madman
Super Moderator
Disorders of Ejaculation: An AUA/SMSNA Guideline (2022)
Alan W. Shindel,* Stanley E. Althof, Serge Carrier, Roger Chou, Chris G. McMahon, John P. Mulhall, Darius A. Paduch, Alexander W. Pastuszak, David Rowland, Ashley H. Tapscott, and Ira D. Sharlip
Purpose: Men who ejaculate before or shortly after penetration, without a sense of control, and who experience distress related to this condition may be diagnosed with premature ejaculation (PE), while men who experience difficulty achieving sexual climax may be diagnosed with delayed ejaculation (DE). The experience of many clinicians suggests that these problems are not rare and can be a source of considerable embarrassment and dissatisfaction for patients. The role of the clinician in managing PE and DE is to conduct an appropriate investigation, provide education, and offer available treatments that are rational and based on sound scientific data.
Materials and Methods: The systematic review utilized to inform this guideline was conducted by a methodology team at the Pacific Northwest Evidence-based Practice Center. A research librarian conducted searches in Ovid MEDLINE (1946 to March 1, 2019), the Cochrane Central Register of Controlled Trials (through January 2019), and the Cochrane Database of Systematic Reviews (through March 1, 2019). An updated search was conducted on September 5, 2019. Database searches resulted in 1,851 potentially relevant articles. After a dual review of abstracts and titles, 223 systematic reviews and individual studies were selected for full-text dual review, and 8 systematic reviews and 59 individual studies were determined to meet inclusion criteria and were included in the review.
Results: Several psychological health, behavioral, and pharmacotherapy options exist for both PE and DE; however, none of these pharmacotherapy options have achieved approval from the United States Food and Drug Administration and their use in the treatment of PE and DE is considered off-label.
Conclusion: Disturbances in the timing of ejaculation can pose a substantial impediment to sexual enjoyment for men and their partners. The Panel recommends shared decision-making as fundamental in the management of disorders of ejaculation; involvement of sexual partner(s) in decision making, when possible, may allow for optimization of outcomes.
IT is typical for men to be able to exert at least partial control of if and when they ejaculate during partnered sexual encounters and masturbation. If a man does not feel that he has control of when ejaculation occurs, and if there is distress on the part of the man or his sexual partner(s), either premature ejaculation (PE) or delayed ejaculation (DE) may be present (Supplemental Material A, American Urological Association). The diagnosis is determined by the application of specified time-based criteria to when/if ejaculation occurs. Disorders of the timing of ejaculation can pose a major impediment to sexual satisfaction for both men and their partners. In the most extreme cases, an ejaculatory disorder may lead to relationship stress or marked trepidation about starting new relationships for men afflicted with the condition.
Although the reported prevalence of clinical PE and DE is less than 5%,1, 2 the experience of many clinicians suggests that these problems are not at all rare. The perception of rarity may stem from the frequency with which other disabling disorders of sexual function, primarily erectile dysfunction (ED), are present in men with comorbid disruption of ejaculation.
Although few treatments have achieved regulatory approval, several interventions can be considered for the management of distressing disruptions of ejaculation latency time (ELT), defined as the time between penetration and ejaculation (see Supplemental Material A, American Urological Association). Education and referral to colleagues with experience in the psychological health evaluation and treatment of sexual problems are essential elements of care for these patients.
GUIDELINE STATEMENTS
Premature Ejaculation
1. Lifelong premature ejaculation is defined as poor ejaculatory control, associated bother, and ejaculation within about 2 minutes of initiation of penetrative sex that has been present since sexual debut. (Expert Opinion)
2. Acquired premature ejaculation is defined as consistently poor ejaculatory control, associated bother, and ejaculation latency that is markedly reduced from prior sexual experience during penetrative sex. (Expert Opinion)
3. Clinicians should assess medical, relationship, and sexual history, and perform a focused physical exam to make the diagnosis of premature ejaculation. (Clinical Principle)
4. Clinicians may use validated instruments to assist in the diagnosis of PE. (Conditional Recommendation; Evidence Level: Grade C)
5. Clinicians should not use additional testing for the evaluation of a patient with lifelong premature ejaculation. (Conditional Recommendation; Evidence Level: Grade C)
6. Clinicians may utilize additional testing as clinically indicated for the evaluation of the patient with acquired premature ejaculation. (Conditional Recommendation; Evidence Level: Grade C)
7. Clinicians should advise patients that ejaculatory latency is not affected by circumcision status. (Conditional Recommendation; Evidence Level: Grade C)
8. Clinicians should consider referring men diagnosed with premature ejaculation to a mental health professional with expertise in sexual health. (Moderate Recommendation, Evidence Level: Grade C)
9. Clinicians should recommend daily SSRIs; on-demand clomipramine or dapoxetine (where available); and topical penile anesthetics as first-line agents of choice in the treatment of premature ejaculation. (Strong Recommendation; Evidence Level: Grade B)
*Off-label selective SSRIs and clomipramine
*Topical Anesthetics
10. Clinicians may consider on-demand dosing of tramadol for the treatment of premature ejaculation in men who have failed first-line therapy pharmacotherapy. (Conditional Recommendation; Evidence Level: Grade C)
11. Clinicians may consider treating men with premature ejaculation who have failed first-line therapy with a1-adrenoreceptor antagonists (Expert Opinion)
12. Clinicians should treat comorbid erectile dysfunction in patients with premature ejaculation according to the AUA Guidelines on Erectile Dysfunction. (Expert Opinion)
13. Clinicians should advise men with premature ejaculation that combining behavioral and pharmacological approaches may be more effective than either modality alone. (Moderate Recommendation; Evidence Level: Grade B)
14. Clinicians should advise patients that there is insufficient evidence to support the use of alternative therapies in the treatment of premature ejaculation. (Expert Opinion)
15. Clinicians should inform patients that surgical management (including injection of bulking agents) of premature ejaculation should be considered experimental and only be used in the context of an ethical board-approved clinical trial. (Expert Opinion)
Delayed Ejaculation
16. Lifelong delayed ejaculation is defined as lifelong, consistent, bothersome inability to achieve ejaculation, or excessive latency of ejaculation, despite adequate sexual stimulation and the desire to ejaculate. (Expert Opinion)
17. Acquired delayed ejaculation is defined as an acquired, consistent, bothersome inability to achieve ejaculation, or an increased latency of ejaculation, despite adequate sexual stimulation and the desire to ejaculate. (Expert Opinion)
EVALUATION AND DIAGNOSIS
18. Clinicians should assess the medical, relationship, and sexual history and perform a focused physical exam to evaluate a patient with delayed ejaculation. (Clinical Principle)
19. Clinicians may utilize additional testing as clinically indicated for the evaluation of delayed ejaculation. (Conditional Recommendation; Evidence Level: Grade C)
TREATMENTS
20. Clinicians should consider referring men diagnosed with lifelong or acquired delayed ejaculation to a mental health professional with expertise in sexual health. (Expert Opinion)
21. Clinicians should advise men with delayed ejaculation that modifying sexual positions or practices to increase arousal may be of benefit. (Expert Opinion)
PHARMACOTHERAPY
22. Clinicians should suggest a replacement, dose adjustment, staged cessation, or medications that may contribute to delayed ejaculation. (Clinical Principle)
23. Clinicians should inform patients that there is insufficient evidence to assess the risk-benefit ratio of oral pharmacotherapy for the management of delayed ejaculation. (Expert Opinion)
24. Clinicians may offer treatment to normalize serum testosterone levels in patients with delayed ejaculation and testosterone deficiency. (Expert Opinion)
25. Clinicians should treat men who have delayed ejaculation and comorbid erectile dysfunction according to the AUA Guidelines on Erectile Dysfunction. (Expert Opinion)
26. Clinicians should counsel patients with delayed ejaculation that no currently available data indicates that invasive nonpharmacological strategies are of benefit. (Expert Opinion)
Alan W. Shindel,* Stanley E. Althof, Serge Carrier, Roger Chou, Chris G. McMahon, John P. Mulhall, Darius A. Paduch, Alexander W. Pastuszak, David Rowland, Ashley H. Tapscott, and Ira D. Sharlip
Purpose: Men who ejaculate before or shortly after penetration, without a sense of control, and who experience distress related to this condition may be diagnosed with premature ejaculation (PE), while men who experience difficulty achieving sexual climax may be diagnosed with delayed ejaculation (DE). The experience of many clinicians suggests that these problems are not rare and can be a source of considerable embarrassment and dissatisfaction for patients. The role of the clinician in managing PE and DE is to conduct an appropriate investigation, provide education, and offer available treatments that are rational and based on sound scientific data.
Materials and Methods: The systematic review utilized to inform this guideline was conducted by a methodology team at the Pacific Northwest Evidence-based Practice Center. A research librarian conducted searches in Ovid MEDLINE (1946 to March 1, 2019), the Cochrane Central Register of Controlled Trials (through January 2019), and the Cochrane Database of Systematic Reviews (through March 1, 2019). An updated search was conducted on September 5, 2019. Database searches resulted in 1,851 potentially relevant articles. After a dual review of abstracts and titles, 223 systematic reviews and individual studies were selected for full-text dual review, and 8 systematic reviews and 59 individual studies were determined to meet inclusion criteria and were included in the review.
Results: Several psychological health, behavioral, and pharmacotherapy options exist for both PE and DE; however, none of these pharmacotherapy options have achieved approval from the United States Food and Drug Administration and their use in the treatment of PE and DE is considered off-label.
Conclusion: Disturbances in the timing of ejaculation can pose a substantial impediment to sexual enjoyment for men and their partners. The Panel recommends shared decision-making as fundamental in the management of disorders of ejaculation; involvement of sexual partner(s) in decision making, when possible, may allow for optimization of outcomes.
IT is typical for men to be able to exert at least partial control of if and when they ejaculate during partnered sexual encounters and masturbation. If a man does not feel that he has control of when ejaculation occurs, and if there is distress on the part of the man or his sexual partner(s), either premature ejaculation (PE) or delayed ejaculation (DE) may be present (Supplemental Material A, American Urological Association). The diagnosis is determined by the application of specified time-based criteria to when/if ejaculation occurs. Disorders of the timing of ejaculation can pose a major impediment to sexual satisfaction for both men and their partners. In the most extreme cases, an ejaculatory disorder may lead to relationship stress or marked trepidation about starting new relationships for men afflicted with the condition.
Although the reported prevalence of clinical PE and DE is less than 5%,1, 2 the experience of many clinicians suggests that these problems are not at all rare. The perception of rarity may stem from the frequency with which other disabling disorders of sexual function, primarily erectile dysfunction (ED), are present in men with comorbid disruption of ejaculation.
Although few treatments have achieved regulatory approval, several interventions can be considered for the management of distressing disruptions of ejaculation latency time (ELT), defined as the time between penetration and ejaculation (see Supplemental Material A, American Urological Association). Education and referral to colleagues with experience in the psychological health evaluation and treatment of sexual problems are essential elements of care for these patients.
GUIDELINE STATEMENTS
Premature Ejaculation
1. Lifelong premature ejaculation is defined as poor ejaculatory control, associated bother, and ejaculation within about 2 minutes of initiation of penetrative sex that has been present since sexual debut. (Expert Opinion)
2. Acquired premature ejaculation is defined as consistently poor ejaculatory control, associated bother, and ejaculation latency that is markedly reduced from prior sexual experience during penetrative sex. (Expert Opinion)
3. Clinicians should assess medical, relationship, and sexual history, and perform a focused physical exam to make the diagnosis of premature ejaculation. (Clinical Principle)
4. Clinicians may use validated instruments to assist in the diagnosis of PE. (Conditional Recommendation; Evidence Level: Grade C)
5. Clinicians should not use additional testing for the evaluation of a patient with lifelong premature ejaculation. (Conditional Recommendation; Evidence Level: Grade C)
6. Clinicians may utilize additional testing as clinically indicated for the evaluation of the patient with acquired premature ejaculation. (Conditional Recommendation; Evidence Level: Grade C)
7. Clinicians should advise patients that ejaculatory latency is not affected by circumcision status. (Conditional Recommendation; Evidence Level: Grade C)
8. Clinicians should consider referring men diagnosed with premature ejaculation to a mental health professional with expertise in sexual health. (Moderate Recommendation, Evidence Level: Grade C)
9. Clinicians should recommend daily SSRIs; on-demand clomipramine or dapoxetine (where available); and topical penile anesthetics as first-line agents of choice in the treatment of premature ejaculation. (Strong Recommendation; Evidence Level: Grade B)
*Off-label selective SSRIs and clomipramine
*Topical Anesthetics
10. Clinicians may consider on-demand dosing of tramadol for the treatment of premature ejaculation in men who have failed first-line therapy pharmacotherapy. (Conditional Recommendation; Evidence Level: Grade C)
11. Clinicians may consider treating men with premature ejaculation who have failed first-line therapy with a1-adrenoreceptor antagonists (Expert Opinion)
12. Clinicians should treat comorbid erectile dysfunction in patients with premature ejaculation according to the AUA Guidelines on Erectile Dysfunction. (Expert Opinion)
13. Clinicians should advise men with premature ejaculation that combining behavioral and pharmacological approaches may be more effective than either modality alone. (Moderate Recommendation; Evidence Level: Grade B)
14. Clinicians should advise patients that there is insufficient evidence to support the use of alternative therapies in the treatment of premature ejaculation. (Expert Opinion)
15. Clinicians should inform patients that surgical management (including injection of bulking agents) of premature ejaculation should be considered experimental and only be used in the context of an ethical board-approved clinical trial. (Expert Opinion)
Delayed Ejaculation
16. Lifelong delayed ejaculation is defined as lifelong, consistent, bothersome inability to achieve ejaculation, or excessive latency of ejaculation, despite adequate sexual stimulation and the desire to ejaculate. (Expert Opinion)
17. Acquired delayed ejaculation is defined as an acquired, consistent, bothersome inability to achieve ejaculation, or an increased latency of ejaculation, despite adequate sexual stimulation and the desire to ejaculate. (Expert Opinion)
EVALUATION AND DIAGNOSIS
18. Clinicians should assess the medical, relationship, and sexual history and perform a focused physical exam to evaluate a patient with delayed ejaculation. (Clinical Principle)
19. Clinicians may utilize additional testing as clinically indicated for the evaluation of delayed ejaculation. (Conditional Recommendation; Evidence Level: Grade C)
TREATMENTS
20. Clinicians should consider referring men diagnosed with lifelong or acquired delayed ejaculation to a mental health professional with expertise in sexual health. (Expert Opinion)
21. Clinicians should advise men with delayed ejaculation that modifying sexual positions or practices to increase arousal may be of benefit. (Expert Opinion)
PHARMACOTHERAPY
22. Clinicians should suggest a replacement, dose adjustment, staged cessation, or medications that may contribute to delayed ejaculation. (Clinical Principle)
23. Clinicians should inform patients that there is insufficient evidence to assess the risk-benefit ratio of oral pharmacotherapy for the management of delayed ejaculation. (Expert Opinion)
24. Clinicians may offer treatment to normalize serum testosterone levels in patients with delayed ejaculation and testosterone deficiency. (Expert Opinion)
25. Clinicians should treat men who have delayed ejaculation and comorbid erectile dysfunction according to the AUA Guidelines on Erectile Dysfunction. (Expert Opinion)
26. Clinicians should counsel patients with delayed ejaculation that no currently available data indicates that invasive nonpharmacological strategies are of benefit. (Expert Opinion)
