Premature Ejaculation

1. PREMATURE
EJACULATION
Kharisma Prasetya Adhyatma

2. Definition
• Premature ejaculation is male sexual dysfunction characterized by :
• perceived inability to control ejaculation that occurs sooner than desired,
or expected,
• either before or shortly after vaginal penetration, and
• causes emotional distress for patient and/or sexual partner
1. Althof SE, McMahon CG, Waldinger MD, et al. An update of the International Society of Sexual Medicine's guidelines for the diagnosis and treatment of premature ejaculation (PE). J Sex Med. 2014
Jun;11(6):1392-422
2. Hellstrom WJ. Update on treatments for premature ejaculation. Int J Clin Pract. 2011 Jan;65(1):16-26

3. Epidemiology
• Most common sexual disorder in men younger than 40 years
• Prevalence of PE were 30% (18-29 yrs), 32% (30-39 yrs), 28% (40-49 yrs)
and 55% (50-59 yrs).
• Prevalence rates were 2.3% (lifelong PE), 3.9% (acquired PE), 8.5% (natural
variable PE) and 5.1% (premature-like ejaculatory dysfunction).
• 3%-33% prevalence of PEDT-diagnosed premature ejaculation reported
among men in Asia-Pacific region
1. Hatzimouratidis K, Giuliano F, Moncada I, Muneer A, Salonia A, Verze P. EAU Guideline on Erectile Dysfunction, Premature Ejaculation, Penile Curvature and Priapism. European Association of Urology. 2019;26-7
2. McMahon CG, Lee G, Park JK, Adaikan PG. Premature ejaculation and erectile dysfunction prevalence and attitudes in the Asia-Pacific region. J Sex Med. 2012 Feb;9(2):454-65

4. Etiology and Pathophysiology
• The etiology of PE is unknown, but little data suggested several underlying cause
• Anxiety
• penile hypersensitivity
• 5-HT receptor dysfunction
• The pathophysiology of PE is largely unknown, but including multifactorial:
• Biological, organ systems directly affected by premature ejaculation
• Male reproductive tract (penis, prostat, seminal vesicles, testicles, and their appendages)
• Portion of central and peripheral nervous system controlling male reproductive tract
• Reproductive organ systems of sexual partner that may not be stimulated sufficiently
• hyposensitivity of 5-HT2C receptor, hypersensitivity of 5-HT1A/5-HT1B receptor,
hypersensitivity of the glans, psychosocial and relational factors, etc
1. Wyllie MG, Hellstorm WJ. The link between penile hypersensitivity and premature ejaculation. BJU Int. 2011 Feb;107(3):452-7
2. Buvat J. Pathophysiology of premature ejaculation. J Sex Med. 2011 Oct;8(4):316-27

5. Lifelong PE
• PE at all or nearly all intercourse
• With all or nearly all women
• In Majority case within 1 minute
• Consistent during life
• Inability to control ejaculation
Waldinger. Premature ejaculation; state of the art. UrolClin NorthAm 2007; 34:591-9, vii-viii

6. Acquired PE
• Rapid ejaculation occurring at some point in life
• Normal onset before
• Often source of problem identifiable
• Inability to control ejaculation
Waldinger. Premature ejaculation; state of the art. UrolClin NorthAm 2007; 34:591-9, vii-viii

7. Diagnostic Criteria
Based onThe International Society for Sexual Medicine (ISSM):
• Ejaculation from the time he began or within about 1 minute of vaginal
penetration (Lifelong Premature Ejaculation) OR clinically significant and
bothersome reduction in latency time, about 3 minutes or less (Acquired
Premature Ejaculation)
• Inability to delay ejaculation on all or nearly all vaginal penetrations
• Negative personal consequences (distress, bother, frustration, avoidance of sexual
intimacy)
Serefoglu, E.C., et al. An evidence-based unified definition of lifelong and acquired premature ejaculation: report of the second International Society for Sexual Medicine Ad Hoc
Committee for the Definition of Premature Ejaculation. J Sex Med, 2014. 11: 1423.

8. DSM-5 Criteria
• Sexual dysfunction disorders characterized by a significant inability to respond
sexually or to experience sexual pleasure
• The specific DSM-5 criteria for premature (early) ejaculation are as follows :
• In almost all or all (75-100%) sexual activity, the experience of a pattern of ejaculation
occurring during partnered sexual activity within 1 minute after vaginal penetration and
before the individual wishes it
• The symptoms above have persisted for at least 6 months
• The symptoms above cause significant distress to the individual
• The dysfunction cannot be better explained by nonsexual mental disorder, a medical
condition, the effects of a drug or medication, or severe relationship distress or other
significant stressors

9. Proposed PE Syndrome
• Variable PE is characterised by inconsistent and irregular early ejaculations,
representing a normal variation in sexual performance.
• Subjective PE is characterised by subjective perception of consistent or
inconsistent rapid ejaculation during intercourse, while ejaculation latency time is
in the normal range or can even last longer. It should not be regarded as a
symptom or manifestation of true medical pathology
Serefoglu, E.C., et al. An evidence-based unified definition of lifelong and acquired premature ejaculation: report of the second International Society for Sexual Medicine Ad Hoc
Committee for the Definition of Premature Ejaculation. J Sex Med, 2014. 11: 1423.

11. Differential Diagnostic
• Important to distinguish Premature Ejaculation from Erectile Dysfunction
• Many patients with ED secondary PE
• chronic bacterial prostatitis
• Hyperthyroidism
• alcohol and/or other substance use
Althof SE, McMahon CG,Waldinger MD, et al. An update of the International Society of Sexual Medicine's guidelines for the diagnosis and treatment of
premature ejaculation (PE). J Sex Med. 2014 Jun;11(6):1392-422, commentary can be found in Nat Rev Urol 2014 Sep;11(9):496

12. Diagnostic Evaluation
• History should classify PE (lifelong or acquired) & determine (situasional or consistent)
• Several overlapping definitions of PE
Intravaginal Ejaculatory LatencyTime (IELT)
IELT alone is not sufficient to define PE
PE assessment quistionnaires : Premature Ejaculation DiagnosticTool
Physical examination and investigation
Recommendation for the diagnostic evaluation of PE
EAU 2019. Althof, S.E., et al. Patient reported outcomes used in the assessment of premature ejaculation. UrolClin NorthAm, 2007. 34: 581.

13. Recommendation for the diagnostic
evaluation of PE
(EAU Guidelines 2019)

15. MANAGEMENT
TREAT OTHER
CONDITION IF
PRESENT
PSYCHOLOGICAL /
BEHAVIOR
STRATEGIES
PHARMACOTHERAPY

16. EAU Guideline

17. LueTF, Basson R, Rosen RC, et
al. Sexual medicine-sexual
dysfunctions in men and
women. Health Publications: Paris;
2004.
Algorithm for
the office
management of
premature
ejaculation

18. BehaviouralTherapy
• Start-stop technique
• Squeeze technique
• Masturbation

19. Pharmacotherapy
• SSRi
• Paroxetine 20-40 mg (Paxil)
• Sertraline 25 – 200 mg (Zolov)
• Clomipramine 25 – 50 mg
• Short acting SSRi
• Dapoxetin (on demand) 30 mg  1– 2 h prior (Poxet, tdk ada di Indonesia)
• Topical Cream
• Lidocaine – prilocaine cream 5%  20 – 30 min prior

21. Prognosis
• Great majority of men (>85%) can be treated successfully with the squeeze-pause
technique between 3 month of therapy
• Squeeze-pause technique combined with SSRI can improve or cure most cases of
PE if both the couple committed to work on the problem
• Reported relapse rate ranges from 20-50%
• Several males may need to make long-term periodic repetition of behavioral
therapy
• Some men who achieve success with SSRI might need to use life-long medication
• No known direct morbidity or mortality form PE but self-esteem maybe affected
and may resulted to depression
Masters WH, Johnson VE. Premature ejaculation. Human Sexual Inadequacy. Boston, Mass: Little Brown & Company; 1970. 92-115.

22. ThankYou