Understanding about the origins of ejaculatory disorders remains limited, but treatment options for the conditions continue to evolve, according to a new guideline from the American Urological Association (AUA) and the Sexual Medicine Society of North America.
Key objectives for the clinician are to conduct an appropriate investigation, provide information and education to the patient, and offer rational therapies supported by the available scientific data, as no FDA-approved therapy currently exists for premature ejaculation (PE) or delayed ejaculation (DE), the two most common types of ejaculatory disorders.
“Disorders of ejaculation are quite prevalent and they can lead to substantial disruption of sexual quality of life,” guideline panel member Alan Shindel, MD, said during the AUA virtual meeting. “The AUA guideline is designed to provide practitioners with actionable evidence-based practice approaches to manage these conditions.”
In addition to a review of literature and evidence, the guideline includes 26 recommendations that focus on PE and DE. The guideline defines PE as “lifelong premature ejaculation, consistently poor ejaculatory control associated bother, and ejaculate within about two minutes of initiation of penetrative sex that has been present since sexual debut.” The definition differs from some prior recommendations that established a latency period of one minute.
“This decision was made after careful consideration of the fact that men who had delayed ejaculation latencies in the one- to two-minute range typically have more in common with men having less than one minute,” said Shindel, of the University of California, San Francisco. “The distress and the bother and lack of control they experience tends to be similar. Therefore, it was determined that including men with latency times of one to two minutes would allow for treatment of these men who may experience benefit.”
“This does, however, raise the possibility that some men, based strictly on latency time criteria alone, could be diagnosed falsely with a diagnosis of premature ejaculation.”
Relying on patient self-reported PE can be misleading, according to the guideline. Studies have shown that up to 30% of men have self-reported PE, but few have ejaculation latency times of less than 2 minutes, making the true prevalence of PE more likely in the range of 5%. The guideline distinguishes between primary and acquired PE, the latter defined as poor ejaculatory control and a marked reduction in latency time from prior sexual experience.
The guideline includes 15 recommendations pertaining to PE. The recommendations cover topics such as focused medical and sexual history, use of validated diagnostic instruments, avoidance of unnecessary testing, absence of evidence for a role of circumcision in PE, and mental health consultation.
The SSRI class of antidepressants, particularly clomipramine or dapoxetine, represent first-line treatment with use on demand. Topical penile anesthetics are also recommended. Clinicians may consider on-demand tramadol for patients who do not respond to first-line treatment. Use of alpha-1 receptor antagonists also has a recommendation as second-line treatment, but supported only by expert opinion. The guideline emphasizes a lack of evidence to support alternative therapies and discourages surgical management of any type.
The remaining 11 recommendations address issues related to DE, defined as “lifelong consistent, bothersome inability to achieve ejaculation, or excessive latency, despite adequate sexual stimulation and the desire to ejaculate.” The evaluation should include the patient’s medical, sexual, and relationship history. Additional testing may be considered as indicated. Referral to a mental or sexual health expert may be considered whether a patient has lifelong or acquired DE.
Clinicians should counsel patients about the lack of evidence supporting drug therapies or invasive nonpharmacologic treatment for DE. Testosterone supplementation may be offered to men who have DE in association with testosterone deficiency.
“Careful attention to mental health and partner dynamics is critical for optimizing management,” Shindel said in conclusion.
The complete guideline is available on the AUA website.
Disclosures
Shindel disclosed no relevant relationships with industry.
Source: MedicalNewsToday.com
