Evaluation of Premature Ejaculation

Comparison of Current International Guidelines on Premature Ejaculation: 2024 Update

Premature ejaculation (PE) is a common male sexual dysfunction that can cause significant distress in the patient and partner. This study aimed to compare the current international guidelines on PE to highlight their similarities and differences. We examined the latest guidelines from the European Association of Urology (EAU), American Urological Association/Sexual Medicine Society of North America (AUA/SMSNA), and International Society of Sexual Medicine (ISSM) by comparing definitions, classifications, epidemiology, pathophysiology, and recommendations on diagnosis and therapy. The quality of guidelines was assessed using the Appraisal of Guidelines for Research and Evaluation (AGREE) Global Rating Scale (GRS). We found significant variations in the definitions of PE and recommendations on management of patients. The EAU guidelines were the most recent, the AUA/SMSNA guidelines lacked detail in some areas, and the ISSM guidelines were the most complete but also the least updated. The search for a unified definition and the development of standardized diagnostic and therapeutic pathways remain concrete issues to improve the management of patients with PE worldwide.

Cyber pornography use and masturbation outburst. Considerations on 150 italian patients complaining erectile dysfunction and trying to solve it

OBJECTIVE

We aimed to verify the rate of masturbation (Mst) in a group of 150 Italian patients complaining Erectile Dysfunction (ED).

MATERIALS AND METHODS

Our diagnostic protocol for penile and sexual problems included the collection of the patient's history, general and local clinical examination, and metabolic and hormonal analyses. Selected patients were also submitted to nocturnal penile tumescence test (Rigiscan), Duplex ultrasound of the penis, Magnetic Resonance Imaging, neurological tests and cardiological examination. A group of 150 Italian males (aged between 20 and 86 years) who complained ED and who presented to our Andrological Center to research the possibility of correcting their ED and being able to recover adequate sexual erectile activity were included in this study. In this group of patients suffering from ED we decided to evaluate the practice of Mst by asking specific questions: 1. Do you sometimes practice Mst? 2. How often in a week? 3. Is Mst hidden or known by the partner? 4. What do you use as a masturbatory sexual stimulus? The frequency of Mst was assessed according to a Likert scale as follow: a: No Mst; b:1-2/week; c: 2-3/week; d: > 3/week; e: daily or more. We also asked if it was possible to have penetrative marital intercourse on the same day as Mst (1-10 hours). We also asked what they used as a triggering sexual stimulus: press magazines, TV movies, the WEB.

RESULTS

Only 5/150 patients did not report Mst while 27/145 pts (aged 20-30 years) reported it more than 3 times a week; 44/145 (aged 31-50 years) 1-3 times a week and 27/145 (51-86 years) 1-2 times a week. Almost all patients used WebPorn as a stimulus for Mst. A group of patients over the age of 50 said they were quite satisfied with the physical results of Mst even though they would prefer to have sex as part of a couple relationship.

CONCLUSIONS

The outburst of Mst in this web-dominated era could affect the sexual activity of individual males and couples.

Redefining a sexual medicine paradigm: subclinical premature ejaculation as a new taxonomic entity

Premature ejaculation (PE) and poor ejaculatory control are multidimensional sexual symptoms estimated to affect almost one-third of men, severely impairing the overall quality of life of patients and their partners. However, patients who do not completely fulfil the definition criteria for PE rarely receive a diagnosis or adequate treatment, with the risk of subsequent progression from initial, subclinical symptoms to clinically overt PE, frequently with other sexual comorbidities. Thus, the current definitions of PE warrant review, in order to consider and propose a new taxonomy encompassing other unaddressed, crucial clinical aspects of PE. These newly proposed criteria include the recommendation for a primary screening for erectile dysfunction (ED), as PE and ED can be comorbid in up to 50% of patients but have never before been considered as a unified clinical entity. In order to facilitate clinical practice and improve clinical management of men with PE and comorbid conditions, we propose and define the new taxonomic clinical entities of subclinical PE (SPE) and loss of control of erection and ejaculation (LCEE). Application of these diagnoses to men who meet the criteria for SPE and/or LCEE, but not the overt conditions, could improve access to treatment for these patients and reduce progression to the more serious clinical disorder.

Safety and efficacy of traditional Chinese medicine, Qiaoshao formula, combined with dapoxetine in the treatment of premature ejaculation: An open-label, real-life, retrospective multicentre study in Chinese men

To evaluate the safety and efficacy of Chinese medicine, Qiaoshao formula combined with dapoxetine was used for the treatment of premature ejaculation in a real-life setting. Nine hundred and five males diagnosed with premature ejaculation were reviewed in this retrospective cohort study. We divided the patients into two groups: dapoxetine alone and Qiaoshao formula combined with dapoxetine according to actual interventions provided to patients in clinics. The perceived intravaginal ejaculation latency time and the premature ejaculation profile measures markedly improved in both groups. However, in men with severe premature ejaculation (baseline perceived intravaginal ejaculation latency time <1 min) and those with baseline age ≤30 years, the perceived intravaginal ejaculation latency time was slightly but significantly longer with combined therapy than with dapoxetine alone (p < .05). Therefore, combined therapy involving the Qiaoshao formula and dapoxetine proved to safe as well as effective for treating premature ejaculation while prolonging the perceived intravaginal ejaculation latency time, which significantly improved the overall satisfaction of the patient and likely that of the couple.

Assessment of hormonal activity in patients with premature ejaculation

Purpose

Premature ejaculation is considered the most common type of male sexual dysfunction. Hormonal controls of ejaculation have not been exactly elucidated. The aim of our study is to investigate the role of hormonal factors in patients with premature ejaculation.

Materials and Methods

Sixty-three participants who consulted our outpatient clinics with complaints of premature ejaculation and 39 healthy men as a control group selected from volunteers were included in the study. A total of 102 sexual active men aged between 21 and 76 years were included. Premature ejaculation diagnostic tool questionnaires were used to assessment of premature ejaculation. Serum levels of follicle stimulating hormone, luteinizing hormone, prolactin, total and free testosterone, thyroid-stimulating hormone, free triiodothyronine and thyroxine were measured.

Results

Thyroid-stimulating hormone, luteinizing hormone, and prolactin levels were significantly lower in men with premature ejaculation according to premature ejaculation diagnostic tool (p=0.017, 0.007 and 0.007, respectively). Luteinizing hormone level (OR, 1.293; p=0.014) was found to be an independent risk factor for premature ejaculation.

Conclusions

Luteinizing hormone, prolactin, and thyroid-stimulating hormone levels are associated with premature ejaculation which was diagnosed by premature ejaculation diagnostic tool questionnaires. The relationship between these findings have to be determined by more extensive studies.

Silodosin versus naftopidil in the treatment of premature ejaculation: A prospective multicenter trial

OBJECTIVES

To determine the efficacy of two α1-adrenoceptor antagonists with different affinities for α1-adrenoceptor subtypes, silodosin and naftopidil, in the treatment of premature ejaculation.

METHODS

This was a prospective, open-label, multicenter trial. A total of 26 patients with untreated acquired premature ejaculation were enrolled. Premature ejaculation was defined based on the International Society for Sexual Medicine recommendation. Patients self-administered on demand silodosin 4 mg or naftopidil 25 mg 1 h before intercourse, alternating drugs at least three times each. Clinical global impression change for premature ejaculation, premature ejaculation profile, and intravaginal ejaculation latency time were evaluated at baseline and during treatment.

RESULTS

Due to clinical global impression change, 24 patients (92%) and 12 patients (46%) reported improvement in their own premature ejaculation problems under silodosin and nafitopidil administration, respectively. Silodosin treatment produced a significantly higher improvement rate compared with naftopidil (P = 0.0002). Objectively, silodosin significantly prolonged intravaginal ejaculation latency time compared with baseline and naftopidil (P < 0.01). Mean intravaginal ejaculation latency times were 1.9, 4.1, and 7.6 min at baseline, control and with silodosin, respectively. The rate of reduced semen volume during silodosin treatment was higher than during naftopidil treatment. There were no adverse systemic effects in either group.

CONCLUSIONS

Silodosin, a highly selective α1A-adrenoceptor antagonist, produces greater improvements in premature ejaculation profiles and related symptoms along with intravaginal ejaculation latency time in acquired premature ejaculation patients with or without erectile dysfunction. This result supports the clinical use of silodosin as an alternative treatment for premature ejaculation.

Rhodiola rosea, folic acid, zinc and biotin (EndEP®) is able to improve ejaculatory control in patients affected by lifelong premature ejaculation: Results from a phase I-II study

The therapeutic armamentarium currently available for the treatment of premature ejaculation (PE) is not highly satisfactory. However, phytotherapeutics appear to be an interesting option for PE management. The present study aimed to evaluate the tolerability and efficacy of a phytotherapeutic combination of Rhodiola rosea, folic acid, biotin and zinc (EndEP^®) in the treatment of patients affected by lifelong PE. All patients affected by lifelong PE who were attending three Urological Institutions from July to December 2014 were enrolled in this prospective, multicentre, phase I–II study. All patients were assigned to receive oral tablets of EndEP^® (one tablet per day) for 90 days. Clinical and instrumental analyses were carried out at enrolment and at the end of the study. International Prostatic Symptom Score (IPSS), International Index of Erectile Function (IIEF)-15, Premature Ejaculation Diagnostic Tool (PEDT) and Short Form (SF)-36 questionnaires were used. The intravaginal ejaculation latency time (IELT) for each event was also evaluated using the stop-watch technique. The main outcome measure was the difference from baseline in PEDT questionnaire and mean IELT at the end of the follow-up period. In total, 91 patients (mean age, 32.3±5.6 years) were analysed. The baseline questionnaires mean scores were 1.1±1.6, 26.1±2.9, 15.3±3.4 and 98.2±0.5, for IPSS, IIEF-15, PEDT and SF-36, respectively. The mean IELT at baseline was 73.6±46.9s. At the follow-up examination (90 days after the start of treatment), no statistically significant differences were identified in terms of IPSS (1.4±1.5) or IIEF-15 (26.3±3.1) compared with the pre-treatment values (P=0.19 and P=0.64, respectively). A statistically significant difference was detected between the mean IELT at enrolment and after treatment (73.6±46.9 vs. 102.3±60.0; P<0.001) and SF-36 questionnaire (98.2±0.5 vs. 99.4±0.1; P<0.001). Fifty-five patients reported improvement in the control of ejaculation (60.4%). Very few adverse events were reported (4.4%). In conclusion, it was found that EndEP^® significantly improved ejaculatory control and the quality of sexual life in patients affected by lifelong PE, with a very low rate of adverse events.

Interplay Between Premature Ejaculation and Erectile Dysfunction: A Systematic Review and Meta-Analysis

INTRODUCTION

The specific determinants and underlying factors linking erectile dysfunction (ED) and premature ejaculation (PE) have yet to be clearly identified.

AIM

The aim of this study was to review and meta-analyze all available data regarding the link between ED and PE.

METHODS

An extensive Medline Embase and Cochrane search was performed including the following words: "premature ejaculation" and "erectile dysfunction".

MAIN OUTCOME MEASURES

All observational trials comparing the risk of ED in relation to PE were included. Data extraction was performed independently by two of the authors (G.R, G.C.), and conflicts resolved by the third investigator (M.M.).

RESULTS

Out of 474 retrieved articles, 18 were included in the study for a total of 57,229 patients, of which 12,144 (21.2%) had PE. The presence of PE, however defined, was associated with a significant increase in ED risk (odds ratio: 3.68[2.61;5.18]; P < 0.0001). Meta-regression analysis showed that the risk of ED in PE subjects was higher in older individuals as well as in those with a lower level of education and in those who reported a stable relationship less frequently. In addition, subjects with PE and ED more often reported anxiety and depressive symptoms and a lower prevalence of organic associated morbidities, including diabetes mellitus, hypertension and dyslipidemia. All the latter associations were confirmed even after adjustment for age. Finally the risk of PE-related ED increased with the increased proportion of acquired ejaculatory problems (adj r = 0.414; P < 0.0001 after the adjustment for age).

CONCLUSIONS

In conclusion, the present data showed that ED and PE are not distinctly separate entities, but should be considered from a dimensional point of view. Understanding this dimensional perspective might help sexual health care professionals in providing the most appropriate therapeutic approach to realistically increase patient related outcomes in sexual medicine.

The 5-HT2C receptor gene Cys23Ser polymorphism influences the intravaginal ejaculation latency time in Dutch Caucasian men with lifelong premature ejaculation

It has been postulated that the persistent short intravaginal ejaculation latency time (IELT) of men with lifelong premature ejaculation (LPE) is related to 5-hydroxytryptamine (HT)_2C receptor functioning. The aim of this study was to investigate the relationship of Cys23Ser 5-HT_2C receptor gene polymorphism and the duration of IELT in men with LPE. Therefore, a prospective study was conducted in 64 Dutch Caucasian men with LPE. Baseline IELT during coitus was assessed by stopwatch over a 1-month period. All men were genotyped for Cys23Ser 5-HT_2C receptor gene polymorphism. Allele frequencies and genotypes of Cys and Ser variants of 5-HT_2C receptor gene polymorphism were determined. Association between Cys/Cys and Ser/Ser genotypes and the natural logarithm of the IELT in men with LPE were investigated. As a result, the geometric mean, median and natural mean IELT were 25.2, 27.0, 33.9 s, respectively. Of all men, 20.0%, 10.8%, 23.1% and 41.5% ejaculated within 10, 10–20, 20–30 and 30–60 s after vaginal penetration. Of the 64 men, the Cys/Cys and Ser/Ser genotype frequency for the Cys23Ser polymorphism of the 5-HT_2C receptor gene was 81% and 19%, respectively. The geometric mean IELT of the wildtypes (Cys/Cys) is significantly lower (22.6 s; 95% CI 18.3–27.8 s) than in male homozygous mutants (Ser/Ser) (40.4 s; 95% CI 20.3–80.4 s) (P = 0.03). It is concluded that Cys23Ser 5-HT_2C receptor gene polymorphism is associated with the IELT in men with LPE. Men with Cys/Cys genotype have shorter IELTs than men with Ser/Ser genotypes.

Clinical correlates of enlarged prostate size in subjects with sexual dysfunction

Digito-rectal examination (DRE) of the prostate provides useful information on the state of prostate growth and on the presence of suspected peripheral nodules. The aim of this study is to describe the clinical and biochemical correlates of finding an enlarged prostate size at DRE in subjects with sexual dysfunction (SD). A consecutive series of 2379 patients was retrospectively studied. The analysis was focused on a subset of subjects (n = 1823; mean age 54.7 ± 11.4) selected for being free from overt prostatic diseases. Several parameters were investigated. After adjusting for confounders, the presence of an enlarged prostate size at DRE was associated with a higher risk of metabolic syndrome (HR = 1.346 (1.129–1.759); P = 0.030), type 2 diabetes mellitus (HR = 1.489 (1.120–1.980); P = 0.006), increased LDL cholesterol (>100 mg dl⁻¹; HR = 1.354 (1.018–1.801); P = 0.037) and increased mean blood pressure (BP) values (HR = 1.017 (1.007–1.027) for each mmHg increment; P = 0.001). Accordingly, enlarged prostate size was also associated with a higher risk of arteriogenic erectile dysfunction (ED), as well as with other andrological conditions, such as varicocele and premature ejaculation (PE). PSA levels were significantly higher in subjects with enlarged prostate size when compared to the rest of the sample (HR = 3.318 (2.304; 4.799) for each log unit increment in PSA levels; P < 0.0001). Arteriogenic ED, according to different criteria, was also associated with increased PSA levels. In conclusion, our data support the need to examine prostate size either by clinical (DRE) or biochemical (PSA) inspection in subjects with SD, in order to have insights into the nature of the SD and the metabolic and cardiovascular (CV) background of the patient.

Hormonal correlations of premature ejaculation

Premature ejaculation is the most frequent male sexual dysfunction, significantly impairing quality of life of both the patient and the partner and affecting up to one-third of men of every age. In the last years, our knowledge about this topic has greatly increased, and studies on the causes and treatments related to ejaculatory disorders have shed a light on previously uncharted territory. Public interest on sexual dysfunctions has likewise increased in the general population: the time lapse between the first symptoms of sexual dysfunction and the seeking of medical advice has been significantly reduced, whereas demand for a treatment has markedly increased. A role of endocrine regulation has been established in all the aspects of male reproduction; however, the endocrine control of ejaculation is not fully understood. Sex steroid, pituitary, and thyroid hormones have all been advocated as potential candidates in the regulation of the ejaculatory process, but exact mechanisms are not clear yet and further studies are required in order to identify potential targets for treatment.

Relationship between premature ejaculation and chronic prostatitis/chronic pelvic pain syndrome

INTRODUCTION

Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) is a common etiology of premature ejaculation (PE). However, the current data are insufficient to explain this relationship and to support routine screening of men with PE.

AIMS

This study aims to evaluate the relationship between PE and CP/CPPS.

METHODS

A cross-sectional study was conducted that included 8,261 men who had participated in a health examination. The Premature Ejaculation Diagnostic Tool (PEDT), the National Institutes of Health-Chronic Prostatitis Symptom Index (NIH-CPSI), and the International Index of Erectile Function-5 (IIEF) were used for assessment of symptoms. A full metabolic work-up and serum testosterone level checks were also performed. We then investigated the relationship using the Spearman correlation test, multiple linear regression, and logistic regression analyses.

MAIN OUTCOME MEASURES

Associations of PEDT with NIH-CPSI.

RESULTS

The mean age was 50.4 ± 5.5 years. In total, 2,205 (24.9%) men had prostatitis-like symptoms (NIH-CPSI pain score of ≥4 and perineal or ejaculatory pain), and 618 (7.0%) men had moderate to severe symptoms (NIH-CPSI pain score of ≥8). Additionally, 2,144 men (24.2%) were classified as demonstrating PE (PEDT > 10). The PEDT score was found to have a significant positive correlation with the NIH-CPSI pain domain score (correlation coefficient = 0.206; P < 0.001). After adjusting for age, metabolic syndrome status, testosterone level, and IIEF score, there was no change in the positive correlation between the NIH-CPSI pain domain score and PEDT score (Beta = 0.175; P < 0.001). After adjusting for age, testosterone level, metabolic syndrome, and IIEF score, the odds ratio (OR) for PE significantly increased with the severity of pelvic pain (mild prostatitis-like symptoms, OR for PE: 1.269, 95% confidence interval: 1.113-1.447; moderate to severe symptoms, OR for PE: 2.134: 95% confidence interval: 1.782-2.557).

CONCLUSIONS

Our data showed a significant correlation between the PEDT score and the NIH-CPSI score. We suggest routine screening for CP/CPPS in men with PE and PE in men with CP/CPPS.

Relationships between intravaginal ejaculatory latency time and national institutes of health-chronic prostatitis symptom index in the four types of premature ejaculation syndromes: a large observational study in China

INTRODUCTION

Besides lifelong premature ejaculation (LPE) and acquired premature ejaculation (APE), Waldinger and Schweitzer proposed two addition PE syndromes (variable PE [VPE] and subjective PE [SPE]).

AIM

We assessed the associations between intravaginal ejaculatory latency time (IELT) and National Institutes of Health-Chronic Prostatitis Symptom Index (NIH-CPSI) in men with different PE syndromes.

METHODS

From September 2011 to September 2012, a total of 4,000 men were enrolled from the Anhui province of China. Subjects were required to complete a verbal questionnaire, including demographic information, medical and sexual history (e.g., IELT), and self-estimated scales (e.g., NIH-CPSI).

MAIN OUTCOME MEASURES

IELT; NIH-CPSI; the new classification of PE syndromes.

RESULTS

Of 3,016 of the men evaluated, 25.80% complained of PE. Distribution of the four PE syndromes among men with complaints of PE was as follows: LPE, 12.34%; APE, 18.77%; VPE, 44.09%; and SPE, 24.81%. Men with complaints of PE reported worse NIH-CPSI scores and lower IELT than men without complaints of PE (P < 0.001 for all). Moreover, total and subdomain scores of NIH-CPSI were higher in men with APE, and IELT was higher in men with SPE. IELT was negatively associated with NIH-CPSI scores in men with complaints of PE. Negative relationships between total and subdomain scores of NIH-CPSI and IELT were stronger in men with APE (total scores: adjusted r = -0.68, P < 0.001; pain symptoms: adjusted r = -0.70, P < 0.001; urinary symptoms: adjusted r = -0.67, P < 0.001; quality of life impact: adjusted r = -0.64, P < 0.001).

CONCLUSION

Men with complaints of PE reported worse NIH-CPSI scores than men without complaints of PE. Relationships between IELT and NIH-CPSI scores were strongest in men with APE.

Chlamydia trachomatis infection is related to premature ejaculation in chronic prostatitis patients: results from a cross-sectional study

INTRODUCTION

Chronic bacterial prostatitis (CBP) is reported to be a common finding in men with acquired premature ejaculation (PE). The impact of different pathogens on PE development in chronic prostatitis patients is, however, unknown.

AIM

To assess a possible link between CBP caused by Chlamydia trachomatis (Ct) and PE.

METHODS

A consecutive series of 317 patients with clinical and instrumental diagnosis of CBP due to Ct was enrolled (group A) and compared with data obtained from a control group of 639 patients with CBP caused by common uropathogen bacteria (group B). Prostatitis symptoms were investigated with the National Institutes of Health-Chronic Prostatitis Symptom Index (NIH-CPSI), while the ejaculatory status of patients was assessed using the PE Diagnostic Tool (PEDT).

MAIN OUTCOME MEASURES

All participants were asked to complete the NIH-CPSI, the International Index of Erectile Function-15 erectile function domain (IIEF-15-EFD), the PEDT, and the Short Form (SF)-36 questionnaires.

RESULTS

Patient groups A and B had comparable scores of NIH-CPSI (P = 0.07), IPSS (P = 0.32), and IIEF-15-EFD (P = 0.33) tests. PE was assessed in 118 patients in group A (37.2%) and in 73 subjects in group B (11.5%). The two groups are different in terms of PE prevalence (P < 0.0002). Compared with group B, group A showed significantly higher scores of the PEDT test (11.3 [±2.6] vs. 4.5 [±2.9], P < 0.0001) and lower scores of the SF-36 tool (96.5 [±1.1] vs. 99.7 [±1.3], P < 0.0001). In our multivariate model assessment, being positive for a Ct infection marker was independently associated with the PEDT score even after adjusting for age, smoking habit, body mass index, and education level (adjusted odds ratio = 3.21; 95% confidence interval: 2.02-4.27; P < 0.003).

CONCLUSIONS

Patients affected by CBP due to Ct infection reported higher prevalence of PE and lower quality of life when compared with patients affected by CBP caused by traditional uropathogenic bacteria.

Further definition on the multiple partner choice arena: a potential animal model for the study of premature ejaculation

INTRODUCTION

The multiple partner choice arena (MPCA) is an experimental setup in which male rats display a significant shortening of ejaculation latency, which is the main characteristic of premature ejaculation (PE) in men. Thus, the MPCA is a potential animal model for PE.

AIM

In this study, we further analyze whether the features of the MPCA satisfy the validity criteria for it to be considered an animal model as well as the possible participation of the serotoninergic system in the faster ejaculation exhibited by male rats in the MPCA.

METHODS

In Experiment 1, male rats were tested in a standard arena to assess their sexual behavior, then were assessed 1 week later in the MPCA. Another group was first tested in the MPCA, then in a standard arena. In Experiment 2, male rats divided into two groups were treated daily with WAY-100635 (5-HT(1A) antagonist) or vehicle for 15 days. In each group, half of the subjects were tested in a standard arena and half were tested in the MPCA on days 1, 8, and 15 of treatment.

MAIN OUTCOME MEASURES

Number of intromissions and intromission and ejaculation latencies were the main outcome measures.

RESULTS

In Experiment 1, males tested in the MPCA ejaculated significantly faster, regardless of the order in which they were evaluated in both arenas. In Experiment 2, the administration of WAY-100635 increased intromission and ejaculation latencies, and the number of intromissions in the MPCA.

CONCLUSIONS

The results obtained in the MPCA support its use as an animal model for PE evaluation.

An Update of the International Society of Sexual Medicine's Guidelines for the Diagnosis and Treatment of Premature Ejaculation (PE)

INTRODUCTION

In 2009, the International Society for Sexual Medicine (ISSM) convened a select panel of experts to develop an evidence-based set of guidelines for patients suffering from lifelong premature ejaculation (PE). That document reviewed definitions, etiology, impact on the patient and partner, assessment, and pharmacological, psychological, and combined treatments. It concluded by recognizing the continually evolving nature of clinical research and recommended a subsequent guideline review and revision every fourth year. Consistent with that recommendation, the ISSM organized a second multidisciplinary panel of experts in April 2013, which met for 2 days in Bangalore, India. This manuscript updates the previous guidelines and reports on the recommendations of the panel of experts.

AIM

The aim of this study was to develop clearly worded, practical, evidenced-based recommendations for the diagnosis and treatment of PE for family practice clinicians as well as sexual medicine experts.

METHOD

A comprehensive literature review was performed.

RESULTS

This article contains the report of the second ISSM PE Guidelines Committee. It offers a new unified definition of PE and updates the previous treatment recommendations. Brief assessment procedures are delineated, and validated diagnostic and treatment questionnaires are reviewed. Finally, the best practices treatment recommendations are presented to guide clinicians, both familiar and unfamiliar with PE, in facilitating treatment of their patients.

CONCLUSION

Development of guidelines is an evolutionary process that continually reviews data and incorporates the best new research. We expect that ongoing research will lead to a more complete understanding of the pathophysiology as well as new efficacious and safe treatments for this sexual dysfunction. We again recommend that these guidelines be reevaluated and updated by the ISSM in 4 years. Althof SE, McMahon CG, Waldinger MD, Serefoglu EC, Shindel AW, Adaikan PG, Becher E, Dean J, Giuliano F, Hellstrom WJG, Giraldi A, Glina S, Incrocci L, Jannini E, McCabe M, Parish S, Rowland D, Segraves RT, Sharlip I, and Torres LO. An update of the International Society of Sexual Medicine's guidelines for the diagnosis and treatment of premature ejaculation (PE). Sex Med 2014;2:60-90.

An update of the International Society of Sexual Medicine's guidelines for the diagnosis and treatment of premature ejaculation (PE)

INTRODUCTION

In 2009, the International Society for Sexual Medicine (ISSM) convened a select panel of experts to develop an evidence-based set of guidelines for patients suffering from lifelong premature ejaculation (PE). That document reviewed definitions, etiology, impact on the patient and partner, assessment, and pharmacological, psychological, and combined treatments. It concluded by recognizing the continually evolving nature of clinical research and recommended a subsequent guideline review and revision every fourth year. Consistent with that recommendation, the ISSM organized a second multidisciplinary panel of experts in April 2013, which met for 2 days in Bangalore, India. This manuscript updates the previous guidelines and reports on the recommendations of the panel of experts.

AIM

The aim of this study was to develop clearly worded, practical, evidenced-based recommendations for the diagnosis and treatment of PE for family practice clinicians as well as sexual medicine experts.

METHOD

A comprehensive literature review was performed.

RESULTS

This article contains the report of the second ISSM PE Guidelines Committee. It offers a new unified definition of PE and updates the previous treatment recommendations. Brief assessment procedures are delineated, and validated diagnostic and treatment questionnaires are reviewed. Finally, the best practices treatment recommendations are presented to guide clinicians, both familiar and unfamiliar with PE, in facilitating treatment of their patients.

CONCLUSION

Development of guidelines is an evolutionary process that continually reviews data and incorporates the best new research. We expect that ongoing research will lead to a more complete understanding of the pathophysiology as well as new efficacious and safe treatments for this sexual dysfunction. We again recommend that these guidelines be reevaluated and updated by the ISSM in 4 years.

Integrating psychotherapy and pharmacotherapy in the treatment of premature ejaculation

OBJECTIVES

To describe the different approaches to the treatment of premature ejaculation (PE), with a final focus on integrated treatment, as conventional theories and therapies for PE are based on an organic or psychogenic dichotomy.

METHODS

We list the principal hypotheses of the causes and therapy of PE on the basis of psychological and medical perspectives, after identifying all relevant studies available on Medline up to 2012.

RESULTS

The cognitive feedback from PE can lead to a 'performance anxiety', which can combine with other conditions to further impair ejaculatory control. For these reasons, a psychological approach is always useful in treating PE, the most useful of which are sex therapy and behavioural therapy. For pharmacological treatment, reports suggest that dapoxetine (60 mg) significantly improves the control of the ejaculatory reflex, and it thus represents the first-line officially approved pharmacotherapy for PE.

CONCLUSIONS

A holistic approach which considers the biological, psychological and relational aspects is the advised treatment for PE. Integrated medical and psycho-sexological therapy requires a mutual understanding of and respect for the different disciplines involved in sexology. In this aspect two very important roles are those of the physician and the psychologist.

Sexual dysfunction in 2013: Advances in epidemiology, diagnosis and treatment

OBJECTIVES

To provide a contemporary review of the epidemiology, diagnosis and treatment of premature ejaculation (PE) and erectile dysfunction (ED).

METHODS

We searched for English-language articles published in the past 12 months using the PubMed database. Relevant articles on the subjects of sexual dysfunction, ED and PE were selected for review.

CONCLUSIONS

Recent studies on male sexual dysfunction have provided new therapeutic possibilities. Tramadol, a well-used analgesic, has a new role in the treatment of PE. Super-selective targeting of dorsal penile nerves by surgery or cryoablative technologies might become a viable treatment option for refractory PE in the future. The role of ED as a harbinger of important comorbidities allows for the early detection and intervention of these conditions, which can optimise therapeutic outcomes. The long-term effect of chronic phosphodiesterase-5 inhibitors on endothelial dysfunction, the angiogenic potential of low-intensity extracorporeal shock wave therapy, and further advances in drug-eluting endovascular stents might in future allow clinicians to treat ED more definitively.

Premature ejaculation: do we have effective therapy?

INTRODUCTION

Premature ejaculation (PE) is the most common sexual dysfunction, with the majority of PE patients remaining undiagnosed and undertreated. Despite its prevalence, there is a current paucity of data regarding available treatment options and mechanisms. The objective of the current investigation is to review and summarize pertinent literature on therapeutic options for the treatment of PE, including behavioral/psychologic, oral pharmacotherapy, and surgery.

METHODS

A pubmed search was conducted on articles reporting data on available treatment options for PE. Articles describing potential mechanisms of action were additionally included for review. Preference was given towards randomized, controlled trials, when available.

RESULTS

PE remains an underdiagnosed and undertreated disease process, with limited data available regarding potential underlying mechanisms and long-term outcomes of treatment options. Psychological/behavioral therapies, including the stop-start, squeeze, and pelvic floor rehabilitation techniques have demonstrated improvements in short-term series, with decreased efficacy with additional follow-up. Topical therapies, which are commonly utilized result in prolonged intravaginal ejaculatory latency time (IELT) at the expense of potential penile/vaginal Hypothesia. Oral therapies similarly demonstrate improved IELTs with variable side effect profiles and include selective serotonin reuptake inhibitors (daily or on demand), phosphodiesterase-5 inhibitors, alpha-1 adrenergic antagonists, and tramadol. Alternative therapies such as acupuncture have shown benefits in limited studies. Surgery is not commonly performed and is not recommended by available guidelines.

CONCLUSIONS

PE is a common condition, with limited data available regarding its underlying pathophysiology and treatment. Available therapies include topical, oral, behavioral/psychologic modification, or a combination thereof. Additional research is required to assess the optimal treatment strategies and algorithms as well as to better define the mechanisms for PE and its management.

Premature ejaculation results in female sexual distress: standardization and validation of a new diagnostic tool for sexual distress

PURPOSE

We measured premature ejaculation related female sexual distress using a new diagnostic tool, the Female Sexual Distress Scale-Revised-Premature Ejaculation questionnaire.

MATERIALS AND METHODS

In this large-scale, Internet based population study we evaluated 2,109 women in a stable relationship during the last 6 months. The 1,361 women in the premature ejaculation group had no female sexual disorder but the partner had premature ejaculation alone. The 748 controls had no female sexual disorder and a partner without premature ejaculation. We determined questionnaire content and discriminant validity, internal consistency and test-retest reliability. Multivariate logistic regression with propensity score reweighting was done to determine the clinical impact of demographics on the perception of sexual distress.

RESULTS

The questionnaire was well understood. Internal consistency was greater than 0.90 and 0.84 in the premature ejaculation and control groups, respectively. Test-retest reliability was 0.82 (95% CI 0.72-0.87) and 0.85 (95% CI 0.79-0.92) in the premature ejaculation and control groups, respectively. The questionnaire had a high AUC of 0.90 (95% CI 0.89-0.91). The new cutoff score of 12 or greater had 79.1% sensitivity (95% CI 73.8-82.5), 99.5% specificity (95% CI 98.0-100.0), 99.3% positive predictive value (95% CI 98.7-100.0) and 67.9% negative predictive value (95% CI 64.2-73.2). Median questionnaire scores were significantly higher in the premature ejaculation group than in controls (20, 95% CI 19-21 vs 6, 95% CI 6-7, p <0.0001). Logistic regression adjusted and unadjusted by propensity score indicated that women in the premature ejaculation group had a 7.12 (95% CI 5.98-10.14, p <0.0001) to 9.83 (95% CI 7.94-12.15) greater probability of sexual distress than controls.

CONCLUSIONS

The Female Sexual Distress Scale-Revised-Premature Ejaculation questionnaire fulfills psychometric requirements for measuring sexual distress related to partner sexual dysfunction.

New insights on premature ejaculation: a review of definition, classification, prevalence and treatment

There are ongoing debates about the definition, classification and prevalence of premature ejaculation (PE). The first evidence-based definition of PE was limited to heterosexual men with lifelong PE who engage in vaginal intercourse. Unfortunately, many patients with the complaint of PE do not meet these criteria. However, these men can be diagnosed as one of the PE subtypes, namely acquired PE, natural variable PE or premature-like ejaculatory dysfunction. Nevertheless, the validity of these subtypes has not yet been supported by evidence. The absence of a universally accepted PE definition and lack of standards for data acquisition have resulted in prevalence studies that have reported conflicting rates. The very high prevalence of 20%-30% is probably due to the vague terminology used in the definitions at the time when such surveys were conducted. Although many men may complain of PE when questioned for a population-based prevalence study, only a few of them will actively seek treatment for their complaint, even though most of these patients would define symptoms congruent with PE. The complaints of acquired PE patients may be more severe, whereas complaints of patients experiencing premature-like ejaculatory dysfunction seem to be least severe among men with various forms of PE. Although numerous treatment modalities have been proposed for management of PE, only antidepressants and topical anaesthetic creams have currently been proven to be effective. However, as none of the treatment modalities have been approved by the regulatory agencies, further studies must be carried to develop a beneficial treatment strategy for PE.

Dapoxetine: a new option in the medical management of premature ejaculation

Premature ejaculation (PE) is a common male sexual disorder which is associated with substantial personal and interpersonal negative psychological consequences. Pharmacotherapy of PE with off-label antidepressant selective serotonin reuptake inhibitors (SSRIs) is common, effective and safe. Development and regulatory approval of drugs specifically for the treatment of PE will reduce reliance on off-label treatments and serve to fill an unmet treatment need. The objective of this article is to review evidence supporting the efficacy and safety of dapoxetine in the treatment of PE. MEDLINE, Web of Science, PICA, EMBASE and the proceedings of major international and regional scientific meetings were searched for publications or abstracts published during the period 1993-2012 that used the word 'dapoxetine' in the title, abstract or keywords. This search was then manually cross referenced for all papers. This review encompasses studies of dapoxetine pharmacokinetics, animal studies, human phase I, II and III studies, independent postmarketing and pharmacovigilance efficacy and safety studies and drug-interaction studies. Dapoxetine is a potent SSRI which is administered on demand 1-3 h prior to planned sexual contact. It is rapidly absorbed and eliminated, resulting in minimal accumulation, and has dose-proportional pharmacokinetics which are unaffected by multiple dosing. Dapoxetine 30 mg and 60 mg has been evaluated in five industry-sponsored randomized, double-blind, placebo-controlled studies in 6081 men aged at least 18 years. Outcome measures included stopwatch-measured intravaginal ejaculatory latency time (IELT), Premature Ejaculation Profile (PEP) inventory items, Clinical Global Impression of Change (CGIC) in PE, and adverse events. Mean IELT, all PEP items and CGIC improved significantly with both doses of dapoxetine versus placebo (all p <0.001). The most common treatment-related adverse effects included nausea (11.0% for 30 mg, 22.2% for 60 mg), dizziness (5.9% for 30 mg, 10.9% for 60 mg), and headache (5.6% for 30 mg, 8.8% for 60 mg), and evaluation of validated rated scales demonstrated no SSRI class-related effects with dapoxetine use. Dapoxetine, as the first drug developed for PE, is an effective and safe treatment for PE and represents a major advance in sexual medicine.

What does premature ejaculation mean to the man, the woman, and the couple?

INTRODUCTION

The relational impact of male and female sexual dysfunction, and specifically premature ejaculation (PE), is an important consideration. Published findings are consistent in identifying the negative psychosocial impact of PE on the man. However, the effect of PE on the female partner, especially in relation to her sexual functioning, has been less well studied.

AIM

Provide an overview of the impact of PE on the man, the woman, and the couple.

METHODS

Review of relevant literature.

RESULTS

Female partners of men with PE report significantly greater sexual problems, with reduced satisfaction, increased distress and interpersonal difficulty, and more orgasmic problems than partners of non-PE men. Both men with PE and their partners feel control over ejaculation is the central issue in PE. For both, the lack of control leads to dissatisfaction, a feeling that something is missing from the relationship, and an impaired sense of intimacy. If left untreated, the situation can lead to increased irritability, interpersonal difficulties, and deepening of an emotional divide.

CONCLUSIONS

When treating a man with PE, the partner's participation should be encouraged to enable the physician to fully understand the extent of the problem, and consider other relevant factors, from her perspective. Identifying the best approach for the couple requires consultation with each person individually and together. In clinical practice, treatments for PE are likely to include a combination of pharmacological, psychological, sexological, and/or behavioral approaches for both the man and his partner. It is important that physicians regard PE as the couple's problem and endeavor to include the partner in its management where possible.