Arver_edit_Layout 1 13/10/2009 12:54 Page 64
Premature Ejaculation
Management Practices and Newly Approved Treatments
for Premature Ejaculation
Stefan Arver
Centre for Andrology and Sexual Medicine, Karolinska University Hospital, and Department of Medicine/Huddinge, Karolinska Insitute
Abstract
Premature ejaculation is the most common male sexual dysfunction, affecting at least one in five men. Premature ejaculation is a
significant problem and causes distress in most affected men, as well as in their partners. Distress is not limited to sexual function but also
to self-image, and interferes with overall quality of of life in men and their partners. Over the years many treatment modalities have been
tried, but only recently has a specific pharmacological therapy been approved and become available. The new treatment is based on
modulation of serotonin activity in the brain, and efficacy is based on the inhibitory action of serotonin on the ejaculatory reflex. Clinical
trials include data from more than 6,000 men and show significant improvement of the three main problems associated with premature
ejaculation: intravaginal latency time (time to ejaculation), distress and sense of control of ejaculation. Dapoxetine is a selective serotonin
re-uptake inhibitor (SSRI) with a pharmacokinetic profile that differs from other SSRIs used for the treatment of depression and anxiety, and
has a rapid onset of action and short half-life (one to two hours). This makes the drug suitable for on-demand use with fewer risks of
undesirable side effects.
Keywords
Premature ejaculation, dapoxetine, treatment, review
Disclosure: The author has participated in clinical trials and has received grants for lectures sponsored by Johnson & Johnson (Janssen Cilag).
Received: 20 July 2009 Accepted: 24 August 2009
Correspondence: Stefan Arver, Centre for Andrology and Sexual Medicine, Karolinska University Hospital/Huddinge, Department of Medicine, Karolinska Institutet, SE141 86
Stockholm, Sweden. E: stefanarver@ki.se
Interest in and awareness and recognition of the clinical significance like ejaculatory dysfunction). There may also be a variation in
of sexual dysfunction have increased the intensity of research in prevalence, with lifelong PE being less common than the prevalently
sexual medicine. This includes improved definition and diagnostic occurring natural variable PE and premature-like ejaculatory sexual
criteria for a number of aspects of both female and male sexual dysfunction.
12,13
The initiative taken by the International Society for
function and dysfunction.
1–5
Meaningful epidemiological as well as Sexual Medicine (ISSM) to formulate an evidence-based definition of PE
interventional studies have been enabled thanks to adequate tools, seems to be the most comprehensive operational definition and is the
although several areas remain to be explored. current benchmark.
2
The consequences of PE include embarrassment,
loss of self-esteem, anxiety and a feeling of inferiority as a result of being
Premature ejaculation (PE) is a common – if not the most common – unable to respond to a partner’s expectations and the partner having
sexual dysfunction in males, with a likely prevalence >21%.
6–10
It causes similar negative experiences.
14
significant concern for both partners in the afflicted relationship.
Clinically, PE comprises rapid ejaculation (prior to or within one to two There is no recognised organic disease associated with PE, and the
minutes after vaginal penetration) and lack of control, causing sexual as aetiology or aetiologies remain to be elucidated.
15
A variety of
well as general frustration and interpersonal difficulties.
2
Further hypotheses have been suggested, including central mechanisms
classification of PE distinguishes between lifelong (present since start of with a dysregulation of serotonin (5-HT) activity (5-HT 1A receptor
sexual life and occurring in more than 75% of sexual encounters) and desensitisation, 5-HT 1B hyperactivity, change in 5-HT-transporter
acquired (occurring at some later point in life after an interval of normal activity) in central nervous system (CNS) structures of importance for
sexual function). Still further classification has been proposed taking into regulation of the ejaculatory reflex control, hypersensitivity of the
account natural variable PE, which occurs in special situations, and glans penis and primary as well as secondary psychological
premature-like ejaculatory dysfunction, which occurs in men with mechanisms.
16
Ejaculation involves two processes: emission
latency time in the normal range but who complain of PE.
3,11
This (emptying of accessory sex glands into the urethra) and expulsion of
introduces other dimensions of PE, suggesting four different subtypes, semen through the urethra caused by contraction of mainly
from very short (lifelong and acquired PE) to normal and long ischiocavernous and bulbocavernous muscles. These processes are
intravaginal ejaculatory latency time (IELT) (natural variable PE and highly co-ordinated and follow a certain sequence, and also involve
premature-like PE). It also identifies both neurobiological (lifelong) and closing of the internal bladder sphincter to prevent emptying of
more psychologically determined subtypes (acquired and premature- semen into the bladder.
17,18
The neural control of ejaculation involves
64 © TOUCH BRIEFINGS 2009