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Questions to assess premature ejaculation, from Campbell's

Algorithm for managing premature ejaculation, from Campbell's

Evaluation

• Definition: some variety of ejaculation within 1 minute or prior to vaginal penetration, inability to delay ejaculation, and subsequent negative emotions
• Types: lifelong (never normal latency) vs acquired (previously normal latency), variable (occurs sometimes with other normal latency periods) vs or subjective (patient-perceived with normal latency times)
• Data: minimal research performed in situations other than with vaginal intercourse
• Accuracy of patient reporting: patient's subjective timing is relatively accurate compared to objective timing of latency period
• History: assess frequency, severity, average time-to-ejaculation, associated factors, partners vs masturbation
• Associated conditions: anxiety, ED (trying to rush intercourse before losing erection), prostatitis, hyperthyroid, drug withdrawal
• Additional tests: not necessary if lifelong, consider checking T, HbA1c, thyroid panel, prolactin, B12, Vit D

Management

• Psychosexual therapy: recommended, can be beneficial for both patient and partner
• Squeeze technique: stop sexual activity and squeeze glans until urge to ejaculate goes away
• Start/stop technique: stop penile stimulation when ejaculation about to occur, then restart once urge goes away
• "Quiet vagina:" female partner stops moving when patient nearing ejaculation, then resume when urge goes away
• Sensate focus: progressing from non-sexual touching to sexual touching to penetrating intercourse to help with self-awareness
• Daily SSRI (off label): paroxetine 10-40mg (recommended choice), clomipramine 12.5-50mg (most side effects, lowers seizure threshold), sertraline 50-200mg, fluoxetine 20-40mg, citalopram 20-40mg (least effective), takes 2-3 weeks for full effect, taper off after 6-8 weeks, watch for agitation, hypomania, and potential increased risk of suicidal ideation
• Topical therapies: EMLA cream (2.5% prilocaine + 2.5% lidocaine), can be applied 5-min prior to intercourse (use with condom) or 20-30min prior (place on penis, wipe off, use without condom)
• PDE5i not recommended