Premature Ejaculation Diagnosis and Treatment

Definition and Diagnosis

The American Urological Association defines premature ejaculation as ejaculation occurring sooner than desired, with poor ejaculatory control and associated distress to the patient or partner, with lifelong PE beginning at sexual debut and persisting throughout life, and acquired PE developing after a period of normal ejaculatory control 1, 2
Diagnosis of premature ejaculation requires assessment of medical history, relationship factors, sexual history, and focused physical examination 2
The European Association of Urology recommends that if both PE and erectile dysfunction coexist, treat the erectile dysfunction first, as many men with ED develop secondary PE due to anxiety or need for intense stimulation to maintain erection 3

The exact cause of PE remains unknown, but involves both biological and psychological factors, including depression, anxiety, and history of sexual abuse, which are associated with PE, although the causal relationship is not proven 4, 5
Psychological and interpersonal factors, such as decreased emotional intimacy and relationship conflict, lower self-esteem, self-confidence, and increased interpersonal conflict, are also associated with PE 4

The American Urological Association recommends daily SSRIs, on-demand clomipramine or dapoxetine, and topical penile anesthetics as first-line treatment options for PE 4
Daily paroxetine 10-40 mg exerts the strongest ejaculation delay, increasing ejaculatory latency time 8.8-fold over baseline, followed by sertraline 50-200 mg, fluoxetine 20-40 mg, and citalopram 20-40 mg 4
The European Association of Urology suggests that for diabetic patients, start sertraline at 50 mg daily and titrate to 200 mg based on clinical response 3

The American Urological Association warns that never abruptly discontinue daily SSRIs, always taper to prevent SSRI withdrawal syndrome, and screen for concurrent serotonergic medications before prescribing to avoid serotonin syndrome 3, 4
The European Association of Urology advises caution when prescribing SSRIs to adolescents with PE, though elevated risk of suicidal ideation has not been found in trials with non-depressed men with PE 4

The American Urological Association suggests that psychotherapy for men and couples may be useful even when no clear psychological or physiological etiology is apparent, and most psychological therapies integrate psychodynamic, systematic, behavioral, and cognitive approaches within a short-term model 4

The European Association of Urology recommends that patient and partner satisfaction is the primary target outcome for PE treatment, not just ejaculatory latency improvement, and discuss risks and benefits of all treatment options before initiating therapy, emphasizing that PE is not life-threatening and safety should be a primary consideration 3
The American Urological Association suggests that shared decision-making is fundamental in managing PE, involvement of sexual partners in decision-making, when possible, may optimize outcomes 1, 2, 6

The American Urological Association recommends that diagnosis of premature ejaculation requires three components, including poor ejaculatory control, which is defined as a lack of self-efficacy regarding when ejaculation occurs 7
The diagnosis also requires associated distress or bother to the patient and/or partner, as well as time-based criteria, such as ejaculation within approximately 2 minutes for lifelong PE 7

The European Association of Urology recommends that penile constriction rings have no established role in the treatment of premature ejaculation and are not mentioned in current evidence-based guidelines as a therapeutic option for this condition 7, 8