Premature ejaculation

Disease Description (Causes and Symptoms)

• Definition summary: A condition in which ejaculation repeatedly occurs before the patient wants it, before, during, or immediately after penetration, causing difficulty with sexual satisfaction and interpersonal relationships.
• Classification
  • Primary (lifelong): Present continuously since the first sexual experience — generally characterized by a very short ejaculation latency time (IELT), usually approximately 1 minute or less.
  • Secondary (acquired): Develops later despite no previous problem — may be associated with medications, diseases (such as prostatitis), erectile dysfunction, and other factors.
• Major causes (multifactorial)
  • Neurotransmitter abnormalities (particularly suspected impaired serotonin-related regulation).
  • Hypersensitivity of the glans penis (research findings are mixed).
  • Psychosocial factors: sexual anxiety, relationship problems, lack of sex education, stress, and others.
  • Physical diseases: prostatitis or urethritis, peripheral nerve damage, diabetes, neurological diseases, alcohol abuse, and others.
  • Medications: May be triggered by starting or stopping certain medications.
• Key symptoms
  • Ejaculation immediately before penetration or within a very short time after penetration (subjectively and objectively uncontrollable).
  • Anxiety, shame, reduced sexual pleasure, and partner dissatisfaction due to failure to control ejaculation.
• Diagnostic points
  • Assess the duration of symptoms (generally at least 6 months), frequency, and personal or interpersonal distress.
  • IELT (intravaginal ejaculation latency time) is used as an objective measure: for primary cases, usually approximately 1 minute or less; for secondary cases, a significant reduction, often considered to be approximately 3 minutes or less, may be used as a criterion (diagnostic criteria vary according to the medical society and clinical guidelines).

Treatment Methods (Standard Treatment · Medications · Procedures/Surgery · Lifestyle Management and Precautions)

• Nonpharmacological treatment (recommended as the first approach)
  • Behavioral therapy: start-stop technique and squeeze technique — practice together with a partner.
  • Cognitive behavioral therapy (CBT) and sex therapy: Address sexual anxiety and relationship factors.
  • Pelvic floor muscle (Kegel) strengthening exercises: May help with urinary and ejaculation control.
• Medication treatment
  • Selective serotonin reuptake inhibitors (SSRIs): Paroxetine, sertraline, fluoxetine, and others (generally have an ejaculation-delaying effect). They are usually used as long-term (daily) treatment, and may cause side effects such as decreased libido, changes in erectile function, and gastrointestinal symptoms.
  • Dapoxetine (short-acting SSRI): An on-demand medication taken 1–3 hours before sexual intercourse and approved in many countries (usual dose 30 mg, increased to 60 mg if necessary). Its advantages are rapid onset and a short half-life. Dizziness, nausea, headache, and risk of syncope have been reported; caution or contraindication applies in patients with cardiovascular disease (heart disease or prolonged QT interval). The contraindication to combination with other SSRIs or MAOIs must be checked.
  • Topical anesthetics: Apply an ointment or spray containing lidocaine or prilocaine to the glans penis before sexual intercourse (directions for use: condom use is recommended, as the medication may be transferred to the partner). Reduced sensation may decrease sexual pleasure.
  • Adjunctive medications: If erectile dysfunction is also present, concomitant use of a PDE-5 inhibitor may be considered (if ED is the cause, treat ED first).
• Procedures/Surgery
  • Procedures such as dorsal penile nerve (sensory nerve of the penis) transection are generally not recommended because of their effects and side effects (loss of sensation and changes in sexual function), and remain highly controversial. Before the procedure, fully discuss the long-term risks and benefits with a specialist.
• Treatment of underlying causes
  • Symptoms may improve when underlying conditions such as prostatitis, urethritis, nerve damage, endocrine abnormalities, alcohol dependence, and diabetes are treated.
• Precautions and complications
  • Medication side effects: SSRIs (decreased libido, delayed ejaculation, gastrointestinal symptoms), dapoxetine (syncope, dizziness, and cardiovascular precautions), and topical anesthetics (numbness caused by transfer to the partner).
  • Interactions: Combining SSRIs with MAOIs is contraindicated (risk of serotonin syndrome). Dapoxetine requires caution because of interactions with certain antidepressants, antipsychotics, and CYP3A4 inhibitors.
  • Treatment effectiveness may be limited if psychological or relationship problems remain unresolved.
• Prognosis
  • Varies depending on the cause: Secondary cases have a high likelihood of improving when the underlying disease is treated. Primary cases tend to become chronic, but behavioral therapy and medication can improve symptoms and quality of life.

Checklist Before an Outpatient Visit (Items to Bring and Information Useful to Record for the Appointment)

• Items/materials to prepare
  • A list of all medications currently being taken (including prescription drugs, OTC medications, and herbal medicines).
  • Recent test results (blood glucose, HbA1c, prostate tests, etc.) and materials related to heart disease (such as previous electrocardiograms).
  • Symptom diary: Number and timing of ejaculations (before penetration/immediately afterward, etc.), estimated IELT (in seconds), and the time of symptom onset and its progression.
  • Partner-related information (duration of the relationship, the partner’s sexual health problems, etc.).
  • Previous treatment experiences (medications, ointments, or treatment methods used, and their effects/side effects).
• Information to tell the doctor in advance
  • When the symptoms first began and whether there was any sudden change (rapid worsening may suggest an underlying disease).
  • Whether penile or urethral pain, urinary symptoms, or neurological symptoms (sensory abnormalities) are present.
  • Whether there is cardiovascular disease, hepatic or renal failure, or use of liver medications (especially CYP3A4 inhibitors).

Examples of General Questions to Ask the Doctor

• "How do you distinguish whether my symptoms are primary or secondary?"
• "What are the expected effects and side effects of the recommended treatment options?"
• "Which should I try first: medication treatment (such as dapoxetine or an SSRI) or behavioral therapy?"
• "Should my partner be included in the treatment process? Is couples therapy necessary?"
• "I am currently taking medication (or have cardiovascular disease). Is it safe for me to take a specific medication such as dapoxetine?"

Examples of Condition-Specific Questions

• "In my case (including the symptom onset and IELT), is this primary or secondary, and what additional tests might be needed?"
• "If I use a topical anesthetic ointment, could it transfer to my partner and cause problems? How should I use it safely?"

(Please consult a specialist and determine an examination and treatment plan suited to your individual circumstances based on the information provided during the appointment.)