Premature Ejaculation Guidelines: A Toolbox for Clinicians

Veronica Hackethal, MD

May 23, 2014

The medical community has long recognized premature ejaculation as a disorder, but lack of a standardized, evidence-based definition has hampered clinical practice and research. Now, two articles provide a unified definition of premature ejaculation and treatment guidelines that could greatly improve patient outcomes.

One article, written by the International Society for Sexual Medicine (ISSM) Premature Ejaculation Guidelines Committee, a multidisciplinary group of international experts in the field of sexual medicine, updates and reevaluates ISSM guidelines published in 2010. The second article provides a unified definition of premature ejaculation that encompasses the lifelong and acquired forms and was developed by the Ad Hoc Committee for the Definition of Premature Ejaculation. Both articles were published online May 22 simultaneously in Sexual Medicine and the Journal of Sexual Medicine.

The articles provide 2 main take-home points for primary care practitioners, urologists, and other providers involved in the care of patients with premature ejaculation, according to Stanley Althof, PhD, first author of the updated guidelines article, executive director of the Center for Marital and Sexual Health of South Florida in West Palm Beach, and emeritus professor at Case Western Reserve University School of Medicine, Cleveland, Ohio.

"The first point is the definition of premature ejaculation," he told Medscape Medical News. "The second point is the recommendations for treatment."

A Clear Definition

"We proposed a unified definition that clinicians can use in diagnosing both the lifelong and acquired forms of premature ejaculation. The newer part is the acquired piece. There was never a good definition for the acquired form of premature ejaculation," explained Dr. Althof. "Acquired means that the man had previously been ejaculating within normal times, which might be around 8 minutes, and then suddenly for unclear reasons began ejaculating very quickly. This could either be due to medical conditions like prostatis or hyperthyroidism, or it could be due to psychological reasons, such as the nature of the relationship."

The guidelines also address 2 other forms of the disorder: subjective premature ejaculation, which is when a man ejaculates within a normal amount of time yet experiences distress about it, and variable, in which the duration of ejaculation varies unpredictably from very short to normal. The treatment for these distinct forms would be different, according to Dr. Althof.

The unified definition of premature ejaculation has 3 main components:

  • The man experiences either recurrent and persistent ejaculation within approximately 1 minute of vaginal containment since the first sexual experience (for lifelong premature ejaculation) or a reduction in ejaculatory latency to about 3 minutes or less (for acquired premature ejaculation).

  • The man experiences negative personal consequences such as distress.

  • The man experiences an inability to delay ejaculation on all or nearly all vaginal penetrations.

Evidence-Based Treatments Available

"We were very thorough in investigating the literature on newer research on treatments and grading the treatments by the Oxford Centres level of evidence," Dr. Althof stated. "The article provides a review of the different forms of treatment, which include pharmacological, psychological, and combined pharmacological and psychological treatment. We hope this review will serve as a guide for providers to make informed choices."

In a sense, the updated guidelines offer a toolbox from which providers can draw. The article includes recommendations about questions to ask and questionnaires to use. It also provides a flowchart providers can use as a treatment algorithm for the 4 types of premature ejaculation. In addition, it reviews the efficacy and safety issues for selective serotonin reuptake inhibitors approved outside the United States for premature ejaculation (such as dapoxetine), off-label selective serotonin reuptake inhibitors, anesthetic sprays used to decrease penile sensation, opiate drugs such as tramadol, and other drugs currently in clinical development.

"I think the updated definition and guidelines for the management of premature ejaculation will be both clinically helpful and helpful in terms of advancing our understanding, diagnosis, and management of premature ejaculation," Peter Stahl, MD, told Medscape Medical News when asked for an independent opinion. Dr. Stahl is the director of male reproductive and sexual medicine and assistant professor of urology at Columbia University Medical Center in New York City.

"Premature ejaculation that meets the new ISSM definition can significantly impair quality of life. It's critical to identify affected patients and to offer them the therapies that we have, which are very effective and evidence-based," Dr. Stahl emphasized. He noted that men affected by premature ejaculation sometimes experience feelings of depression, relationship issues, loss of confidence, and quality-of-life problems that extend beyond their sexual quality of life.

Dr. Stahl also explained that standardization of the definition of premature ejaculation was necessary because it will allow clinicians and researchers to get a better grasp of the true extent of the problem. Past estimates have suggested that between 20% and 30% of men suffer to some degree from premature ejaculation. The newer, more standardized ISSM definition may more appropriately capture the true prevalence of men whose quality of life is affected by premature ejaculation, suggesting that around 4% of men suffer from premature ejaculation that has a negative clinical effect.

"Having the standardized, clinically appropriate definition is the essential first step in understanding the prevalence, severity, and clinical impact of premature ejaculation. It is also critical to monitoring response to therapy," Dr. Stahl stated, "Our hope, as experts in this field, is that more specifically and precisely defining premature ejaculation will pave the way for the development and regulatory approval of new therapies for premature ejaculation."

"The majority of men with premature ejaculation are treated by primary care physicians, as well as nonspecialized urologists, psychiatrists, psychologists, and family practitioners. These updated guidelines provide really clear, up-to-date, evidence-based recommendations for how to diagnose and manage premature ejaculation," Dr. Stahl commented. "Specifically, the recommended diagnostic questions in this article provide a framework that enables improved communication between physicians who are not used to discussing sexual dysfunction and their patients. Once that door is open, they're able to identify and treat the problem."

Both the ISSM Premature Ejaculation Guidelines Committee and the ISSM Ad hoc committee for the Definition of Premature Ejaculation were supported by a grant from Johnson & Johnson, but the authors report that the committees had complete independence during the development of the guidelines and definition of premature ejaculation. Multiple authors report consulting agreements, advisory board memberships, and receiving grants from or being investigators for 1 or more of the following companies: Allergan, Abvie, Eli Lilly, Ixchelsis, Menarini, Palitan, Sprout, Trimel, Johnson & Johnson, Bayer Schering, Plethora Solutions, Emotional Brain BV, Pound International Ltd, Elsevier, GSK, Pfizer, The Urology Company, Shianogi Pharmaceuticals, Repros Pharmaceuticals, Spimaco (Saudi Arabia), Sanofi, American Medical Systems, Andromedical, Auxilium, Coloplast, Cook, Endo, Slat Pharmaceuticals, Theralogix, VIVUS, Astra Zeneca, Besins, Isba, Shinogi, Apricus, Strategic Science and Technology, S1 Biopharm, Aboprtion Pharmaceuticals, Janssen, ISSM, Sexual Medicine Society of North America, International Society for the Study of Women's Sexual Health, and Asia-Pacific Men's Health Counsel. Dr. Stahl has disclosed no relevant financial relationships.

Sex Med. Published online May 22, 2014. Guidelines full text, Definition full text

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