Guideline sources The following summarized guidelines for the evaluation and management of premature ejaculation (PE) 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 2 3 Guidelines 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. E As per ISSM 2014 guidelines, recognize that PE is defined as a male sexual dysfunction characterized by ejaculation always or nearly always occurring before or within about 1 minute of vaginal penetration, either present from the first sexual experience or following a https://web.pathway.md/diseases/recl3M8tcAoHx8b8w 1/6 6/29/23, 11:25 PM Premature ejaculation Pathway new bothersome change in ejaculatory latency, and the 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. E Indications for screening: Insufficient evidence to recommend screening or case finding for PE, either in a general population or in any subpopulation. I Screen patients with erectile dysfunction for PE. E 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. A Show 3 more As per AUA 2022 guidelines: Elicit a medical, relationship, and sexual history and perform a focused physical examination for the evaluation of patients with PE. B Consider using validated instruments to assist in the diagnosis of PE. C As per ISSM 2014 guidelines, elicit a medical and psychosocial history for the evaluation of PE. E Show 4 more Additional testing: As per EAU 2023 guidelines, do not advise measuring intravaginal ejaculation latency time using a stopwatch. D Show 2 more As per AUA 2022 guidelines: Do not obtain additional testing for the evaluation of patients with lifelong PE. D Consider obtaining additional testing, as clinically indicated, for the evaluation of patients with acquired PE. C 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. A Offer off-label topical anesthetic agents as a viable alternative to oral treatment with SSRIs. A As per AUA 2022 guidelines, offer daily SSRIs, on-demand clomipramine or dapoxetine (where available), and topical penile anesthetics as first-line pharmacotherapies for the https://web.pathway.md/diseases/recl3M8tcAoHx8b8w 2/6 6/29/23, 11:25 PM Premature ejaculation Pathway treatment of patients with PE. B As per ISSM 2014 guidelines, offer on-demand dosing of dapoxetine for the treatment of patients with lifelong and acquired PE. E Show 2 more Second-line therapy: As per EAU 2023 guidelines, consider offering tramadol on-demand as a weak alternative to SSRIs. C As per AUA 2022 guidelines, consider offering on-demand dosing of tramadol C or alpha-1 adrenergic receptor antagonists for the treatment of patients with PE failed first-line therapy. E As per ISSM 2014 guidelines, consider offering tramadol for the treatment of patients with PE when other therapies have failed because of the risk of addiction and side effects. Do not combine tramadol with SSRIs because of the risk of serotonin syndrome, a potentially fatal outcome. E Phosphodiesterase-5 inhibitors: As per EAU 2023 guidelines, offer PDE5 inhibitors alone or in combination with other therapies in patients with PE (without erectile dysfunction). A As per ISSM 2014 guidelines, do not offer off-label on-demand or daily dosing of PDE5 inhibitors for the treatment of patients with lifelong PE with normal erectile function. D Management of comorbidities: As per EAU 2023 guidelines, treat erectile dysfunction, other sexual dysfunction or genitourinary infection (such as prostatitis) first. A As per AUA 2022 guidelines, treat comorbid erectile dysfunction in patients with PE according to the guidelines for erectile dysfunction. E As per ISSM 2014 guidelines, offer pharmacotherapy for erectile dysfunction in patients with PE and comorbid erectile dysfunction. Consider offering combination pharmacotherapy for erectile dysfunction and PE in patients with PE and comorbid erectile dysfunction. E 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. B Offer psychological/behavioral therapy in combination with pharmacological treatment for the management of patients with acquired PE. B As per AUA 2022 guidelines, consider offering combination therapy with behavioral and pharmacological approaches rather than monotherapy with either modality in patients with PE. C As per ISSM 2014 guidelines: https://web.pathway.md/diseases/recl3M8tcAoHx8b8w 3/6 6/29/23, 11:25 PM Premature ejaculation Pathway Consider offering psychological/behavioral interventions in combination with pharmacological treatment in patients with acquired PE if there is a clear psychosocial precipitant and in patients with lifelong PE if the individual or couple's responses to PE are likely to interfere in the medical treatment and ultimate success of therapy. Consider offering psychological/behavioral interventions in combination with pharmacological treatment in patients with PE and comorbid erectile dysfunction, to manage the psychosocial aspects of these sexual dysfunctions. E Alternative therapies: insufficient evidence to support the use of alternative therapies for the treatment of patients with PE. I 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. E As per ISSM 2014 guidelines, do not perform selective dorsal nerve neurotomy or glans penis augmentation using hyaluronic acid gel for the management of patients with PE because of the associated risk of permanent loss of sexual function. D 6. Patient education General counseling: inform patients that ejaculatory latency is not affected by circumcision status. B 7. Follow-up and surveillance Indications for referral: consider referring patients with PE to a mental health professional with expertise in sexual health. C Assessment of treatment response: Consider assessing treatment outcome with the Clinical Global Impression of Change question, asking the patient how would he describe his PE problem compared to before starting treatment: much worse worse slightly worse no change slightly better better much better. E Use the Premature Ejaculation Profile or Index of Premature Ejaculation questionnaires for monitoring responsiveness to treatment. E https://web.pathway.md/diseases/recl3M8tcAoHx8b8w 4/6 6/29/23, 11:25 PM Premature ejaculation Pathway Clinical findings Symptoms Past medical history Anxiety Chronic prostatitis/chronic pelvic pain syndrome Decreased libido Depression Decreased sexual pleasure because of poor control over ejaculation Depression Ejaculation sooner than expected Ejaculation that routinely occurs with little sexual stimulation and with little control Erectile dysfunction Feelings of guilt, embarrassment or frustration Lack of control over ejaculation Provoked by stress Social history Negative sexual experiences in childhood Problems within the relationship Religious beliefs References 1. Alan W Shindel, Stanley E Althof, Serge Carrier et al. Disorders of Ejaculation: An AUA/SMSNA Guideline. J Urol. 2022 Mar;207 3 504 512. Open 2. Stanley E Althof, Chris G McMahon, Marcel D Waldinger et al. An update of the International Society of Sexual Medicine's guidelines for the diagnosis and treatment of premature ejaculation PE . J Sex Med. 2014 Jun;11 6 1392 422. Open 3. A. Salonia, C. Bettocchi, J. Carvalho et al. EAU Guidelines on Sexual and Reproductive Health. EAU. 2023. Open 4. Montague DK, Jarow J, Broderick GA et al. AUA guideline on the pharmacologic management of premature ejaculation. J Urol. 2004 Jul;172 1 290 4. Open 5. C Carson, K Gunn. Premature ejaculation: definition and prevalence. Int J Impot Res. Sep-Oct 2006;18 Suppl 1 S5 13. Open 6. Mohammed Abu El-Hamd, Ramadan Saleh, Ahmad Majzoub. Premature ejaculation: an update on definition and pathophysiology. Asian J Androl. Sep-Oct 2019;21 5 425 432. Open 7. Marissa Crowdis, Saad Nazir. Premature Ejaculation. In: StatPearls Internet]. Treasure Island FL StatPearls Publishing; 2020 Jan. 2020 Jun 28. Open https://web.pathway.md/diseases/recl3M8tcAoHx8b8w 5/6 6/29/23, 11:25 PM Premature ejaculation Pathway 8. Christopher Martin, Hunter Nolen, Jason Podolnick et al. Current and emerging therapies in premature ejaculation: Where we are coming from, where we are going. Int J Urol. 2017 Jan;24 1 40 50. Open 9. Bijil Simon Arackal, Vivek Benegal. Prevalence of sexual dysfunction in male subjects with alcohol dependence. Indian J Psychiatry. 2007 Apr;49 2 109 12. Open 10. Paolo Capogrosso, Christian Fuglesang S Jensen, Giulia Rastrelli et al. Male Sexual Dysfunctions in the Infertile Couple-Recommendations From the European Society of Sexual Medicine ESSM . Sex Med. 2021 Jun;9 3 100377. Open https://web.pathway.md/diseases/recl3M8tcAoHx8b8w 6/6