History of the patient's premature ejaculation

For completeness, a general medical history should be taken to screen for other medical conditions that might be relevant. For example, if the patient has angina and this causes fear of a myocardial infarction during sexual activity, he might present with premature ejaculation when the actual underlying problem is his cardiac disease and his mental insecurity regarding his cardiac disease. Resolution of the cardiac problem usually solves the premature ejaculation, with no specific therapy for the premature ejaculation. For the purpose of this discussion, the patient is assumed to be healthy, and sexual dysfunction is the only significant problem.

If the patient has always experienced premature ejaculation from the time he began coitus, then he has primary premature ejaculation. If he had successful coital relationships in the past, yet began experiencing premature ejaculation with the current relationship, then he has secondary premature ejaculation. In most cases, secondary premature ejaculation is easier to treat and has a better prognosis.

• Primary premature ejaculation

• In addition to the general medical history, inquire about any prior psychological difficulties because males with primary premature ejaculation have a higher incidence of associated psychiatric conditions than that found in the general population.

• The history should include questions about the patient's early sexual experiences. Did he experience a traumatic sexual episode as a child or teenager? An example might be discovery by a parent during masturbation, with subsequent feelings of guilt. Alternatively, the patient may have been punished or threatened with punishment for masturbation.

• Inquire about the patient's family relationships while he was growing up. How did he relate to his mother, father, brother(s), sister(s)? Does his family have a history of incest or sexual assault? Males can be sexually assaulted by other males and, in rare instances, by females, including siblings.

• What were peer relationships like? Did he have other male friends, any female friends? How does he regard himself with respect to peers (eg, inferior, superior, athletic, frail, more intelligent, less intelligent)?

• Does the patient have any difficulties with work (or school, if still a student)?

• What is the patient's general attitude toward sex (ie, whether it is regarded as dirty), and what is the patient's sexual preference, fantasy, and arousal pattern?

• Did the patient have a strict religious upbringing? If so, what was the teaching about sex?

• If the premature ejaculation began with an initial nonmarital relationship, does he feel guilt about this?

• If the first coital experience was within a marital relationship that involved premature ejaculation from the start, inquire about premarital, noncoital sexual play between the partners.

• Ask about the sexual attitude and response of the female partner; if she is having a problem, such as dyspareunia, it could relate to the male's problem or may have preceded it.

• What is the nonsexual part of the relationship like? Does the couple fight or are they going through a power struggle?

• If the sexual partner is not present, inquire as to why (ie, whether the partner is not supportive or is blaming him).

• Clues from these and similar questions usually point toward causation factors that may be addressed specifically with therapy.

• Secondary premature ejaculation

• In addition to a general medical history, the history should include details about prior relationships in which premature ejaculation was not a problem for this individual and any prior relationships in which transient episodes of premature ejaculation occurred.

• In the current relationship, was premature ejaculation always a problem or did it start after an initial time frame when coitus was satisfactory to both partners?

• Inquire specifically as to the quality of the relationship with respect to nonsexual factors. Do the partners get along on most issues, or is conflict present? Who is dominant in the relationship, or is the relationship generally equal?

• Is the female partner in the office with the male patient? If not, ask why. Possibly, she regards the problem as only his problem and not a problem of the couple, which may be an important clue.

• Does he have an impotence problem? If erectile dysfunction (ED) is present, did this begin after the problem with premature ejaculation or before? If ED is not present, what is the general timing for the male (ie, commencement of intromission to climax)?

• Can actual coitus be achieved, or does premature ejaculation prevent this?

• Is the patient experiencing premature ejaculation with self-stimulation (ie, masturbation), with nonintercourse stimulation by the partner, or just with coitus?

• What is the time required for the female partner to reach climax? Can she reach climax with intercourse, or does she require direct clitoral stimulation (oral or manual) to be able to climax?

• If ED is present but began after the premature ejaculation, then treatment of both conditions may be required; sometimes, the ED resolves when the patient gains confidence in controlling his ejaculation. If the ED started initially, then the premature ejaculation may be a secondary sexual dysfunction, which resolves when the patient is confident in being able to maintain his erection.

• Clarification of these and other factors usually proves very helpful when arriving at a treatment plan.

Physical: Physical examination findings are normal in males when premature ejaculation is the only presenting condition.

Causes: The cause of premature ejaculation is considered psychological, although no one really knows.

• Primary premature ejaculation

• In primary premature ejaculation, in which the male has never experienced sexual relations without also experiencing premature ejaculation, a deep-seated emotional disturbance may be present and the causes may be multiple.

• Sometimes, the behavior is a conditioned response resulting from teen masturbation practices, but, sometimes, the patient has deep anxiety about sex that relates to one or more traumatic experiences encountered during development. Examples may include family incest, sexual assault, conflict with one or both parents, or other serious disturbances.

• In most cases, a primary care physician or a urologist should consult with a psychiatrist, psychologist, or other professional in cases of primary premature ejaculation.

• Secondary premature ejaculation

• With regard to secondary premature ejaculation, some type of performance anxiety is often a major factor.

• Performance pressure (ie, fear of failure to satisfy the partner) can arise from various precipitating events. ED is a common precipitating event. If the male is afraid his erection will not last, because of either actual instances of previous ED or imagined failure of his erection, this may precipitate premature ejaculation. The patient may have used the phrase, "Honey, you excited me so much I just could not hold back," which might be a way for him to avoid admitting to the humiliation of being unable to keep his erection throughout intercourse. If he climaxes quickly, he then has an excuse to justify his inability to maintain his erection.

• However, a careful history is needed because the situation may be complex.

• Perhaps ED is not a part of the problem.

• Possibly, his partner has belittled him with comments such as "You must not be much of a man, since you cannot stay hard until I am satisfied." In addition, she actually may have difficulty achieving climax through intercourse and may require direct clitoral stimulation to reach a climax. If she does not communicate this to him (and she may conceal it because of feelings about her own inadequacy), then he will always fail to provide coital satisfaction for her.

• Because most physicians are not trained sex therapists, sorting out conflicts in the relationship and then referring couples for counseling to professionals with experience and training in that area is important. If a physician has some training or experience in the treatment of premature ejaculation and is comfortable managing the problem, then the physician may choose to begin treatment (eg, counseling, medication, both). If the patient does not respond favorably or if the physician is not comfortable with the treatment of premature ejaculation, then referral to a sex therapist, psychologist, or psychiatrist is the next step.

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