Disorders of Ejaculation: An AUA/SMSNA Guideline

American Urological Association (AUA) and the Sexual Medicine Society of North America ha be released its new guidelines on Ejaculatory Disorders.

Ejaculation and orgasm are distinct but simultaneous events that occur with peak sexual arousal. It is typical for men to have some control over the timing of ejaculation during a sexual encounter. Men who ejaculate before or shortly after penetration, without a sense of control, and who experience distress related to this condition may be diagnosed with Premature Ejaculation (PE).

The World Health Organization's International Classification of Diseases 11th edition (ICD-11) defines male early ejaculation as "ejaculation that occurs prior to or within a very short duration of the initiation of vaginal penetration or other relevant sexual stimulation, with no or little perceived control over ejaculation. The pattern of early ejaculation has occurred episodically or persistently over a period at least several months and is associated with clinically significant distress

As of now there are no FDA-approved therapy exists for premature ejaculation (PE) or delayed ejaculation (DE), the two most common types of ejaculatory disorders.

The guidelines will equip clinicians to conduct appropriate investigations , educate patients and offer rational therapies supported by the available scientific data.

Premature Ejaculation

Lifelong premature ejaculation is defined as poor ejaculatory control, associated bother, and ejaculation within about 2 minutes of initiation of penetrative sex that has been present since sexual debut. (Expert Opinion)

Acquired premature ejaculation is defined as consistently poor ejaculatory control, associated bother, and ejaculation latency that is markedly reduced from prior sexual experience during penetrative sex. (Expert Opinion)

Clinicians should assess medical, relationship, and sexual history and perform a focused physical exam to evaluate a patient with premature ejaculation. (Clinical Principle)

Clinicians may use validated instruments to assist in the diagnosis of premature ejaculation. (Conditional Recommendation; Evidence Level: Grade C)

Clinicians should not use additional testing for the evaluation of a patient with lifelong premature ejaculation. (Conditional Recommendation; Evidence Level: Grade C

Clinicians may utilize additional testing, as clinically indicated, for the evaluation of the patient with acquired premature ejaculation. (Conditional Recommendation; Evidence Level: Grade C)

Clinicians should advise patients that ejaculatory latency is not affected by circumcision status. (Conditional Recommendation; Evidence Level: Grade C)

Clinicians should consider referring men with premature ejaculation to a mental health professional with expertise in sexual health. (Moderate Recommendation, Evidence Level: Grade C)

Clinicians should recommend daily SSRIs; on demand clomipramine or dapoxetine (where available); and topical penile anaesthetics as first-line pharmacotherapies in the treatment of premature ejaculation. (Strong Recommendation; Evidence Level: Grade B)

Clinicians may consider on-demand dosing of tramadol for the treatment premature ejaculation in men who have failed first-line pharmacotherapy. (Conditional Recommendation; Evidence Level: Grade C)

Clinicians may consider treating men with premature ejaculation who have failed first-line therapy with α1-adrenoreceptor antagonists. (Expert Opinion)

Clinicians should treat comorbid erectile dysfunction in patients with premature ejaculation according to the AUA Guidelines on Erectile Dysfunction. (Expert Opinion)

Clinicians should advise men with premature ejaculation that combining behavioral and pharmacological approaches may be more effective than either modality alone. (Moderate Recommendation; Evidence Level: Grade B)

Clinicians should advise patients that there is insufficient evidence to support the use of alternative therapies in the treatment of premature ejaculation. (Expert Opinion)

Clinicians should inform patients that surgical management (including injection of bulking agents) for premature ejaculation should be considered experimental and only be used in the context of an ethical board-approved clinical trial. (Expert Opinion)

Delayed Ejaculation

Lifelong delayed ejaculation is defined as lifelong, consistent, bothersome inability to achieve ejaculation, or excessive latency of ejaculation, despite adequate sexual stimulation and the desire to ejaculate. (Expert Opinion)

Acquired delayed ejaculation is defined as an acquired, consistent, bothersome inability to achieve ejaculation, or an increased latency of ejaculation, despite adequate sexual stimulation and the desire to ejaculate. (Expert Opinion)

Clinicians should assess medical, relationship, and sexual history and perform a focused physical exam to evaluate a patient with delayed ejaculation. (Clinical Principle)

Clinicians may utilize additional testing as clinically indicated for the evaluation of delayed ejaculation. (Conditional Recommendation; Evidence Level: Grade C)

Clinicians should consider referring men diagnosed with lifelong or acquired delayed ejaculation to a mental health professional with expertise in sexual health. (Expert Opinion)

Clinicians should advise men with delayed ejaculation that modifying sexual positions or practices to increase arousal may be of benefit. (Expert Opinion)

Clinicians should suggest replacement, dose adjustment, or staged cessation of medications that may contribute to delayed ejaculation in men with delayed ejaculation. (Clinical Principle)

Clinicians should inform patients that there is insufficient evidence to assess the risk-benefit ratio of oral pharmacotherapy for the management of delayed ejaculation. (Expert Opinion)

Clinicians may offer treatment to normalize serum testosterone levels in patients with delayed ejaculation and testosterone deficiency. (Expert Opinion)

Clinicians should treat men who have delayed ejaculation and comorbid erectile dysfunction according to the AUA Guidelines on Erectile Dysfunction. (Expert Opinion)

Clinicians should counsel patients with delayed ejaculation that no currently available data indicate that invasive non-pharmacological strategies are of benefit. (Expert Opinion)

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Source Reference:Shindel AW, et al "Disorders of ejaculation: An AUA/SMSNA guideline" AUA 2020.