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Blackwell Publishing IncMalden, USAJSMJournal of Sexual Medicine1743-6095 2006 International Society for Sexual Medicine20063610041012Review ArticleCombination Treatment for PE: A Sex Therapist’s PerspectivePerelman et al.
ORIGINAL RESEARCH—PSYCHOLOGY
A New Combination Treatment for Premature Ejaculation:
A Sex Therapist’s Perspective

*Weill Medical College of Cornell University, Departments of Psychiatry, Reproductive Medicine, and Urology, New York, NY, USA A B S T R A C T
This article describes the diagnosis and treatment of premature ejaculation (PE) from a sex therapist’s perspective
and proposes that combination therapy integrating sex therapy and sexual pharmaceuticals is frequently the best
treatment approach. Failure to appreciate the multimodal etiology and pathophysiology of PE makes the condition
more difficult to diagnose and treat. Many physicians have tried pharmacologic approaches, but are limited to
providing topical anesthetics or suggesting off-label uses of antidepressant and erectile dysfunction medications,
because no medication is currently indicated specifically for PE. Furthermore, patients frequently relapse after
discontinuation of the pharmaceutical. Sex therapists appreciate the multidimensional nature of PE for the patient
and partner, but few patients seek out this approach, which is labor-intensive and often lacking long-term follow-
up success. Most men with PE are not receiving treatment, secondary to their embarrassment about discussing their
condition and a lack of clinician inquiry about sexual dysfunction. Even for those who do engage in discussion,
diagnoses may be inconsistent, because a universally accepted definition of the condition and diagnostic criteria are
nonexistent. Men with PE experience anxiety and lack sexual self-confidence; subsequently, their sexual and overall
relationship frequently suffer. Because PE involves psychosocial and physiologic factors, treatment that addresses
both should yield the best balance of function. There is interest in new agents designed specifically for PE to provide
an improved pharmacotherapeutic opportunity. Yet, a combination treatment integrating pharmaceuticals and sex
therapy would provide an optimized approach. Besides increasing coital latency directly, sexual pharmaceuticals
could be used to provide greater opportunity for men to recognize their premonitory sensations to ejaculation more
readily, facilitating a “choice point”, which is key to facilitating behavioral change and learning. Such a combination
approach would result in prolonged ejaculatory latency, improved treatment satisfaction, and superior long-term
outcome. Perelman MA. A new combination treatment for premature ejaculation: A sex therapist’s perspec-
tive. J Sex Med 2006;3:1004–1012.

Key Words. Primary Care Perspective in Treatment of Sexual Dysfunction; Sex Therapy; Premature Ejaculation;
Psychophysiologic Studies of Sexual Function; Combination Treatment
Introduction
nium, it is clear that both organic and psychosocialfactors play a role in the etiology [3]. For nearly a remature ejaculation (PE) is a very common half-century, the etiology of PE was attributed male sexual dysfunction. The condition is predominantly to a variety of psychogenic causes, characterized by both physiologic and psycholog- including numerous early psychodynamic formu- ical disturbances—concerns regarding ejaculatory lations. Semans (in the 1950s) [4], Masters and latency, control over ejaculation, and distress [1,2].
Johnson (in the 1960s) [5], and later Kaplan (in the While the pathophysiology is not fully under- 1970s) [6] described PE as a learned behavior and/ stood, from the perspective of the new millen- or conditioned response that resulted from early 2006 International Society for Sexual Medicine Combination Treatment for PE: A Sex Therapist’s Perspective sexual experiences that were rushed and frequently off-label use of drugs developed to treat other associated with anxiety. Many psychological theo- disorders, such as depression and ED, because no ries include anxiety as an important component, medication is currently approved by the US Food and anxiety does play a role in PE, especially and Drug Administration (FDA) for the treatment when it coexists with erectile dysfunction (ED).
of PE. Additionally, patients using these pharma- Although often suggested historically, there is no ceuticals frequently relapse when treatment is dis- evidence that specific psychological traits or styles continued [17]. Medications are in development are clearly associated with PE, although depres- specifically for the treatment of PE and may pro- sion and anxiety disorders may manifest as sexual vide advantages over current pharmaceutical dysfunction. Relationship problems and other options. However, because PE involves both psychosocial events/stresses may contribute to or physiologic and psychological aspects, an inte- possibly cause PE, and should be considered, espe- grated approach to therapy may be most success- cially for men with acquired and/or situational PE.
ful. In an earlier publication in The Journal of In addition, the burden of PE frequently extends Sexual Medicine, Sharlip provided a physician’s to the man’s sexual partner. The man’s anxiety viewpoint on the diagnosis and treatment of PE about sex and decreased sexual self-confidence, [19]. The objective of this article, which describes along with the interruption of intimacy (which PE diagnosis and treatment from a sex therapist’s often results from his or her reaction to the short perspective, was to propose that combination latency), subsequently affect the quality of both treatment integrating sex therapy and sexual phar- the sexual and nonsexual relationship [1,2,7].
maceuticals is the best approach to the treatment Thus, the effects of PE on the man, the partner, and the relationship as a whole warrant effectivemethods for diagnosis and treatment to improve Nosology and Definition
Despite the large early literature suggesting a PE has both neurobiologic and psychologic fea- variety of psychogenic etiologies, there is also sig- tures, and while it is referred to most commonly nificant later evidence of organic determinants of as premature ejaculation, it has also been called variability in male ejaculatory latency and, sub- early ejaculation and rapid ejaculation. Although sequently, PE. In fact, a review of the research not all investigators agree on one name, there is a suggests that male ejaculatory latency probably consensus as to what constitutes the condition distributes along a curve similar to numerous being named [14]. Each of the above names other human characteristics [8–15]. Organic fac- focuses on a defect in timing; however, PE is more tors suggested to account for such biologic prede- than just a shortened time to ejaculation. PE termination include: (i) central phenomena, such affects satisfaction with sexual intercourse, psy- as hypersensitivity of serotonin (5-HT) receptors; chological well-being, and relationship well- (ii) sex hormones; (iii) variation in sexual “arous- being, in addition to time to ejaculation and ability,” or a hypersensitive ejaculatory reflex; (iv) control over ejaculation [1,2,7]. These factors are disease—primarily prostatitis associated; as well as reflected in the majority of definitions that have (v) an evolutionary perspective, invoking natural been put forth to describe the condition. The selection and viewing rapid copulation as a supe- Diagnostic and Statistical Manual of Mental Dis- orders, 4th Edition, text revision (DSM-IV-TR) Unfortunately, PE may remain undiagnosed in defines PE as “persistent or recurrent ejaculation many men, secondary to the man’s reluctance to with minimal sexual stimulation before, on, or discuss it with his clinician, reluctance by clini- shortly after penetration and before the person cians to ask their patients about the presence of wishes it. The condition must also cause marked sexual dysfunction, and lack of universal, validated distress or interpersonal difficulty, and cannot be criteria for screening men for PE [7,16–18]. For due exclusively to the direct effects of a substance” those who are diagnosed, treatment is not well [20]. The guideline of the American Urological defined, as numerous approaches exist. Sex ther- Association for the pharmacologic management of apy approaches can be effective, but they cannot PE uses a definition of “ejaculation that occurs alleviate dysfunction in all cases. In addition, sex sooner than desired, either before or shortly after therapy is labor-intensive and has limited docu- penetration, causing distress to either one or both mented efficacy on long-term follow-up. Pharma- partners” [17]. The International Consultation on cologic approaches have been limited to the Urological Diseases defined PE as “persistent or recurrent ejaculation with minimal stimulation Etiology
before, on, or shortly after penetration, andbefore the person wishes it, over which the suf- Ejaculation can be easily understood as occurring ferer has little or no voluntary control which during the orgasm phase of an interactive, non-lin- causes the sufferer and/or his partner bother or ear sexual response cycle, which also includes desire, arousal, and resolution [5,6,14]. Ejaculationitself is comprised of two stages, emission andexpulsion. During the emission stage, the bladder Prevalence and Description
neck closes, and seminal fluid is deposited into the The prevalence of PE has been estimated in large posterior urethra. Men often experience the emis- U.S. and international surveys to range from 16% sion stage (phenomenologically) as the point of to 23% [2,22–25]. PE may be either lifelong ejaculatory inevitability (EI). They are correct in (present since sexual maturation) or acquired recognizing that, at that time, it is “too late” to (developed after a period of normal ejaculatory delay ejaculation, as expulsion is automatically sec- function). These forms of PE are sometimes onds away. Often, unaware of these two stages, referred to as primary and secondary PE, res- men presume that the expulsion stage, with its pectively. Additionally, PE may be generalized attendant ejection of seminal fluid, relaxation of (happens in all situations, with all partners) or sit- the external sphincter, and coordinated pelvic uational (happens in specific situations and/or with floor bulbospongiosus contraction, constitutes the specific partners). PE most commonly refers to entire ejaculatory process. Premonitory sensations distress over heterosexual coital latency. Men (PS), which correspond to bodily changes reflect- commonly report a progressively greater sense ing arousal, such as testicular elevation, myotonia, of perceived control and increased ejaculatory increased breathing, heart rate, and so forth, all latency with masturbation compared with manual precede and foreshadow the emission stage. Men stimulation by their partner. Manual stimulation with PE frequently are unable to identify and/or do latency is usually easier to control than oral stim- not, or cannot respond quickly enough to these ulation latency, which is usually perceived as easier early warning signals to delay their ejaculatory to control than coital latency. The clinician is process consciously. Indeed, consciously delaying reminded that such generalities provide diagnostic the ejaculatory process requires both identification guidance, but individual men may have a different of these PS and a cognitive/behavioral response to phenomenological experience, which is obtained them, prior to (initiation of ) the emission stage.
Men with PE must learn to “dial down” their men- The effect of PE on the individual and the sex- tal and/or physical arousal in response to PS, to a ual relationship is significant, and has recently level below their threshold for emission, in order been explored in greater depth. For example, men to truly control their ejaculatory process [27]. Cli- with PE have reported decreased sexual self- nicians must also understand this sequence and confidence, difficulty in establishing relationships, should educate their patients with PE about it, in and distress at not satisfying their partner because order to accomplish long-term treatment success.
of their PE [2,7]. Results of a large U.S. observa- While the ejaculatory process can be described, tional study of men classified according to DSM- the normal ejaculatory reflex is not completely IV criteria as with or without PE showed that characterized. Both serotonergic and dopaminer- men with PE reported lower levels of sexual satis- gic neurons in the central nervous system (CNS) faction and higher levels of interpersonal diffi- have been identified as playing a primary role, with culty and distress compared with men without secondary influences from several other neu- PE. In addition, women partners of men with PE rotransmitters [21]. Data regarding the exact reported lower levels of sexual satisfaction and alteration(s) in the neurologic pathway of the higher levels of interpersonal difficulty and dis- ejaculatory reflex in PE vary, and this is an area tress than women partners of men without PE of active research [28,29]. Waldinger [8–11], [1,2]. Hartmann and colleagues recently reported Perelman [12–15], and Rowland [30,31] have all that men with PE reported being preoccupied proposed ejaculation distribution theories, postu- with ejaculatory control and experienced anxiety lating that ejaculatory latency is distributed along during sex, while men without PE reported a continuum, with genetic and biologic factors thinking about their sexual arousal and satisfac- influencing either end, resulting in PE in one respect and retarded ejaculation in the other.
Combination Treatment for PE: A Sex Therapist’s Perspective potential psychosocial and physiologic factors forany given moment or circumstance, with one oranother dominating, while others recede inimportance (Figure 2).
Summarizing the research, one can conclude that the causes of PE are multidimensional andmost likely reflect a man’s biologic predispositionto a rapid ejaculatory latency interacting withintrapsychic and interpersonal issues. In fact,despite the degree of organic pathogenesis, PE Figure 1 The multifactorial etiology of sexual function and
will always have a psychosocial component, even dysfunction. The Sexual Tipping Point™ is the characteristic if the condition is initially the result of constitu- threshold for an expression of sexual response for anyindividual, which may vary within and between individuals tion, illness, or treatment [14]. The final phenom- and any given sexual experience. 2005 Michael A. Perel- enological pathway for men with PE is the lack of ability or skill in identifying the aforementionedPS and/or adequately managing their body’s Recent observational studies of normal ejaculatory response to PS and progressively escalating levels latency support these hypotheses, although repli- of sexual arousal, regardless of other predisposing cation with larger and more diverse samples is factors [27]. Such multidetermined variation in the needed [1,10]. Waldinger and colleagues specifi- ejaculation threshold, both among men and within cally suggested that CNS alterations in PE involve a given individual, can be understood using the the serotonergic system [28,32]. A number of organic hypotheses for the etiology of PE havebeen put forth, including 5-HT receptor distur- Evaluation of PE
bances, diminished serotonergic transmission, ahypersensitive ejaculatory reflex, and increased In clinical trials investigating men with PE and assessing PE treatments, intravaginal ejaculatory Although recent research identified predomi- latency time (IELT, defined as the time from vag- nantly neurobiological components to PE [32], inal penetration to the start of intravaginal ejacu- early theories on PE attributed the disorder pri- lation) [11] is often used as a diagnostic and/or marily to psychological causes [4,5]. Psychological efficacy measure. Methods for evaluating PE in issues, such as increased anxiety, depression, and clinical practice, however, differ from those used negative relationship dynamics, may profoundly in clinical trials. Perhaps because PE is largely a influence overall treatment outcomes. Further- subjective definition, and uniform methods of more, PE can exacerbate the psychosocial issues IELT measurement and interpretation have not that may have originally contributed to it, creating been established, many clinicians do not use a threshold IELT for diagnosis, relying more on It now seems clear that the majority of PE cases their own clinical impression, as well as patient are due to a multifactorial combination of both psychosocial and organic factors [14]. The concept After it is established that the patient has con- of a variable set point, or Sexual Tipping PointTM, cerns regarding his ejaculatory function, it is can be used to illustrate the multidimensionalnature of a variety of sexual dysfunctions in bothmen and women [34,35]. In this model, the SexualTipping PointTM is the characteristic threshold foran expression of sexual response for any individual,which may vary dynamically within and betweenindividuals and any given sexual experience. Theresponse may be inhibited or facilitated by influ-ences from a mixture of both psychosocial andorganic factors (Figure 1). Applying this conceptto PE, one can envision a model for ejaculatory Figure 2 The multifactorial etiology of premature ejacula-
latency, based on an orgasmic or “ejaculatory tip- tion; the “ejaculatory tipping point.” 2005 Michael A. Per- ping point,” which is influenced by numerous elman, PhD (adapted with permission).
imperative to collect a focused sexual history to from the individual and his partner, and follow-up obtain a full understanding of his disorder. Poten- data have shown that their efficacy tends to tial initial questions are: “What do you mean by decrease over time [40]. Importantly, some men PE?” “How long do you last from penetration to have reported PE that was so severe that they ejaculation (once you enter, how long before you were unable to identify their PS, for example, “I ejaculate)?” This would be followed by more in- get no warning, I just come when I penetrate or depth questioning, including an exploration of before.” These individuals were often frustrated underlying psychosocial and organic factors and with their attempts at sex therapy, and probably barriers to successful treatment. In this sex status suffered from a more profound organic determi- exam approach, both the immediate cause and the nation of their disorder. Thus, while sex therapy history of the disorder are identified, as well as its can be effective in improving the relationship characteristics [36]. Of course, it must be deter- between the individual and his partner, it cannot mined whether the patient is able to identify his alleviate sexual dysfunction in all patients. In addi- PS. While some men will naturally last longer tion, for the men not involved in a committed than others, it is the capacity to identify PS and relationship or for those starting a new relation- respond to them that essentially defines a “choice ship, this option becomes difficult and may not be point” or ability to voluntarily delay ejaculation. If feasible. While modern sex therapists have used he can identify his PS, can he and does he choose varied techniques and protocols, including self- to respond to these sensations in such a manner help therapy, group therapy, and video treatments, that his orgasm is delayed? What actions does he all of these approaches have limitations [27,37, take, or what does he think about in order to attempt/accomplish this task? For instance, many Currently available pharmacotherapeutic options men will ineffectively attempt to delay ejaculation include topical anesthetics, selective serotonin by diverting their attention to neutral or negative reuptake inhibitors (SSRIs), and phosphodiest- distracting thoughts [37]. Does his ability to iden- erase-5 (PDE-5) inhibitors. Topical anesthetics, tify PS vary with different sexual experiences, such such as lidocaine/prilocaine cream, have been as alternative partners and forms of stimulation? used with some efficacy [42]. SS-cream, a mixture If the patient has tried previous treatments for his of nine oriental herbs, has also been reported to PE, these should also be explored, and reasons for prolong ejaculatory latency [43]. However, these treatments are typically messy and interfere withspontaneity, and burning sensations and numbingmay occur with some formulations [42]. The Treatment
observation that use of SSRIs for the treatment Numerous treatments to improve ejaculatory con- of depression was associated with the side effect trol including devices, herbs, elixirs, and tech- of delayed ejaculation [44–47], along with find- niques have been referenced throughout human ings in preclinical studies of a role for serotonin history [27]. As recently as 2000, Wise and Watson in the ejaculatory response [47], led to the off- reported results for a very small case series using label use of SSRIs in treating PE [44]. However, a “desensitizing ring” to treat “penile hypersensi- long-acting, conventional SSRIs are usually tivity” [38]. However, from the early 1900s until given on a chronic, daily basis to achieve the best the 1990s, PE was considered a psychological effect on ejaculatory latency [48,49]. This dosing problem, and it was treated primarily with psycho- schedule is highly associated with typical SSRI social therapy [29]. Methods included the stop- side effects, including nausea, decreased libido, start technique and the squeeze technique [4,5], as and ED [44–47]. Furthermore, when these phar- well as psychotherapy combined with variations of maceuticals are discontinued, symptomatic those techniques [6]. During the 1970s, experi- relapse usually occurs [17]. PDE-5 inhibitors, mentation with treatment format was conducted either alone or in combination with psychologi- so that both single men without partners and cal and psychosocial counseling and/or SSRIs, larger numbers of patients could be treated have also been assessed recently in small trials and shown to provide some efficacy [50–52].
Sex therapy methods for PE have shown good However, it would appear that this approach has efficacy, and often allow the man to learn to rec- the best efficacy and is primarily appropriate for ognize and respond to his PS. However, they those men suffering from a PE secondary to an require considerable commitment and practice Combination Treatment for PE: A Sex Therapist’s Perspective improvements in latency are significant and mean- Future Treatments
ingful to many men and their partners, others may The shortcomings of current treatments for PE be disheartened by this sometimes limited magni- have prompted efforts to develop pharmaceuticals tude of improvement in latency. There are also no with intended indications specific to the treatment data to suggest that new sexual pharmaceuticals of men with PE. Dapoxetine, which is currently will provide any greater long-term benefit or unavailable in the United States (per a 2005 FDA improved relapse rate once discontinued, com- ruling), was demonstrated to provide significant pared with drugs currently being used off-label.
improvements in ejaculatory latency, control overejaculation, satisfaction with sexual intercourse, Combination Treatment for PE:
and partner satisfaction with sexual intercourse, Creating a “Choice Point”
when given in an on-demand dosing schedule inlarge clinical trials of men with PE and their While PE medications will benefit some men with women partners [53]. Dapoxetine and any drugs PE fully, using medication to reset the ejaculatory for PE which may obtain FDA approval and pro- threshold on a physiological basis will likely long ejaculatory latency (like other successful increase IELT for almost all men with PE. It is treatments for SD) are also likely to improve sex- also likely that many of their partners would be ual confidence. This increased confidence would pleased by that outcome. However, there is an presumably benefit the patient’s sense of self- even greater potential for any sexual pharmaceu- esteem, lower his anxiety, and benefit his relation- ticals (both existing and new) which extend coital ship and partner’s sense of overall satisfaction with latency. A very positive prognosis for men with PE and their partners can be realized through a com- However, clinicians’ recent experiences with bination treatment approach, in which the phar- sexual pharmaceuticals, including the three major maceuticals used for treating PE are integrated medications used to treat ED—Viagra® (sildenafil with sex therapy strategies (Figure 3). Men suffer- citrate; Pfizer, Inc., New York, USA), Levitra® ing from a profoundly organically predetermined (vardenafil HCl; Bayer Pharmaceuticals Corpora- PE with a brief coital latency (<1 minute, as tion, Leverkusen, Germany), and Cialis® (tadalafil; defined by Waldinger and colleagues [11]) often Lilly ICOS LLC, Indianapolis, USA)—have report both being surprised by their orgasm and reported patient-initiated discontinuation rates of unable to either identify or respond to their PS.
up to 50% [54,55]. A rich literature is evolving, Yet, identifying these key physiological markers showing a number of psychosocial reasons for this, and deciding to reduce stimulation (mental and lending support to a combination treatment physical) is the key to a “stop-start” [6] behavioral approach to ED [35,55,56]. Table 10 of the World approach. Sex therapy treatment failure is inevita- Health Organization’s 2nd Consultation on Erec- ble if a man with severe PE is unable to learn that tile and Sexual Dysfunction, Psychological andInterpersonal Dimensions of Sexual Function andDysfunction Committee report [56] provides anexcellent summary of the existing evidence to datefor combination treatment, primarily for ED,along with a few studies on female sexual dysfunc-tion. There is a growing consensus that combina-tion treatment will be the treatment of choice forall sexual dysfunctions, as new pharmaceuticals aredeveloped for desire, arousal, and orgasm prob-lems in both men and women [3,35,54]. In partic-ular, a combination treatment approach may beuseful and necessary for treating PE. While PDE-5 inhibitors are quite effective in restoring sexualcapacity in men with ED, new pharmaceuticals in Figure 3 Combination treatment for premature ejaculation
development such as dapoxetine [53] have shown should optimize the response to therapy, as it addressesboth types of factors while focusing on fixing the predomi- somewhat modest improvements in coital latency nant factors in each case, to create a better balance of time for men suffering from PE. Although clinical function. 2005 Michael A. Perelman, PhD (adapted with trial data suggest that even brief (1–2 minutes) PS must trigger him to reduce stimulation. While Conclusions
there is IELT variability between these men, Premature ejaculation is a common sexual dys- almost all of them suffer from severe frustration, function that has a significant impact on the man, despair, and distress. Although applicable to oth- his sexual partner, the sexual relationship, and in ers, for these men with severe PE in particular, the some cases, their overall relationship. Because PE pharmaceutically increased IELT creates a critical involves both psychosocial and physiologic deter- minants, clinicians must aim to identify both types For instance, use of a serotonergic agent could of factors in every patient in order to maximize alter the ejaculatory threshold of a man with PE; therapeutic outcomes. When attempting to allevi- this would increase IELT, and subsequently slow ate the symptoms of PE, a combination psycho- down the ejaculatory process sufficiently so that social and pharmacologic therapy should be he would be able to more easily recognize his PS.
prescribed, with routine follow-up reassessment in This would consequently increase his capability to order to optimize efficacy and minimize relapse. A adjust to the stimulation he is receiving sufficiently combination treatment approach, utilizing the to voluntarily delay (control) initiation of the conceptual model of an ejaculatory tipping point, emission stage of the ejaculatory process. The addresses these multicausal influences while focus- medication has then created the potential for ing on fixing the predominant factor in each case, awareness of PS when none previously existed.
rather than addressing dichotomous factors in iso- Subsequently, a new, meaningful opportunity for lation. This will create a better functional balance control or choice emerges, for the man with an extremely short IELT or anteportal ejaculation[57]. Now able to recognize and respond to thepreviously elusive PS, these newly empowered Acknowledgement
men feel “in control.” Feeling “relaxed” and “notlike work” becomes the new norm benefiting him- The author acknowledges Stephanie Leinbach’s contri- self and his partner. Of course, such an approach bution in reviewing earlier drafts of this manuscript.
requires a critical, albeit brief, patient education Corresponding Author: Michael Perelman, PhD, Co-
component, where PS, EI, emission, expulsion, Director, Human Sexuality Program, NY Weill Cornell and the basics of a stop-start sex therapy technique Medical Center, 70 East 77th Street, Suite 1C New York, NY10021, USA. Tel: (212) 570-5000; Fax: (212) As he becomes more skilled in recognizing his “choice point” and responding to it, a potentialfor decreased medication dosage and weaning becomes possible [57]. Other men could be taughthow to adjust medication usage according to their References
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