The first step in the treatment of premature ejaculation is to establish the type that the patient suffers from and the underlying causes as summarised below:
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Primary life long premature ejaculation
The criteria for a patient to be classified as having Primary premature ejaculation are the following:
- From the first sexual experience
- Intravaginal latency time IELT ≤ 1-2min (90% of patients will have IELT < 1min, 10% between 1-2 min)
- Inability to delay ejaculation on all or nearly all vaginal penetrations.
- Negative impact e.g distress, bother, frustration, and/or the avoidance of sexual intimacy.
Ante-portal ejaculation is the severest form of primary PE when IELT= Zero, which means that the patient ejaculates even before penetration.
Causes
Lifelong premature ejaculation is usually neuro-biologically rather than psychologically determined meaning that the patients suffering from this have genetic predisposition with environmental influences. Unfortunately, the exact neuro-biological mechanisms have not been established (hence multi-optional treatment rather than targeted treatment is recommended) although there are a number of theories in development.
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Acquired or secondary premature ejaculation
The criteria for a patient to be classified as having Acquired or Secondary PE are the following:
- PE symptoms beginning after a period of normal ejaculatory function causing a clinically significant reduction in the IELT
- IELT≤ 3min
- Inability to delay ejaculation on all or nearly all vaginal penetrations;
- Negative impact e.g distress, bother, frustration, and/or the avoidance of sexual intimacy.
Causes
Potential causes of Secondary PE are the following:
- Neurological factors causing hypersensitivity of genital skin and hyper excitability of the ejaculatory reflex e.g increased sympathetic tone (Hypertension), Diabetes, metabolic syndrome and alcoholism
- Hormonal Causes such as Hyperthyroidism/ Hypothyroidism / reduced Prolactin/ increased Leptin
- Erectile Dysfunction causing secondary PE
- Tight Frenulum
- Phimosis / Balanoposthitis causing Dyspareunia
- Chronic Prostatitis
- Chronic Pelvic pain syndrome
- Psychological factors; e.g Anxiety/depression, partner issues, paranoia habituation through early sexual experiences, habituation via masturbation, negative early sexual experiences
- Recreational drugs
- Certain medication such sympathomimetics
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Variable PE:
Variable premature ejaculation will happen naturally in certain situations such as:
- Abstaining from sex for a long time
- Over sexually excited, e.g having sex for the first time
- New sexual stimulants: sexually exciting situations e.g special occasions, fantasy enactments
This should not be considered a pathology but a small variation in normal sexual performance.
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Premature-like ejaculatory dysfunction (Subjective PE)
Subjective complaint of premature ejaculation (SPE) in men with a normal IELT of more than 3min. SPE is characterized by one or more of the following:
- Subjective perception of consistent or inconsistent short IELT;
- Preoccupation with an imagined short ejaculatory latency or lack of control over the timing of ejaculation;
- IELT in the normal range or even of longer duration (i.e., an ejaculation that occurs after 5 minutes);and
- Ejaculation control that may be diminished or lacking.
