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The Role of Pharmacotherapy in the Treatment of Premature Ejaculation
hyperthyroidism were prone to PE.
19
Men with erectile dysfunction (ED) may
Table 1: Pathologies of Premature Ejaculation
also suffer from PE, triggering early ejaculation before losing their erection.
Mechanism of Action Aetiology
Diagnosis of Premature Ejaculation
Psychorelational Anxiety
As few as 18% of men seek medical treatment for sexual dysfunction,
Relationship problems
Neurobiological Serotonin hyperactivity (5-HT
and within that group more men with ED seek medical attention
1A
receptor)
Serotonin hypoactivity (5-HT
2C
receptor)
than men with PE.
20
Perceived social stigma, personal embarrassment
Penile hypersensitivity
and lack of knowledge about treatment options are among the reasons
Urological Prostate inflammation/infection
that patients with PE are often reluctant to seek treatment, and some Hormonal Hyperthyroidism
men are unaware that PE is even considered a medical problem, instead
Andrological Erectile dysfunction
considering the problem to be transient or of psychological origin. Adapted from Jannini et al., 2006.
10
However, PE has a significant effect on a patient’s psychological
wellbeing and quality of life, as well as that of his partner, affecting a medical examination to rule out any health issues that may interfere
emotions and relationships and in many cases ultimately resulting in with healthy sexual functioning, such as neurological or endocrine
separation or divorce. For these reasons, it is important for clinicians to impairment, systemic illness or infection of the urethra, prostate or
recognise, address and treat PE. Unfortunately, even many clinicians still epididymis. Certain medications or recreational drug or alcohol
view PE as an issue relating to quality of life rather than a use/abuse may also lead to PE.
23,24
medical problem with a considerable impact on a man’s self-esteem
and relationship. Psychological Approach to Premature Ejaculation
PE was historically considered a psychological rather than a
In contrast to ED, for which all epidemiological studies have shown a physiological problem. As such, behavioural approaches have become
clear age dependency, PE in its lifelong pattern affects men of all ages, well established methods in managing PE. Two widely used methods
i.e. it commences with onset of sexual activities and continues over the are the ‘stop–start’ programme
25
and the squeeze technique.
11
These
life span if untreated; there are no specific risk factors nor any single ‘re-training’ methods are based primarily on the idea that PE results
group that is most at risk. When diagnosing PE, physicians are urged from the man’s unawareness of heightened arousal and inability to
to consider four prominent factors: either the reported (felt) or recognise the feelings of inevitable ejaculation. It is believed that by
measured IELT and the three subjective patient assessments: control intensifying and prolonging stimulation while maintaining stimulus
over ejaculation; satisfaction with intercourse; and personal distress below the threshold for triggering ejaculation, the procedures help to
and anxiety and interpersonal difficulties relating to the condition.
5,21
attenuate the patient’s stimulus-response connections.
26
However,
Although no single factor is sufficient in a diagnosis of PE, IELT and although 60% short-term success rates have been reported with these
the three patient-reported criteria are positively correlated, with the psychological approaches,
27
they are short-lived: after three years of
strongest correlation being between IELT and control over follow-up, 75% of patients who initially responded to sex therapies
ejaculation.
21
Patient assessment of control over ejaculation is the failed to show any lasting improvements.
28,29
strongest predictor of PE.
22
Pharmacological Options in Premature Ejaculation
There is not yet any validated means by which to diagnose PE. The Recognition of an underlying neurobiologic basis in the aetiology of PE
AUA Guideline on the Pharmacologic Management of Premature has led to the evolution of pharmacotherapies to help manage the
Ejaculation recommends that diagnosis be based solely on the disorder. All currently available pharmacological approaches, whether
patient’s sexual history.
3
The guidelines suggest that physicians obtain topical or oral, are administered with off-label usage either daily or as
information as to the onset, frequency and duration of PE, as well as needed (pro re nata [PRN]). As yet, no pharmaceutical agents have been
the proportion of sexual encounters that are affected by PE. The approved or indicated by the US Food and Drug Administration (FDA)
or the European Medicines Agency (EMEA) for the management of PE.
Topical Agents
The AUA Guideline on the
Topical medications, first described in 1943,
30
are the oldest form of
pharmacological therapy. The aim was to treat penile hypersensitivity,
Pharmacologic Management of
one of the purported causes of PE, by applying local anaesthetics in a
Premature Ejaculation recommends
cream, gel or spray formulation to decrease penile sensitivity. Patients
treated with lidocaine–prilocaine cream have been shown to experience
that diagnosis be based solely on the
significant increases in IELT compared with patients taking placebo.
31,32
patient’s sexual history. However, patients considering topical agents face a trade-off, as
pleasurable sensations are also diminished. The advantage of topical
medications is that no systemic adverse effects have been reported,
although topical adverse effects of localised mild burning or pain,
patient’s sexual history should also outline the frequency and nature of numbness and irritation have been observed.
32,33
There is also a risk of
the patient’s sexual activity, his relationships and the impact of PE on transfer of the agent to the partner if a condom is not used, potentially
his life, as well as whether the PE in question is lifelong or acquired, causing the female to experience numbness or decreased vaginal
global or situational. It would be prudent for the clinician to perform sensitivity.
32
However, using a topical cream with a condom creates a
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