Premature Ejaculation

Background

 

Definition: Premature ejaculation is defined by the World Health Organization as "an inability to delay ejaculation sufficiently to enjoy lovemaking, which is manifested by either an occurrence of ejaculation before or very soon after the beginning of intercourse or ejaculation occurs in the absence of sufficient erection to make intercourse possible."

 

Premature ejaculation is reported by some 20-30% of men. Premature ejaculation should not be considered a disease if it occurs infrequently since infrequent premature ejaculation is part of the normal variability of ejaculatory performance. It is when premature ejaculation occurs on a persistent basis that evaluation and treatment should be considered.

 

Information on penile anatomy can be found here. In general, the average length of an erect penis is about 5.5 inches.

 

Causes

The cause of premature ejaculation is not fully understood but may be related to peripheral nerve function, the serotonin system, cognitive and unconscious mental processes. There is probably no one single cause to explain premature ejaculation in all men.

 

Diagnosis & Evaulation

Evaluation only requires a clinical review and physical examination. There is no special testing for premature ejaculation. Prior to a clinic visit it is helpful to have completed an IIEF questionnaire which can be found here.

 

Treatment

 

There is no cure for premature ejaculation but there are some treatments which can increase the duration of intercourse. There is no surgical treatment for premature ejaculation. It is important to note that these medications are used 'off-label' for the treatment of premature ejaculation.

 

If erectile dysfunction is present, it is usually treated first or at the same time as premature ejaculation, using regular treatments for ED.

 

There are several general measures which may be tried before medications are attempted. These include:

 

  1. Graded stimulation - working up to penetration with adequate foreplay
  2. Use of condoms - this can decrease the sensitivity of the penis
  3. Topical anesthetics (see link below). The anesthetic sprays that are used for sunburns can also be tried as can sprays 'specifically designed' for premature ejaculation (see links below)
  4. Sexual counselling - the importance of having an understanding partner cannot be understated. Psychologists with an interest in sexual counselling should be sought.
  5. Medications for the treatment of erectile dysfunction or low testosterone (if present)

 

Medications for the treatment of premature ejaculation:

 

  1. Selective Serotonin Reuptake Inhibitors (SSRI's)
    1. Paroxetine  (Paxil) 10, 20 or 40 mg daily or on demand. low doses of SSRIs may help recalibrate the sensory reflexes important in the ejaculatory response.
    2. Sertraline (Zoloft) 25 - 200 mg daily OR 50 mg 4-8 hours pre-intercourse
    3. Fluoxetine (Prozac) 5 - 20 mg daily
    4. Potential side-effects: Some common side effects which tend to improve after to 3 weeks of usage include fatigue, yawning, mild nausea, dry mouth. Rare side effects include bleeding (the medications should be is cautiously with aspirin and nonsteroidal anti-inflammatories), priapism (erection lasts too long).
  2. Non-Selective Serotonin Reuptake Inhibitors (SRI's)
    1. Clomipramine (Anafranil) 25-50 mg daily OR 25 mg on-demand 4-8 hours pre-intercourse. Side effects include nausea
  3. Lidocaine/prilocain cream (EMLA cream) lidocaine 2.5%/prilocain 2.5% 20-30 min pre-intercourse. Note: important not to apply to soon before having intercourse and numbness of the head of the penis can impair ability to achieve erection

 

Daily dosing is probably best for men having intercourse more than a couple of times per week whereas a single dose a few hours prior to intercourse may be more practical for men having intercourse less than once weekly.

 

Retrograde and Anejaculation are different than premature ejaculation. Follow the link for more information on these conditions.

 

On the Web

AUA Brochure on Treatment Options in Erectile Dysfunction