Disorders of ejaculation include premature ejaculation, delayed ejaculation, retrograde ejaculation, and hematospermia. Lifelong premature ejaculation is defined as ejaculation always or nearly always within 1 minute of vaginal penetration that has been present since the first sexual encounter. Acquired premature ejaculation typically begins after a period of normal function, with ejaculation occurring within 3 minutes of penetration. Treatment options include medications and behavioral techniques. Selective serotonin reuptake inhibitors and tricyclic antidepressants are first-line drugs. Delayed ejaculation applies to a range of issues, from delay to complete absence of ejaculation. Guidelines suggest use of an ejaculatory latency time greater than 25 to 30 minutes for diagnosis. Etiologies include psychological and organic factors, such as adverse effects of medications. Treatment focuses on causal medication discontinuation, psychological interventions, and use of off-label drug therapy. Retrograde ejaculation occurs when semen enters the bladder due to an anatomic, neurogenic, or pharmacologic cause. Treatment options include sympathomimetic medications and surgical correction of anatomic abnormalities. Hematospermia, or blood in the semen, is generally benign and self-limited. However, underlying malignancy is possible and should be considered based on patient age and risk factors. Treatment ranges from reassurance to management of the underlying cause.
Case 3. DJ is a 55-year-old man with a history of diabetes, hypertension, and erectile dysfunction. He presents to your office for evaluation of rapid ejaculation within 1 minute of vaginal penetration with his new sexual partner and associated emotional distress.
Premature Ejaculation
BACKGROUND
Medical specialty societies divide premature ejaculation into the two broad categories of lifelong and acquired.1,2 Lifelong premature ejaculation is defined as ejaculation always or nearly always within 1 minute of penetration that has been present since the first sexual encounter.1 Acquired premature ejaculation typically begins after a period of normal function, with ejaculation occurring within 3 minutes of penetration.2 Diagnosis of both categories typically requires negative personal consequences such as emotional distress, frustration, or avoidance of sexual intimacy.1,2
The exact limits for ejaculatory latency time (ELT) in premature ejaculation are debated. The International Society for Sexual Medicine (ISSM) and Diagnostic and Statistical Manual of Mental Disorders, 5th ed., text revision, use a 1-minute definition.1,3 However, one study showed that approximately 20% of patients seeking treatment ejaculated after 2 minutes.4 Guidelines from the American Urological Association (AUA) and Sexual Medicine Society of North America (SMSNA) define ELT as 2 minutes or less from the time of penetration.2
The current consensus definition of premature ejaculation from the ISSM does not incorporate language inclusive of masturbation latency, oral sex, and men who have sex with men.1 The AUA/SMSNA guidelines use broader language to include penetrative sex.2
Numerous epidemiologic studies have attempted to determine the prevalence of premature ejaculation. The estimated prevalence has been reported to be 5% with use of a 2-minute ELT.1 However, results vary widely and are likely affected by underreporting bias, as the perceived stigma surrounding this diagnosis often discourages patients from seeking treatment.1,5
The pathophysiology remains unclear, with theories focusing on altered sensitivity of 5-hydroxytryptamine receptors, underlying prostatic inflammation, genetic predisposition, hyperthyroidism, and penile hypersensitivity.1,6,7 Patients with acquired premature ejaculation are typically older and have comorbid erectile dysfunction and cardiovascular risk factors.8
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