Premature Ejaculation and Psychogenic Impotence

The definition for premature ejaculation in terms of time varies from 30 seconds up to 4 minutes.¹ Therefore the best definition is an inability to control ejaculation sufficiently to permit both partners to enjoy sexual intercourse.

Epidemiology

• The prevalence of premature ejaculation varies according to definition and is difficult to assess in view of many men not wanting to seek help or even discuss the problem.
• One random survey of in the United States found that about 30% of men had ejaculated prematurely in the past year.²
• Risk factors Underlying causes include:³
  • Premature ejaculation may be anxiety related.
  • It is therefore more common in young men and early in a relationship. In these situations, the problem usually resolves with time.
  • Iatrogenic causes include amphetamine, cocaine and dopaminergic drugs. Although effective for the treatment of premature ejaculation in some men, sildenafil may also be a cause of premature ejaculation in others.⁴
  • Urological causes, e.g. prostatitis.
  • Neurological causes, e.g. multiple sclerosis, peripheral neuropathies.

Management

• General advice:
  • More frequent sex (or masturbation): premature ejaculation is more likely if there is a longer gap between sexual intercourse.
  • Using a condom to decrease sensation.
  • Sex with the woman on top reduces the likelihood of premature ejaculation.
  • Squeeze and stop-go techniques: stimulating the penis almost to the point of ejaculation and then stopping. These techniques are often effective but may take a few months to produce any benefit and relapse is common.
  • Anaesthetic creams may be effective.⁵
• Drug therapy:
  • SSRI antidepressants are the most commonly used, but relapse may occur after stopping the medication.⁶ Paroxetine, clomipramine, sertraline and fluoxetine have all been shown to be effective.⁷
  • Sildenafil is an effective alternative, especially in older men and when associated with erectile dysfunction.⁸
• Psycho-sexual therapy:
  • Includes assessment, behavioural and educational methods, psychotherapy in terms of the relationship, and sexual timetables.⁹

Complications

Premature ejaculation may have a significant adverse effect on both self confidence and the relationship.¹⁰

Only about 10-20% of patients with erectile dysfunction are believed to have a solely psychogenic cause, but psychogenic factors are often present in those who are diagnosed as having a physical cause.

Presentation

Features suggestive of psychogenic cause for erectile dysfunction include:

• Sudden onset
• Early loss of erection
• Better erections when masturbating or on waking in the morning
• Premature ejaculation or inability to ejaculate
• Problems or changes in the relationship
• Major life events
• Psychological problems

Differential Diagnosis

Physical causes of erectile dysfunction.

Investigations

To explore possible physical causes.

Management

Includes the management of any specific underlying psychological problem.

• Psychosexual therapy:
  • May be used in conjunction with physical therapies.
  • Successful outcomes in 50-80% of pre-selected patients.¹¹
  • Depends on the motivation of the patient and is time consuming.
• Drugs:
  • Drug treatments, e.g. phosphodiesterase type-5 inhibitors, may be effective and sometimes need only be used short term.