Page 77 - Remedial Andrology

assessed the efficacy and safety of oxytocin receptor antagonists in the treatment of PE [837]. Epelsiban [838]
and cligosiban [839-841] have been found to be safe and mildly effective in delaying ejaculation, but further
controlled trials are needed [841].

The role of other proposed treatment modalities for the treatment of PE such as penis-root masturbation
[842], vibrator-assisted start-stop exercises [745], transcutaneous functional electric stimulation [843],
transcutaneous posterior tibial nerve stimulation [844], and practicing yoga [845] need more evidence to be
considered in the clinical setting.

6.2.7 Summary of evidence on the epidemiology/aetiology/pathophysiology of PE

Summary of evidence LE
Pharmacotherapy includes either dapoxetine on-demand (an oral short-acting SSRI) and eutectic 1a
lidocaine/prilocaine spray (a topical desensitising agent) which are the only approved treatments for
PE, or other off-label antidepressants (daily/on-demand SSRIs and clomipramine).

6.2.8 Recommendations for the treatment of PE

Recommendations Strength rating
Treat erectile dysfunction (ED), other sexual dysfunction or genitourinary infection (e.g., Strong
prostatitis) first.
Use either dapoxetine or the lidocaine/prilocaine spray as first-line treatments for lifelong Strong
premature ejaculation (PE).
Use off-label topical anaesthetic agents as a viable alternative to oral treatment with Strong
selective serotonin re-uptake inhibitor (SSRIs).
Use tramadol on-demand as a weak alternative to SSRIs. Weak
Use PDE5Is alone or in combination with other therapies in patients with PE (without ED). Stong
Use psychological/behavioural therapies in combination with pharmacological treatment in Weak
the management of acquired PE.

6.3 Delayed Ejaculation
6.3.1 Definition and classification
The American Psychiatric Association defines delayed ejaculation (DE) as requiring one of two symptoms as
follows: marked delay, infrequency, or absence of ejaculation on 75-100% of occasions, that persists for at
least 6 months, and which causes personal distress [200]. However, in a recent study, while ejaculatory latency
and control were significant criteria to differentiate men with DE from those without ejaculatory disorders,
bother/distress did not emerge as a significant factor [846]. Similar to PE, there are distinctions among lifelong,
acquired and situational DE [200]. Although the evidence is limited, the prevalence of lifelong DE and acquired
DE is estimated around 1% and 4%, respectively [201].

6.3.2 Pathophysiology and risk factors
The aetiology of DE can be psychological, organic (e.g., incomplete spinal cord lesion or iatrogenic penile
nerve damage), or pharmacological (e.g., SSRIs, antihypertensive drugs, or antipsychotics) [847, 848] (Table
20). Other factors that may play a role in the aetiology of DE include tactile sensitivity and tissue atrophy [849].
Although low testosterone level has been considered a risk factor in the past [55, 687], more contemporary
studies have not confirmed any association between ejaculation times and serum testosterone levels [850,
851]. Idiosyncratic masturbation and lack of desire for stimuli are also proposed risk factors for DE [195-197].

76 SEXUAL AND REPRODUCTIVE HEALTH - MARCH 2021