Premature Ejaculation

Premature ejaculation is ejaculation that occurs always or nearly always within about 1 minute of vaginal penetration (lifelong), or a clinically significant reduction in latency to about 3 minutes or less (acquired), with inability to delay ejaculation and negative personal consequences such as distress, frustration and avoidance of sexual intimacy.

• Prevalence about 20 to 30 percent of men by self-report; true lifelong rate (intravaginal ejaculatory latency under 1 minute) about 1 to 4 percent.
• Types: lifelong (primary, since first sexual experiences, probably neurobiological, related to serotonin receptor sensitivity and penile hypersensitivity); acquired (secondary: erectile dysfunction, prostatitis, thyroid disease especially hyperthyroidism, anxiety, relationship issues, drug withdrawal); variable and subjective forms.
• Associated: erectile dysfunction (about a third), anxiety, depression, chronic prostatitis, lower urinary tract symptoms, hyperthyroidism, drug withdrawal (opioids, alcohol, SSRIs), genetics (family history).
• Prognosis: chronic if untreated; responds to behavioural and drug therapy but relapse on stopping drugs is common.

• Ask about onset and duration (lifelong versus acquired), proportion of encounters affected, latency (stopwatch estimate), partner context, perceived control, distress, erections, desire, orgasm, masturbation pattern, pain, urinary symptoms, anxiety, depression, alcohol and drug use, relationship factors, partner function, and medications.
• Examination: blood pressure, BMI, secondary sexual characteristics, genitalia (phimosis, frenulum, balanitis), prostate on rectal examination (tenderness suggests prostatitis), thyroid, peripheral neurological examination (perineal sensation).
• Red flags: new onset with erectile dysfunction, urinary symptoms, perineal pain, tremor, weight loss, mood disorder, substance misuse, relationship violence.

• Clinical diagnosis from the history; validated questionnaires (Premature Ejaculation Diagnostic Tool, Index of Premature Ejaculation) may help.
• Investigations only if indicated: fasting glucose or HbA1c, lipids, morning total testosterone, thyroid function (TSH), urinalysis and urine culture if urinary symptoms, STI screen if symptoms, prolactin if low desire.
• Differential: erectile dysfunction with rushed intercourse, performance anxiety, prostatitis, hyperthyroidism, drug withdrawal.

• Education and counselling for the individual and couple; manage anxiety; reduce performance pressure.
• Behavioural methods: stop start technique (stimulate until the urge to ejaculate, then stop until it passes, repeat 3 times before ejaculating, practised 3 times weekly over several weeks); squeeze technique (squeeze the glans firmly for 10 to 20 seconds at the urge); pelvic floor physiotherapy; condoms (thicker types) to reduce sensitivity; masturbating 1 to 2 hours beforehand. Sex therapy or cognitive behavioural therapy.
• Topical anaesthetics (on demand):
  • Lidocaine 150 mg/mL with prilocaine 50 mg/mL spray: 3 actuations to the glans 5 minutes before intercourse; wipe off excess before penetration; use a condom to avoid transfer to the partner.
  • Lidocaine 2.5 percent with prilocaine 2.5 percent cream: 5 g applied to the glans and shaft 10 to 20 minutes before, wash off before sex or use a condom.
• Oral pharmacotherapy:
  • Dapoxetine 30 mg orally 1 to 3 hours before sexual activity, on demand, no more than once every 24 hours; increase to 60 mg (maximum) if inadequate response and tolerated. Contraindicated with monoamine oxidase inhibitors (within 14 days), thioridazine, SSRIs, SNRIs, tricyclics, potent CYP3A4 inhibitors (ketoconazole, ritonavir), significant cardiac disease (heart failure, conduction abnormalities, ischaemic heart disease), moderate to severe hepatic impairment, and a history of mania or depression. Side effects include nausea, headache, dizziness, syncope and diarrhoea; counsel about orthostatic hypotension; avoid alcohol. Not licensed in all countries.
  • Paroxetine 10 mg orally daily, increased to 20 to 40 mg daily, or 20 mg 3 to 4 hours before intercourse on demand; sertraline 25 to 50 mg daily (up to 200 mg); fluoxetine 20 mg daily; escitalopram 10 mg daily; clomipramine 10 to 25 mg daily or 25 mg 3 to 24 hours before intercourse. Delay of benefit with daily use is 1 to 2 weeks; sexual side effects, withdrawal syndromes on abrupt stopping, and the risk of suicidal ideation in young adults require counselling. Avoid daily SSRIs in bipolar disorder without specialist input.
  • Tramadol 50 mg orally 1 to 2 hours before sex is used off label but is generally avoided because of dependence, seizure and serotonin syndrome risk.
  • Phosphodiesterase-5 inhibitors (tadalafil 5 mg daily or 10 to 20 mg on demand; sildenafil 50 mg on demand) when co-existing erectile dysfunction; avoid with nitrates.
• Combining behavioural methods with a drug works better than either alone.
• Review at 4 to 6 weeks; if a daily SSRI was used and has been effective, step down after 3 to 6 months. Refer to a sexual medicine specialist or urologist for failure of two treatments or complex relationship problems.