Premature Ejaculation Disorder
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May 13, 2020
Abstract
Premature ejaculation (PD) is a sexual dysfunction present at any age, but is currently underdiagnosed in primary care despite its incidence on sexual health and quality of life. It does not heal or disappear with age or with sexual frequency, quite the contrary. The avoidance of sexual intercourse or even erectile dysfunction complicate it. Pharmacological treatment, although fundamental, is not enough. A psychological and sexological approach, from the couple’s point of view, is essential. The woman has to become a co-therapist. This article makes a bibliographic review on the definition of the term, diagnostic methods, implications in the couple and therapeutic approach.
For this, the original articles published in Spanish and English from 2006 to 2013 have been consulted in the Pubmed and Cochrane databases. There is no single definition of PE. Current DSM definitions show low positive predictive value and high false positive diagnoses. All the definitions affect the vaginal penetration time. There are several standardized questionnaires for diagnosis. Although there are a variety of treatment offers, from local anesthetics to surgery, in Spain the only drug with a specific indication is dapoxetine and it has been shown to be effective. In conclusion, PD is the most frequent sexual dysfunction in men, above erectile dysfunction. The diagnosis and therapeutic approach is possible from the primary care consultation and requires a pharmacological and sexological approach.
KEY WORDS: Premature ejaculation, sexual dysfunction, diagnosis, primary health care
Premature Ejaculation Disorder
The social changes that have occurred in the last century have led to a proactive role for women in social relationships and, therefore, in sexual ones. The woman demands a sexual relation of quality and with the sufficient duration to reach orgasm, so that the ejaculation of the man now has to adapt and take into account the phase of sexual response of the woman, much slower. If not, the sexual health of the couple and the coexistence can be seriously affected.
The cause of premature ejaculation (PE) is not known exactly. A negative and hurried first sexual experience, a relationship with a prostitute, the habitual practice of masturbation with fear of being discovered in adolescence or sexual inexperience are described as habitual antecedents. But there are also many premature ejaculators, expert lovers without this background.
Various types of ejaculators are described, but all agree on the inability to control the moment of ejaculation that they live with anxiety and they with dissatisfaction. This dysfunction is not cured by time or age, both complicate it with sexual avoidance behaviors and even erectile dysfunction. Premature ejaculation is less consulted than erectile dysfunction. You have to ask about it in the primary care consultation, from here you can treat or refer. There are means to do it from sexological approaches and from the pharmacological essential.
PD is a sexual dysfunction in which the male ejaculates earlier than desired, sometimes just after starting the sexual act, touching the vagina or even before attempting penetration. The intravaginal latency time to ejaculation (IELT) that is considered average is between 3 and 6 minutes. Premature ejaculation is considered if it occurs before one minute and probable PE if the IELT is between 1 and 1.5 minutes. Scientific associations and organizations have proposed several definitions of premature ejaculation, all focused on control over the time before ejaculation, although they also consider the perception of the degree of control over the reflex and the negative consequences for the partner relationship. For the American Association of Urology, time is the decisive criterion and defines it as “ejaculation that occurs earlier than desired, either before or shortly after penetration, causing distress to one or both partners.”
The International Classification of Diseases-10 (ICD10), based on the capacity for sexual satisfaction, defines it as “the inability to delay ejaculation long enough to enjoy sexual intercourse, which is manifested by the appearance of ejaculation before or very soon after the start of penetration, or ejaculation occurs in the absence of sufficient erection for penetration to be possible ”2. The International Society for Sexual Medicine (ISSM) includes in the definition the negative consequences on the male . He proposes, focusing on a classic male-vaginal penetration sexual relationship, the following definition: “sexual dysfunction in which ejaculation occurs always or almost always before or approximately one minute after penetration, due to the inability to delay ejaculation in all or almost all vaginal penetrations and with negative personal consequences, such as anguish, discomfort, frustration and avoidance of intimate relationships ”
The DSM-V proposes the following classification:
Permanent Premature Ejaculation, when it occurs within one minute. It has always been and probably is of genetic or neurobiological cause; Acquired Premature Ejaculation. It can be psychological or somatic. The male reports a clear biographical moment of onset; Variable Natural Premature Ejaculation. Only on certain occasions it occurs. It can be diagnosed as a normal variant; Premature Ejaculatory Dysfunction that includes ejaculators considered normal, from 3 to 7 minutes, including those that last more than ten minutes. These are the men who subjectively complain about premature ejaculation, despite the normality of their times. The origin is clearly psychological.
Premature ejaculation is the most frequent sexual dysfunction, affecting 16-23% of men. In the NHSLS study, conducted in the USA, the prevalence increased from 30%, between 18 and 29 years old, to 55%, in men from 50 to 59 years old. The methodological bias used in this study, when proposing only the yes / no option, could explain the finding of a much higher prevalence than in other studies. 43% of Spaniards suffer from premature ejaculation at some point in their life according to the Spanish Demographic Study on Premature Ejaculation (DEEP 2009) carried out by the Spanish Association of Andrology, Sexual and Reproductive Medicine
TREATMENT
The following text shows a summary of the main therapeutic alternatives in cases of premature ejaculation. Etiological treatment: The organic symptoms that are causing premature ejaculation must be treated; Pharmacological treatment: Topical anesthetics are not in use. They can cause skin reactions and excessive hypoaesthesia on the penis and vagina. There are no reliable studies with these drugs.
Tricyclic antidepressants, such as chlorimipramine, began to be used in the early 1970s. They were effective, but today, due to their side effects, they have fallen out of use.
Phosphodiesterase type 5 (IPDE-5) inhibitors and alpha-1 adrenergic blockers have not been approved for the treatment of PD in the US (Food and Drug Administration [FDA]) or in the European Union (European Medicines Agency [EMEA]).
Selective serotonin reuptake inhibitors (SSRIs). In 1994 Waldinger was the first to demonstrate the effectiveness of SSRIs in lengthening the IELT. Dapoxetine, a short-acting SSRI, is the first drug designed specifically for the treatment of premature ejaculation on demand in men 18 to 64 years old and the only one approved for such use by international drug agencies. Its marketing is currently authorized in seven countries of the European Union (Finland, Sweden, Austria, Germany, Spain, Italy and Portugal). It is a short-acting SSRI, which has been shown to statistically significantly inhibit the ejaculatory reflex at the supraspinal level14. It does not need, unlike other SSRIs, an impregnation period, so it is not necessary to administer it daily, but on demand, in an initial dose of 30 mg 1-3 hours before intercourse15. It has been equally effective in both primary and secondary ejaculation. It is mainly eliminated by the urinary route in 24 hours, without other active substances. This pharmacokinetics makes it the ideal drug for on-demand treatment. The efficacy of dapoxetine has been proven in clinical trials, controlling the following parameters: the intravaginal latency time to ejaculation (IELT), the profile of premature ejaculation (PEP) and the perception of control over ejaculation (PE) 16. All this makes dapoxetine the drug that provides the most data on the efficacy in the treatment of premature ejaculation.
Tramadol. Without the side effects of SSRIs. Delays ejaculation by inhibiting reuptake of norepinephrine and serotonin. Administered on demand, in doses of 50 mg two hours before intercourse, it has been shown to lengthen the IELT very significantly, according to the study carried out in cases of primary ejaculation17,18. Used on demand it has shown very few adverse effects.
Many subjects prefer homemade methods to those that are scientifically proven. One of the reasons for choosing these over therapeutics is the shame that some people feel when faced with this condition. Premature ejaculators generally know that with the second sexual intercourse they achieve a longer ejaculatory time and that is why some of them masturbate before making love. Even some women who discover this fact speed up the first ejaculation in order to get their orgasm on the second try. However, this has the disadvantage that as the years pass, the absolute refractory period.
During this period, no stimulation, however intense it may be, can produce excitement – it lasts over time, and a greater degree of stimulation is necessary to achieve an erection, so the solution of the problem is only postponed. Others try to think of something or someone that generates aversion to them, which in general is not effective and, if it is, by association, it would end up producing in the long term an aversive effect on sexuality, in addition to the lack of attention to their own body and the stranger at the moment of the act, choosing fantasy over reality.
The therapy that has proven effective, should be brief, focused and can integrate other individual aspects or the couple’s relationship, always led by a trained professional dedicated to Clinical Sexology. Behavior modification techniques are used through scheduled exercises. that must be adapted to the situations of each client. These types of treatment programs have proven to be very effective. The consultant performs the indicated tasks at home, which by the way can be very fun.
In short, there are different therapeutic offers, most focused on delaying the ejaculation reflex. Many succeed. It is not clear that the couple is only and exclusively demanding that we delay the stopwatch, extend the duration. Surely your demand also includes increasing satisfaction, so the inalienable goal with any therapy used should be to get the couple to “rebuild” another type of sexual relationship more satisfying for both of them.
Currently it is considered that 90% of premature ejaculation cases are due to psychological or environmental factors, so that only 10% originate from anatomical or physiological problems. Depression, stress, insecurity, anxiety … are some of the psychological factors that predispose to premature ejaculation, it is believed that because these psychological conditions lead to a reduction in the concentration of serotonin, a neurotransmitter that plays an important role in control of emotions.
Anxiety before intercourse, very common among adolescents due to inexperience or fear of facing a sexual relationship, can circumstantially cause premature ejaculation. Also sexual repression and inhibition. But there are also diseases that can cause premature ejaculation, such as infections of the prostate or urethra. Another cause of physiological order is the hypersensitivity of the glans.
References
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