What should I do if I have premature ejaculation?

If your ejaculation is earlier than desired (before or soon after penetration) with minimal stimulation and you have little control over it, you should consider seeking further advice from your GP.

What are the facts about premature ejaculation?

• Premature ejaculation is usually lifelong (i.e. it usually dates back to the first sexual experience)
• Rarely, premature ejaculation may develop in later life when it is often progressive
• We do not know accurately how common it is but between 1 in 3 & 1 in 5 men (20-30%) are thought to have premature ejaculation
• Less than a quarter of men with premature ejaculation actually seek medical advice for their condition
• Premature ejaculation is often associated with erectile dysfunction (impotence) and with rapid loss of erection after ejaculation

What should I expect when I visit my GP?

Your GP should work through a recommended scheme of assessment for men with troublesome premature ejaculation. This will normally include one or all of the following:

1. A full history

Your GP will enquire about lifestyle factors (e.g. your job, work pressures, smoking habits, alcohol intake and drug consumption and will take a detailed sexual history.

Your GP may also ask you to complete a premature ejaculation symptom questionnaire as an aid to further assessment and discussion of treatment options. This will allow your GP to:

• identify your needs & expectations
• help you & your partner share in decision-making
• decide whether psychosexual counselling might be helpful

2. A physical examination

A general physical examination will be performed to assess the development of your male sexual characteristics and to detect any abnormality of your penis or genitals. Your blood pressure will normally be measured as part of this examination. The pulses in your legs will normally be assessed. The nerve reflexes involving your legs, penis and anus (back passage) are also tested. Rectal examination (pictured) is normally performed to assess the tone of your anal muscles and to feel your prostate gland.

3. Additional tests

Specific tests are not usually needed but the following may be performed:

a. General blood tests

The actual tests performed will be left to your GP’s discretion. It is common to measure kidney function, liver function and cholesterol as well as checking your blood cells for anaemia or other problems. A blood sugar measurement may be performed to exclude diabetes

b. Routine urine tests

Your urine will normally be assessed by stick-testing to see whether it contains sugar which might indicate diabetes

c. Hormone measurements

Blood levels of testosterone, prolactin, FSH (follicle-stimulating hormone), LH (luteinising hormone) and thyroid hormones may be measured if you also have erectile dysfunction (impotence).

d. Other specific tests

Your GP may ask you to time the interval between penetration and ejaculation (the intravaginal ejaculation latency time, IELT) using a stopwatch. A latency time of less than 1 minute is regarded as abnormal.

What could have caused by premature ejaculation?

The cause of premature ejaculation is unknown; it appears unrelated to performance anxiety, hypersensitivity of the penis or nerve receptor sensitivity.

Premature ejaculation may, however, have a genetic tendency and is also associated with prostate inflammation (prostatitis), thyroid disorders, emotional disorders and previous traumatic sexual experiences.

What treatments are available?

Psychosexual counselling may help men with less troublesome premature ejaculation but, in most men, the mainstay of long-term treatment is with drugs.

Most patients can be managed in general practice without the need for urological referral. If you have troublesome erectile dysfuncton (impotence) as well, your GP may ask you to consult a urologist.

Drugs

Selective serotonin uptake inhibitors (SSRIs) are powerful antidepressants but they also have a beneficial effect on premature ejaculation. They are used as first-line treatment for this condition and their effectiveness is often maintained for several years. Dapoxetine (Priligy®, pictured) is the only SSRI licensed for use in premature ejaculation. It is not available on the NHS and requires a private prescription, allowing purchase of the drug at cost price. This can prove expensive, so your GP may recommend another SSRI (e.g. paroxetine, fluoxetine, fluvoxamine, sertraline, clomipramine). Dapoxetine is, however, the only drug which can be taken “on demand” (i.e. when needed) Common side-effects of SSRIs include fatigue, drowsiness, nausea, dry mouth, diarrhoea & excessive perspiration. These are often mild and usually settle after 2-3 weeks.

SSRIs are powerful drugs. You should only take them by getting a prescription from your GP & you should have a detailed discussion about the risks & benefits before starting treatment.

Other drugs which delay ejaculation (e.g. tramodol, terazosin, alfuzosin) have been used but their role is unclear and, at the moment, they are not recommended for clinical use in premature ejaculation.

Viagra®, Cialis® or Levitra® and self-administered penile injections have also been used to help premature ejaculation but their exact role is uncertain. They do, however, improve sexual confidence and reduce performance anxiety by producing better erections (if this is a problem).

Topical treatment

Local anaesthetic cream (lignocaine + prilocaine or SS-cream), applied 20 – 60 minutes before intercourse, can be useful but may numb the vagina unless used with a condom. It can occasionally cause irritation of the penile skin.

“Long love” condoms, containing the local anaesthetic benzocaine, are also available commercially and have proved useful in some patients.

Psychosexual counselling

Behavioural strategies, listed below, are all effective.

• the “stop-start” technique (developed by Semans)
• the “squeeze” technique (developed by Masters & Johnson)
• the Kegel technique (learning to control the ejaculatory muscles)

Improvements are seen in 50-60% of patients but may not be maintained in the long term. These techniques are best learnt under the supervision of a psychosexual counsellor. They can be used alone in acquired premature ejaculation and when symptoms are mild. When problems are severe or lifelong, they are best used in conjunction with drugs.