premature ejaculation

Question 1

Diagnosis

Answer 1

The diagnosis of PE is based on sexual history alone.

Obtain a detailed sexual history from all patients with ejaculatory complaints.

• Components of the historical evaluation:
• frequency and duration of PE
• relationship to specific partners
• occurrence with all or some attempts
• degree of stimulus resulting in PE
• nature and frequency of sexual activity
• impact of PE on sexual activity
• types and quality of personal relationships and quality of life
• aggravating or alleviating factors
• relationship to drug use or abuse
• Determine whether erectile dysfunction (ED) is a concurrent problem. In patients with concomitant PE and ED, treat ED first.
• Laboratory or physiological testing is not required unless the history and physical examination reveal indications beyond uncomplicated PE

Question 2

Treatment

Answer 2

Patient and partner satisfaction is the primary target outcome for treatment.

• Reassure the patient and, if possible, his partner that PE is common and treatable.
• Inform the patient of the treatment options and their risk and benefits prior to any intervention: The selective serotonin reuptake inhibitors (fluoxetine, paroxetine, and sertraline), a tricyclic antidepressant (clomipramine) and topical anesthetic agents (lidocaine/prilocaine cream) (Table 1) can be used to effectively treat PE.
• Base treatment choice on both physician judgment and patient preference.

Question 3

SSRI

Answer 3

• Whether continuous or situational dosing is more effective is unclear. Choice of regimen is based on frequency of sexual activity. The optimal interval for situational dosing before intercourse has not been established.
• Therapy most likely will be needed on a continuing basis. PE usually returns upon discontinuing therapy.
• Although the adverse effects of the SRIs have been well-described in the management of clinical depression, consider the following facts when prescribing these agents for PE:
• Evidence to date suggests that adverse event profiles for SRIs in the treatment of PE are similar to those reported in patients with depression (nausea, dry mouth, drowsiness and reduced libido).
• Doses effective in the treatment of PE are usually lower than those recommended in the treatment of depression.
• Adverse event profiles may differ among patients depending on the dosing regimen prescribed (continuous daily dosing or situational dosing).
• Pharmacodynamic drug interactions resulting in a “serotonergic syndrome” have been reported rarely with the concomitant use of monoamine oxidase inhibitors, lithium, sumatriptan and tryptophan. Pharmacokinetic interactions resulting in alterations of drug blood levels may occur with the anticonvulsants, benzodiazepines, cimetidine, tricyclic antidepressants, antipsychotic agents, tolbutamide, antiarrhythmics and warfarin, especially in elderly patients.
• None of the SRIs have been approved by the U.S. Food and Drug Administration for the treatment of PE.

Question 4

Topical Anesthetic Agents

Answer 4

• Should be applied to the penis prior to intercourse and used with or without a condom. The condom may be removed and penis washed clean prior to intercourse.
• Prolonged application (30 t45 minutes) may result in loss of erection due to numbness. Diffusion of residual topical anesthetic into the vaginal wall may produce numbness of the partner.

Question 5

Medical treatment time frames

Answer 5