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Premature Ejaculation and Psychogenic Impotence

Premature Ejaculation

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

Psychogenic Impotence

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.


Document References
  1. Bandolier; Premature ejaculation treatments reviewed. October 2004.
  2. Laumann EO, Paik A, Rosen RC; Sexual dysfunction in the United States: prevalence and predictors. JAMA. 1999 Feb 10;281(6):537-44. [abstract]
  3. Piediferro G, Colpi EM, Castiglioni F, et al; Premature ejaculation. 1. Definition and etiology. Arch Ital Urol Androl. 2004 Dec;76(4):181-7. [abstract]
  4. Chia S; Management of premature ejaculation -- a comparison of treatment outcome in patients with and without erectile dysfunction. Int J Androl. 2002 Oct;25(5):301-5. [abstract]
  5. Busato W, Galindo CC; Topical anaesthetic use for treating premature ejaculation: a double-blind, randomized, placebo-controlled study. BJU Int. 2004 May;93(7):1018-21. [abstract]
  6. Piediferro G, Colpi EM, Castiglioni F, et al; Premature ejaculation. 3. Therapy. Arch Ital Urol Androl. 2004 Dec;76(4):192-8. [abstract]
  7. Waldinger MD, Zwinderman AH, Schweitzer DH, et al; Relevance of methodological design for the interpretation of efficacy of drug treatment of premature ejaculation: a systematic review and meta-analysis. Int J Impot Res. 2004 Aug;16(4):369-81. [abstract]
  8. Abdel-Hamid IA, El Naggar EA, El Gilany AH; Assessment of as needed use of pharmacotherapy and the pause-squeeze technique in premature ejaculation. Int J Impot Res. 2001 Feb;13(1):41-5. [abstract]
  9. Jannini EA, Simonelli C, Lenzi A; Sexological approach to ejaculatory dysfunction. Int J Androl. 2002 Dec;25(6):317-23. [abstract]
  10. Symonds T, Roblin D, Hart K, et al; How does premature ejaculation impact a man s life? J Sex Marital Ther. 2003 Oct-Dec;29(5):361-70. [abstract]
  11. Ralph D, McNicholas T; UK management guidelines for erectile dysfunction. BMJ. 2000 Aug 19-26;321(7259):499-503.

Internet and Further Reading Acknowledgements EMIS is grateful to Dr Colin Tidy for writing this article. The final copy has passed scrutiny by the independent Mentor GP reviewing team. ©EMIS 2007.
DocID: 2652
Document Version: 20
DocRef: bgp24651
Last Updated: 28 Jun 2007
Review Date: 27 Jun 2009




















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