Fig. 25.1
Algorithm of PE diagnosis and management (adapted from Jannini et al. 2010 [79]). Note that the possibility of another comorbid sexual dysfunction should be ruled out first. When risk factors are present, they should be addressed before any symptomatic treatment is considered. However, some patients may require symptomatic treatment in addition to etiologic therapy. Both sexual therapy (e.g., behavioral and cognitive) and pharmacotherapy [selective serotonin reuptake inhibitors (SSRI), dapoxetine] should be considered symptomatic in nature
25.2.1 Obtain the Patient’s History
A primitive and fallacious concept in diagnosing PE is to consider affected patients as a homogenous group (Table 25.1), [16–18]. On the contrary, clinical practice demonstrates that several different subsets of patients can be classified as having PE (Fig. 25.1, step 1).
Table 25.1
The different Ejaculation Latency Times to be evaluated during the in-office management of premature ejaculation
IELT | During vaginal penetration, as measured by stopwatch |
PIELT | Perceived IELT (not measured by stopwatch) |
PPIELT | Partner Perceived IELT |
OELT | Timing of ejaculation during oral stimulation |
AELT | Timing of ejaculation during anal penetration |
MELT | Timing of ejaculation during masturbation |
ELT = 0 | Ejaculation before any kind of penetration or stimulation |
To start the in office diagnosis of PE, the evaluation of men presenting with self-reported PE should include a full general medical and sexual history to construct a profile of the patient [19]. The profile should be based on demographic factors (e.g., age and education); psychological factors (e.g., level of sexual experience, conditioning, and guilt); relationship factors (e.g., emotional closeness, satisfaction, and amount of sexual activity); and attitudes towards sexuality (e.g., personality, sexual performance anxiety, techniques, and early experiences). Sexual performance anxiety (and other psychosocial factors) can be identified using psychometric tools [20] (see Chap. 16).
Inventories for male and female sexual dysfunctions provide the physician with relevant questions to ask patients and help with interpreting answers [19]. Several tools are available to help assess the patient’s history, including the Arabic Index of Premature Ejaculation (AIPE) [21], Premature Ejaculation Profile (PEP) [22], and the Premature Ejaculation Diagnostic Tool (PEDT) [23]. The PEDT is a particularly useful and validated questionnaire to identify men who may have suspected PE. Please note that the PEDT provides a cutoff where the score <9 suggests no PE, the score 9–11 admits the possibility of real PE, while the score >11 is strongly in favor of the presence of a true PE.
At this step it is important to draw the identikit of our patients considering demography (age, culture, education), religion, sexual conditioning (sexual guilt, masturbation rate, sexual experience), the actual and previous relationship(s) (satisfaction, emotional closeness, amount of sexual activity), personal attitudes towards sexuality (performance anxiety, personality, sexual techniques, early sexual experiences).
It is very important to have, when possible, both the partner’s point of view and description on the PE, as well the partner’s sexual history and attitudes. Premature ejaculation, in fact, not only affects the man, but also has a negative impact on his partner, which can lead to feelings of distress [24], frustration [25], and a breakdown of intimacy [26]. Therefore, it is worthwhile interviewing the partner to determine their view of the situation and how PE is impacting on them and the couple as a whole [24]. This also provides an opportunity to assess the couple’s overall relationship and to evaluate whether or not the partner suffers from female sexual dysfunction [27, 28]. It is to be noted, in fact, that female sexual dysfunction (FSD) may be involved in the pathogenesis of PE [e.g., vaginism or hypoactive sexual desire disorder (HSDD)], due to PE (e.g., anorgasmia and HSDD), or casually comorbid. A simple and short screening tool, such as the abridged female sexual function index (FSFI-6), would be clinically useful for this purpose [29].
Even in absence of FSDs, PE can induce distress for the partner, mistrust, frustration, and anger. Typically, and differently to the partner of the patient with ED (where several women believe to be guilty because of the symptom), several partners of PE patients perceive PE as the results of selfishness of the male partner. However, at the best, in the western societies, PE due to selfishness or machismo seems now more rare. Hence, this point should be carefully taken into account when a couple’s therapy is prescribed.
In any case, the breakdown of intimacy between partners is a common feature in PE, which should be considered, assessed, and treated.
25.2.2 Classify the Symptom
The second step is about the classification of PE. Here the aim is to evaluate the severity of the symptom as measured by the Intravaginal Ejaculation Latency Time (IELT) and clinical characteristics (Fig. 25.1, step 2).
The IELT is an objective measure of time to ejaculation and is commonly used in clinical trials [30]. It is defined as the time from the start of vaginal intromission to the start of intravaginal ejaculation as measured by stopwatch [31]. Each ejaculation after vaginal intromission is measured in seconds or minutes. An ejaculation before intromission (ante portas, see later) has an IELT of zero. According to Waldinger’s suggestion, the patient’s own perception of ejaculatory latency in four different outlets (vaginal, or IELT, oral, or OALT, anal penetration, or AELT, and masturbation, or MELT) should be obtained and compared [32].
The European Association of Urology (EAU) guidelines state that stopwatch-measured IELT is necessary in clinical trials, but the use of self-estimated IELT (perceived IELT, PIELT) is adequate in the practice setting [33]. The presence of the stopwatch, even for short diagnostic purposes, is not frequently accepted. Furthermore, the patent presence (usually the partner is the holder of the stopwatch) of a time-measuring instrument could worsen performance anxiety and, thus, the IELT.
We suggest to ask for the Partner-Perceived IELT (PPIELT), possibly in a separate room, and to compare it with the PIELT. This comparison, both when identical or discordant IELTs are recorded, will provide clinical insights into the couple’s architecture. Furthermore, it is very important to have measurable and initially measured parameters for when, during the follow up, the treatment efficacy is evaluated (Table 25.1).
After assessing the severity, PE should be classified on the basis of onset (e.g., lifelong/primary or acquired/secondary) (Table 25.2), [17]. Lifelong PE is characterized by an onset from the first sexual experience and persists throughout life [34]. Acquired PE is characterized by having a gradual or sudden onset, following a period of normal ejaculation [34]. PE can also be classified on the basis of timing (e.g., ante portas—literally ‘before the gates’, i.e., prior to vaginal intercourse—or intra moenia—literally ‘within the walls of the city’, i.e., during vaginal intercourse) and type (e.g., absolute/generalized or relative/situational) (Table 25.1) [34].
Categories | Symptom | Occurs… |
|---|---|---|
Onset | lifelong (primary) acquired (secondary) | …from the first sexual experience and persists throughout life …following a period of normal ejaculation experiences |
Time | ante–portas intra–moenia | …literally ‘before the gates’, i.e., before vaginal penetration …literally ‘within the walls of the city’, i.e., during vaginal penetration |
Type | absolute (generalized) relative (situational) | …irrespective of partners or context …in the presence of a particular partner or context |
Comorbidities | simple complicated | …in the absence of other sexual symptoms …in the presence of other sexual symptoms (e.g., erectile dysfunction) |
Note that the classification of PE does not necessarily imply an etiological diagnosis: a situational PE is not necessarily psychogenic in origin; a lifelong PE is not necessarily organic in nature [4]. Current literature has been, unfortunately, quite misleading with this respect, carrying the idea that the simple finding of a symptom present from the first sexual act has always an organic etiology (congenital, genetic). This is nonsense. An intrapsychic risk factor (see Chap. 18) could dramatically modify the ability to control ejaculation from the beginning of the sexual life.
Premature ejaculation can be considered a tridimensional condition that is defined by a set of constructs (Fig. 25.2), [16, 35]. These include rapidity of ejaculation, lack of perceived control and self-efficacy over ejaculation; and negative personal consequences (e.g., decreased satisfaction, and increased distress and interpersonal difficulty) related to ejaculation. Thus, the three dimensions of PE are: time, control, and distress. Several definitions of PE exist that incorporate all or most of these constructs [36–38]. Most of these, however, are expert opinion-led, rather than evidence-based. In 2007, the International Society for Sexual Medicine (ISSM) proposed an evidence-based consensus definition of lifelong PE [16]: A male sexual dysfunction characterized by ejaculation which always or nearly always occurs prior to or within about one minute of vaginal penetration, and the inability to delay ejaculation on all or nearly all vaginal penetrations, and negative personal consequences, such as distress, bother, frustration and/or the avoidance of sexual intimacy. Note that all three dimensions (time, control, and stress) are embedded in the ISSM definition (in bold text).
Fig. 25.2
Premature ejaculation can be considered a tridimensional condition (adapted from Jannini et al., 2011 [3]). The three main elements are shortened intravaginal ejaculatory latency time (TIME), lack of perceived control (CONTROL), and negative personal consequences related to ejaculation (STRESS)
Current published definitions of PE do not specify a precise ‘time to ejaculation’ [35]. However, by incorporating the phrase ‘within about one minute’, the ISSM definition provides the physician with flexibility to diagnose PE in treatment-seeking men who ejaculate within 1–2 min of penetration without unnecessarily stigmatizing men who also ejaculate within this time frame, but have no complaints of PE. It also minimizes the potential for inclusion and exclusion errors because more restrictive criteria would increase the likelihood of exclusion errors, whereas more lenient criteria would increase the likelihood of inclusion errors [13]. In addition, it allows a multivariate approach to diagnosing PE that considers objective time to ejaculation as well as subjective components associated with this condition [16]. Because PE comprises a defined and measurable set of symptoms, there is an emerging role for using evidence-based multidimensional definitions in the diagnosis and management of lifelong PE in the office-based practice setting.
At present, there is no ISSM evidence-based definition of acquired PE due to insufficient objective data from well-designed and controlled trials [16] (see Chap. 7). Nevertheless, similar Intravaginal Ejaculatory Latency Time (IELT) and levels of control over ejaculation and distress between men with lifelong or acquired PE, indicate the possibility of a single unifying definition of PE [39].
The unit of measurement of the first PE dimension (time) is a shortened IELT (see above).
The second and third dimensions can be measured using psychometric tools such as the PEP [22] and PEDT [23]. Patient-reported outcomes (PROs) assess important subjective components of PE, including control over ejaculation and satisfaction with intercourse, as well as personal distress and interpersonal difficulty related to ejaculation. In clinical trials, PROs are typically evaluated using questionnaires, such as the Index of Premature Ejaculation [40, 41], PEP [22, 42], and tools based on the Diagnostic and Statistical Manual of Mental Disorders (4th edn., Revised text; DSM-IV-TR) criteria, such as the PEDT [23, 43, 44]. The use of questionnaires, such as the PEP [22], to evaluate PROs is important in the diagnosis of PE in clinical practice. Moreover, assessing PROs when the patient initially visits the physician enables treatment outcomes to be monitored at subsequent followup visits [see Appendix].
25.2.3 Perform Physical Examination
Recently published EAU guidelines recommend that a simple but complete andrological assessment should be performed at the initial visit on the man presenting with self-reported PE [33]. This includes an examination of the penis, testes and epididymis, prostate and the man’s level of virilization, as well as a check of his reflexes (Fig. 25.1, step 3). The aim is to identify underlying medical conditions associated with PE or other sexual dysfunctions, such as chronic illness, endocrinopathy, autonomic neuropathy, Peyronie’s disease, urethritis, vesciculitis, or prostatitis. Laboratory or physiological testing should be directed by specific findings from history or physical examination and is not routinely recommended.
The importance of physical examination in PE should be stressed as well in all sexual dysfunctions. In particular, in the patient with PE, although LUTS and prostatic diseases are not very frequent in the clinical practice with PE patients (see Chaps. 7 and 13), the symptom of inadequate control over ejaculation must be considered by the physician as a great occasion for urological prevention and to evaluate prostatic health.
25.2.4 Identify Underlying Risk Factors
Together with the previous step 3, it is now time to identify the possible risk factors that can cause, contribute to, or be comorbid with PE (Fig. 25.1, step 4).
We stress here again that the suggestion to look exclusively for etiologies other than genetic in patients with acquired PE is not evidence- nor logic-based. All chronic etiologies or risk factors present in a patient with acquired PE could be present also in a patient with lifelong PE. The unique exception is a severe disease, such as hyperthyroidism, which is in fact present only in acquired PE [45] and, obviously, not in lifelong PE [46]. It is also potentially possible that a genetic predisposition to PE could be symptomatic only later in life, when relational or other epigenetic factors may become effective, and not from the beginning of sexual life.
There are a number of potential causative factors of PE, including those that are organic (e.g., genetic, neurobiological, urological, hormonal, or pharmacological) and those that are non-organic or idiopathic [e.g., functional (experience and education), constitutive (intra-psychological), stress-induced, relational, or psychosexual] [4, 20]. Several etiologies and risk factors of PE are discussed in detail in Chap. 7 and followings.
As a first fundamental message, it is important to diagnose the underlying primary cause of PE and any associated comorbidities, because these should be treated first [34]. Examination should be extended to assess endocrine, urological, and psychorelational/psychosocial risk factors, in order to identify possible underlying medical conditions associated with PE.
25.2.4.1 Endocrine Risk Factors
Symptomatic hyperthyroidism can be simply diagnosed at the clinical visit, by evaluating heart frequency, and signs of hyperreflexia and psychic hyperactivity (e.g., agitation, irritability, mood disturbances and anxiousness) [47], and other factors, such as fatigue, tremors, sweating and muscle aches. Thyroid dysfunction (i.e., hyperthyroidism) can be detected by a test that analyzes levels of thyroid stimulating hormone (TSH) and/or thyroxine (T4) in the blood (see Chap. 12). However, because the clinical picture of hyperthyroidism is often self-evident and in agreement with the ISSM guidelines on diagnosis of PE [48], we do not suggest TSH screening in all PE patients. A patient with thyroid dysfunction should be referred to an endocrinologist for thyrostatic pharmacology, radioiodine or thyroidectomy (see Chap. 23).
25.2.4.2 Urological Risk Factors
Evaluation of prostatic health should be considered mandatory during the andrological visit, and not only in cases of PE (see Chap. 13). When a prostatitis is suspected, the diagnostic workup should include prostate evaluation by transrectal ultrasonography and standardized Meares and Stamey protocol [53]. Urethral and midstream bladder urine, expressed prostate secretions by prostate massage, and postmassage urine samples are collected, examined microscopically, and cultured bacteriologically. Prostate inflammation is diagnosed if 10 or more white blood cells per high power field are present in the expressed prostate secretions. Nonbacterial prostatitis is defined by evidence of prostate inflammation together with negative urine and prostate fluid cultures. Prostate infection is defined by a colony count 10 times greater in the expressed prostate secretion or post-massage urine sample than in the urethral urine sample. The presence of Chlamydia trachomatis, Trichomonas vaginalis, Mycoplasma hominis, Candida species, and Ureaplasma urealyticum should be carefully checked for. Hence, it is critical to have a competent microbiology laboratory: the large majority of negative findings in the Meares and Stamey test is due to an inadequate expertise of the according operator, to errors in storing samples or, perhaps more frequently, to an inadequate laboratory.
25.2.4.3 Psychorelational/Psychosocial Risk Factors
Premature ejaculation has long been viewed as a psychological condition [54], associated with a number of psychorelational comorbidities [8], such as emotional distress [26], anxiety [8, 26], depression [8, 14], and social phobia [55, 56]. All these psychological symptoms may be cause, rather than caused, by PE [25]. Several Chapters (Chaps. 8, 11, 15, 16) highlight the role of psychological and relational derangements involved in PE. However, as a matter of evidence, we cannot recommend a specific psychometric tool for the assessment of a possible psychological derangement comorbid with PE.
25.2.5 Is the Patient Really Affected by PE?
At the end of this part of the in-office management of PE, the physician should be able to define if the patient is really affected by PE (Fig. 25.1, step 5). Premature ejaculation is, in fact, a self-diagnosis, carrying the risks of inadequate and incorrect ideas about what is pathological and what is to be considered normal. In some subjects of both sexes, an IELT equal to 10 min could be considered pathological. However, although potentially affecting the sexual health of a given couple, this timing could be hardly considered pathological.
As assessed in Chap. 4, cases other than lifelong and acquired PE have been described. Natural variable PE [57] is a symptom occurring sometimes and not characterizing the sexual life of the patient. It could be better considered a ‘situational PE’. (i.e., the psychological factors that result in PE with the wife and not with the mistress are significantly affecting the control over ejaculation and likely to reflect considerable psychological distress). It is probably a frequent condition, which could be different from chronic PE.
Premature-like ejaculatory dysfunction [57] is a PE complaint grounding on essentially unrealistic expectations, ignorance and sexual myth. The patient fulfilling the latter definition cannot be considered to be affected by PE. Like in other sexual myths, this subject should be treated with counselling [58] and possibly with cognitive reconstruction, and not necessarily going through the following steps.
25.2.6 Identify Sexual Comorbidities
In presence of a real PE at this step, it is clinically mandatory to define whether PE is simple (occurring in the absence of other sexual dysfunctions) or complicated (occurring in the presence of other sexual symptoms, such as erectile dysfunction) (Fig. 25.1, step 6), [59]. Evidence indicates a high prevalence of comorbid PE and erectile dysfunction [60]. Results from the Premature Ejaculation Prevalence and Attitudes (PEPA) survey showed that approx. a third (32 %) of men with PE also reported erectile dysfunction [8]. The possible correlation between these two sexual dysfunctions may be due, at least in part, to a shared vicious cycle. For example, in trying to control his ejaculation, the man instinctively reduces his level of excitation, which results in erectile dysfunction. Conversely, in trying to achieve an erection, the man instinctively increases his level of excitation, which results in PE (Fig. 25.3) [60].
Fig. 25.3
The possible correlation between premature ejaculation and erectile dysfunction (from Jannini et al., 2005 [60], mod.)
Even the self-diagnosis can be misleading. In fact, in some patients PE can be a conscious or unconscious ‘bed trick’. These patients may consider it easier and less humiliating to admit to PE caused by “enthusiasm” than to other sexual dysfunctions, such as the socially worst, the ED. For this reason, the possibility that other sexual problems coexist with PE should always be investigated.
Erectile dysfunction can be assessed using the International Index of Erectile Dysfunction (IIEF) and/or Sexual Health Inventory for Men (SHIM) [8, 61, 62]. However, evidence suggests that some men with PE, but normal erectile function, record contradictory responses to the SHIM, and may be incorrectly categorized as having erectile dysfunction [63]. Findings from a study demonstrated that the SHIM generated false-positive results in approx. a third of cases [63]; therefore, the SHIM has limited reliability when used to discriminate ED from PE. Erectile dysfunction is typically treated with phosphodiesterase type 5 (PDE5) inhibitors, such as sildenafil, tadalafil, or vardenafil [33]. Finally, it has been recommended that men with ED be screened for PE [64].
Related posts:
Endocrine Control of Ejaculation
Patient Reported Outcomes Used in the Assessment of Premature Ejaculation
Complementary, Surgical, and Experimental Modalities for Management of Premature Ejaculation
Risks Factors in Premature Ejaculation: The Neurological Risk Factor and the Local Hypersensitivity
Treatment of Premature Ejaculation with Dapoxetine
Treatment of Premature Ejaculation with Selective Serotonin Re-Uptake Inhibitors
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