PDE5 inhibitors are recommended as the first line of treatment for patients with ED (and no correctable cause) [35, 55]. Moreover, a few studies have suggested that these agents might prolong IELT even in patients with lifelong PE and normal erectile function [10]. The speculative rationale for their use includes: (i) possible reduction of performance anxiety due to more rigid and more sustainable erections, (ii) re-setting of the erectile threshold to a lower level of arousal, requiring less penile stimulation to cause rigidity and thus decreasing the postejaculatory latency time, (iii) peripheral modulation of smooth muscle activity of vas deferens, seminal vesicles, prostate and urethra, (iv) induction of peripheral analgesia, and (v) a central effect involving increased nitric oxide and reduced sympathetic tone [1]. It is likely that their effect is most likely related to factors (i) and (ii) above.

In a cohort of 459 men with ED, 399 responded to treatment with a PDE5 inhibitor [19]. Of the responders, 28 % (112 patients) developed PE, defined as IELT <2min. Treatment of these men with on-demand sertraline 50mg improved mean IELT from 34.6 to 111.6 s, however, the improvement was much less pronounced than in a contemporary group of men with primary PE without ED, in whom the mean IELT increased from 46.0 to 247.2 s. Another study of 45 men with ED and PE investigated the effects of sildenafil treatment on both conditions [48]. Improvement of erectile function and IELT was achieved in 27 patients (60 %), and a further 13 individuals had improved erections but unchanged IELT. Satisfaction rate was 81 % among the patients who showed improvement in both conditions, vs. 7 % (one patient) among the ones that were still experiencing PE.

Combined data from two phase 3 dapoxetine trials have been recently reported [63]. These studies included 753 men with acquired PE who had mild or no ED as per the erectile function domain of the IIEF (patients with a score of <22 were excluded). Subjects were randomized to receive dapoxetine 30, 60 mg, or placebo on an as needed basis. The 60 mg resulted in statistically significant improvement in IELT versus placebo in patients with no ED as well as dose with mild ED, whereas the 30 mg dose was superior to placebo only in patients with no ED. Of note, treatment with dapoxetine did not result in consistent improvement in patient-reported outcomes in patients with mild ED. Among these, rates of satisfaction with sexual intercourse were 17.5, 32.6 and 36.1 % in the placebo, dapoxetine 30 and 60 mg groups, respectively. These results support the recommendations from the current guidelines, which state that ED should be addressed first when both conditions are present.

Cognitive behavioral therapy when combined with pharmacotherapy has been found to be an effective intervention for acquired PE related to sexual performance anxiety, allowing a substantial proportion of men to maintain improvements on ejaculatory latency and control following cessation of pharmacotherapy [34, 60]. Different studies have found that the combination of behavioral therapy with an SSRI or PDE5 inhibitor achieves better results than pharmacotherapy alone [47, 74]. Psychological therapy aims at indirectly increasing IELT by increasing confidence (in sexual performance) and decreasing (performance) anxiety. For patients in stable relationships psychotherapy can also assist in increasing communication with the partner and resolving interpersonal problems.

Similarly, in patients with ED the combination of psychotherapy and a PDE5 inhibitor has been found to afford better results than either treatment alone [2, 9, 53].

Treatment results are summarized in Table 22.2
.

Evaluation involves a comprehensive sexual history and physical exam focusing on identifying factors that may contribute to its occurrence and persistence. IELT alone is not sufficient to define PE. Important aspects to be explored in history are summarized in Table 22.3. The use of stopwatch to measure IELT is probably only required for research purposes. Validated questionnaires include the Premature Ejaculation Diagnostic Tool (PEDT) [73], the Premature Ejaculation Profile (PEP) [59], the Index of Premature Ejaculation (IPE) [7], and the Male Sexual Health Questionnaire Ejaculatory Dysfunction (MSHQ-EjD) [68]. The ISSM suggests the preferential use of the PEP or IPE for the monitoring of treatment response.

To address erectile function, the erectile function domain of the IIEF can be used.

Physical exam and adjunctive testing are directed toward identifying and/or better characterizing factors contributing to occurrence of PE. Thereby one should look for features of erectile dysfunction and its correlates, prostatitis/chronic pelvic pain syndrome, and hyperthyroidism.

The first step in the treatment is to correct potential causes. Any degree of erectile impairment should be treated promptly. Addressing psychological issues is advisable, if these are not thought to be the culprit. In an individualized fashion the practitioner can decide to concurrently start therapies directed towards the PE per se, or leave those for the cases that do not respond to initial treatment. Patients should be reassessed for treatment response, which should include a validated questionnaire such as the PEP or IPE.

If the response to treatment is deemed suboptimal, specific treatments for PE, which include SSRI and/or topical anesthetics, should be employed. No studies have compared the efficacy of different treatments specifically in patients with acquired PE. Treatment options should be attempted according to patient preference.

When patients are started on PE-specific therapy, it is sensible to make an attempt at withdrawing treatment once the factor initially thought to be contributing to the PE has been corrected. Because there is no data in the literature to suggest an optimal timing, this should be an informed decision made by patients.