Invited lecture by Dr Sujoy Dasgupta in the Webinar on "Sexual Dysfunction" organized by the BOGS (Bengal Obstetric and Gynaecological Society) and the Sexual Medicine Committee of FOGSI (federation of Obstetric and Gynaecological Societies of India) held in September, 2021

1. Dr Sujoy Dasgupta
MBBS (Gold Medalist, Hons)
MS (OBGY- Gold Medalist)
DNB (New Delhi)
MRCOG (London)
Advanced ART Course for Clinicians (NUHS, Singapore)
Diploma, Sexual & Reproductive Medicine (South Wales, UK)
Consultant: Reproductive Medicine, Genome Fertility Centre, Kolkata
Visiting Consultant, RSV Hospital, Kolkata
Bhagirathi Neotia Women and Child Care centre
Woodlands Multispeciality Hospital, Kolkata
Managing Committee Member, Bengal Obstetric & Gynaecological Society (BOGS)
Executive Committee Member, Indian Fertility Society (IFS)- West Bengal Chapter
Executive Committee Member, Indian Society for Assisted Reproduction (ISAR)- Bengal
Winner, Prof Geoffrey Chamberlain Award, RCOG World Congress, London, 2019
Premature Ejaculation

2. Mr AC
• 30 year-old
man came
with c/o “I
cum too
early”

3. Is it Premature Ejaculation (PE)?

4. Common factors in all definitions
• Time to ejaculation
assessed by IELT
• Perceived control
• Distress
• Interpersonal difficulty
related to the
ejaculatory dysfunction

5. International Society for Sexual
Medicine (ISSM), 2010, 2015
1. Ejaculation that always or nearly always occurs prior
to or within about 1 minute of vaginal penetration
(lifelong PE) or a clinically significant and
bothersome reduction in latency time, often to about 3
minutes or less (acquired PE).
2. The inability to delay ejaculation on all or nearly all
vaginal penetrations.
3. Negative personal consequences, such as distress,
bother, frustration, and/or the avoidance of sexual
intimacy.
4. Occurs in 75%-100% of sexual encounters

6. Intravaginal ejaculatory latency time (IELT)
Time taken to ejaculate after
vaginal penetration
Waldinger et al., 2005-
• median IELT 5.4 minutes
(range 0.55–44.1 minutes)
• Distribution- positively
skewed.
• Independent of condom use
or circumcision status
Waldinger et al., 2009-
• median IELT of 6 minutes
(range 0.1–15.2)

7. IELT decreases with age
• Waldinger et al., 2005

8. IELT in clinical practice
• Significant overlap between
men with PE and without PE
• Self-estimated IELT is
sufficient in clinical practice
(EUA, ISSM, AUA)
• Self-estimated IELT- 80%
sensitive and 80% specific (cf-
stopwatch-measured IELT)
• Stopwatch-measured ILET- for
clinical trial

9. Classification of PE
• Lifelong
• Acquired
PE like syndromes
• ‘Natural Variable PE’- inconsistent and irregular early ejaculations,
representing a normal variation
• ‘Subjective PE/ Premature like Ejaculatory problem’-
1. subjective perception of consistent or inconsistent rapid ejaculation
2. Perceived inability to control ejaculation
3. preoccupation with an imagined early ejaculation or lack of control of
ejaculation
4. preoccupation not explained by another mental disorder
5. IELT is normal/ longer
• Situational (under specific situation/
particular partner)
• Consistent (in all cases)

11. Diagnostic Dilemma
• Mr ID- I cum within 5 minutes. My wife said her
friend’s partner is able to hold for 30 minutes !!!!
(overdiagnosis of PE)
• Mr BM- I find it difficult to hold my hardness.
Even when I am hard, I cum quickly (ED
misdiagnosed as PE)
• Mr JS- I lose hardness immediately after the
discharge (PE misdiagnosed as ED)

12. Prevalence of PE
The USA National Health and
Social Life Survey (NHSLS)
study, 1999-
• 31% in men 18-59 years
• 30% (18-29 years)
• 32% (30-39 years)
• 28% (40-49 years)
• 55% (50-59 years).
The Premature Ejaculation
Prevalence and Attitudes
(PEPA) survey, 2007-
• prevalence 22.7%
• Does not vary with age
The Global Study of Sexual
Attitudes and Behaviors
(GSSAB), 2005-
• prevalence 30% in all age groups
Waldinger et al., 2008-
• 2.3% (lifelong PE),
• 3.9% (acquired PE)
• 8.5% (natural variable PE)
• 5.1% (premature-like
ejaculatory dysfunction)

13. How many seek treatment
The Global Study of Sexual Attitudes and
Behaviors (GSSAB), 2005-
• 78% men with perceived PE do not seek
professional help
• More likely to seek treatment for ED
The Premature Ejaculation Prevalence and
Attitudes (PEPA) survey, 2007-
• Only 9% men with PE seeks treatment

14. If we are not confident
• Mr PB, 36 years-old came for infertility with
his partner.
• Asked to advise semen analysis
• Said he cannot ejaculate for last 2 years.
• Initially (5 yrs ago), he suffered from PE.
Taken “herbal medicines”. PE was cured
but……
• Abdel-Hamid et al., 2016- Herbal medicines
can cause delayed/ absent ejaculation

16. Pathophysiology of PE
• Ejaculation is retarded by 5HT2C
receptors
• Ejaculation is facilitated by
5HT1A receptors
PE happens if there are
1. hyposensitivity of the 5-HT2C
2. hypersensitivity of the 5-HT1A
3. low 5-HT neurotransmission
4. spinal command set at lower
threshold

17. Risk factors
• Prostate inflammation – 26-77% (Corona et al., 2010)
• Hyperthyroidism- 50% to 15% (Carani et al., 2005)
• Glans penis hypersensitivity
• Varicocele
• Detoxification from prescribed drugs (e.g., raboxetine ,citalopram) or recreational drugs
• Chronic pelvic pain syndrome
• Varicocele
• ED
• Anxiety, emotional problem, stress
• Traumatic sexual experience
• Ethnicity- common in black men, Hispanic men and men from Islamic backgrounds
• Lower education levels
• Overall health status and obesity
• Family H/O (Waldinger et al., 1998; Finish Twin study, 2007)
• Genetics- the LL genotype ejaculated in a 100% shorter time than SL and SS genotype.

18. Evaluation

19. Limitation of questionnaires
• 40% of men with PEDT-diagnosed PE and 19%
of men with probable PE self-reported the
condition

20. Examination and investigations
• Embarrassment
• Attitude of the patient
• Reassuring for the patient
• Urethritis, Peyronie’s disease, phimosis
• Testicular examination in ED
• Prostatitis- routine screening?
• Endocrinopathy- Thyroid
• Neurological examination
• More important in acquired PE than lifelong PE (ISSM)
• Targeted investigations- dictated by H/O and examination
• No role of routine TSH screening

21. LOFTI approach (Cowan and
Frodsham, 2015)
• Listening
• Observing
• Feeling
• Thinking
• Interpreting

22. EUA Recommendation

23. Effect of PE in QoL
• Low satisfaction with
their sexual relationship
• Low satisfaction with
sexual intercourse
• Difficulty relaxing during
intercourse
• Less frequent intercourse
• Detrimental effect on self-
confidence
• Relationship-conflict
• Mental distress, anxiety,
depression

24. Can it affect fertility?
• Ho et al., 2019- overt PE 4.7%, probable PE 7.1%
• Lotti and Maggi, 2018- 16.67%
• Our study- 32%, more with timed intercourse

25. Anteportal Ejaculation
• Ejaculation prior to vaginal penetration
• Considered the most severe form of PE
• Typically present when they are having
difficulty conceiving children.
• 5% of lifelong PE men suffer from anteprotal
PE (De Carufel et al., 2006; Waldinger et al.,
1998; Pagani et al., 1996)

26. Mr SP
• 36 yr, businessman
• Apparently “unexplained infertility”
• Multiple cycles of OI
• C/O inability to deposit sperms in the vagina
• Multiple operations for hypospadias
• Conceived after 1st cycle of IUI (H), delivered

27. Principles of treatment
• Discuss the patient’s expectations thoroughly.
• Treat them first, if present
1. ED
2. Chronic prostatitis
3. Hyperthyroidism
Lifelong PE
1. Pharnacotherapy is the basis
• Dapoxetine on demand is the ONLY
approved treatment for PE
2. Behavioural therapy- adjuct-
• time-intensive
• require the support of a partner
• difficult to perform
• long-term outcomes ?
Acquired PE
• Behavioural treatment first
• Add pharmacotherapy

28. Physical/ Behavioural Therapy
• Hypothesis- PE occurs
because the man fails to
appreciate the sensations
before feelings of
ejaculatory inevitability.
• Re-training- attenuates
stimulus-response
connections by
progressively more intense
and more prolonged
stimulation, just below the
threshold for triggering the
response.

30. Stop Start Technique
• Semans, 1956
• The partner stimulates the
penis until the patient feels the
urge to ejaculate.
• At this point, he instructs his
partner to stop, waits for the
sensation to pass
• Then stimulation is resumed
• 3 pauses before orgasm
Squeezing technique
• Masters and Johnson, 1970
• The partner applies manual
pressure to the glans just
before ejaculation until the
patient loses his urge.
• Squeeze for 15-20 sec
• 3 pauses before orgasm

31. Masturbation before coitus
• For younger men
• The penis is desensitised
resulting in greater
ejaculatory delay after the
refractory period is over.
Pelvic floor exercise
• Stop the flow of urine
(several times) while you
are peeing intentionally

32. Outcome of behavioural therapy
• Short-term success rates of 50-60% (Grenier et
al., 1995; Metz et al., 1997)
• 8 fold increase in IELT than doing nothing (De
Carufel and Trudel, 2006)
• A double-blind, randomised, crossover study-
pharmacotherapy better IELT prolongation than
physical therapy (Abdel-Hamid et al., 2001)
• Combination with dapoxetine is better than
dapoxetrine alone in lifelong PE (Cormio et al.,
2015)
• Level 2b evidence (ISSM)

33. Dapoxetine hydrochloride
• Short-acting SSRI
• Rapid Tmax (1.3 hours) and a short half-life (95% clearance after 24
hours)
• On demand (1-2 hr before coitus)
• Dose 30 mg and 60 mg increases IELT by 2.5- and 3.0-fold
respectively (Macmahon et al., 2011; Porst et al., 2010).
• Effective from the first dose (Porst et al., 2010)
• Side-effects- dose-dependent - nausea, diarrhoea, headache, dizziness.
• No increased risk of suicidal ideation or suicide attempts
• No withdrawal symptoms with abrupt cessation
• No drug interaction
• Level 1a evidence (ISSM)

34. How does Dapoxetine act?
• An abrupt increase in
extracellular 5-HT
following
administration that
might be sufficient to
overwhelm the
compensating
autoregulation
processes.
• Acts on 5HT2C
receptors

35. Long acting antidepressants
• To be given for 1-2 weeks before any benefit is seen
• TCA- Clomipramine 12.5-50 mg
• SSRIs- Paroxetine (8.8 fold delay in IELT) > Sertraline.>
fluoxetine > Citalopram
• Tachyphylaxis (decreasing response to a drug following chronic
administration)
• Side effects- fatigue, drowsiness, yawning, nausea, vomiting, dry
mouth, diarrhoea and perspiration- gradually improve after two to
three weeks
• Decreased libido, anorgasmia, anejaculation and ED
• Should not be stopped abruptly
• Avoided in men with depressive disorders and <18 yr age
(suicidal ideation)
• Level 1a evidence (ISSM)

36. Desensitising agents
• Local anaesthetic gel- oldest pharmacological
treatment of PE
• Lidocaine-prilocaine cream- 20-30 min before
intercourse
• Prolonged application (30-45 minutes) → loss of
erection due to numbness of the penis
• A condom will prevent diffusion of the topical
anaesthetic agent into the vaginal wall
• Contra-indicated in patients or partners with an
allergy to any ingredient in the product.
• Level of evidence 1b (ISSM)

37. Condom only

38. Tramadol
• Atypical opioid
• Activates opioid (µ) receptors centrally, inhibits
serotonin and noradrenaline uptake
• Readily absorbed after oral administration
• On demand, like dapoxetine
• 62 and 89 mg increases IELT by 2.4 and 2.5 fold
respectively
• US-FDA, 2009- addiction, dyspnoea
• Level of evidence 2d (ISSM)
• Not recommended for PE

39. Phosphodiesterase-5 inhibitors
• Sildenafil vs placebo- does not improve IELT, improves
satisfaction and confidence, reduces the refractory time to
achieve a second erection after ejaculation.
• Sildenafil + physical therapy- better than physical therapy
alone
• SSRI+sildenafil- better than monotherapy with SSRI
(paroxetine, sertraline)
• Sildenafil with chronic SSRI- prodromal symptoms,
vasovagal reaction
• Sildenafil + Dapoxetine- well tolerated
• Limited data on other drugs (Vardenafil, Tadalafil)
• Level 4d evidence
• Should NOT be used in PE without any evidence of ED

40. Role of surgery
• In refractory lifelong PE,
• Surgically induced penile hypo-anesthesia
1. Selective dorsal nerve neurotomy
2. Hyaluronic acid gel glans penis augmentation
• May be associated with permanent loss of
sexual function
• Needs further evidence
• Level 4 evidence (ISSM)
• NOT recommended

41. Combination of therapies
• Physical and Pharmaco-therapy
• Pharmacotherapy- quicker
results
• Physical therapy-
patient factors (performance anxiety,
self-confidence)
partner factors (partner sexual
dysfunction)
relationship factors (conflict, lack of
communication)
sexual factors in the relationship
(sexual scripts, sexual
satisfaction);
contextual factors (life stressors)
• Acquired PE-clear psychosocial
components
• Lifelong PE- patient and partner
factors
• Coexistent ED- with
psychosexual factors

43. Take Home Messages
• PE is common sexual dysfunction
• PE is poorly understood
• Thorough evaluation is needed
• Treatment of the primary cause, if any should
be the priority
• Physical and pharmacotherapy are effective in
combination