Different Etiologies and Pathophysiologies of Premature Ejaculation Determine its Treatment - 27/06/08

Doi : 10.1016/S1158-1360(08)72638-0 
M. Waldinger
Department of Psychiatry and Neurosexology, Leyenburg HagaHospital, The Hague, The Netherlands 

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Résumé

For many years, different views have existed regarding etiology and treatment of premature ejaculation (PE). On one hand it was argued that PE is caused by psychological factors, like unresolved unconscious conflicts, relationship problems, and/or self-learned behaviour. On the other hand, it has been argued that PE is caused by either somatic factors, like hypersensitivity of the glans penis, a higher cortical representation of the pudendal nerve, or neurobiological factors, like disturbances in the central serotonergic neurotransmission and serotonergic receptor functioning. Until recently, there has not been a theory integrating these different views. Recenty, Waldinger emphasized that the occurrence of PE does not automatically imply the existence of a male sexual disorder. PE is a frequent males sexual complaint, but its occurrence is not always the result of mental or physical pathology. Therefore, Waldinger proposed a new classification of PE for the pending DSM-V. According to this new classification there are four PE syndromes; lifelong PE, acquired PE, natural variable PE and premature-like ejaculatory dysfunction. These syndrome are distinguished by the duration of the IELT, frequency of complaints, its course in lifetime, etiology, pathophysiology and treatment. For example, men with lifelong PE usually ejaculate within 1 minute after penetration from about the first sexual encounters. As this disorder is also recognized in male rats, it is highly likely that this disorder is mainly neurobiologically determined. These men need drug treatment to delay ejaculation. In contrast, the new defined category of men with premature-like ejaculatory dysfunction complain of PE while having normal IELT (3-7 minutes) and even long IELTs (10-25 minutes). As the IELT is normal and there is nothing biologically disturbed in these men, it is very likely that this syndrome is mainly psychological and perhaps even culturally determined. These men should not be treated with medication, but with counselling, psycho-education or psychotherapy in order to learn how to cope with their complaints. Acquired PE may be psychologically or somatically determined. These men need either counselling or psychotherapy, or adequate treatment of the underlying somatic disorder (thyroid or urological diseases). Lastly, a second new defined category are men with natural variable PE. These men only occasionally have early ejaculations. There is no indication that occasional occurrence of PE is either related to psychological or somatic pathology. Therefore it is assumed that natural variable PE is only a manifestation of normal ejaculatory performance. In case of seeking treatment, these men need reassurance or counselling.

The new classification of PE integrates both psychological as neurobiological etiologies and pathophysiologies of PE. These different etiologies determine the different treatments of PE, which is either medication, somatic treatment, psychotherapy, counselling, psychoeducation or reassurance.

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Vol 17 - N° S1

P. 45 - janvier-mars 2008 Retour au numéro

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