This presentation discusses clinical case scenarios for management of premature ejaculation in Delhi India. This slides contain 1. Definition of Premature Ejacualtion 2. Management Aids 3. Clinical algorithm 4. Novel treatment modalities

1. PREMATURE EJACULATIONTreatment in
Delhi
How do I treat?
Dr. Vijayant Govinda Gupta
MBBS MS MCh Urology
Consultant Andrologist
Govinda Healthcare
New Delhi India

2. Evidence-based definition of lifelong PE:
The International Society for Sexual Medicine
• PE is a male sexual dysfunction characterized by:
– Ejaculation which always or nearly always occurs prior to
or within about one minute of vaginal penetration; and
– Inability to delay ejaculation on all or nearly all vaginal
penetrations;
and
– Negative personal consequences, such as
distress, bother, frustration and/or the avoidance of sexual
intimacy

3. Lifelong PE Acquired PE
• Previously called ‘primary’ PE
• Occurs from the first sexual
encounter and continues on
throughout adulthood
• Previously called ‘secondary’ PE
• Occurs after a period of normal
sexual functioning
• May be related to performance
anxiety, ED or, occasionally,
surgical problems (Phimosis)
• Involves a substantial decrease
in time-to-ejaculation
compared with previous sexual
experience

4. Estimated IELT Reported by Men with
“Normal” Ejaculation and by their Partners
Estimated IELT (minutes)
Men Women
USA 13.6 11.2
UK 9.9 8.5
France 9.3 8.4
Germany 6.9 7.4
Italy 9.6 8.6
India = ?? Research needed
What is Normal ?

5. Normal Male Sexual Response
Time
Sexual interest/
stimulation
Penile
tumescence
High arousal /
penile erection
Plateau
Orgasm Ejaculation
accompanied
by orgasm
Penile
detumescence
Resolution
Adapted from Donatucci (2006) J Sex Med 3(suppl 4):303–308
Excitement
Penetration

6. PE
Time
Rapid ejaculation and
associated orgasm with
normal erection
Normal response
Adapted from Donatucci (2006) J Sex Med 3(suppl 4):303–308
Short plateau phase
Steep excitement
phase with normal
erection
Premature Ejaculation

7. Treatment Options
• Behavioral Therapy
• Surgical Therapy (Circumcision)
• Local Anesthetic Application
• Pharmacological
– PDE5 inhibitors (For concomitant ED)
– Tricyclic antidepressant (clomipramine)
– Selective Serotonin Reuptake Inhibitors (SSRI’s)
– Dapoxetine

8. Novel (Research)
• On demand Silodosin

9. Behavioral Therapy
• Mental Control – 3C’s
– Calmness
– Confidence
– Control
• Squeeze technique (Stop – Start technique)
• Stop start flow of urine or Kegels to
strengthen Pelvic Floor

10. Topical Therapy
• Desensitizing creams or sprays use
lidocaine (Emla) or lidocaine with prilocaine
applied 20-30 minutes prior to sexual
activity
– Lessen penile sensitivity during foreplay and
intercourse – Thus delaying Ejaculation

11. New topical penile spray using a combination
of lidocaine and prilocaine to treat PE
Study of 43 men with PE
Drug Placebo
Number of men 20 23
Baseline IELT (min) 1.0 0.9
Follow-up (min) 4.9 1.6
Dinsmore WW et al. BJU International 99:369-375, 2007 (Feb)

12. PDE 5 Inhibitor
Efficacy of Sildenafil for Premature Ejaculation and
Post-Ejaculatory Refractory Time
Double-blind placebo-controlled study
157 men with PE ages 18-65 (mean 43 yrs)
Compared sildenafil (50-100 mg) to placebo
McMahon CG, Stuckey BGA, Andersen M, et al. J Sex Med 2: 368-375, 2005

13. Results
No significant difference between sildenafil and
placebo in IELT (Time) (In men without ED)
Sildenafil-treated men had greater ejaculatory control
and sexual satisfaction scores
Sildenafil-treated men had decreased post-ejaculatory
refractory time (Re erection after Ejaculation)
McMahon CG, Stuckey BGA, Andersen M, et al. J Sex Med 2: 368-375, 2005

14. PME plus ED
Recommendation (AUA Guideline)
In patients with concomitant PE
and ED, the ED should be treated
first.
•Many patients with ED develop secondary PE
•Premature ejaculation may improve in patients when concomitant ED is effectively
treated.

15. Antidepressants (SSRI)
• Antidepressants cause anorgasmia and
delayed ejaculation.
• These antidepressants include selective
(SSRIs) — fluoxetine, paroxetine, and
sertraline

16. The problem of Dosing
• Most SRI work best with continuous dosing –
Which increases the chance of side effects
• The solution Ultrashort acting Dapoxetine

17. Dapoxetine (Duralast)
A highly potent ultra short acting inhibitor of serotonin
reuptake transporter
Following oral administration, it is rapidly absorbed
After reaching T max, serum concentration declines rapidly
At 60 mg dose: T max = 1.2 hr
T ½ initial = 1.5 hr
Single dose and multiple dose pharmacokinetics are similar
No interaction when used with food, alcohol or PDE5 inhibitors

18. 0.5
0.8
0.3
0.50.5
1.4*
0.3
0.9*
0.5
1.8*
0.3
1.2*
0
0.5
1
1.5
2
2.5
3
Baseline<1min Endpoint<1min Baseline<0.5min Endpoint<0.5min
MeanIELT(Min)
Placebo Dapoxetine 30 mg Dapoxetine 60 mg
Pooled IELT values at endpoint for baseline IELT ≤1min & ≤0.5min †
Dapoxetine IELT for ≤1min &
≤0.5min
McMahon et al. (2008) Presented at ESSM/ISSM
Fold Increase=4.3Fold Increase=3.4
Fold Increase=2.7 Fold Increase=3.4
IELT≤Imin IELT≤0.5min

19. Dapoxetine
• 60 Mg better than 30 mg
• Increases IELT 3 to 4 times
• Takes 6 to 12 weeks to exert full effect

20. Case Scenarios

21. Case 1
• Young Boy
• 19 Year old Virgin
• No partner
• Suffering from PME
• On Examination
– Phimosis
– UTI

22. Management
• Counseling (Dispel fears on
Masturbation/STD)
• Correct Phimosis and treat UTI
• Placebo – Multi Vitamins
• Behavioral Therapy

23. Case 2
• Newly married
• 25 years old
• Physically normal
• Sexually Naïve / Complaining of new onset ED
• Initial 2 3 episodes with wife
• Overtly anxious
• No PME earlier

24. Management
• Counseling/ Relieve anxiety
• Add On Demand PDE5 Inhibitor
• Add on Local therapy
• Confidence building measures

25. Case 3
• 35 year old married man
• Family complete
• Life Long PME
• No ED

26. Management
• Counseling/ Master and Johnson technique
• Dapoxetine (start with 30 and go to 60 mg)
• Add Local therapy

27. Case 4
• 60 year old retired recently widowed man
• Diabetic/Hypertensive
• Good libido/ New partner
• Both ED and PME

28. Management
• Counseling/ Behavioral
• Correct Serum testosterone
• Add PDE 5 inhibitors
• Then add Local therapy
• Start Dapoxetine – Be careful with
antihypertensives

29. Latest On demand Sildosin
• The inhibition of ARs α1A induces smooth muscle cells
relaxation of the vas deferens (VD), seminal vesicles
(SV) and prostate and may lead to an ejaculatory
delay
• Suppression of seminal emission may induce an
enlarged ejaculatory latency.
• Silodosin proved to be advantageous when taken on-
demand, 2 to 3 hours before sexual intercourse.
Subjects experienced a reduction in anxiety and PE
related symptoms, with a significant improvement in
IELT and PE profile (PEP).

31. Results

32. Other reports

33. Summary
Patient presents with suspected PE
• Establish PE diagnosis using ISSM definition
• Perform a sexual, medical and psychological history and physical examination
Is PE secondary to ED or other condition?
NO
ACQUIRED PE
• Behavioural therapy
• Pharmacotherapy 
relationship counselling
YES
Manage
primary cause
first
LIFELONG PE
• Pharmacotherapy
• Behavioural therapy +
relationship counselling
Patient
preference
Adapted from 1. McMahon et al, 2004. 2. Hatzimouratidis K et al, 2010 3. Althof et. al, 2010
PE management algorithm