Premature Ejaculation (PE) is the most prevalent male sexual complaint, affecting some 20% to 30% of men. However, the prevalence of PE as sexual disorder is assumed to be much lower, around 2% to 5% of men.
According to the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Diseases (4th ed., revised 1994)(DSM-IV-R), PE is defined as persistent or recurrent ejaculation with minimal ejaculation before, on or shortly after penetration or before the person wishes it. The three essential components of PE are short ejaculatory latency (less than 2 minutes), lack of control and sexual dissatisfaction. The International Classification of Diseases (ICD-10) by World Health Organisation defines PE as "the 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 (if a time limit is required: before or within 15 seconds of the beginning of intercourse) or ejaculation occurs in the absence of sufficient erection to make intercourse possible"
PE mediated by alcohol, substance abuse or medication or situation leading to high level of arousal by definition are excluded for the diagnosis. PE is further classified into lifelong PE, acquired PE, natural variable PE and premature like ejaculatory dysfunction.
2. Early sexual experience
3. Infrequent sexual intercourse
4. Poor ejaculatory control techniques
1. Penile hypersensitivity
2. Hyperexictable ejaculatory reflex
5. Genetic predisposition
6. 5-HT-recpetor dysfunction
(Source: Campbell-Walsh’s Urology, 9th ed. Saunders Elsevier, Philadelphia, USA)
Detailed medical and sexual history, thorough physical examination and relevant investigations to rule out urological dysfunction, thyroid dysfunction, psychological dysfunction, medications and recent pelvic surgeries.
This is a problem specific approach with few side effects. It is most useful for natural variable PE and premature like ejaculatory dysfunction. However, it is time consuming, requires substantial commitment of time, money and partner’s co-operation. Results are mixed and lack immediacy.
Empirically supported psychological approaches including stop-squeeze and stop-pause methods have low success rates, around 50% to 60%.
1. Selective Serotonin Uptake Inhibitors (SSRIs)
Daily treatment with SSRIs like sertaline (50-100mg/day) or fluoxetine (20-40mg/day) induce ejaculatory delay by the end of first or second week. Side effects like fatigue, nausea, loose stools,etc. gradually disappear within 2 to 3 weeks. Except fluoxetine, SSRIs should be withdrawn gradually over 3-4 weeks.
On demand treatment with SSRI like dapoxetine 30 mg 1-3 hours before the sexual act.
2. Topical local anaesthetics like lidocaine/prolocaine cream 20-30 minutes before intercourse.