Premature Ejaculation: State of the Art

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Premature ejaculation (PE) is a frequent male sexual complaint.This occurrence does not automatically imply the existence of a male sexual disorder. The current DSM definition of PE has a low positive predictive value with a high associated risk for false-positive diagnoses of PE. A new classification in four well-defined PE syndromes has recently been proposed for the pending DSM-V. According to this new classification there are different pathophysiologies and treatments of PE, dependent on the underlying PE syndrome. Some types are particularly neurobiologically or medically determined and need drug treatment; other types, which are mainly psychologically determined, need psychotherapy or both drug treatment and psychotherapy. A meta-analysis of all selective serotonin reuptake inhibitors (SSRIs) and clomipramine studies, which were performed according to current standards of evidence-based medicine, demonstrated a similar efficacy for the daily treatment with the serotonergic antidepressants paroxetine hemihydrate, clomipramine, sertraline, and fluoxetine, with paroxetine hemihydrate exerting the strongest effect on ejaculation. On-demand treatment with SSRIs generally exerts much less ejaculation delay than daily SSRI treatment. Other on-demand treatment options are the topical use of anesthetics, tramadol, and phosphodiesterase type 5 inhibitors. Caution is needed with tramadol with regard to its potential addictive properties. There is insufficient evidence for the ejaculation delaying effects of phosphodiesterase type 5 inhibitors and intracavernous injection of vasoactive drugs.

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Diagnostic and Statistical Manual of Mental Disorders and International Classification of Diseases definition of premature ejaculation

Currently, there are two official definitions of PE. In the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR), which is issued by the American Psychiatric Association, premature ejaculation is defined as a “persistent or recurrent ejaculation with minimal sexual stimulation before, on, or shortly after penetration and before the person wishes it. The clinician must take into account factors that affect duration of the excitement phase, such as age, novelty of the sexual partner

Proposal for new definition of premature ejaculation

Recently, a new proposal for the pending DSM-V and ICD-11 definition of PE has been put forward [6], [7]. According to this proposal, PE should be classified according to a “syndromal” approach, incorporating well-controlled clinical and epidemiologic stopwatch studies [6]. PE as a clinical entity or a syndrome has for the first time been described by Schapiro in 1943 [8]. He distinguished Types A and B that were later termed “lifelong” and “acquired” PE by Godpodinoff [9]. Both types have been

Continuum of neurobiology and psychology

The distinction of the four PE syndromes shows a continuum of PE along a line from mainly neurobiologically to mainly psychologically determined forms (Fig. 1). For example, from both human and animal research it may be derived that lifelong PE is presumably highly neurobiologically and perhaps also genetically determined. However, as yet, one cannot rule out that certain forms of lifelong PE are psychologically determined. As is the case in major depression, a biologic marker of lifelong PE

Prevalences

Epidemiologic research has repeatedly shown a prevalence of PE of 20% to 30% [14]. Erroneously, by not distinguishing PE as a complaint and as a syndrome, it has been concluded that the “disorder” PE has a high prevalence. However, these studies have only shown that the “complaint” of PE in the general male population has a high prevalence of 20% to 30%. Studies into the prevalence of lifelong PE and acquired PE have never been conducted. However, it is of note that the prevalence of lifelong

Pathophysiology

The distinction of the four PE syndromes illustrates that there is not one particular pathophysiology of PE, but that there a different pathophysiologies dependent on the type of PE. For example, the serotonin hypothesis of PE, that is, a disturbance of serotonin neurotransmission and/or serotonin receptor functioning [15], pertains only to lifelong PE and partly to acquired PE. In other words, the serotonin hypothesis explains probably only a small percentage (2%–5%) of complaints of PE in the

Diagnosis of premature ejaculation syndromes

Lifelong, acquired, natural variable PE, and premature-like ejaculatory dysfunction are recognizable by taking a brief medical and sexual history with special attention to the duration of the ejaculation time, the frequency of occurrences, and the course since the first sexual encounters. In daily clinical practice, diagnosis of the four PE syndromes is not difficult, and therefore, evaluation with questionnaires or the use of a stopwatch is not required [4]. However, for drug treatment trials

Treatment

The distinction of the four PE syndromes has consequences for treatment. Lifelong PE should be treated with drugs that strongly delay ejaculation. It is a matter of debate whether additional counseling is always needed for these men. A lot of these men will manage without additional counseling. However, clinicians should take time to talk with these men, to inform them about the current knowledge of lifelong PE, and to regularly check their well-being, particularly when using SSRIs on a daily

Evidence-based drug treatment

Apart from randomized, double-blind controlled study designs, drug treatment studies of PE should include a baseline and a drug treatment period in which the IELT is measured prospectively at each coitus using a stopwatch handled by the female partner. The IELT is expressed in seconds or minutes, and in case an ejaculation occurs outside the vagina (ejaculatio ante portas), the IELT is by definition equal to zero. As the IELT distribution is positively skewed, IELT values should be

Daily selective serotonin reuptake inhibitor treatment

During the last decade, daily use of SSRIs, on-demand use of the tricyclic antidepressant clomipramine, and topical use of anesthetics has become most popular to treat PE [16]. Although none of these treatment options have been approved by the Food and Drug Administration, their use has been recognized and is supported by evidence-based studies [16]. The serotonergic antidepressants modify the course of PE by modulating the central serotonergic system, and the anesthetics suppress the

Summary

The DSM-IV-TR definition has a high risk for false-positive diagnoses of PE. Recently, a new classification of four PE syndromes has been proposed for the pending DSM-V. According to this classification PE can no longer be defined in one overall descriptive definition, but should be defined according to the symptomatology of the underlying PE syndrome.

The high prevalence rate of 20% to 30% is more likely to reflect the percentage of men that has “complaints” of PE, rather than the percentage of

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