Treatment

Premature Ejaculation

Premature Ejaculation Treatments

The treatment of primary premature ejaculation is usually more complex given its neurobiological component, and requires a great deal of involvement on the part of the man, the health professional, and often the "patient's" partner.

In this case, the cornerstone of treatment is pharmacological treatment, either topical or oral, accompanied by sex therapy, pelvic floor rehabilitation, and anxiety and arousal control.

In the case of secondary premature ejaculation, the more treatable the cause is, the better the treatment will work. Treating urinary problems, erectile dysfunction or accompaniment during a stressful life phase are often sufficient to improve mild cases. In more advanced cases, multimodal treatment will be necessary, combining sex therapy, pelvic floor rehabilitation, anxiety-excitation control, occasionally supported by drugs.

Regarding the different treatments, it is necessary to emphasize that multimodal treatment will achieve better results when compared to simpler strategies. We will have to adapt the treatments to the needs and desires of the patient and his partner, and to his sexual life.

As for the available treatments, they are discussed below:

• Pelvic floor rehabilitation. The relationship between pelvic floor problems and problems in the sexual sphere has been demonstrated. Pelvic floor toning and rehabilitation will give a man greater sexual control and more ability to inhibit sexual response. The treatment is performed by teaching to contract the pelvic floor muscles anteriorly ("stop the urinary stream") and posteriorly ("contract the muscles of the anus"). Both exercises have to be repeated several times a day over a period of weeks to be effective. To optimize learning, the biofeedback technique is used, in which the health professional - usually a physiotherapist - teaches how to perform the contraction by means of a machine that measures the effectiveness of the contraction being performed by the patient.
• Medication. There are two main medications that can help us in the treatment of premature ejaculation. The first of these is Fortacin. Fortacin is a spray applied on the penis, which is a eutectic mixture of prilocaine and xylocaine, which decreases the sensitivity of the penis, and therefore delays the moment of orgasm. It manages to multiply by three times the time of coitus after 3 months, increasing its efficacy up to x6 after 6 months of treatment. It should be noted that it is effective in both circumcised and uncircumcised men. It has to be applied 5 minutes before intercourse and left to act, and then washed off before sex or use a barrier to prevent transfer. The second drug is dapoxetine. Dapoxetine is a short-acting selective serotonin reuptake inhibitor, which inhibits and delays the onset of orgasm. It is taken on demand, approximately 1 hour before sexual intercourse. It has few side effects, and is effective especially in men with primary premature ejaculation. It is available in doses of 30 and 60mg, and it is advisable to start treatment with the low dose and titrate it if necessary. The use of erection medications (phosphodiesterase-5 inhibitors: sildenafil, tadalafil, vardenafil and avanafil) to increase coitus time deserves additional comment. Although these drugs improve erection, there is abundant scientific literature supporting their use to improve coitus time.
• Anxiety and arousal control. Aimed at reducing the adrenergic tone and negative thoughts, as well as to "accustom" the man to increasingly higher levels of eroticism. It has a cognitive, emotional and physical part, and it is usually a treatment that we would include within sex therapy. An example is the reduction of anxiety through the triangular breathing technique, in which the man is taught to dominate anxiety through deep and slow breathing.
• Start and stop. It is surely the basis of the treatment, and consists of understanding and controlling the sexual response. It is essential to identify the point of orgasmic no return, a moment that if we go beyond, we will not be able to stop the triggering of orgasm and ejaculation. Once this point is identified, we teach how to inhibit orgasm through pelvic floor contraction. Repeating this exercise leads to the so-called "reflex exhaustion phenomenon", which allows to lengthen the sexual intercourse and "re-educate" the sexual response. It is a very effective treatment but requires a lot of commitment on the part of the patient.

In our experience the best treatment is multimodal, associating different strategies in a unified treatment. Success depends largely on the commitment of the man with premature ejaculation and the involvement of the team of health professionals who are necessary to help the person (urologist, psychologist, physiotherapist).

Finally, a brief mention should be made of surgical treatments. There is much debate about their usefulness. Post-ectomy -also called circumcision- has been postulated as a treatment for premature ejaculation, although its usefulness has not been sufficiently demonstrated. Other treatments, such as dorsal penile nerve neurotomy, are considered experimental. Recently, radiofrequency neuromodulation has achieved promising results.