejaculation. Sunay et al. demonstrated that acupuncture is indeed more effective than placebo in the treatment of premature ejaculation, although it is less effective than daily paroxetine. However, apart from this study, there are few reports demonstrating the effectiveness of acupuncture in the treatment of premature ejaculation.
Surgery is another possible unconventional treatment, and several authors have reported that selective dorsal nerve dissection and hyaluronic acid colloid glans augmentation can be applied in the treatment of refractory primary premature ejaculation where both pharmacological and behavioral treatments have failed. However, further studies are needed to investigate the efficacy of surgical treatment.
Premature ejaculation is often due to multiple causes, so treatment of patients with premature ejaculation is complex and requires a combination of treatment modalities. When deciding on a treatment plan for premature ejaculation, physicians must take into account the severity of symptoms and side effects of treatment, and consider combining multiple treatments in refractory cases. In clinical practice, treatment of premature ejaculation generally includes medication, psychotherapy, and behavioral therapy, and partners should be encouraged to participate in treatment if necessary. In addition, follow-up during treatment is also important for the treatment of premature ejaculation. Further research and summary of the diagnostic methods of premature ejaculation will help to improve the efficacy of premature ejaculation treatment.
Summary
The ISSM definition of primary premature ejaculation is the first evidence-based definition of premature ejaculation, and further research is needed to obtain more objective evidence in order to provide evidence-based definitions of natural variant premature ejaculation, secondary premature ejaculation, and premature ejaculation-like ejaculatory disorders. The current definition of premature ejaculation based on clinical experience has some clinical value and helps to classify patients with premature ejaculation complaints.