Clinical Essentials Guidelines for the diagnosis and treatment of premature ejaculation

Guide

With the increasing demand of people for a better life, the diagnosis and treatment of premature ejaculation related fields has progressed rapidly
.
The Andrology Branch of the Chinese Medical Association organized the preparation of a new version of the guidelines for the diagnosis and treatment of premature ejaculation, adjusted some of the structure of the guidelines, and focused on clinical diagnosis and treatment, which is suitable for the clinical application of the majority of andrologists, hoping to provide useful guidance and help
for clinicians in the diagnosis and treatment of premature ejaculation.
The main points of the medical pulse are compiled as follows for the readers
.

Premature ejaculation classification

Premature ejaculation is divided into 4 categories: primary premature ejaculation, secondary premature ejaculation, natural variability premature ejaculation, subjective premature ejaculation
.
This classification covers different pathophysiological bases and facilitates different treatment options
for patients.

Table 1 Classification of premature ejaculation

Diagnosis and evaluation of premature ejaculation

1.
Medical history

The diagnosis of premature ejaculation is based on history, particularly sexual history
.
A detailed history distinguishes between primary, secondary, natural variability, and subjective premature ejaculation
.
Questions should include the time to latency of intravaginal ejaculation (IELT), the time of onset of premature ejaculation (premature ejaculation from the first sexual activity or after a certain point in time), and whether it is natural variability (in a particular environment or with a particular partner).

In addition, attention should be paid to the control of ejaculation, satisfaction of both parties, the degree of sexual stimulation, the impact on sexual activity and quality of life, and the use and abuse of
drugs.
When taking a medical history, it is necessary to ask about erectile function, libido, orgasm and other sexual features, as well as urination status, perineal pain and other symptoms, to distinguish it from erectile dysfunction (ED), chronic prostatitis and other diseases, while noting that ED and chronic prostatitis are often combined with premature ejaculation, and attention should be paid to asking about premature ejaculation in these patients
.

2.
IELT

IIELT's definition: The time between the insertion of the penis into the vagina and the onset of ejaculation, which can be measured
by a stopwatch.
In daily outpatient work, self-assessed IELT (eIELT) or stopwatch measured IELT (sIELT) can be used to distinguish the type of premature ejaculation, but in the evaluation of normal male sex time, eIELT has a higher trend than sIELT, and direct replacement is
not recommended.

3.
Premature ejaculation assessment questionnaire

At present, there are three kinds of questionnaires commonly used, namely the Premature Ejaculation Brief Form (PEP), Premature Ejaculation Index (IPE), and Premature Ejaculation Diagnostic Tool (PEDT).

Of these three scales, PEDT is more widely
used.

Patients with premature ejaculation are often accompanied by psychological abnormalities, and a mental health questionnaire is also necessary
for patients with premature ejaculation.
If possible, various psychological scales can be applied, and for premature ejaculation patients with serious mental illness, it is recommended to go to a professional psychiatrist or psychologist for further evaluation and treatment
.

4.
Diagnostic process

Figure 1 Flow chart of premature ejaculation diagnosis

Table 2 Evidence-based and recommended levels for the diagnosis of premature ejaculation

Treatment of premature ejaculation

The treatment of premature ejaculation includes: medication, behavioral therapy, psychosexual intervention, and comprehensive treatment should receive more attention
to improve efficacy and adherence.

1.
Psychological and behavioral therapy: From the perspective of clinical experience, psychological counseling and education of patients and spouses should be ranked in the first place in the treatment of premature ejaculation, and all premature ejaculation patients seeking treatment should receive basic psychosexual education or counseling
.
Including: (1) the prevalence of premature ejaculation in the general population and the average IELT to eliminate the misunderstanding of premature ejaculation; (2) Depict a harmonious and satisfying sexual process to improve the sexual interest of premature ejaculation patients and their partners, and encourage good communication
about sexual life between patients and partners.

2.
Drug combination psycho-behavioral therapy: Although there is insufficient evidence to support the efficacy of psycho-behavioral therapy alone, there have been a number of controlled studies comparing drug combination psycho-behavioral therapy with drug therapy alone to support the superiority
of combination therapy.

3.
Drug therapy: including approved indications for premature ejaculation treatment, such as on-demand dapoxetine, topical lidocaine cream or spray (local desensitizer), or other selective 5-HT reuptake inhibitors (SSRIs).

(1) Dapoxetine: Dapoxetine is the first and so far the only oral drug approved for premature ejaculation indications, the initial dose of treatment is recommended to be 30 mg, can be taken with a glass of water 1~3h before sexual intercourse, up to 1 time a day, generally 6 times within 4 weeks after use evaluation
.

(2) Other SSRIs: including citalopram, fluoxetine, clofloxamine, paroxetine and sertraline, all of which have common pharmacological effects but are not approved for the treatment of premature ejaculation
.

(3) Local anesthetics: there are currently gels, creams, sprays and other dosage forms, the ingredients include lidocaine, proprivacaine or different combinations with other drugs, commonly used are compound chamomile lidocaine cream / gel, lidocaine/proprivacaine spray, etc
.
Generally, it is used 5~10 minutes before sex, and is applied or sprayed on the front of the penis and around
the frenulum.

(4) Other drug treatment: including type 5 phosphodiesterase inhibitor (PDE5i), α1 adrenergic blocker, tramadol, etc
.

Table 3 Recommended levels of premature ejaculation drug treatment

4.
Traditional Chinese medicine treatment: based on dialectical treatment, it can also be combined with external treatment methods such as acupuncture, external washing of Chinese medicine and other means
.

(1) Dialectical treatment: liver qi depressed type, renal qi insolid type, renal yin deficiency type, lower scorching humid heat type, heart and kidney incommunicado type and kidney deficiency liver depression type
.

Table 4 Dialectical treatment of premature ejaculation

(2) External treatment: (1) Acupuncture therapy mainly emphasizes the treatment of heart and kidney, and acupuncture points are mainly based on the heart and kidney meridians and Ren Du veins, and attaches importance to the role of
adjusting the mind.
Choose the main acupoints: kidney Yu, Qi Hai, Guan Yuan, three yin intercourse, Neiguan, Shenmen, if accompanied by kidney yin deficiency and deficiency, Taixi, if humid heat bet plus Zhongji, Yin Ling Spring, kidney yang deficiency plus life gate, Yang pool, liver qi stagnation plus Tai Chong, Hegu, acupuncture once a day or every other day, twisting and laxative method, leaving needles for 30 minutes, can also be combined with moxibustion therapy, easy to operate, easy to implement
。 (2) Chinese medicine is commonly used for external use of pentabit, snake monnieri and cloves Chinese medicine water after frying with hot air to smoke the head of the penis, soak the penis after the temperature is suitable, soak the drug once a day or use alcohol for 3~7 days, take the supernatant for storage, spray on the head of the penis, coronal groove, frenulum and other parts of the penis 30 min before sexual life, and spray evenly to make it naturally absorbed, and wash it with water before sex
.
20 days is 1 course of treatment
.
(3) Combination of traditional Chinese and Western medicine can consider the combination of traditional Chinese and Western medicine treatment on the basis of traditional Chinese medicine treatment, such as dapoxetine combined with imsack tablets, Qiao Peony Fang, Chaihu Evacuating Liver and Loosening Yiyang Capsules, etc.
, there is evidence that the therapeutic effect of dapoxetine combined with traditional Chinese medicine is better and safe and well tolerated
.

5.
Surgical treatment: The surgical treatment of premature ejaculation mainly refers to the selective dissection of the dorsal nerve of the penis, and its treatment principle is to reduce sensory afference and increase the patient's sensory threshold during the ejaculation process, so as to prolong IELT and improve the sexual satisfaction
of patients and their partners 。 The indications for this surgery are patients with primary premature ejaculation, stable partner, regular sexual life for more than 6 months, stable psychological state, and the following conditions: (1) normal erectile function; (2) Increased excitability/sensitivity of the head of the penis; (3) Sexual life seriously affects the relationship between husband and wife; (4) Those who voluntarily give up conservative therapy and have a strong willingness for surgical treatment
.

References:

1.
Premature Ejaculation Diagnosis and Treatment Writing Group, Andrology Branch of Chinese Medical Association.
Guidelines for the diagnosis and treatment of premature ejaculation[J].
Chinese Journal of Andrology,2022,28(7):656-665.
)