Premature ejaculation treatments

Premature ejaculation treatments

The article provides an overview of treatments for premature ejaculation. Drug therapy has been shown to be the method of choice for the treatment of premature ejaculation. Selective serotonin reuptake inhibitors are used, mainly dapoxetine. A special place is occupied by behavioral strategies, which are most often used in combination with drug therapy.

Premature ejaculation (PE) is a common sexual dysfunction. It should be noted that the patient does not always accurately describe his complaints, this was the reason for the constant improvement of the very definition of this pathological condition. Inaccurate definitions of PE prevent correct identification of its prevalence.

According to the 2017 European Clinical Guidelines for Urology, PE meets the following criteria:

  • occurs before penetration or after about 1 min (with primary PE);
  • a clinically significant decrease in the duration of intercourse to 3 minutes or less (with acquired PE);
  • inability to control ejaculation;
  • psychological discomfort due to the existing ejaculatory disorder and interpersonal conflicts in a couple.

The diagnosis of PE is based on the time of onset of ejaculation , the ability to control it, and the emotional impact on the patient. First of all, PE has a negative impact on the patient’s quality of life, self-esteem and couple relationships. Remember that age is not a risk factor for the development of PE.

In general, therapeutic approaches must be based on the identification of the pathogenetic mechanisms of this
phenomenon.

Erection, emission, ejaculation and orgasm have different mechanisms. With the exception of nocturnal emissions, emission and ejaculation occur only when the genitals are stimulated. Emission and ejaculation represent the culmination of male sexual intercourse. As sensory fiber stimulation increases during coitus, sympathetic efferent nerves in the lower thoracic and upper lumbar segments are activated. Afferent fibers, the excitation of which leads to emission, pass through the pudendal and pelvic nerves to the sacral parts of the spinal cord and, as part of the sympathetic nerves, to the thoracolumbar parts.

Activation of sympathetic neurons causes contraction of the epididymis, vas deferens, seminal vesicles and prostate; as a result, semen is thrown into the posterior parts of the urethra. Reflex stimulation of sympathetic fibers causes contraction of the internal bladder sphincter, which prevents reflux of seminal fluid into the bladder.

Filling of the proximal urethra with semen leads to excitation of the afferent fibers of the pudendal nerve, which activates the reflex center of the sacral spinal cord, which causes rhythmic contractions of the sciatic-cavernous and bulbous-cavernous muscles located at the base of the penis. It is this process that leads to the rhythmic expulsion of sperm from the urethra.

Rhythmic contractions of the bulbous-spongy muscle push sperm through the narrowest part of the urethra, compressed by the swollen corpus cavernosum and corpus spongiosum. Finally, 2-5 ml of ejaculate is discarded. Ejaculation is carried out by the motor fibers of the pudendal nerve, which cause contractions of the bulbous-cancellous muscle.

Ejaculation is mediated by the nerve center in the spine, under stimulating or inhibiting influences from the brain and peripheral centers.

Thus, ejaculation is an involuntary process. For its implementation, the interaction of the somatic and autonomic nervous systems is necessary.premature ejaculationpremature ejaculationpremature ejaculation

Diagnostic

Understanding the physiology of ejaculation is central to the diagnosis and treatment of PE. First of all, it should be clarified when the PE appeared, from the beginning of sexual activity or occurred later. It is important to know the conditions of onset of PE in order to understand what form of PE takes place – situational or permanent. It is important to know the features of the implementation of intimate contact.

The consequences of premature ejaculation are an important component of the diagnosis. The decrease in self-esteem, the deterioration of the couple relationship most often motivate the patient to seek help.

It is necessary to establish whether drugs are used and whether there is addiction. PE often develops in patients in response to difficulty getting an erection. It should be explained to the patient that loss of erection after ejaculation is natural. Common risk factors for PE include time to ejaculation, feelings of control over ejaculation, negative emotional reactions, and negative relationships in a couple.

An objective indicator – intravaginal delay time (IRT) – is not enough to establish a diagnosis, since this indicator does not differ significantly in men with complaints and their absence. As mentioned above, in order to establish a diagnosis, it is necessary to identify not only a decrease in subjective control, but also negative consequences both for the patient himself and for the couple as a whole. Although IRR is an objective measure of PE, satisfaction with intercourse and anxiety of the patient and the couple as a whole do not reflect this indicator. TRI is more strongly associated with a sense of ejaculation control than with self-measured ejaculation time.

The Premature Ejaculation Diagnostic Tool (PEDT) helps distinguish between PE and its absence. It makes it possible to evaluate the degree of control, the frequency, the level of stimulation, the negative consequences for the patient and the couple. The Arabic Premature Ejaculation Index questionnaire assesses the level of desire, degree of erection , satisfaction, anxiety and depression. In general, the principle of construction of these questionnaires is based on the key points of the diagnosis of PE.

There was a weak correlation between the PEDT data and the condition described by the patient. An objective examination of a patient with complaints of PE, in addition to specific questions, includes clarification of the state of the cardiovascular, endocrine and nervous systems.
The specialist must take into account the factors that influence the duration of the arousal phase: age, new or old sexual partner in the patient, peculiarities of the situation, frequency of sexual contacts in recent years.

Treatment

Pharmacotherapy is currently the treatment of choice for PE. Selective serotonin reuptake inhibitors (SSRIs) are used, including dapoxetine, a short-acting drug that can be taken on demand.

Along with SSRIs, tramadol or local anesthetics are given as alternatives. In patients with complaints of PE with concomitant erectile dysfunction , phosphodiesterase type 5 inhibitors are used. Behavioral strategies, most often associated with pharmacotherapy, occupy a special place in the treatment of PE.

The goal of behavioral techniques is to develop intimate contact skills, increase ejaculation time, increase self-confidence and reduce anxiety. Behavioral strategies are subdivided into psychotherapeutic and physical methods, which include stop-start, compression, and pelvic floor exercises. The effectiveness of behavioral therapy methods is 50-60%, the effect is short-lived. Behavioral techniques are often used in conjunction with drug treatment.

SSRIs reduce the movement of serotonin from the synaptic cleft in central and peripheral serotonergic neurons. As a result, the concentration of serotonin increases and there is increased stimulation of postsynaptic 5-HT2C receptors. Drugs in this group can be used daily or as needed.

The slowing effect of serotonin on ejaculation is probably due to spinal or supraspinal activation of 5-HT1B and 5-HT2C receptors, while stimulation of 5-HT1A receptors induces ejaculation.

SSRIs are used to treat emotional disturbances, but there is also experience with drugs to delay ejaculation, and therefore they were previously used for PE as over-the-counter drugs. As with depression, SSRIs are prescribed for 1-2 weeks to achieve an effect on PE.

Long-term use of SSRIs causes a long-term increase in the concentration of serotonin in the synaptic cleft, thereby desensitizing the 5-HT1A and 5-HT1B receptors. But it should be remembered that with the cumulative effect of SSRIs, the risk of developing adverse reactions, up to suicidal manifestations, increases. For a long time, doctors prescribed long-acting SSRIs to patients with PE at their peril.

This changed with the introduction of the drug dapoxetine, which was developed specifically for the treatment of PE. A naphthyl component has been added to the molecule, which results in a rapid reabsorption and excretion time of the drug. It is these pharmacokinetic properties that distinguish dapoxetine from other SSRIs.

To date, the only dapoxetine drug available to domestic urologists is Priligy®, which is included in List B and is prescribed for patients with PE. The pharmacological properties of the drug have been confirmed by bioequivalence studies. According to accumulated clinical experience , treatment with the drug should be started with a dose of 30 mg, however, in the absence of appropriate positive dynamics, the doctor has the opportunity to adjust the dosage of the drug to 60 mg. Dapoxetine is currently the only drug perfectly suited for the treatment of PE.

A large amount of data indicates the effectiveness and safety of the drug. Ejaculation IRR while taking dapoxetine increases significantly from baseline. Dapoxetine has been shown to be well tolerated and has no serious side effects. Most side effects associated with drug treatment are dose-dependent.

Rapid absorption of dapoxetine may lead to a large increase in extracellular 5-HT concentration after administration, sufficient to overcome compensatory autoregulatory mechanisms.

Contraindications to dapoxetine include hypersensitivity, severe heart disease , concomitant use of monoamine oxidase inhibitors and SSRIs , administration of thioridazine, hepatic and renal impairment. It is necessary to identify such contraindications when establishing the diagnosis and clarifying the anamnesis.

Before the advent of dapoxetine, daily SSRIs were considered the treatment of choice for PE. Widely used SSRIs have a similar pharmacological mechanism of action, but their effect is based on the accumulation properties of drugs, which greatly increases the risk of side effects. A number of studies have shown the effectiveness of taking SSRIs daily for PE.
Another treatment for PE is the use of local anesthetics. Topical desensitizing medications reduce penile glans sensitivity and increase ejaculation time without altering ejaculation sensation. Despite the proven increase in VIVZ with the use of local anesthetics, the effect is short-lived. Creams and ointments with an analgesic effect are inconvenient to use and allergenic. It is because of these properties that the method has not become widespread.

Tramadol is a centrally acting analgesic that combines activation of opioid receptors with inhibition of serotonin and norepinephrine uptake. Tramadol has activity at opiate receptors but also antagonizes norepinephrine and 5-HT transporters. The efficacy and tolerance of two doses of tramadol 62 and 89 mg in the form of orally dispersible tablets for the treatment of PE have been demonstrated.

Considering the data on the neuropharmacology of ejaculation and the mechanism of action of tramadol, the prolongation of the ejaculation delay can be explained by the combined stimulation of mu-opiate receptors in the central nervous system and an increase in the availability of 5-HT in the brain.

Thus, the construction of a clinical diagnosis in a patient with complaints of PE includes the time until the onset of ejaculation, the degree of patient control over ejaculation, the presence of anxiety and depression and the absence of anatomical abnormalities. These are the main elements of the diagnosis. The start and duration of complaints are taken into account. The history and physical examination allow you to choose a treatment for PE, taking into account contraindications and possible side effects.

Remember that dapoxetine is currently the drug of choice for the treatment of PE. This drug is used on demand 1 r./Day 1-3 hours before the intended coitus. Primaxetin® is available in a dosage of 30mg and is included in List B. The prescription of dapoxetine in patients with PE is in full compliance with the clinical guidelines of the European Society of Urology. Behavioral therapy and topical medications can improve the effectiveness of PE treatment.

Conclusion

Thus, modern approaches to the treatment of PE are based on the concept of the structure and function of serotonin receptors. The use of SSRIs can achieve clinical efficacy. The distribution of serotonin receptors that implement various physiological functions explains not only the slowing of ejaculation, but also the side effects. The duration of use of selective serotonin uptake inhibitors increases the risk of side effects, which requires monitoring of the intake and prompt withdrawal of the drugs. Dapoxetine pharmacokinetics can significantly reduce the incidence of undesirable side effects, improve the patient’s condition with premature ejaculation, and take the drug on demand.

Scroll to Top