MALE SEXUAL DYSFUNCTION
Semir A. S. Al Samarrai
Premature ejaculation is a very common male sexual dysfunction, it is poorly understood. Patients are often unwilling to discuss their symptoms and many physicians do not know about effective treatment. As a result, patients may be misdiagnosed or mistreated (1).
Premature ejaculation is defined in the DSM-IV-TR as a “persistent or recurrent ejaculation with minimal sexual stimulation before, on , or shortly after penetration and before the person wishes it”.
The clinician must take into account factors that affect duration of the excitement phase, such as age, noretly of the sexual partner or situation, and recent frequency of sexual activity (3).
‘ In the (ICD-IO) premature ejaculation is defined as the inability to delay ejaculation sufficiently to enjoy love-making, which is manifested by either on occurrence of ejaculation before or very soon after the beginning of intercourse (if a time limit is required; before or within 15 seconds of beginning of intercourse) or ejaculation occurs in the absence of sufficient erection to make intercourse possible. The problem is not the result of prolonged absence from sexual activity '(4).
The International Society of Sexual Medicine (ISSM) have adopted a completely new definition of premature ejaculation which is the first evidence-based definition.
“ Premature ejaculation is a male sexual dysfunction characterized by ejaculation which always or nearly always occurs prior to or within about one minute of vaginal penetration, and 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”.
It must be noted that this definition is limited to men with lifelong premature ejaculation who engage in vaginal intercourse since there are sufficient objective data to propose an evidence-based definition from acquired (6).
All definitions have taken into account the time to ejaculation, the inability to control or delay ejaculation, and negative consequences (bother / distress) from premature ejaculation (7,8,9,10,11)
Premature ejaculation is classified as 'lifelong' (primary) or 'acquired' (secondary) (12).
The lifelong PE is characterized by onset from the first sexual experience, remains so during life and ejaculation or occurs too to fast before vaginal penetration <1-2minutes after.
Acquired PE is characterized by gradual or sudden onset following normal ejaculation experiences before onset, and time to ejaculation is short (usually not as short as in lifelong premature ejaculation.
4.) Epidemiology of Premature Ejaculation
Epidemiological research has consistently shown that premature ejaculation, at least according to del DSM-IV definition is the most common male sexual dysfunction, with prevalence rate of 20-30% (15,16,17).
5.) Risk factors:
The aetiology of premature ejaculation is unknown, with little data to support suggested biological and psychological hypothesis, including
5-HT receptor dysfunction (5)
A significant proportion of men with erectile dysfunction also experience premature ejaculation (15). High levels of performance anxiety related to erectile dysfunction may worsen remature ejaculation, with a risk of misdiagnosing premature ejaculation instead of the underlying erectile dysfunction.
According to the NHLS, the prevalence of premature ejaculation is not affected by age (16,17), unlike erectile dysfunction, which increases with age.
Premature ejaculation is not affected by marital or income status (16), However, premature ejaculation is more common in blacks, Hispanic men and men from Islamic backgrounds (28,29) and may higher in men with a lower educational level (15.16).
Other risk factors may include a genetic predispositions (30)., poor overall health status and obesity (16), Prostate inflammation (31,32), thyroid hormone disorders(33), emotional problems and stress (16,34), and traumatic sexual experience (15.16)
Successful eradication of causative organisms in patients with chronic prostatitis and premature ejaculation produced marked improvements in IELT (Intravaginal Ejaculatory Latence Time) and ejaculatory control compared to untreated patients.
Diagnosis of PE is based on the patients medical and sexual history (35,36). History should classify PE as lifelong or acquired.
Special attention should be given to the duration time of ejaculation, degree of sexual stimulus, impact on sexual activity and quality of life, and drug use or abuse.
It is also important to distinguish Premature Ejaculation from erectile dysfunction.
The use of intravaginal ejaculatory latency time (IELT) alone is not sufficient to define Premature ejaculation, as there is significant overlap between men with and without PE (24,25). In everyday clinical practice, self-estimated(IELT) is sufficient. Self-estimated and stopwatch-measured IELT are interchangeable and correctly assign PE status with 80% sensitivity and 80% specificity (37).
Specificity can be improved further to 96% by combining IELT with a single-item patient-reported outcome (PRO) an control over ejaculation and satisfaction with sexual intercourse (scale ranging from 0= very poor to 4= very good) and an personal distress and interpersonal difficulty (0= not at all to 4= extremely).
Physical examination and investigation:
Physical examination is a part of the initial assessment of men with premature ejaculation. It includes a brief examination of the vascular, endocrine and neurological systems to identify underlying medical condition associated with PE and other sexual dysfunctions, such as chronic illness, endocrinopathy, autonomic neuropathy, Peyronic disease, urethritis or prostatitis.
In many relationships, premature ejaculation causes few, if any, problem, in such cases, treatment should be limited to psychosexual counselling.
Before beginning treatment, it is essential to discuss patient expectations thoroughly, erectile dysfunction, in particular, or other sexual dysfunction or genitorurinary infection (e.g. prostatitis), should be treated first or at the same time as the premature premature ejaculation.
Various behavioural techniques have demonstrated benefit in treating PE and are indicated for patients uncomfortable with pharmacological therapy.
In lifelong, PE, behavioural techniques are not recommended for first line treatment.
Pharmacotherapy, is the basis of treatment in lifelong premature ejaculation only chronic selective serotonin reuptake inhibitors (SSRIs) and on demand topical anesthetic agents have consistently shown efficacy in premature ejaculation therapy.
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Correspondence:Prof. Dr. SEMIR AHMED SALIM AL SAMARRAI
Professor Doctor of Medicine-Urosurgery, Andrology, and Male Infertility
Dubai Healthcare City, Dubai, United Arab Emirates.
Mailing Address: Dubai Healthcare City, Bldg. No. 64, Al Razi building, Block D,
2nd floor, Dubai, United Arab Emirates, PO box 13576