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Premature ejaculation

Key sources
The following summarized guidelines for the evaluation and management of premature ejaculation are prepared by our editorial team based on guidelines from the European Association of Urology (EAU 2023), the American Urological Association (AUA/SMSNA 2022), and the International Society for Sexual Medicine (ISSM 2014).


1.Screening and diagnosis

Definitions: as per AUA 2022 guidelines, recognize the following definitions:
lifelong PE: poor ejaculatory control, associated bother, and ejaculation within about 2 minutes of initiation of penetrative sex presenting since sexual debut
acquired PE: consistently poor ejaculatory control, associated bother, and ejaculation latency markedly reduced from prior sexual experience during penetrative sex.
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  • Indications for screening

2.Diagnostic investigations

History and physical examination: as per EAU 2023 guidelines, elicit a medical and sexual history including assessment of intravaginal ejaculatory latency time (self-estimated), perceived control, distress and interpersonal difficulty due to the ejaculatory dysfunction for the diagnosis and classification of PE.
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  • Additional testing

3.Medical management

First-line therapy
As per EAU 2023 guidelines:
Offer either dapoxetine or the lidocaine/prilocaine spray as first-line therapy in patients with lifelong PE.
Offer off-label topical anesthetic agents as a viable alternative to oral treatment with SSRIs.

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  • Second-line therapy

  • PDE5 inhibitors

  • Management of comorbidities

4.Nonpharmacologic interventions

Behavioral and psychosexual therapy
As per EAU 2023 guidelines:
Offer behavioral, cognitive and/or couple therapy approaches in patients with PE. Consider advising mindfulness exercises.
Offer psychological/behavioral therapy in combination with pharmacological treatment for the management of patients with acquired PE.

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  • Alternative therapies

5.Surgical interventions

Surgical interventions: as per AUA 2022 guidelines, consider offering surgical management (including injection of bulking agents) in patients with PE only in the context of an ethical board-approved clinical trial.

6.Patient education

General counseling: inform patients that ejaculatory latency is not affected by circumcision status.

7.Follow-up and surveillance

Indications for referral: consider referring patients with PE to a mental health professional with expertise in sexual health.

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  • Assessment of treatment response