For more than 100 years, premature ejaculation has been considered a clinical syndrome, but the treatment and research of premature ejaculation has been hampered by the varying criteria and lack of uniformity in the definition of premature ejaculation. The American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM) definition of premature ejaculation used to be widely accepted, although not supported by evidence-based medicine. Recently, the International Society of Sexual Medicine (ISSM) Special Committee on the Definition of Premature Ejaculation and the Committee on Guidelines for Premature Ejaculation both released guidelines related to the diagnosis and treatment of premature ejaculation. The guidelines are an update and reevaluation of the 2010 guidelines for the diagnosis and treatment of premature ejaculation and were developed by a multidisciplinary group of international experts in the field of sexuality. In addition, the Special Committee on the Definition of Premature Ejaculation developed a uniform definition of premature ejaculation that includes both lifelong and acquired premature ejaculation.
Etiology unknown
Over the past 20 years, the etiology of premature ejaculation has been hypothesized to revolve around somatic and neurobiological aspects. Scientists have proposed numerous biological factors to explain premature ejaculation, including overly sensitive glans, overly strong cortical representation of the pubic nerves, interference with central serotonin neurotransmission, erectile difficulties and other sexual coexisting disorders, as well as prostatitis, prescription drug withdrawal, recreational drug use, chronic pelvic pain syndrome, and thyroid disease. It is important to note, however, that none of these “causes” have been validated in large-scale studies.
Definition of acquired and lifelong premature ejaculation
The Special Committee on the Definition of Premature Ejaculation agreed that there is a clear distinction between lifelong premature ejaculation and acquired premature ejaculation, and that they have different demographic characteristics and etiologies. However, they share some degree of definition in terms of the composition of the time from penetration to ejaculation, delayed ejaculation disorder, and the negative consequences associated with premature ejaculation. Therefore, the Special Committee believes that the two have common conceptual components, which led to the development of a unified definition of lifelong premature ejaculation and acquired premature ejaculation. Finally, the committee considered an ejaculatory latency time of about 3 minutes or less as an additional key definitional criterion for acquired premature ejaculation.
The unified definition of premature ejaculation as a male sexual dysfunction consists of the following three components.
1. repeated or continuous ejaculation after vaginal contact from the first sexual intercourse in about 1 minute (lifelong premature ejaculation), or ejaculatory latency time reduced to 3 minutes or less (acquired premature ejaculation).
2. delayed ejaculation disorder occurring with all or almost all vaginal penetration.
3. the occurrence of negative personal outcomes, such as apprehension, worry, confusion and/or avoidance of sexual intimacy.
In addition, the committee concluded that the available objective evidence for premature ejaculation is limited to studies on male vaginal intercourse and that there is a lack of sufficient data to objectively define premature ejaculation for oral, anal, and same-sex sex.
Prevalence
Based on the ISSM and DSM 5th edition definition of premature ejaculation according to an intravaginal ejaculatory latency time (IELT) of about 1 minute, the lifetime prevalence of premature ejaculation would not exceed 4%.
Mean ejaculatory latency time
The median IELT is 5.4 minutes, according to studies in several countries, but it may vary from country to country.
Premature ejaculation assessment
1. the committee concluded that there was insufficient evidence for screening or patient detection of premature ejaculation, either in the general population or in a specific population, but recommended screening for patients with erectile dysfunction (ED)
2. recommending that clinicians use a series of screening questions and ask about history of prior drug use and psychosocial profile.
3. since patient self-report is a determinant of treatment-seeking and satisfaction when premature ejaculation occurs, it is recommended that patients and their partners self-evaluate ejaculatory latency time, which should be routinely performed in the clinic
4. the Premature Ejaculation Profile (PEP) and the Index of Premature Ejaculation (IPE) questionnaires are the better available measures of premature ejaculation questionnaires and are particularly suitable for monitoring treatment response
5. for lifelong premature ejaculation, a physical examination is recommended for most patients
6. For acquired premature ejaculation, purposeful correlative testing must be performed to evaluate underlying or associated disorders such as ED, thyroid disease, prostatitis.
Treatment
1. strong evidence that dapoxetine is safe and effective when given as needed, whether for acquired or lifelong premature ejaculation, and that dapoxetine is available in some countries
2. strong evidence that off-label use of daily doses of selective 5-hydroxytryptamine reuptake inhibitors (SSRIs), such as paroxetine, sertraline, citalopram, fluoxetine, and serotonin-containing tricyclic chlorpromazine, is safe and effective; in addition, on-demand administration of chlorpromazine, paroxetine, and sertraline for acquired or lifelong premature ejaculation is also safe and effective
3. there is better evidence that off-label use of local anesthetic drugs given on demand is safe and effective for the treatment of lifelong premature ejaculation
4. although some evidence suggests that off-label on-demand or daily dose administration of phosphodiesterase 5 inhibitors (PDE5is) is safe and effective in men with normal erectile function who have lifelong premature ejaculation. However, the use of PDE5is is not recommended for men with lifelong premature ejaculation with normal erectile function and further evidence-based studies are needed.
5. Tramadol may be an effective option for premature ejaculation treatment, but given its addictive nature and side effects, it should only be considered when other treatments fail. Tramadol should not be used in combination with an SSRI due to the risk of serotonin syndrome and potential fatalities. Tramadol for the treatment of premature ejaculation still requires further controlled studies to assess its effectiveness and safety.
6. a small body of evidence suggests that psychological or behavioral interventions are effective
7. the combined use of pharmacological and psychological/behavioral treatment may be very useful when men with acquired premature ejaculation have a clear sudden psychological cause or lifelong event that can be treated or successfully treated with pharmacological interventions by the individual or partner. Similarly, in men with premature ejaculation with ED, combined treatment may be beneficial for the psychosocial aspects of sexual dysfunction
8. there is reliable evidence to support the use of ED medications for the treatment of premature ejaculation with ED. Combined use of premature ejaculation medication and ED medication for premature ejaculation with ED is not recommended (Level of Evidence IIIc).
9. Selective dorsal penile nerve excision or enlargement of the glans with hyaluronic acid may result in permanent loss of sexual function and is not recommended for the treatment of premature ejaculation.
Feedback on treatment outcomes
For treatment outcomes, a simple and clear and effective question from the Clinical Global Impression of Change (CGIC) can be used: “Compared to before treatment, please describe your premature ejaculation problem: very severe, severe, more severe, no change, slightly improved, improved, very good”.