Premature ejaculation is probably the most common sexual problem that afflicts men, affecting approximately 20% of the adult male population. If it is true that in daily clinical practice, requests for andrology consultation for erectile dysfunction or fertility problems predominate, an accurate examination by the andrologist of the case history on ejaculatory problems can identify problems which the patient often does not explain, because of cultural factors or embarrassment.
The definition of premature ejaculation is not simple and unambiguous, in the sense that a temporal basis can be used (eg. immediately before – the so-called ejaculation ante portas – or immediately after introduction of the penis into the vagina or after 30-60 seconds from penetration), or a criterion based on the number of pelvic thrusts (eg. ejaculation within the first 10-15 thrusts). Alternatively, ejaculation can be considered as premature if it occurs before the male wants it to (regardless of time or the number of pelvic thrusts) or if it occurs before the partner is satisfied. The problem is very complex and therefore can exclude couple interaction, at least regarding the decision to undergo diagnostic therapeutic procedures. Apart from the obviously vexatious situations (ejaculation ante portas or immediately following vaginal penetration), it is important to assess if and how the ejaculation situation affects the couple’s sexuality. Finally, it must be remembered that the ejaculatory reflex tends to be naturally fast; just think of how it is organized in animals, where copulatory activity is finalized for procreative reasons; sexual pleasure and involvement of the partner is an almost exclusive prerogative of the human species.
As for other sexuality disorders, premature ejaculation can have organic and non-organic causes. Although the latter is generally more frequent, all potential organic causes must be excluded. A proper andrological diagnostic procedure should therefore primarily aim at excluding inflammation and/or infection of the urogenital tract, including any subacute or chronic prostate diseases. Appropriate clinical and instrumental examinations (from rectal exploration to culture tests, and possible diagnostic imaging) may be useful in defining the problem. Though rare, possible neurological causes are worth being considered, such as multiple sclerosis or spinal cord injury, whose evaluation and possible further diagnosis should be decided on by a specialized urologist who evaluates the patient. Equally rare are metabolic causes such as diabetes and endocrine disorders such as hyperthyroidism. It must be repeated that any decision for further diagnosis in these directions has to be made by a specialized urologist, in order to prevent the patient from undergoing examinations, including relatively invasive ones (eg. sacral evoked potential), which may not be appropriate on the basis of patient’s medical history.
Treatment of premature ejaculation
“Sexual Counselling” is the main therapeutic tool, regardless of the cause. Correct, neutral sexual information is always a great help, both because it provides the patient with clear, scientifically proven information about how the ejaculatory system works, and also because it redefines the experience of the problem (almost always in less dramatic terms than those considered by the patient).
The so-called ” Sex Therapy ” is based on a series of practical exercises deriving from cognitive-behavioral techniques, such as Kegel exercises (pubococcygeas muscle recognition-training, a kind of pelvic exercise) or the “squeeze” or “stop and start” technique, the latter in particular is aimed at focusing on the sensory perception of the ejaculatory reflex and, therefore, learning to control it.
The pharmacological approach is based mainly on so-called selective serotonin reuptake inhibitors (SSRIs). Specifically this is a category of drugs that have, among others, an inhibitory effect on the ejaculatory reflex. Their use is currently the responsibility of the clinical sexologist. Drugs of this type, with short duration activity, are currently available and can be used as a symptomatic treatment.
Identification of organic causes (infection of the urogenital tract or other) will be subject to appropriate treatment.
The use of anaesthetic cream applied on the glans before sexual intercourse, the suggestion of uncovering the glans for desensitizing purposes or even practicing circumcision for the same reason have not, in our experience, produced any decisive effects.
In conclusion, premature ejaculation is a complex problem, only properly addressed using a multifactorial approach, which includes medical and psychological strategies, provided by specialists who are specifically trained in the field of sexology.