Premature ejaculation: do we have effective therapy?

The role of surgical therapy in the management of premature ejaculation: a narrative review

Background and Objective

Premature ejaculation (PE) is a common sexual disorder among male adults and negatively impacts a man's sexual life. Currently, the mainstay treatment of PE is still medical therapy which has drawbacks among patients as a consequence of side effects. Despite the new definitions, the evolution of medical therapy, and the consensus for the management of PE, it remains challenging to treat for many clinicians especially when medical treatment fails. However, the International Society for Sexual Medicine (ISSM) and the American Urological Association (AUA) guidelines ignored surgical therapy due to conflicting medical reports and doubts about the safety of surgical management. This article discusses the surgical management of PE based on recent guidelines, reviews, and evolving techniques.

Methods

We reviewed the literature using PubMed and searched for the following keywords: premature ejaculation, selective dorsal neurectomy, hyaluronic acid, dorsal nerve neuromodulation, cryo-ablation of the dorsal nerve and inner condom technique until May 2023. Seventeen studies were found.

Key Content and Findings

Even though the widespread use of many surgical modalities in Asia such as glans penis augmentation (GPA) using hyaluronic acid (HA) selective dorsal neurectomy (SDN), cryo-ablation of the dorsal nerve, neuromodulation of the dorsal nerve (NMDN), and circumcision are still considered as controversial for the guidelines.

Conclusions

The mainstay treatment of PE is still pharmaceutical. However, the current body of evidence on surgical treatments for PE is limited. Men considering surgical therapy for PE should be counseled well for the risks and benefits as there may be chronic disabilities. Further, well-designed trials are needed to establish safety and efficacy for the surgical treatment.

Surgical treatment of premature ejaculation: a narrative review

Recurrence after drug cessation is the biggest drawback of medical premature ejaculation (PE) treatments. Although these treatments are demonstrated to be safe and effective, most of the PE patients are interested in a more permanent solution. Despite the fact that currently available guidelines do not recommend surgical treatment for PE, some surgical interventions have been commonly performed for many years, especially in the Asian countries. The main purpose of these surgical treatments is to decrease the sensitivity of the glans penis. However, they are associated with irreversible complications such as penile deformity, sensory loss and erectile dysfunction. The aim of this narrative review is to summarize the advantages and disadvantages of various surgical interventions introduced for the treatment of PE. PubMed, Scopus and Web of Science have been utilized to search articles about glans penis augmentation and penile dorsal nerve interventions. A total of 11 articles were included, three articles excluded because they were in non-English languages. Glans penis augmentation offered a less invasive treatment that avoids severe side effects but requires retreatment in time. Selective dorsal neurectomy provided a more invasive but curative treatment alternative. However, more clinical data are necessary before surgical treatment options can be recommended to patients with PE.

Efficacy of combination therapy with biofeedback and dapoxetine in lifelong premature ejaculation treatment: a prospective randomized study

PURPOSE

Premature ejaculation (PE) is a common sexual dysfunction that significantly affects the quality of life of the patient and their partner. We aimed to compare the efficacy and safety of the combination therapy with biofeedback-guided pelvic floor exercise therapy (BFT) and dapoxetine 30 mg.

METHODS

Sixty-five patients diagnosed with lifelong PE were included in the study. Patients were divided into three groups as BFT, dapoxetine 30 mg and a combination of BFT and dapoxetine 30 mg. The patients were compared with the intravaginal ejaculatory latency time (IELT) pre-treatment and post-treatment 1st and 3rd months.

RESULTS

The mean IELTs of the patients in Group 1 were 40 s in pre-treatment, 115 s at the end of the 4th week and 140 s at the end of the 12th week. The IELT values of the patients in Group 2 were 40 s in pre-treatment, 145 s in the 4th week and 170 s in the 12th week. The IELT values were calculated in Group 3 as 42.5 s in pre-treatment, 185 s in the 4th week and 205 s in the 12th week When the IELT was statistically compared between the groups at 1st and 3rd months, the duration in the combination group was found to increase significantly (p < 0.001).

CONCLUSION

Combination therapy with BFT and dapoxetine 30 mg in lifelong PE treatment is a good alternative with a low side effect profile and acceptable continuous efficiency.

Which of available selective serotonin reuptake inhibitors (SSRIs) is more effective in treatment of premature ejaculation? A randomized clinical trial

Purpose:

To compare the efficacy and safety of available selective serotonin reuptake inhibitors (SSRIs) in order to find the most effective drug with the least number of side effects in treatment of premature ejaculation (PE).

Materials and Methods:

This study was a randomized clinical trial. Four hundred and eighty patients with PE in the 4 groups referred to Imam Reza hospital Tehran, Iran from July 2018 to February 2019 were enrolled in the study. The patients received sertraline 50mg, fluoxetine 20mg, paroxetine 20mg and citalopram 20mg, every 12 hours daily. The intravaginal ejaculatory latency time (IELT) before treatment, fourth and eighth weeks after treatment was recorded by the patient's wife with a stopwatch.

Results:

Mean IELT before, 4 and 8 weeks after treatment in four groups were: sertraline 69.4±54.3, 353.5±190.4, 376.3±143.5; fluoxetine 75.5±64.3, 255.4±168.2, 314.8±190.4; paroxetine 71.5±69.1, 320.7±198.3, 379.9±154.3; citalopram 90.39±79.3, 279.9±192.1, 282.5±171.1 seconds, respectively. The ejaculation time significantly increased in all groups (p <0.05), but there was no significant difference between the groups (P=0.75). Also, there was no significant difference in drugs side effects between groups (p >0.05). The most common side effects were drowsiness and dyspepsia, which were not severe enough to cause discontinuation of the drug.

Conclusions:

All available SSRIs were effective and usually had no serious complications. In patients who did not respond to any of these drugs, other SSRI drugs could be used as a salvage therapy.

Pelvic muscle floor rehabilitation as a therapeutic option in lifelong premature ejaculation: long-term outcomes

The aim of the study was to evaluate the long-term outcomes of pelvic floor muscle (PFM) rehabilitation in males with lifelong premature ejaculation (PE), using intravaginal ejaculatory latency time (IELT) and the self-report Premature Ejaculation Diagnostic Tool (PEDT) as primary outcomes. A total of 154 participants were retrospectively reviewed in this study, with 122 completing the training protocol. At baseline, all participants had an IELT ≤60 s and PEDT score >11. Participants completed a 12-week program of PFM rehabilitation, including physio-kinesiotherapy treatment, electrostimulation, and biofeedback, with three sessions per week, with 20 min for each component completed at each session. The effectiveness of intervention was evaluated by comparing the change in the geometric mean of IELT and PEDT values, from baseline, at 3, 6, and 12 months during the intervention, and at 24 and 36 months postintervention, using a paired sample 2-tailed t-test, including the associated 95% confidence intervals. Of the 122 participants who completed PFM rehabilitation, 111 gained control of their ejaculation reflex, with a mean IELT of 161.6 s and PEDT score of 2.3 at the 12-week endpoint of the intervention, representing an increase from baseline of 40.4 s and 17.0 scores, respectively, for IELT and PEDT (P < 0.0001). Of the 95 participants who completed the 36-month follow-up, 64% and 56% maintained satisfactory ejaculation control at 24 and 36 months postintervention, respectively.

The office management of ejaculatory disorders

Premature ejaculation (PE), delayed ejaculation (DE), anejaculation (AE) and retrograde ejaculation (RE) are four main ejaculatory disorders (EjDs) observed in clinical practice. Despite their high prevalence, EjDs remain underdiagnosed and undertreated. Primary care physicians should incorporate the discussion of sexual health topics into routine visits to facilitate EjD diagnosis and treatment. Because the causes of EjDs are multifactorial, the management of EjDs is etiology-specific and may require a holistic approach. Dapoxetine, a selective serotonin reuptake inhibitor, is the only drug approved for on-demand treatment of lifelong and acquired PE. In clinical practice, scheduled follow-up visits, risk factor treatment, appropriate dose escalation, adequate sexual attempts, patient education, and partner involvement are critical factors responsible for optimal overall management of PE and dapoxetine treatment outcomes.

Effectiveness of 'on demand' silodosin in the treatment of premature ejaculation in patients dissatisfied with dapoxetine: a randomized control study

Introduction

Premature ejaculation is a common sexual disorder, which is usually underreported. Multiple treatment methodologies are in use due to the absence of an effective, universally acceptable treatment modality. The most common drug used is dapoxetine, which has adverse effects limiting its long-term use. Hence, we decided to evaluate the effectiveness of ‘on demand’ silidosin 4 mg in patients with premature ejaculation, who were dissatisfied with dapoxetine 30 mg.

Material and methods

The study included 64 patients who reported premature ejaculation who were unhappy with the treatment with ‘on demand’ dapoxetine 30 mg, either due to its adverse effects or because of its overall inefficacy. They were divided into two groups of 33 and 31 respectively by simple randomization, with Group A treated with ‘on demand’ silodosin 4 mg three hours prior to intercourse, whereas Group B was treated with placebo. Pre- and post-treatment intravaginal ejaculatory latency time (IELT), premature ejaculation profile (PEP) and clinical global impression of change (CGIC) for premature ejaculation were evaluated.

Results

Patients in Group A (silodosin 4 mg) reported statistically significant improvement (p <0.005) in intravaginal ejaculatory latency time (IELT), premature ejaculation profile (PEP) and clinical global impression of change (CGIC) for premature ejaculation, with four patients reporting uncomfortably-delayed ejaculation.

Conclusions

‘On demand’ silodosin 4 mg is an effective treatment option with very few adverse events in those patients suffering from premature ejaculation, who are dissatisfied with dapoxetine 30 mg due to its adverse effects or inefficacy.