In Search of Effective Treatment for Premature Ejaculation: ‘I Really Have No Idea’

WASHINGTON — After decades of study and treatment refinement, urologists and sex therapists, along with their patients, remain flummoxed by the origins of premature ejaculation.

Presented with the discussion topic, “Do We Actually Help Patients With Premature Ejaculation?” the answer seemed obvious to Daniel Watter, EdD, of the Morris Psychological Group in Parsippany, New Jersey.

“Of course we do. We’ve all seen it,” Watter said during the Society of Sexual Medicine of North America [SMSNA] session at the American Urological Association meeting.

But after some reflection, he decided, “Well, sometimes we do well.”

As Watter continued to delve into the literature and evidence, the answer evolved.

“Really, it depends.”

“Maybe we do.”

“I’m not really sure that we do.”

And finally, “After preparing this presentation and thinking about my own clinical experience, I really have no idea.”

Back to the Basics

Confusion over the answer to the question posed in the session title goes back to the limited literature on the topic and data that “can be very confusing.” For example, some researchers estimate that PE affects 5-15% of adult men, but others suggest the prevalence might be as high as 33%, said Watter. The precise etiology remains unknown. Most outcome studies have been “problematically designed,” lacked control groups, and had small sample sizes, poor outcome measures, and lack of follow-up.

“Most of our outcome studies rely on patient self-report, which is notoriously unreliable,” he said. “However, the few that are more methodologically sound have suggested improved outcome measures.”

Definitions and terminology associated with PE vary, but most include three key principles or concepts:

• Ejaculation occurs with minimal stimulation or short latency period
• Lack of ability to delay or postpone ejaculation
• Negative consequences related to distress or concern

The criteria apply only to partnered sex, Watter emphasized. Most men report attenuation of symptoms during solo masturbation.

“This is something that I think requires a lot more attention and that I think is often overlooked, because this is true with most male sexual dysfunction,” he said. “I’m sure we’ve all seen this. Men with ED [erectile dysfunction] typically have no difficulty with masturbation, as do men with PE. Men with no sexual desire typically have a rather robust masturbatory sex life.”

The field of sexual medicine has identified several subtypes of PE, which can help inform discussions with patients and among sex therapists.

• Lifelong: problematic for the patient since first attempts at sexual intercourse
• Acquired: functioned well at one point but not now
• Global: occurs in all sexual encounters
• Situational: occurs in specific situations or circumstances
• Intermittent: the most puzzling and probably the most difficult to treat

“We have very limited data about how we do with each of these subtypes, and we also don’t know what interventions are going to be most effective with each subtype,” said Watter.

Treatment Options

The field of sexual medicine has “a lot” to offer men with PE, beginning with behavioral interventions, such as squeeze technique and stop/start technique.

“These can be effective, although most of the time when behavioral techniques do not work, it is because of poor patient compliance or, surprisingly common, practitioners not being consistent in how they give the instructions,” said Watter. “Very often patients are taught to do these retraining exercises in a way that is incorrect.”

Other options include:

• Off-label use of selective serotonin reuptake inhibitor (SSRI)-class antidepressants to delay ejaculatory latency: Ironically, paroxetine seems to be most effective but least prescribed and escitalopram (Lexapro) is prescribed most often but has relatively poor efficacy, said Watter.
• Tramadol, clomipramine, and intracavernosal self-injections: often recommended to men who have not responded to an SSRI, despite a lack of efficacy data.
• Topical anesthetics and desensitizing sprays and creams.
• Constriction devices.
• Pelvic floor physiotherapy.

“Combined psychological and pharmacological therapy has become the gold standard, as we have increasingly recognized the complexities and the impacts of PE on the man and his partner,” said Watter. “We know that treatment efficacy is improved when treatment decisions include the partner, for those in partner relationships. More information will be forthcoming, especially when the [SMSNA] climax registry is available [expected later this year].”

Asked by the audience about his own approach to treating lifelong and acquired PE, Watter said men with lifelong PE “actually respond pretty well to behavioral training exercises, if they follow the protocols correctly and they are willing to put in the time. That, oftentimes with an SSRI, has been very helpful.”

Acquired PE is more complicated.

“Does it have anything to do with the partner?” he asked. “In other words, is there something about the way these two people interact that might somehow be disrupting the man’s ability to control his ejaculation? Or is there something more psychological going on? I would probably dig a little deeper psychologically on the acquired cases than on the lifelong cases.”

Asking the Right Question

Perhaps the difficulty with PE lies not in answering the question posed by the session title but in the question itself, Watter suggested.

“Maybe we should be asking a different question, not do we actually help, but do we help enough,” he said.

The alternative question has its origin in a passage from “Fires in the Dark: Healing the Unquiet Mind,” by clinical psychologist Kay Redfield Jamison, PhD.

“She looks at what really is healing, what contributes to the healing process, both psychologically and medically,” said Watter. “Very early in the book she makes a comment that I think is really simple but profound: ‘To treat, even to cure, is not always to heal.’ This observation needs to be more seriously considered by those of us in sexual medicine and therapy. We can often ameliorate symptoms, but we really haven’t assessed whether or not this alleviates the distress or the personal and/or relational dissatisfaction of our patients.”

“We’ve seen this clearly in our treatment of ED, as evidenced by the high treatment dropout rate,” he continued. “We need to have the same consideration for our patients with PE. We may remove the symptom, but does this result in more sexually, relationally, existentially satisfied patients? I think this is a vitally important question.”

During a discussion, Alan Shindel, MD, of the University of California San Francisco, asked whether a man’s fixation on ejaculatory latency contributes more to the problem than the latency itself. “Not clinical PE, the 30-second guy, but more the 1- to 2-minute guys, who fixate so much on the notion that if [they last longer] ‘my partner will orgasm.’ So much of that is miscommunication, misunderstanding about what happens.”

Watter agreed.

“This is true for men with PE, and it is true for men with ED,” he said. “They are so fixated on the outcome that it detracts from any pleasure they might experience or that their partners might experience. Men have told me that when they take an SSRI, for example, and it seems to be helpful, and I ask them whether they enjoyed sex, they will usually say, ‘I felt relieved.’ They feel relief, not pleasure, not joy, just relief. What happens is this obsession creates a much higher level of anxiety.”