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Premature Ejaculation

Premature ejaculation (PME) has been a difficult entity to define. WHO definition as it appears in the 10th International classification of diseases is as follows:
“An inability to delay ejaculation sufficiently to enjoy lovemaking, manifest as Either of the following : occurrence of ejaculation before or very soon after the beginning of intercourse,(if a time limit is required, before or within 15 seconds of the beginning of intercourse);occurrence of ejaculation in the absence of sufficient erection to make intercourse possible. The problem is not the result of prolonged absence from sexual activity.” In other words, it is a condition leading to sexual dissatisfaction due to short duration of intercourse.
There are three main components of this condition

1) Short ejaculatory latency period:

This is technically termed as Intra Vaginal Ejaculatory Latency Time (IVELT). This is defined as the time between vaginal intromission and ejaculation, averaged over a number of sexual encounters. The crucial thing to define in this is the lower limit of IVELT.As per the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental diseases, latencies of 15 seconds or less are consistent with the diagnosis of PME. However many others, like Waldinger et al suggest that this lower limit of IVELT should be less than 2 minutes. There is also another suggestion to define early ejaculation in terms of number of thrusts during intercourse. It must be borne in mind at this stage that defining the IVELT may require use of a stopwatch or a thrust counter, which may in itself, be detrimental to the pleasure of sexual activity. 

2) The patient’s ability to control / delay ejaculation

is crucial to his satisfaction in enjoying the sexual activity. Men with PME rate their ejaculatory control between 2 and 4 on a scale of 1to 7(1= no control and 7= complete control).

3) Concern or distress due to the condition

is apparent because perhaps this is the genesis of all the exercise outlined above. 
It is important to keep in mind that there are certain factors which must be excluded at the time of diagnosis. These are:

  1. Temporary nature of the condition. Occasional inability to enjoy intercourse due to insufficient control is just a variation and must not be confused with the pathological PME
  2. Early ejaculation under the influence of substance abuse/ alcohol
  3. Situations leading to high arousal states e.g. new partner.
  4. Prolonged stimulation without ejaculation and infrequent ejaculations can temporarily reduce the ability to delay IVELT. Etiology of PME is multi factorial. The difficulty and controversies in definition and quantification of this entity is the reason behind establishing a causal relationship of various proposed etiologic factors.

The two broad categories of proposed etiological factors are as follows

  1. Psychogenic:
    1) Anxiety
    2) Early sexual experience
    3) Infrequent sexual intercourse
    4) Evolutional
  2. Organic:
    1) Penile hypersensitivity
    2) Hyperexcitable ejaculatory reflex
    3) Hyperarousability
    4) Endocrinopathy 
    5) Genetic predisposition
    6) 5- HT receptor dysfunction 
    7) Prostatitis

It may be evident that there is no single factor responsible for this condition and most of above factors need to be established as etiological agents by well designed clinical studies. Diagnosis of PME is primarily on history and no diagnostic investigation may be required. However associated medical/psychiatric co morbidities and erectile dysfunction may be excluded by suitable means. Management of these patients involves patient listening of history followed by reassurance. The specific management modalities include psychological and pharmacological interventions.

  1. Psychological/behavioral interventions. Even though more and more pharmacological modalities are being used to treat this condition, psychological intervention encourage open communication, without adverse effects and more satisfying and acceptable to the couple. However it has the disadvantages of being time consuming, requires partner’s cooperation, and yields results which are difficult to document and assess. One such method is the well documented stop- squeeze technique described by Seman (1956) and adopted by Masters and Johnson(1970).The other slightly different technique was described by Kaplan in 1984,and involved a stop- pause method. Both of these techniques bank upon reducing the hyper excitability of ejaculatory reflex. However the results documented by the original workers (97-98% by Masters and Johnson) have not been reproduced by others in subsequent studies (50-60% by Grenier and Byers, 1995).
  2. Pharmacotherapy. There are two categories of pharmacotherapy, oral medication and topical agents. The oral medications are antidepressants of SSRI category. Individually various agents in this category have differences in potency efficacy, onset and duration of action besides adverse events profile. Some of these agents include paroxetine(20-40mg), Clomipramine(10-50mg), sertaline(50-100mg) and fluoxetine(20-40mg).However, Dupoxetine has been recently shown to be effective from the first dose and minimal side effects. The various adverse events include fatigue, yawing, nausea, loose stools, perspiration and loss of appetite. The topical agents act by reducing the sensation from glans and include local anesthetic agents like lignocaine and prilocaine. These agents have the disadvantages of anejaculation and causing numbness in vagina .This latter effect may be prevented by use of condom. A herbal combination cream of Chinese origin by the name of ‘SS Cream’ has been shown to be effective in delaying ejaculation in almost 90% of men ( Xin et al,1997) . PDE5 inhibitors have been used alone and in combination with SSRIs to delay the IVELT. It is an entity in evolution as we look at its diagnosis and management. It is difficult to characterize and quantify and therefore difficult to study. However it seems important to include the psychological and behavioral tools in addition to pharmaco therapy for optimal treatment of PME.
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