It’s usually towards the end of a consultation that it comes up. After the benign sore throat or the ingrowing toenail. And it can sometimes take a few seconds to work out what’s being asked. Once you have, though. Once you’ve established that the man in front of you has plucked up enough courage to tell you that he’s having problems with premature ejaculation. What do you do next?
Well, a recent paper in the International Journal of Urology helpfully summarises the current evidence on premature ejaculation (PE) from across the world. The authors acknowledge that prevalence is difficult to estimate due to embarrassment from both patients and doctors, but it is undoubtedly the most common sexual dysfunction in men and could affect up to 30% of the male population. Needless to say, we see only a small fraction presenting to us in practice.
Although there have been suggestions that the diagnosis should be made exclusively on subjective feelings, there seems to be consensus that PE should be considered only when ejaculation is within one minute of vaginal penetration and where there is significant distress. With this definition in mind, the authors of this review considered the treatment goal to be extending the time between penetration and ejaculation rather than subjective sexual satisfaction scores.
The first step when assessing patients is to complete a full urological history and examination. Perhaps not feasible when the issue is raised in the last minute of a consultation, so a follow-up appointment might be needed to get through this. The authors suggest that if there are associated erectile dysfunction issues, PDE-5 inhibitors should be used first line and if there is either hypertension or prostatic enlargement, alpha blockers should be the initial drug of choice. If neither of these are present, though, the first line drug should be an SSRI or SNRI. Local anaesthetic preparations can be considered if there are no initial improvements, as can sexual counselling and yoga for patients thought to have a psychosocial component.
The paper also discusses common behavioural therapies used in the treatment of PE, including the “start–stop” technique and the “squeeze” technique, which are exactly what they sound like they might be. Although early evaluations of these approaches many decades ago reported suspiciously promising results, these have not been replicated in follow up studies. There are, though, a number of experimental treatments on the horizon, including medical and surgical devices, botox injections, and dorsal nerve stimulation.
As ever, the best approach is to take time to explore each presentation and tailor the treatment according to individual circumstances. Although there is no ‘solution’ to PE, by exploring possible anatomical and psychological causes, we can work with patients to try and do our best to make things better for them.
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