Premature ejaculation (PE)

Overview

Premature ejaculation (PE) is a common male sexual problem that is frequently overlooked, resulting in an unmet treatment need. PE has previously been classified in a variety of ways, some of which were confusing, contributing to incorrect prevalence estimates.

Despite this, it is a neglected area of male sexual health, providing an unmet therapy need. This is most likely owing to a mix of reasons, including low rates of seeking therapy as a consequence of humiliation or shame, as well as professional misunderstanding over therapeutic care of the disorder.

Patient evaluation and care choices vary based on the categorization of PE, and it is the clinician's responsibility to correctly identify patients and be aware of the proper therapeutic tactics.

Patients with both lifelong and acquired PE are most likely to benefit from a combination of pharmaceutical treatment (dapoxetine, a selective serotonin reuptake inhibitor), psychosexual behavioral therapy, and psychological therapy.

Premature ejaculation (PE) definition

Premature (early) ejaculation is the most frequent sexual condition in men under the age of 40, affecting 30-70 percent of males in the United States at some point. Historically, it was thought to be a psychiatric disorder with no biological etiology.

Premature ejaculation is defined by most specialists who treat it as the occurrence of ejaculation before both sexual partners want. As a result, this wide definition avoids defining a certain "normal" length for sexual interactions and attaining a climax. The longevity of romantic relationships varies greatly and is determined by a variety of circumstances unique to the persons involved.

A guy may attain climax after 8 minutes of sexual intercourse, but if his partner consistently reaches climax in 5 minutes and both are comfortable with the timing, this is not premature ejaculation. Alternatively, a male may delay ejaculation for up to 20 minutes of sexual intercourse, but if his partner requires 35 minutes of stimulation before reaching climax, even with foreplay, he may consider his ejaculation and subsequent loss of erection premature because his partner will not have been satisfied.

Because many females, no matter how prolonged, are unable to reach climax with vaginal intercourse, the second scenario described may actually represent delayed orgasm in the female partner rather than premature ejaculation in the male; the problem can be either or both, depending on the point of view. Such disparities in viewpoint underline the necessity of having a complete sexual history from the patient.

Premature ejaculation can be hereditary or acquired. Lifelong premature ejaculation refers to those who have had the problem since they were sexually competent.

The term "acquired premature ejaculation" refers to a condition that originated in a person who previously had an adequate degree of ejaculatory control and then, for unexplained reasons, began suffering premature ejaculation later in life. Premature ejaculation is not caused by a general medical issue and is not generally caused by substance abuse, however in rare circumstances, hyperexcitability may be caused by a psychiatric medication and resolve when the drug is stopped.

Epidemiology

Premature ejaculation affects between 30% and 70% of males in the United States. The National Health and Social Life Survey (NHSLS) reports a prevalence of 30%, which is very consistent across all adult age groups.

However, according to several polls, many men do not disclose premature ejaculation to their doctor, maybe due to shame or a belief that there is no cure for the condition. Some men may not even recognize premature ejaculation as a medical issue. According to such survey results, the number of men who suffer premature ejaculation at some point in their life is very definitely higher than the 30% recorded in the NHSLS.

Premature ejaculation can occur at almost any age in the life of an adult male. As a reported ailment, it is more frequent in males aged 18-30 years, although it can also occur in men aged 45-65 years in association with secondary impotence.

There are currently no replicable data suggesting significant variations in the incidence or frequency of premature ejaculation between racial groups. A few surveys, however, imply that significant racial variance may exist.

According to one study, African American men (34%) and white men (29%) were more likely than Hispanic men to ejaculate prematurely (27 %)

In a short study of a sexual health clinic in Australia, males of Asian or Middle Eastern heritage received 59 percent of premature ejaculation diagnoses, whereas those of Western or European origin received 41 percent. However, given the small number of such research and the scarcity of appropriate control participants, it is difficult to make clear conclusions from this data.

Cause of Premature Ejaculation

The definition divides patients into two groups: those who have ejaculated with reduced latency since their first sexual encounter (lifelong PE) and those who have reported a clinically significant reduction from prior latency (acquired PE). Because PE is not uniform among populations, this difference is established. PE can be divided into four categories: lifelong (primary), acquired (secondary), variable, and subjective.

Acquired PE, on the other hand, refers to decreased ejaculatory latency that occurs at some time in the patient's life. Patients with acquired PE had previously had normal ejaculations, and the dysfunction is typically the result of an identified medical, psychological, or interpersonal etiology. Psycho-relational, endocrine, and urologic dysfunction are all risk factors for acquired PE.

Other sexual comorbidities, most notably erectile dysfunction, may also be present in patients. Other reasons of acquired premature ejaculation have been noted on occasion, including prostatitis and hyperthyroidism.

Pathophysiology of Premature Ejaculation

Sexual Response Cycle

The normal male sexual reaction may be described as a four-step, sequential process. This process begins with excitement, with penile tumescence and eventual erection occurring in response to sexual attraction and/or stimulation. After then, there is a plateau phase in which ejaculation is postponed and sexual intercourse may occur.

Following this peak, ejaculation and orgasm occur, followed by resolution and concomitant postejaculatory detumescence. This process is supposed to be sped up in people with PE. Patients may experience a sharp excitation stage, followed by decreased latency and fast ejaculation during the plateau phase.

Process of Ejaculation

The process and regulation of ejaculation must be understood in order to grasp the scientific justification for PE therapy. Ejaculation is a spinal reflex that is heavily modulated by the brain. It consists of two sequential phases: emission and expulsion. The synchronization of this process enables antegrade semen propulsion.

Spermatozoa and seminal fluid are secreted into the prostatic urethra during emission. Expulsion occurs next, which is a process in which rhythmic contractions of the bulbospongiosus and ischiocavernosus muscles, as well as the pelvic striated muscles, cause semen to travel through the urethra and out the urethral meatus.

Peripheral Control

The autonomic sympathetic and parasympathetic efferent fibres from the pelvic plexus are regarded to be the primary stimulators of this process. The sympathetic influence is assumed to be strong during ejaculation, influencing the contractile activity of seminal tract smooth muscle. Sympathetic innervation is important in promoting sex gland contraction, according to functional investigations.

The role of the parasympathetic nervous system in ejaculation is unknown, while it may have a role in preventing seminal fluid reflux through the ejaculatory duct as well as seminal fluid production. Finally, the pudendal nerve's somatic fibers are hypothesized to have a role in ejaculation through controlling pelvic striated muscles.

Spinal Control

The process of ejaculation requires a great deal of coordination. This coordination is accomplished and controlled in critical spinal centers that comprise the spinal network of ejaculation. Sympathetic outflow originates in the dorsal grey column and the intermediolateral column of the thoracolumbar segments.

Recent study in rats has revealed a group of lumbar spinothalamic neurons that may contribute to the synchronization of these spinal centers. This set of neurons is known as the spinal ejaculation generator (SGE). There is evidence that humans may also carry an SGE, which might give a novel therapeutic target for ejaculatory diseases.

Cerebral Control

A complex ejaculatory network, consisting of numerous groups of linked neurons located at various levels of the brain, controls ejaculation. These supraspinal centers have sensory/integrative, excitatory, and inhibitory functions in the ejaculatory process.

Excitatory brain circuits have been identified as being important in ejaculation. Neurons going from the medial pre-optic region into the paraventricular hypothalamic nucleus are one example of these routes. Projections are then transmitted to autonomic neurons found in ejaculatory spinal centres. Finally, nuclei of the ventral medulla have been identified as a source of ejaculatory inhibitory regulation.

Signs and symptoms

Premature ejaculation can be acquired or lifelong. With lifelong premature ejaculation, the patient has had premature ejaculation since the onset of coitus. The patient with acquired premature ejaculation previously had successful coital relationships and has just recently developed premature ejaculation.

Patient characteristics in lifelong premature ejaculation can include the following:

Psychological difficulties
Deep anxiety about sex that relates to 1 or more traumatic experiences encountered during development

In patients with lifelong premature ejaculation, inquire about the following:

Previous psychological difficulties
Early sexual experiences
Family relationships during childhood and adolescence
Peer relationships
Work or school
General attitude toward sex
Context of the event (eg, marital versus nonmarital)
Sexual attitude and response of the female partner
Nonsexual aspects of the current relationship
The sexual partner's level of involvement in treatment

Clues from these and similar questions usually point toward causative factors that may be addressed specifically with therapy.

Patient characteristics in cases of acquired premature ejaculation can include the following:

Erectile dysfunction
Performance anxiety
Psychotropic drug use

In patients with acquired premature ejaculation, inquire about the following:

Previous relationships
Current relationship
Nonsexual aspects of the current relationship
The sexual partner's level of involvement in treatment
Impotence problems
Capacity for coitus
Sexual context
Sexual response of partner

Patient Assessment

Patients with PE may feel uncomfortable expressing their ejaculatory dysfunction and, as a result, may resist seeking therapy. As a result, practitioners must make sexual health a regular topic of discussion during consultations.

No particular conventional laboratory tests help or impact therapy in males with premature (early) ejaculation and no other medical concerns. Checking the patient's blood testosterone (free and total) and prolactin levels may be necessary if premature ejaculation is noted in combination with an impotence condition. If depression and other illnesses coexist, laboratory investigations that are specific to depression or another medical or psychological disease are suitable.

Diagnostic criteria

The International Society for Sexual Medicine produced an evidence-based unified definition of premature ejaculation in 2014, which included the following criteria:

Ejaculation that always or nearly always occurs before, or within about 1 minute of, vaginal penetration from the first sexual experience (lifelong premature ejaculation) or a clinically significant and bothersome reduction in latency time, often to about 3 minutes or less (lifelong delayed ejaculation) (acquired premature ejaculation)
The inability to postpone ejaculation on all or virtually all vaginal penetrations.
Distress, worry, irritation, and/or avoidance of sexual intimacy are all examples of negative personal repercussions.

DSM-5 criteria

Premature (early) ejaculation is classified as a sexual dysfunction disorder by the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), and is defined by a clinically significant inability to respond sexually or enjoy sexual pleasure.

Sexual functioning is the result of a complex combination of physiological, social, and psychological variables, and the intricacy of this relationship makes determining the clinical etiology of sexual dysfunction challenging. Prior to making a diagnosis of sexual dysfunction, difficulties caused by a nonsexual mental condition or other stresses must be addressed. As a result, in addition to the criteria for premature (early) ejaculation, the following must be taken into account:

Partner determinants (eg, partner sexual problems or health issues)
Factors influencing relationships (eg, communication problems and differing levels of desire for sexual activity)
Individual vulnerabilities (eg, history of sexual or emotional abuse, existing psychiatric conditions such as depression, or stressors such as job loss)
Factors of culture or religion (eg, inhibitions or conflicted attitudes regarding sexuality)
Factors of health (eg, an existing medical condition or the effects of drugs or medications)

The specific DSM-5 criteria for premature (early) ejaculation are as follows :

The experience of a pattern of ejaculation happening during partnered sexual activity within 1 minute after vaginal penetration and before the participant requests it occurs in almost all or all (75-100 percent) sexual engagement.
The aforesaid symptoms have continued for at least 6 months.
The individual is greatly distressed as a result of the symptoms listed above.
Nonsexual mental problem, a physical disease, the effects of a drug or medicine, severe interpersonal distress, or other substantial stresses cannot explain the dysfunction.

The severity of premature (early) ejaculation is specified as follows:

Mild (occurring within approximately 30 seconds to 1 minute of vaginal penetration)
Mediocre (occurring within approximately 15-30 seconds of vaginal penetration)
Extreme (occurring before sexual activity, at the start of sexual activity, or within approximately 15 seconds of vaginal penetration)

In addition, the context in which the dysfunction occurs is specified as follows:

Generalized: not limited to certain types of stimulation, situations, or partners
Situational: limited to specific types of stimulation, situations, or partners

Premature ejaculation treatment

Both the patient and his partner are involved in management. Therapeutic choices should be suited for both spouses' habits in planning and frequency of intercourse. Follow-up at suitable intervals is required to assess effectiveness, titrate dosage of pharmacological therapies, and determine adverse effects.

The difficulty with all therapies for premature ejaculation is that the recurrence rate varies from 20% to 50%, depending on the research, making the sustainability of the response unclear. Some guys may need to make a long-term commitment to repeating the behavioral tactics on a regular basis; long-standing behaviors can be difficult to change.

Psychological counseling

It is more likely for psychological issues to arise as a result of PE than than as the cause. Counseling may be beneficial in conjunction with other therapies if it is thought to improve self-esteem, but it is ineffective in curing the underlying cause of lifelong PE.

Behavioral techniques

Active therapy of PE most likely began more than 50 years ago with Semans' "stop-start" approach for delaying the neuromuscular reaction that causes ejaculation. The male instructs his partner to discontinue genital stimulation until the subjective experience of extreme arousal has passed. If required, stimulation is reapplied, and the cycle is repeated.

They are generally obtrusive and mechanical, and they have the potential to disrupt a natural love/lust act, connection, and spontaneity.

Drug therapy treatment options

Although various medications have been tested in clinical trials to enhance ejaculatory control and minimize emotional discomfort, none are presently authorized by the Food and Drug Administration for the treatment of PE. However, the AUA presently recommends behavior modification methods and pharmacologic medicines such as selective serotonin reuptake inhibitors (SSRIs), tricyclic antidepressants (TCAs), and topical treatments (e.g., lidocaine/prilocaine cream) for the treatment of PE.

Topical anesthetics efficiently desensitize the penis to tactile stimuli, increase latency time, and have relatively modest local side effects. Because SSRIs and TCAs have traditionally been used as antidepressants, and some are associated with unpleasant side effects and potentially substantial medication interactions, persistent use of these medicines for the treatment of PE can be unattractive and may result in poor patient adherence.

To address these issues, numerous clinical trials have used lower dosages and on-demand dosing of these medicines rather than continuous daily administration, but the benefit of this dosing approach has not been convincingly shown.

Measures that reduce penile sensation/topical treatments

Condoms reduce glans penis sensitivity and have been used in the treatment of PE. Topical preparations have also been used to reduce glans penis sensitivity. These include.

Lignocaine-prilocaine

Aerosol of lignocaine and prilocaine administered 20-30 minutes before sexual intercourse and withdrawn before contact with the partner. Trials of this medication in the United Kingdom and the Netherlands shown statistically and clinically substantial IELT prolongation when compared to placebo. For 10-20 minutes, apply a thin layer of lignocaine-prilocaine cream on the glans and distal shaft and cover with a condom.

If the condom is removed for sexual contact, any remaining cream should be wiped away. IELT improved considerably above baseline in a randomized placebo-controlled evaluation of this therapy. 5-15 minutes before sexual contact, apply 3-6 sprays of lignocaine to the glans. Despite the fact that this medication has been accessible for 25 years, no randomized controlled trials have been conducted to evaluate its effectiveness.

Dapoxetine

Among the experimental medicines for PE, dapoxetine, a quickly absorbed SSRI with a short half-life, has garnered the greatest interest. Dapoxetine, a medicine created exclusively for the "on demand" treatment of PE, is currently the first and only therapy approved by Health Authorities in a rising number of nations throughout the world. Dapoxetine has been demonstrated to be effective and well-tolerated in placebo-controlled clinical studies involving over 6000 people. Furthermore, physicians can offer guidance on behavioral and psychological strategies that may aid in the improvement of PE.

Conclusion

Premature ejaculation (PE) is a prevalent sexual condition among men. The Diagnostic and Statistical Manual of Mental Disorders defines it as "uncontrollable ejaculation happening on or shortly after penetration and before the individual intends it, creating considerable anxiety or interpersonal problems." Although the timing of intravaginal ejaculatory latency time is not included in this definition, an IELT of 2 minutes, or ejaculation happening before penetration, has been regarded compatible with PE.