Premature Rapid Ejaculation

Premature ejaculation refers to the occurrence of male ejaculation, usually with orgasm, before desired by the individual, his partner, or both. Premature ejaculation is also referred to as rapid ejaculation or difficulty with ejaculatory control.

Evaluation of premature ejaculation is by history. Onset, circumstances, and meaning (personal and relationship) of the dysfunction should be explored, as well as pertinent past sexual experiences. For example, young men whose first sexual experiences were rushed may later have difficulty establishing ejaculatory control in more relaxed contexts. Men having intercourse infrequently are more likely to ejaculate rapidly. The clinician should determine whether a patient can delay his ejaculation while masturbating. In addition, information regarding the patient's level of sexual knowledge and his partner's expectations may be significant.

Behavioral techniques, such as the squeeze technique, stop and start, masturbation training, and non-intercourse-based pleasuring may be used to treat premature ejaculation. In the "squeeze technique," firm (squeezing) pressure for 3 to 5 seconds on the ventral surface of the penis at the frenulum or base, followed by quick release, will temporarily relieve the need to ejaculate. "Stop and start" refers to the man learning to stop or reduce penile stimulation when ejaculation is approaching (but not imminent) and resume when arousal has partially dissipated. Masturbation training aimed at increasing ejacu-latory control may also be useful. Changing the focus of the relationship from achieving partner orgasm with intercourse to mutual pleasuring often results in an improved sexual relationship, regardless of immediate success in delaying ejaculation.

The SSRI antidepressants can cause prolongation of the preorgasmic plateau and thus may delay ejaculation. Using SSRIs for premature ejaculation is currently an off-label use, although research is ongoing. In a single-blinded prospective study of paroxetine, fluoxetine, and escitalopram, 100% of men complaining of premature ejaculation experienced an improvement in their symptoms, with no difference detected between the three treatment groups (Arafa and Shamioul, 2007). Dapoxetine is a short-acting SSRI that can be taken as needed, instead of daily as with other SSRIs, but is not yet approved by the FDA for use in the United States. Phase III randomized, double-blind, placebo-controlled trials show dapoxetine, 30 and 60 mg as needed, achieved statistically significant improvements in perceived control over ejaculation (Hellstrom, 2009). PDE-5 inhibitors added to SSRIs may further improve premature ejaculation. Sildenafil with paroxetine or fluoxetine and tadalafil with fluoxetine have been shown to improve premature ejaculation better than the SSRI alone (Husseini and Yarmohammadi, 2007; Mattos et al., 2008; Salonia et al., 2002). Several studies show various formulations of topical treatments that reduce the sensory stimuli to the penis (e.g., topical eutectic mixture of lidocaine-prilocaine spray) appear to increase ejaculatory latency time compared to baseline or placebo (Morales et al., 2007). However, unless behavioral means of delaying ejaculation are also used, success is often not sustained following discontinuation of medication. In patients without underlying relationship difficulties, prognosis for premature ejaculation is excellent.

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