Premature (early) ejaculation is the most common sexual disorder in men younger than 40 years, with 30-70% of males in the United States affected to some degree at one time or another. It has historically been considered a psychological disease with no identified organic cause.

Signs and symptoms

Premature ejaculation can be lifelong or acquired. With lifelong premature ejaculation, the patient has experienced premature ejaculation since first beginning coitus. With acquired premature ejaculation, the patient previously had successful coital relationships and only now has developed premature ejaculation.

Patient characteristics in lifelong premature ejaculation can include the following:

• Psychological difficulties
• Deep anxiety about sex that relates to 1 or more traumatic experiences encountered during development

In patients with lifelong premature ejaculation, inquire about the following:

• Previous psychological difficulties
• Early sexual experiences
• Family relationships during childhood and adolescence
• Peer relationships
• Work or school
• General attitude toward sex
• Context of the event (eg, marital versus nonmarital)
• Sexual attitude and response of the female partner
• Nonsexual aspects of the current relationship
• level of involvement of the sexual partner in treatment

Clues from these and similar questions usually point toward causative factors that may be addressed specifically with therapy.

Patient characteristics in cases of acquired premature ejaculation can include the following:

• Erectile dysfunction
• Performance anxiety
• Psychotropic drug use

In patients with acquired premature ejaculation, inquire about the following:

• Previous relationships
• Current relationship
• Nonsexual aspects of the current relationship
• level of involvement of the sexual partner in treatment
• Impotence problems
• Capacity for coitus
• Sexual context
• Sexual response of partner

Diagnosis

In males with premature (early) ejaculation and no other medical problems, no specific conventional laboratory tests aid or affect treatment. Checking the patient’s levels of serum testosterone (free and total) and prolactin may be appropriate if premature ejaculation is observed in conjunction with an impotence problem. If depression or other conditions coexist, laboratory studies specific to depression or to another medical or psychological problem are appropriate.

Other conditions that should be considered in making the diagnosis of premature ejaculation include the following:

• Severely delayed orgasm in the female partner
• Adverse effect from a psychotropic drug
• Presence of preejaculate
• Erectile dysfunction

Management

Medical treatment for premature (early) ejaculation includes several options. Any serious primary medical condition (eg, angina) should be treated, as should any accompanying erection problem (eg, erectile dysfunction). To achieve the best outcome, the female partner should be included as fully as possible in the treatment and counseling sessions. Outpatient care can be scheduled as appropriate for the clinical circumstances.

Nonpharmacologic therapy may include the following:

• Efforts to relief of underlying performance pressure on the male
• Sex therapy (eg, instruction in the stop-start or squeeze-pause technique popularized by Masters and Johnson)
• Second attempt at coitus – If another erection can be achieved shortly after an episode of premature ejaculation, ejaculatory control may be much better the second time

• Topical desensitizing agents (eg, lidocaine and prilocaine) for the male
• Selective serotonin reuptake inhibitor (SSRI) therapy (eg, sertraline, paroxetine, fluoxetine, citalopram, or dapoxetine); alternatively, use of an agent with SSRI-like effect
• Phosphodiesterase type 5 (PDE5) inhibitor therapy (eg, sildenafil, tadalafil, or possibly vardenafil)
• Other agents (eg, pindolol or tramadol)