Management of Male Ejaculatory Disorders

Definition and Diagnosis

• The American Urological Association defines premature ejaculation (PE) as ejaculation within approximately 2 minutes of penetration, with poor ejaculatory control and associated bother, present since sexual debut 1, 2
• The normal median ejaculatory latency time (ELT) in Western countries is 5-6 minutes 4, 5
• Delayed ejaculation (DE) is characterized by a lifelong or acquired, consistent, bothersome inability to achieve ejaculation or excessive latency despite adequate stimulation and desire to ejaculate 6
• Men with latencies beyond 25-30 minutes who report distress, or who cease sexual activity due to partner's request, fatigue, or ejaculatory futility qualify for diagnosis of DE 4, 5, 7

Management of Premature Ejaculation

• Behavioral therapy combined with pharmacotherapy provides superior outcomes compared to either modality alone for PE 6
• The primary pharmacologic treatment for PE is selective serotonin reuptake inhibitors (SSRIs), which are used off-label 1, 2
• Surgical management of PE, including dorsal nerve neurotomy, radiofrequency ablation, or hyaluronic acid augmentation, should be considered experimental and only performed in ethical board-approved clinical trials due to risk of permanent penile sensation loss 6

Management of Delayed Ejaculation

• Referral to a mental health professional with sexual health expertise should be considered for all men with lifelong or acquired DE, as psycho-behavioral strategies enhance psychosexual arousal and remove barriers to sexual excitement 4, 7, 8
• Behavioral modifications to increase arousal, such as alternative sexual practices, scripts, and sexual enhancement devices, may benefit men with DE 4, 7, 8
• Pharmacotherapy options for DE, including oxytocin, pseudoephedrine, and ephedrine, are used off-label and should be considered after reviewing and modifying medications that may contribute to DE 4, 5, 7
• The following table summarizes pharmacotherapy options for DE:

4, 5, 7

Retrograde Ejaculation

• First-line treatment for retrograde ejaculation in men seeking fertility is sympathomimetic medications, with pseudoephedrine 60-120 mg taken 120-150 minutes prior to ejaculation showing the highest success rates for converting retrograde to antegrade ejaculation 9
• Alternative options for retrograde ejaculation include imipramine, urine alkalinization with urethral catheterization, and assisted reproductive techniques 9

Critical Clinical Considerations

• No medications for PE or DE have FDA approval, and all pharmacotherapy is off-label use 1, 2, 10
• Shared decision-making is fundamental in managing ejaculatory disorders, with involvement of sexual partners when possible to optimize outcomes 1, 2, 10
• Age is one of the most significant factors in DE, combining psychological and physiological processes, and age-related increases in latency may be managed with psychological and behavioral approaches aimed at increasing arousal 4, 7, 8