Premature Ejaculation is one of the most common male sexual complaints. Ejaculatory control is culturally acquired and combining drug treatment and psychological therapy is best to tackle PE

Premature ejaculation (PE) is a common male sexual dysfunction that can have a dramatic impact on the sexual and relational health of a couple. Animals ejaculate in the fastest and safest possible way to be always ready to flee in case of attack. Unlike animal sexuality which is aimed just at reproduction and survival of the species, human sexuality pursues pleasure as well, and this is one of the reasons why men have learned to control their ejaculation. In other words, ejaculation control doesn’t come naturally but is culturally acquired, and the ability to control the timing of ejaculation is pivotal for the couple’s sexual health. In a published paper based on a review of scientific literature, Emmanuele Jannini and colleagues from the Universities of L’Aquila and Rome examined the physiology of ejaculatory control, the pathogenesis of PE and available treatments. Their conclusion is that PE is a condition still far from being completely understood. In their review they found a number of interesting and intriguing hypotheses on the causes of this condition and solid data supporting the efficacy of the only pharmacological treatment licensed for PE, in 48 countries.

In assessing the best approach to and the best treatment for PE, the first step is asking whether it is a medical condition or the symptom of a medical condition. The answer of the authors is that, as with all sexual disorders, PE is a symptom rather than a disease. From a clinical point of view, this suggests that in all PE cases the disease behind the symptom must be adequately sought, addressed and, whenever possible, cured. Psychological disorders are often present, either as the primary causes of the condition or in the form of a stressful response to it. The authors believe, however, that the old distinction between psychological and neurobiological (physiological) causes needs to be overcome and PE should be tackled under a modern holistic approach as ‘a psycho-neuro-endocrine and urologic disorder affecting the couple’.

Several psychometric tools (questionnaires) are used for the diagnosis of PE; these can be of help in assessing the perception of and satisfaction with ejaculatory control and sexual intercourse. It is important, however, that the symptoms be assessed within the context of the couple, e.g. comparing the man’s description of the symptoms with that of his partner, because, for example, perception of penetration time is very subjective. A physical examination is always mandatory. As noted earlier, PE is a symptom, so doctors should always check for any underlying condition, e.g. prostatitis. Recently, there have been several studies investigating the correlation between premature ejaculation (in particular acquired PE) and prostatitis, a correlation which was found to exist. For this reason, the authors advise to always include a prostate examination for patients with acquired PE.

As pointed out by the authors, the scientific community is increasingly embracing the view that a holistic approach to PE is the best to ensure the sexual and relational health of the couple. This means combining pharmacological treatment and psychological therapy (e.g. sex therapy) under a multidisciplinary holistic approach which is fundamental to ensure the best management of PE.

In the past topical anaesthetics and drugs that increase serotonin levels (i.e. antidepressants like SSRIs) have been prescribed for PE. Drugs that increase serotonin levels can be quite effective in PE, but they have a number of adverse effects (anxiety, insomnia, weight gain, hypoactive sexual desire disorder, erectile dysfunction, anejaculation); in addition, their use in PE is ‘off label’, which means that patients must sign an informed consent form to use these drugs for this indication. At present, there is only one drug treatment licensed for PE; this drug shares a common origin with SSRIs (selective serotonin reuptake inhibitors) but it doesn’t have any effect on mood and has an excellent safety profile.

Reference: Jannini EA et al., Fertility and Sterility 2015.