Premature Ejaculation

Timothy G. Schuster, M.D.

Disclosures

Urol Nurs. 2006;24(4):245-249. 

In This Article

Treatment

Because the etiology of PE is disputed, treatment options include behavioral, psychological, and attempts to alter the sensory input or retard the ejaculatory reflex through pharmacological means. It is important to review all available treatment options and side effects with the patient and preferably with his spouse as well so that an informed decision can be made.

Because of the belief by some researchers that PE is due to a learned behavior because of performance anxiety, sex therapy became the mainstay of treatment for many years and is still one option for treatment of PE today. Acquired or situational PE is believed by many to have a psychological basis and most clinicians would recommend counseling at least as part of the treatment recommendations.

The most common form of sex therapy is the "squeeze technique" during which the patient and/or his partner squeeze the erect penile shaft before the ejaculatory reflex is stimulated. Using this technique, the patient will learn to voluntarily delay ejaculation while maintaining sexual excitation (Masters et al. 1970). While this technique can have significant improvements for men, therapy is time consuming and requires a partner willing to participate.

The start-stop method, first introduced by Dr. James Semans (1956), is an alternative treatment option for treating PE. As suggested by the name, this technique involves masturbatory stimulation of the penis until the sensation of heightened arousal is met but prior to the onset of the ejaculatory reflex. The stimulation is then withheld until the sensation resolves. This is repeated until the man reaches the point that extravaginal stimulation occurs without ever reaching the sensation of inevitability.

An alternative option for patients includes the application of 2.5 gms of prilocaine-lidocaine cream to the glans 30 minutes prior to intercourse. After application, a condom is used to hold the cream in place. In a preliminary unblinded study, 81% of men reported improvements in their PE (Berkovitch, Keresteci, Koren, 1995). Men can titrate the degree of penile numbness by adjusting the exposure time to the cream. It is important to inform patients that the cream should be wiped off completely prior to intercourse to prevent vaginal numbness (Sahin & Bircan, 1996)

An alternative topical agent, SS cream, is available currently in Korea. It is a natural agent derived from nine products. In a double blind, randomized, placebo controlled Phase III trial, men with primary PE had a significant improvement in ejaculatory latency when using SS cream when compared to controls (Choi, Jung, Moon, Xin, Choi, Lee, et al., 2000).

Treatment of PE may be effective with the use of several different classes of medications. Currently no medication is Food and Drug Administration (FDA) approved for treatment of PE. Despite this, several medications discussed below are routinely prescribed to successfully treat PE.

Initial medical treatments for PE involved use of medications to inhibit alpha receptors. A small, nonrandomized study 20-30 mg of the alpha-adrenergic blocker phenoxybenzamine was used successfully to treat PE in nine patients (Shilon, Paz, Homonnai, 1984). It should be noted that a significant side effect of the medication is aspermia, therefore this therapy should not be considered in men wishing to procreate.

The tricyclic antidepressant clomipramine has been shown to be effective in treating PE in several double-blind placebo controlled trials with doses ranging from 10-50 mg per day (Girgis, El-Haggar, El-Hermouzy, 1982; Haensel, Rowland, Kallan, 1996; Kim & Seo, 1998; Strassberg, De Gouveia Brazao, Rowland, Tan, Slob, 1999; Rowland, De Gouveia Brazao, Koos Slob, 2001). Possible mechanisms for action of the medication include inhibition of the autonomic processes involved in the ejaculatory reflex, diminished psychological arousal, or a direct anxiolytic effect. The most common side effects of clomipramine include dry mouth and fatigue which are due to the anticholinergic properties of the medication and appear to be dose related.

Given the inhibitory effects of serotonin on the central ejaculatory reflex, the efficacy of selective serotonin reuptake inhibitors (SSRIs) in the treatment of PE is not surprising. These inhibitors have been shown to delay ejaculation in multiple placebo-controlled randomized studies (Biri, et al., 1998; Haensel, Klem, Hop, Slob, 1998; Kara et al.,, 1996; Kim & Soo. 1998; Waldinger , Hengeveld, Zwinderman, Olivier, 1994, 1997, 1998) and is the most common class of medications used to treat PE currently. Dosing of the various SSRIs for the treatment of PE include fluoxetine (20-40 mg/day), sertraline (50-100 mg/day), paroxetine (20-40 mg/day), and fluvoxamine (100 mg/day). Common reported side effects of SSRIs are usually tolerable and include gastrointestinal complaints and anxiety. One study comparing all four SSRIs with placebo reported paroxetine to exert the strongest delay in ejaculation (Waldinger et al. 1998).

A double-blind, placebo controlled study compared fluoxetine (40 mg QD), sertraline (100 mg QD), and clomipramine (50 mg QD) for the treatment of PE (Kim SC, et al. 1998). Although both patient and partner sexual satisfaction were statistically significantly higher with clomipramine when compared to the SSRIs and placebo, the reported side effects of the medication was also significantly higher. Of the remaining medications, sertraline was found to be more effective than fluoxetine and placebo with fewer side effects than clomipramine.

Addition studies have evaluated if clomipramine (Haensel, Rowland & & Kallan, 1996), sertraline (Kim &, Paick, 1999), or paroxetine (McMahon & Touma, 1999) taken as needed rather than continuously could be effective to increase ejaculatory latency. All of the studies suggested effectiveness in treatment using this regimen when the medication is administered 12-24 hours (clomipramine); 4-8 hours (sertraline); or 3-4 hours (paroxetine) prior to intercourse.

More recently, the use of sildenafil citrate as an adjuvant therapy to paroxetine to treat PE was evaluated (Salonia et al., 2002). It was demonstrated that combination therapy with sildenafil and paroxetine improved time to ejaculation and sexual satisfaction compared to paroxetine alone; however, a slight increase was noted in drug related side effects. This was not a placebo controlled trial however and it is unclear if phosphodiesterase inhibitors have a significant pharmacological role in the treatment of men with PE.

Dapoxetine is a new fast-acting selective serotonin reuptake inhibitor specifically for PE. Pryor ,Althof, Steidle, Miloslavsky and Kell. (2005) recently reported on two multicenter, randomized, double-blind, placebo controlled trials . A total of 2,614 men with PE were enrolled in the trials which consisted of a 2 week baseline period followed by a 12 week treatment period. Intravaginal latency time (IELT) was measured by a stopwatch held by the sexual partner. After the 2 week baseline period, men with IELT of less than two minutes were randomized into three groups: placebo or dapoxetine at either 30 or 60 mg used on an as needed basis over the next 12 weeks. In addition to IELT, feelings of having control over ejaculation and overall sexual intercourse satisfaction were measured. A significant difference was found between the placebo and each treatment group in all three outcomes measured. The IELT improved from 0.9 to 1.75 minutes in the placebo group; 0.92 to 2.78 minutes in the 30 mg dapoxetine group, and 0.91 to 3.32 minutes in the 60 mg dapoxetine group. Additionally, both 30 mg and 60 mg of dapoxetine were significantly better than placebo in increasing IELT at first dose. Although the study medication appeared to be well tolerated, common side effects included reports of nausea in 8.7% of men taking the 30 mg dose and 20.1% of men taking the 60 mg dose. Headache was also reported in 5.9% and 6.8% respectively. Additionally, 6.8% of men reported diarrhea and 6.2% reported dizziness with the 60 mg dose. The medication is under FDA review.

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