vfn.cz
Abstract:
Premature ejaculation is the second most frequent sexual dysfunction in men.
According to various authors, as much as 40% of men suffer from this disorder,
which affects mostly younger individuals. It represents a major problem not only
for the men themselves, but also for their partners.
In fact, it could be said that prolonging coitus is unimportant from an
evolutionary aspect. It does not in any way affect the man´s ability to
reproduce, similarly to orgasm in women. However both these disorders
significantly disrupt the recreational character of sexual intercourse.
The aim of this work is to present a comprehensive overview of the aetiology,
epidemiology, diagnosis and treatment of this very frequent dysfunction.
The therapeutic options available to sexologists have expanded in recent years,
especially thanks to the use of modern pharmacological means.
The aim is to acquaint not only sexologists but also urologists and other
physicians with the complex issues of this disorder.
Premature ejaculation is not only a medical but also a social problem. It is
usually the cause of breakup between partners
or divorce in married couples. This is regrettable given that modern
psychopharmaceuticals, especially antidepressants are able to manage even severe
manifestations of this sexual dysfunction.
Keywords:
Sexual dysfunction, disorders of ejaculation, premature ejaculation, aetiology,
diagnosis, therapy
Premature
Ejaculation
Comments regarding the term premature
ejaculation –ejaculatio praecox (EP[jm1] )
The terminology and how it is perceivedhasundergone remarkable developments over
the decades since it was first used in medicine and medical literature.
Translations into modern national languages as well as developments in our
understanding of the pathophysiology of this sexual disorder or dysfunction have
both played an important role in this process. Some designations of the types of
this disorder developed based on the study of its genesis and duration. Whether
it had affected the patient from the beginning or had appeared during his life
and whether its occurrence was clearly associated with another disorder or
illness. To this end it is quite instructive to refer to the description of the
development of EP definitions, classifications and standpoints issued by various
international healthcare institutions and related documents as described by
Russo and Serefoglu (2020) over a period dating from the mid-20th
century since when EP has been recognised as an issue that needs to be
addressed. A number of
terms have emerged. Though these are not always synonyms, it may be said that
they indicate that ejaculation occurred before it was desirable for the man
performing sexual intercourse.
As far back as half a century ago, the pioneers of sexology emphasised that the
indicator of premature ejaculation should be whether it induces dissatisfaction
in the partner in more than 50% of all instances of sexual intercourse. Since
then, only less than useful discussions have emerged whether the sexual
satisfaction or lackof it as perceived by the other person involved in the act
is sufficiently scientific to warrant acquisition of objective proof for
evidence based medicine. Some authors prefer the objective measurement of the
period from penis intromission to the start of ejaculation – so-called
intravaginal ejaculation latency time (IELT) and expect that the pair suffering
from EP will be satisfied by the fact that their IELT is statistically within
some sort of normal range.
With the possible exception of ejaculatio ante portas (ejaculation prior to
vaginal penetration), there is no risk in the various forms of ejaculatio
praecox that the biological target expected of coitus,namely impregnation of the
woman, will bethwarted. In humans, coitus and related sexual activities
undoubtedly developed under the influence of geographical conditions dependent
on socioeconomic status and the particularities of cultural development,
religion, level of education and arts into a wide spectrum of activities and
experiences of sexual life. In my opinion, setting up some kind of
scientifically justified IELT norms in seconds or minutes for couples worldwide
and stating that if these are met then there is nothing to treat is quite
erroneous. Patients and their sexologists would agree (Daneš 2011, Weiss, Zvěřina
2001) . Data from large studies clearly illustrate the wide ranging IELT values
in various countries. IELT of around five minutes is the most commonly reported.
In the Czech Republic IELT is 15 minutes. It is clear from many studies
that the average duration of intercourse today is longer than that reported in
older studies.
However, measurement of IELT as the determinative indicator of changes induced
by treatment,be it physical, psychological or pharmacological is of course
absolutely necessary. Measurement of IELT must be performed with great care, so
that the conditions and methods used do not affect the results of the comparison
before and after treatment, e.g. embarrassment or inhibitions of the persons
undergoing measurement.
Aetiology
It still applies that data regarding the causes of EP are relatively few
compared to other illnesses or dysfunctions and only EP pathophysiology or
factors that affect its development and are applicable in its treatmenthave
received wider attention. McMahon, Waldinger, Rowland et al. (2006) described on
the basis of animal experiments the role of sections of the CNS (brainstem and
lumbar spine) in disorders of ejaculation. Zvěřina (2010) drew attention to
the role of the sacral spine in ejaculation based on the results of experimental
electrostimulation of some patients with nerve lesions. Rowland
(2010) e.g. showed that the sympathetic system responds to sexual stimulation
faster than the parasympathetic system in men with EP. However, he was unable to
uncover the cause if this.
A number of authors have tried to determine the effect of the psyche on EP.
Neither works that were part of extensive studies nor the evaluation of the
publications of many authors has helped elucidate the cause of EP, not even congenital
[jm1] or
lifelong EP. The only exception is EP due to specific mechanical reasons,
related to changes in the sensitivity and excitability of tissues that play an
important role in ejaculation. Possibly the most suspected phenomenon linked
with EP is the short frenulum. This was first demonstrated in a study by Gallo,
Perdona et Gallo (2010) that dealt with the treatment of patients using
frenulectomy. Not every case of
short frenulum is associated with high irritability of the glans penis that may
lead to EP. In some cases it is obvious that the short frenulum is the cause per
se of EP and surgery corrects the dysfunction. A relationship between
reproductive organ inflammation and the presence of EP has been demonstrated by
a number of studies. A possible causal link has been shown in chronic
prostatitis. Testing for the presenceof urethritis, inflammation of the urinary
bladder, seminal glands and prostate should always be performed in order to rule
out inflammation as a possible cause of painful ejaculation and EP.
Nonetheless, the fact remains that Zvěřina (2010) presented a long list
of causes of dyspareunia and algopareunia as well as genital paresthesia and
pain, but failed to mention EP in any of these.
Authors who recognized the shortcomings all works studying the etiology of EP to
date and who were the first to study alexithymia as the inability to identify
and communicate emotions include Michetti, Rossi Bonnano et al. (2007). These
authors demonstrated a concordance between a high alexithymia score and EP
severity using a questionnairemethod.
Reports by a number of authors who over the past 15 years studied EP associated
with various comorbidities or in different socioeconomic conditions have
provided much information as well as surprises, such as EP concurrence together
with certain forms of erectile dysfunction or decreased libido. Occurrence of EP
in diabetes and hypertension of some duration was also reported, as was the
correlation between EP and social status, with a higher incidence of EP in men
with lower incomes and lower levels of education.
One
persistent opinion is that EP is a neuro-biogenic and psycho-biogenic complex,
emphasising evidence that the pivotal role in ejaculation and EP is played by
biological mechanisms associated with the neurotransmitters norepinephrine,
serotonin, oxytocin, gamma-aminobutyric acid and nitrogen oxide as well as the
hormone oestrogen. These may also
actually directly induce EP. Evidence has also been presented regarding the
direct relationship between EP and hyperthyroidism. Some works have also shown
an association between EP and low magnesium levels in semen.
Comments
regarding epidemiology
Data regarding the incidence of EP in different parts of the world and in
various social groups are burdened by differing methodologies of detection and
different attitudes of populations to such issues being addressed by the
healthcare system at all. It is generally said that EP is the second most
frequent sexual dysfunction and also the most frequent dysfunction together with
erectile dysfunction. The accepted fact is that the prevalence of EP in Europe
is lower while it is generally higher in Asia, especially East Asia. In the
Czech Republic EP is cited as representing 38% of the total number of sexual
dysfunctions affecting 20% of men. All data regarding sexual dysfunctions are
burdened by a significant error or rather uncertainty given not only by the very
essence of these disorders and the difficulty of assessing them but also by the
low proportion of affected persons seeking medical help.
Diagnosing EP
When describing a concrete case of EP, it is essential to determine whether
the condition is lifelongEP that occurred during the first and all subsequent
intercourses, i.e. primary EP or whether the condition is secondary i.e.
acquired. This is determined by the
man and his partner by measuring or estimating in minutes or seconds the time
that elapses from penis intromission into the vagina until ejaculation begins.
This is based on recommendations of a committee set up in 2007 by the
International Society for Sexual Medicine. This recommendation concerns the
lifelong form, not the acquired form. Apart from the time limit, this form must
include the man´s inability to maintain his erection without ejaculation before
penetrating the vagina or within one minute before penetration or nearly during
all intromission into the vagina. It must also be associated with undesirable
consequences such as distress, frustration or a detrimental effect on the sexual
understanding between the man and his partner. Diagnosis and subsequent
treatment of potential comorbidities of the given pair must be kept in mind at
all times, not only in order to resolve any concurrent illness that may worsen
the intensity of EP but also seeing that concurrent treatment of comorbidities
could prevent pharmacotherapy of EP.
The report by Althof and Rowland (2008) could be considered as one of the most
complex experiments that aimed to objectivise the term EP. Apart from the IELT
value they assigned great importance to self-control when timing ejaculation and
they paid much attention to assessments by the pairs studied regarding their
dissatisfaction with IELT and the problems that undermined their relationship.
The authors stressed the importance of evaluating all indicators of
dysfunction in a concrete pair and were the first to dare recommend that when
diagnosing EP and its severity the sexologist should also try and change the
threshold of findings based on the needs of a concrete pair and according to the
goals of EP diagnosis and treatment. Patrick,
Rowland and Rothman (2007) evaluated relationships between individual diagnostic
criteria using regressive analysis (path analysis) and found that IELT values
did not demonstrate a direct effect on the partner´s satisfaction with
intercourse or on the inter-personal mood of the given pair. Lack of conscious
control over ejaculation and efforts to sustain it directly affected
satisfaction with ejaculation.
EP requires that diagnosis be based not only on objective measurements but also
on maximum cooperation with the patient and optimally with both partners. From
an overview of the most frequently used questionnaires as reported by (Daneš
2011) we include herethe so-called Premature Ejaculation Diagnostic Tool (PEDT).
The authors Serefoglu, Cimen, Ozdemir et al. (2009) demonstrated that data thus
acquired were in agreement with the IELT. An interesting result was seen when
comparing patient answers on the PEDT questionnaire with the findings and
conclusions of the examinations of these same patients by a group of sexology
specialists. An important rate of concurrence was noted. When assessing
diagnostic problems in EP, physicians always return to the discussion regarding
patient embarrassment and reluctance to seek medical advice and help. Similarly
as in the case of erectile dysfunction, it may be presumed that EP is
under-diagnosed and insufficiently treated.
Treatment
Psychological and behavioural treatment dominated therapeutic options at the end
of the twentieth
century. Today, greater success and efficacy is expected from pharmacotherapy, especially
in lifelong EP. However, sexologists remain convinced that it is advisable not
to abandon behavioural therapy and that it should be combined with pharmacotherapy
(Cormio, Massdenio, Rocca et al. (2015). Psychosexual forms
of therapy usually distinguish behavioural, cognitive and affective relational techniques.
Among the behavioural techniques used, the so-called squeeze technique and the
stop start (or rather star-stop) techniques have a long tradition and have been
successful at times. These may be performed by the patient himself, once
ejaculation is imminent and he may be assisted in this by his partner at
suitably chosen time intervals. Cognitivetherapy
denotes improving communication and encouraging openness, deepening
emotions
and cooperation within the pair. A similar approach is also termed as effective
or
relational. Based on the experience of sexologists, combined psychosexual
and pharmacological
treatment may be expected to decrease the risk of EP recurrence once it has
been temporarily brought under control. More recent studies and overviews have
stressed the advantage of combining e.g. dapoxetine treatment with psychosexual
behavioural
and psychological
therapy (Gillman et Gillman (2019).
An interesting option of non-pharmacological EP treatment is the use of
neuromuscular electrical stimulation (NMES; authors Gruenwald, Serefoglu and
Springer (2017). These
authors applied the experience of other physicians who described the effect of
electrical stimulation of afferent pudendal nerves on the contraction of both
smooth and striated musclesof the pelvic diaphragmin the treatment of the
urinary tract, urine incontinenceand erectile dysfunction. This stimulation led
to the contraction of the bulbospongiosus and ischiocavernosus (perineal
striated) muscles, which had a positive effect on EP.
Using NMES before planned coitus induces in these muscles a subtetanic
state lasting several minutes, thus preventing termination of the ejaculation
process.
So far it is not clear whether this form of treatment is not associated with any
undesirable prolongation of IELT.So far there is very limited experience with
yoga. A comparative pilot study using paroxetine showed that yoga increased IELT
values as well as the subjective sexual experience. Yoga was associated with
decreased persistent problems inrelation to EP (Jitendra Rohilla et al. (2020)).
Pharmacotherapy has been the focus of much attention over the past years. More
exhaustive studies are being performed involving large numbers of patients.
Progress in this field is not due to the precipitous increase in new types of
drugs or drug groups compared to ten years ago: we could compare an overview of
these e.g. ten years ago (Daneš, (2011) with the recent overview by Gilleman et
Gilleman (2019). The latter cite that six important pharmacotherapeutic
options are available today: daily long-acting SSRIs, on-demand short
acting SSRIs- daily dapoxetine or clomipramine on demand; on-demand local
anaesthetics; on-demand tramadol and on-demand phosphodiesterase type 5
inhibitors (PDE-5). This overview (Gillman et Gillman (2019) includes an
evaluation of the efficacy of daily administration of the SSRIs clomipramine,
sertraline and fluoxetine. It was shown that daily paroxetine demonstrated the
best effect on delaying ejaculation. Ejaculation was delayed usually beginning
several days from starting daily administration and the maximum effect occurred
in 1 to 3 days. This effect was
usually permanent as long as the drug was administered, but sometimes it was
lost for as yet unclear reasons. Daily administration of SSRIs may be expected
to improve IELT during each intercourse. However, adverse events may occur such
as fatigue, yawning, mild nausea, watery stools, sweating during the first week
or two of treatment. Weight gain and sometimes loss of libido and erectile
dysfunction have also been reported. Other rarer long-term adverse events
included restless genital syndrome, priapism etc.
Dapoxetine administered on-demand is also a selective serotonin reuptake
inhibitor on nerve synapses. It is administered 1 to 2 hours before intercourse.
Lastly, the authors cited above report a high increase in IELT values associated
with greater sexual satisfaction of patients with both lifelong and acquired EP.
This preparation is safe. Mild adverse events include vertigo, nausea and
headache.
Similar effects have been published in the case of on-demand clomipramine. In 14
randomised controlled studies encompassing 710 patients receiving clomipramine,
there was a significant improvement in IELT compared to placebo. However, this
drug was associated with a higher risk of general symptoms involving the nervous
and respiratory system. This medication provided greater satisfaction than did
placebo (Wu,Hung Kang et al. 2021).
Dapoxetine
was never intended to be a chronically used drug and it was designed only for
on-demand use. Among the reasons for this was the rapid onset of its effect, as
early as following the first dose. During
clinical trials of dapoxetine as a new drug, Modi, Dresser, Simonová et al.
(2006) found that its peak plasma concentration was reached around one hour
after ingestion. Dresser, Desai, Gidwaniová et al. (2006) demonstrated that the
concomitant administration of phosphodiesterase-5 inhibitors, tadalafil and
sildenafil did not affect the pharmacokinetics of dapoxetine or that their
mutual interactions led to adverse events. Nonetheless, it may be deduced from
the results of a number of studies published thus far that the use of
phosphodiesterase inhibitors does not appear to be suitable in evidence based
medicine studies. It may be useful in individual cases, especially in patients
where EP is associated with erectile dysfunction, which should always be given
priority when planning any treatment.
Reports regarding the therapeutic and basically positive use of SSRIs such as
escitalopram, venlafaxine, duloxetine are summarised in the monography published
by Daneš (2011).
Tramadolhydrochloride is a strong synthetic analgesic that partially
binds to opioid receptors and probably reuptakes noradrenalin and serotonin in
the central nervous system[jm2] .There
are authors like Salem et Bisada (2008) and others who expected promising
results from tramadol not only in the treatment of EP. It may be assumed that
the analgesic effect of tramadol per se may play an important role in some
patients with EP, namely via suppression of pain of various aetiology that may
affect EP and induce erectile disorders. However, there are works that warn of
the risk of opioid dependence during such treatment (Gillman et Gillman (2019).
The sedative effects that could endanger the patient´s alertness when operating
machine or driving vehicles are dose dependent. This need not exceed 25 mg on
demand e.g. before intercourse.
The use of local anaesthetics locally on the penis in the form of various
ointments, creams or sprays has a long tradition. In the 1990s, preparations
containing lidocaine and prilocaine were quite popular (Berkovitch, Keresteci,
Koren (1995)). Data regarding their optimal use before intercourse are
summarised by Atikeler, Gecit and Senol (2002)). It is usually recommended to
apply them 15 minutes before intercourse. Some consider 30 minutes to be the
normal period of time from anaesthetic application to erection weakening.
Convincing results were reported by the study of Dinstmore and Wilkie (2009)
involving a cohort of men from 31 European centres. The men demonstrated two or
three times out of three intercourses an IELT of up to two minutes in the
initial four-week phase. The spray was applied three times, 5 minutes before
intercourse. After three months, the study that used questionnaires and
measurement of IELT demonstrated an increase in IELT (geometric average) from
0.6 minutes to 3.8 minutes, with 66% of patients evaluating the preparation and
its application as good to excellent. Adverse events were only local in 2.6% of
patients and in 3.1% of their partners.
I have tried with good results lidocaine combined with chlorhexidine such as
Instillagel in my patients. This preparation is designed for anaesthetising the
urethra during urological procedures. We have also had very good results with 1%
cinchocaine.
In my work published in 2011 I cited a case report using lubrication for
gratification and prolongation of IELT that was not that premature or short but
was uncomfortablein different ways for both partners and had led to
disagreements between them. Moistening of the vagina and penis using a
lubricating gel before every intercourse was sufficient to abolish this
disorder.
Supported
by theproject Ministry ofHealth, Czech Republic forconceptual development
ofresearchorganization 64165 (General University Hospital in Prague,
Czech Republic).
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