Premature Ejaculation:complex problem and solution

Premature Ejaculation:
Premature ejaculation (PE; also known as rapid ejaculation) is the most common type of sexual dysfunction in men younger than 40 years. Most professionals who treat premature ejaculation define this condition as the occurrence of ejaculation prior to the wishes of both sexual partners.

Complex problem:

Premature ejaculation sometimes is confused with delayed orgasm in female partner.
To explain,a male may reach climax after 5 minutes of sexual intercourse, but this is not premature ejaculation if his partner regularly climaxes in 3 minutes and both are satisfied with the timing. Another male might delay his ejaculation for a maximum of 30 minutes, yet he may consider this premature if his partner, even with foreplay, requires 45 minutes of stimulation before reaching climax.
Because many females are unable to reach climax at all with vaginal intercourse ;they sometime need foreplay simultaneously or before , this situation may actually represent delayed orgasm in the female partner rather than premature ejaculation in the male; the problem can be either or both, depending on the point of view. This highlights the importance of obtaining a thorough sexual history from the patient (and preferably from the couple).

How to define premature ejaculation?
The criteria for premature ejaculation stated in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, text revision (DSM-IV-TR) is as follows: (1) persistent and recurrent ejaculation with minimal sexual stimulation before, on, or shortly after penetration before the person wishes it; (2) marked distress or interpersonal difficulty; and (3) not exclusively due to direct effects.

Cauasative Factors:
This can either be primary:senice beginning or secondary: after having period of normal ejaculatory latency.Many research aerticle are published regarding the causative factors for premature ejaculation but at large it is attributed to pyschological factor.These men have increased Intra Vaginal Ejaculatory Latency Time.Hyperexcitability many times are due to strict religeous upbringing,sexual taboo in family and sciety,previous traumatic sexual experience,sexual abuse.Sometimes guilt of previous sexual exposure also contributes to the premature ejaculation.
Sometimes performace anxiety plays important role in PE.The male often then give excuse that the female partner excited him so much that he could not hold back.
Now-a-days underlying erectile dysfunction also has been seen as cause for premature ejaculation.
Sometimes cardiac patients ejaculate early having fear in mind that prolonged sexual act may precipitate heart attcak.
Management:
Many times detailed sexual history only suffices no other investigations are really necessary.
Sexual counselling plays important role as to remove/allay previous fear/guilt from the minds of patients.
Step by step approach may help patients many-a-times:
1) Engaging in a lot of foreplay thus removing performace anxiety and avoiding actual insertional sex
2) squeeze-pause technique popularized by Masters and Johnson where partner masturbates the patient and before the climax squeezes the glans(the pressure should be applied underneath the glans) to stop the ejaculate and ceases to stimulate the organ.Once the male organ is flaccid again,the female partner starts the technique again.This is repeated to gradually increase the ejaculatory latency.
3)After that female should stride across the male partner on his lap and repeat the same thing but only diffrence is that the penis is rubbed to the vulva(NO INSERTION AGAIN)
4)Finally they can engage in sexual act with the female partner on the top.
5)Once this sets the sex right normal conentional position can be tried.



Drugs : Novel drug:Dapoxetene in Premature Ejaculation

Normally Selective Serotonin Uptake Inhibitors are used for such patients along with psychotherapy. The mechanism of action of SSRIs is linked to their inhibition of neuronal uptake of serotonin in the CNS. Various animal studies suggest that SSRIs have weak effects on norepinephrine and dopamine neuronal reuptake.They prolong the sexual climax causing relief from early unwanted ejaculation.
These SSRI (Sertraline,Paroxetene.Fluoxitine)may take until at least 3 weeks following initiation of treatment to cause improvement in sexual latency.
It has been seen that many patients with PE have undelying erectile dysfunction also so adding PDE-5 inhibitors like Viagra(sildenafil),Tadalafil works well.
Dapoxetine is an SSRI developed specifically for the treatment of premature ejaculation. Dapoxetine may be effective at first dose (ie, on-demand) for premature ejaculation when given 1-3 hours prior to sexual intercourse.
The optimal medical treatment for premature ejaculation has not been established but single dosing prior to sexual relations can work for many males.While raised blood levels through daily use of the medication may be unnecessary resulting in many CNS side effects. Obviously, if single dosing is successful, therapy is simpler and is associated with fewer adverse effects. Therefore, this may be the preferred initial therapy.
Dapoxitine right now although is manufactured in India ;is not available in market.But it soon expected after Food Drug Administration approves it.


Certain other methods:
Wearing condom,applying lignocaine jelly sometime are practised. These agents may reduce penile sensitivity and excitability and delay ejaculation.Some andrologist give tramadol- centrally acting opioid drug (weak μ-opioid effect) in addition to reuptake inhibition of 5-HT and norepinephrine.
Circumcision practised thinking that keratinisation of the glans may help in reduction of sensitivity of the glans is occasionally practised but it is a painful option with seemingly doubtful benefit.

Premature ejaculation in most cases is psychological.Sexual counselling of both partners is necessary (unlike in India -most of the times only male partner visits.The female partner thinking it as HIS PROBLEM RATHER THAN THEIR PROBLEM .
SSRIs along with PDE-5 inhibitors in most cases along with Master and Johnsons technique is helpful.Condom and Lignocaine jelly can complement for the delay in ejaculation