AUA practice guideline on premature ejaculation
The Practice Guidelines Committee of the American Urological Association (AUA) has released a new guideline on the treatment of premature ejaculation. “Premature Ejaculation: Guideline on the Pharmacologic Management of Premature Ejaculation” is available online at http:// www.auanet.org/timssnet/products/ guidelines/pme.cfm.
The guideline does not explicitly rate the strength of evidence for recommendations, but it is based on consensus opinion.
While survey findings vary considerably, most epidemiologic studies suggest that premature ejaculation may be the most common male sexual disorder, occurring in 21 percent of men ages 18 to 59 in the United States. There are two forms of premature ejaculation: a primary (lifelong) form that begins when a male first becomes sexually active, and a secondary (acquired) form.
Premature ejaculation is a self-reported diagnosis. A sexual history in which the patient uses language that explicitly communicates the circumstances of the condition is the fundamental basis of assessment, with time to ejaculation as the most important feature. The opinion of a partner can provide a significant contribution to diagnosis. A complete description is essential in distinguishing premature ejaculation from erectile dysfunction because these conditions frequently coexist. Moreover, some men are unaware that loss of erection after ejaculation is normal; thus, they may erroneously complain of erectile dysfunction when the actual problem is premature ejaculation. In patients with concomitant premature ejaculation and erectile dysfunction, the erectile dysfunction should be treated first.
Premature ejaculation can be treated with psychotherapy and behavioral therapy. This guideline is the first to address pharmacologic treatment. Although not approved by the U.S. Food and Drug Administration (FDA) for this indication, oral anti-depressants and topical anesthetic agents have been shown to delay ejaculation in men with premature ejaculation and have minimal side effects when used for this purpose (see accompanying table). Dosages and dosing regimens for premature ejaculation frequently deviate from those used for FDA-approved indications, and this difference should be considered in the risk-versus-benefit assessment of pharmacologic therapy. Treatment with specific oral anti-depressants known to cause anorgasmia and delayed ejaculation should be started at the lowest possible dosage that is compatible with a reasonable chance of success.
Topical anesthetic agents may be applied to the penis before intercourse to delay ejaculation. After topical application, these agents have been used with and without a condom. Prolonged application of topical anesthetic (30 to 45 minutes) has been reported in a significant percentage of men to result in loss of erection because of numbness of the penis. Diffusion of residual topical anesthetic on the penis into the vaginal wall also may result in numbness in the partner.
The choice of additional therapy is based on the patient and partner reports of efficacy, side effects, and acceptance of the therapy as well as on a regular review of alternative approaches. Support and education of the patient and, when possible, the partner are an integral part of therapy for premature ejaculation.
COPYRIGHT 2004 American Academy of Family Physicians
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