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Keywords:

  • Premature Ejaculation;
  • Practice Patterns;
  • Therapy

ABSTRACT

  1. Top of page
  2. ABSTRACT
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. References
  8. Appendix

Introduction.  Contemporary U.S. urologist's “real world” practice patterns in treating premature ejaculation (PE) are unknown.

Aim.  To ascertain contemporary urologist practice patterns in the management of PE.

Method.  A randomly generated mailing list of 1,009 practicing urologists was generated from the American Urologic Association (AUA) member directory. A custom-designed survey was mailed to these urologists with a cover letter and a return-address envelope. Responses were compared with the AUA 2004 guidelines for the treatment of PE.

Main Outcome Measures.  The survey assessed several practice-related factors and asked questions of how the subject would handle various presentations of PE in their practice.

Results.  Responses from practicing urologists totaled 207 (21%). Eighty-four percent of the respondents were in private practice and 11% were in academics. Most urologists (73%) saw less than one PE patient per week. On-demand selective serotonin reuptake inhibitor (SSRI) therapy was the most commonly selected first line treatment (26%), with daily dosing a close second (22%). Combination SSRI therapy, the “stop/start” technique, the “squeeze” technique, and topical anesthetics were favored by 13, 18, 18, and 11% of the respondents, respectively. If primary treatment failed, changing dosing of SSRIs, topical anesthetics, and referral to psychiatry were increasingly popular options. Ten percent of urologists would treat PE before erectile dysfunction (ED) in a patient with both conditions, with the remainder of the respondents treating ED first, typically with a phosphodiesterase type 5 inhibitor (78% of total). Fifty-one percent of urologists report that they would inquire about the sexual partner, but only 8, 7, and 4% would evaluate, refer, or treat the partner, respectively.

Conclusions.  The majority of our respondents diagnose PE by patient complaint, and treat ED before PE, as per the 2004 PE guidelines. Very few urologists offer referral or treatment to sexual partners of men suffering from PE. Additional randomized studies in the treatment of PE are needed. Shindel A, Nelson C, and Brandes S. Urologist practice patterns in the management of premature ejaculation: A nationwide survey. J Sex Med 2008;5:199–205.


Introduction

  1. Top of page
  2. ABSTRACT
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. References
  8. Appendix

Premature ejaculation (PE) is a poorly defined but prevalent male sexual dysfunction, with estimates of a lifetime incidence among American men between the ages of 18–59 of around 30% [1]. At least four contemporary definitions for what constitutes PE exist. The most commonly accepted criteria for the diagnosis include a markedly diminished latency time between penile penetration and ejaculation, a lack of feeling of control over ejaculation, dissatisfaction with intercourse, and patient and/or partner distress over the condition [2,3]. Some experts have advocated for more stringent time-based criteria such as an intravaginal ejaculatory latency time (IELT) of 90 seconds as a basis for the diagnosis of PE, arguing that this criterion is based on normative data and permits more accurate and realistic categorization of patients for clinical and research purposes [4]. Other investigators argue that distress is the key variable in the diagnosis, and a strictly defined IELT as the basis for diagnosis neglects the important aspects of quantity and quality of sexual stimulation in ejaculatory function [5].

This controversy reflects the underlying problem that the etiology of PE is poorly understood and likely multifactorial, with neurobiological processes related to the metabolism of serotonin and other neurotransmitters, hyperthyroidism, and psychological stressors, particularly internal stress and critical life events, figuring prominently in the pathogenesis of the condition.[6–8] Data from the National Health and Social Life Survey indicate an association between PE and poor-to-fair health, as well as psychological stress, but no association with diminished quality of life [1].

For many years, penile manipulation via either squeezing the glans when ejaculation is near imminent (the “squeeze” technique) or a program of intermittent cessation of penile thrusting during intercourse (the “stop/start” technique) were the mainstays of therapy for PE. Masters and Johnson reported excellent results in the treatment of PE using manipulation of the penis via the squeeze technique, but their results have not been replicated by other investigators [9]. Topical anesthetics have also been used for some time in the treatment of PE. The introduction of the selective serotonin reuptake inhibitors (SSRIs) for depression has lead to the serendipitous discovery of the ejaculation-delaying properties of this drug class, and they have subsequently been utilized in the treatment of PE [10].

The recommendations of the 2004 AUA guidelines on the treatment of PE are summarized in Figure 1. The guidelines sanctioned with the use of topical anesthetics and oral antidepressants, such as SSRIs, for management of PE [11]. Unfortunately, these therapies are currently utilized off-label as there are at this time no U.S. Food and Drug Administration (FDA)-approved treatments for PE [12].

image

Figure 1. Summary of the 2004 AUA Guidelines for Management of Premature Ejaculation (adapted from Montague et al. [11]).

Download figure to PowerPoint

In order to determine how urologists in practice are actually managing the problem of PE, we conducted a mail-based survey of practice patterns among American urologists with regard to the management of PE. Our hypothesis was that the majority of practicing urologists adhere to the 2004 AUA guidelines.

Methods

  1. Top of page
  2. ABSTRACT
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. References
  8. Appendix

Approval was obtained from our Institutional Review Board. A randomly generated mailing list of 1,009 practicing urologists was generated from the American Urologic Association member directory by a nonurologist who was not otherwise affiliated with the research project. A specifically designed survey (Appendix) was mailed to all selected subjects with a cover letter and a postage-paid return envelope. The survey assessed several practice-related factors and asked questions of how the subject would handle various presentations of PE in their practice. Nonresponders were sent a second cover letter and a survey instrument 3 months after the initial mailing. The subjects were not compensated for participation.

Results were tabulated, and descriptive statistics were obtained. Chi-square analysis was used to assess for differences in practice patterns based on respondent location, private vs. academic practice, time in practice, and fellowship training.

Results

  1. Top of page
  2. ABSTRACT
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. References
  8. Appendix

Two hundred twenty-eight surveys were returned for a response rate of 23%. Twenty-one responses were from urologists who were deceased or retired, and hence, were excluded. The remaining 207 responses (21%) form the study cohort.

Practice information is presented in Table 1. Thirty-eight (18%) of the respondents had pursued fellowship training in oncology (N = 12), female urology/neurourology (N = 7), endourology (N = 7), pediatrics (N = 3), trauma/reconstruction (N = 3), andrology (N = 2), pathology, nephrology, infection, and research (N = 1 each).

Table 1.  Demographics
Practice settingNPercentage
 Private practice17283
 Academic practice2311
 Other126
Community
 Rural4019
 Sub-urban8843
 Urban7536
AUA region
 North East147
 Mid Atlantic2110
 North Central4120
 Western3316
 New England178
 South East2914
 South Central5125
Estimated patient demographics
 Medicarexx47
 Private insurancexx34
 Medicaidxx8
 Private payxx4
 Uninsuredxx4
Years in practice
  0–53316
  6–102010
 11–153115
 16–203517
 21+8843

Over two-thirds of the respondents (139, 67%) saw less than one PE patient per week. Twelve (6%) saw no PE patients, 39 (19%) saw one PE patient per week, and 13 (6%) saw 2–3 PE patients per week. PE was diagnosed based on patient complaint by 177 (86%) of the respondents. Eighteen (9%) relied on partner complaint. An objective time-based criterion was used for diagnosis by 23 (11%) of the respondents.

The preferred initial management for PE among our respondents was on-demand SSRIs, with 53 (26%) of the respondents selecting this as their initial therapy. SSRIs given daily, on a combined daily and demand dose regimen, and with no specific dose regimen specified were favored by 46 (22%), 27 (13%), and 21 (10%) of the respondents, respectively. The “stop/start” technique and the “squeeze” technique were favored as initial management by 37 (18%) of respondents each. Topical anesthetics were the first line agents of 23 (11%) of the respondents. Six respondents (3%) would use a phosphodiesterase type 5 (PDE5) inhibitor as initial therapy, three (1%) stated that they would counsel the patient, and two each (1%) recommended condom usage or a tricyclic antidepressant. Two favored “retraining,” and one recommended masturbation prior to intercourse.

Preferred secondary management for patients who fail the initial management is presented in Table 2. Many urologists favored changing the dosing regimen of SSRI, although a significant portion turned to topical anesthetics and psychiatric or psychological evaluation in patients who were refractory to the initial management. Eight urologists (4%) recommended therapy with a PDE5 inhibitor as secondary therapy. Other secondary options included anafranil (N = 2, 1%), corporal injection of prostaglandins (N = 2, 1%), condoms (N = 2, 1%), trazodone, a book, wine (N = 1 each), or other management not otherwise specified (N = 6, 3%).

Table 2.  Secondary management choices for premature ejaculation
 Defer management (%)Squeeze technique (%)Start/stop (%)Topical anesthetic (%)SSRI, nonspecific (%)SSRI, demand only (%)SSRI, daily dose (%)SSRI, demand and daily (%)Psychiatric referral (%)Urologic referral (%)
  1. SSRI = selective serotonin reuptake inhibitor.

1st line210914611169156
2nd line0273112130
3rd line0321000130
4th line0001000020

Twenty-one (10%) of the respondents reported that they would treat PE before ED in a patient who presented with both conditions. The remainder of the respondents would treat ED first; oral PDE5 inhibitors were the most-favored initial option with 162 (78%) of the respondents choosing this as first line therapy. Initial treatment choices and secondary choices for patients who fail the initial management are presented in Table 3.

Table 3.  Management of coincident ED in patients with premature ejaculation
 Phosphodiesterase type 5 inhibitors (%)Penile injections (%)Muse* (%)Vacuum tumescence device (%)Penile prosthesis (%)Psychiatric referral (%)
  • *

    Muse is manufactured by Vivus, Mountain View, CA, USA.

Initial therapy783014304
2nd line118111001
3rd line01461801
4th line0787122
5th line0011144
6th line000053

One hundred six (51%) of the respondents stated that they would inquire about the PE patient's partner's sexual function. Of this group 16 (8%), 15 (7%), and 9 (4%) would evaluate, refer, or treat the patient, respectively. Potential treatments for the female partner included counseling (N = 2), testosterone or estrogen supplementation, PDE5 inhibitors, the Eros device (Nu-gyn, Spring Lake Park, MN, USA), hypnosis, “a slow approach,” and “fondling.”

The use of SSRIs was more prevalent among private practitioners (72%) than academic practitioners (46%, chi-square for difference P < 0.05). Academic practitioners were more likely to use “other” therapies compared to those in private practice (18% vs. 5%). Interestingly, although PDE5 inhibitors were the most popular “other” treatment in our survey, no academic urologists selected this as their preferred management of PE. Counseling as a treatment option was only selected by academic urologists.

To ascertain whether experience and number of years in practice were predictive of PE management, practitioners were divided into those who had been in practice for 0–15 years vs. 15+ years. Chi-square analysis revealed that those in practice for more than 15 years were significantly more likely to be in solo practice (33% vs. 13%, chi-square for difference P = 0.001) and to see zero PE patients per week (11% vs. 3%, chi-square for difference P = 0.01).

Chi-square analysis did not reveal any other demographic variables that were associated with practice patterns in the management of PE (P value for differences >0.05). There were no significant differences in subject responses between those who saw PE frequently and those who did not.

Discussion

  1. Top of page
  2. ABSTRACT
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. References
  8. Appendix

The advent of effective oral therapy for ED in 1998 led to a renaissance in sexual medicine [13]. Increased public awareness of ED sparked interest in other aspects of sexual function and dysfunction. Progress in the management of ED has continued, and now, other sexual dysfunctions, such as PE and female sexual problems, have been receiving increasing attention from researchers, medical practitioners, and patients.

Interestingly, prevalence data suggest that around 30% of men endorse problems with PE [1]. While this number may not represent the number of men who meet strict Diagnostic and Statistical Manual of Mental Disorders, 4th ed. or World Health Organization critiera for the diagnosis of PE, the disconnect between the number of men presenting for evaluation according to our respondents and the number of men who may be struggling with PE is striking. The reason for this finding is unknown. One particularly appealing explanation is that the lack of an effective, simple, and widely acknowledged therapy for PE keeps patients from even bringing the problem to the attention of the physician. A lack of distress regarding the problem is another possible explanation for the rarity of patients presenting for evaluation of PE, although in the absence of distress, the question must be asked if early ejaculation truly represents premature ejaculation.

Our results indicate that the urologists who responded to our survey do a fairly good job of adhering to the AUA 2004 guidelines on the management of PE. A significant minority of the respondents prescribe the “squeeze” or “stop/start” techniques, although published data on the true efficacy of these approaches in general practice are lacking. Given the lack of an FDA-approved therapy, these approaches are not unreasonable, but they do not seem to be associated with appreciable gains in ejaculatory control.

It is interesting that older urologists (those in practice for 16+ years) were less likely to see PE patients in clinical practice. The reasons for this finding cannot be determined based on available data, but we hypothesize that it may be related to referral patterns within urologic practices, that is, in some practices, more experienced urologists may refer this type of problem to more junior partners.

The majority of our respondents also follow the AUA guidelines regarding the management of concomitant PE and ED, with 90% of the respondents treating ED first. As might be expected, the favored therapy for ED in this patient population is oral PDE5 inhibitors.

While a fair number of urologists inquire about partner sexual function, very few evaluate the partner, and even fewer offer treatment. This reticence is not entirely surprising, given that few urologists have training in female sexual medicine and there are very few therapies for female sexual dysfunction. Nevertheless, the emerging paradigm among experts in sexual medicine is that sexual dysfunction is a disorder of a couple rather than an individual. The treatment of sexual problems is unlikely to be effective, or efficacy will be markedly reduced, if an undiagnosed and untreated dysfunction is present in the partner.

It is interesting that the use of SSRIs for PE is less common among academic urologists. One possible explanation is that academic practitioners are oftentimes oriented to a specific subspecialty of urology and may not be as up-to-date on subspecialty practice patterns outside their area of interest. This possibility is purely conjecture and no definite reason for this difference can be inferred from our data. Our analysis did not reveal any other practice factors that were predictive of management algorithms, although it is possible that this is an artifact of our relatively small sample size.

Several therapies for PE are currently being developed and are in the process of obtaining FDA approval. Until such therapy becomes available, urologists and other physicians who see patients with PE will have to continue to treat this problem with the available therapies of off-label SSRIs, topical anesthetics, and behavioral modification.

Limitations of our data include a relatively small sample size and a high proportion of nonresponders. This is not, however, out of line with standard response rates for mailed surveys. The number of subjects selected for recruitment was based on convenience rather than power calculation. The majority of our respondents were from the North Central and South Central AUA regions; given our location in the South Central section, it is not surprising that urologists who may be more familiar with our institution were more likely to respond. Whether our results can be generalized to American urologists as a whole is unclear, so caution should be exercised in extrapolating the results of our study to all U.S. urologists. However, based on the demographic responses obtained, the breakdown of practice settings, patient insurance status, and years in practice of our subject group are fairly representative of the U.S. urologist population.

An additional potential criticism could be our selection of survey instrument. We designed the instrument to concisely assess what we deemed to be important practice information as well as key factors in the management choices regarding PE. Additional factors that may have been of interest were of necessity excluded. Examples include the number of patients typically seen and the average duration of clinic visits, differences in management of primary vs. secondary PE, effect of patient age on treatment choices, and the role of partner input into the choice of therapy. These important factors may be of interest in any future research on the management of PE in clinical practice.

Nevertheless, in the absence of other practice patterns surveys regarding the treatment of PE, we believe our data represent a reasonable gauge of how PE is managed in contemporary urology practices. Additional research is needed to further characterize this disorder from not just the biological but also from the psychological and interpersonal standpoints [14]. Further understanding of these factors will enhance our ability to treat this condition and improve the sexual function of our patients.

Conflict of Interest: Dr. Shindel was a compensated speaker for Boehringer-Ingelheim and a teaching lab assistant for Coloplast. None of the authors have conflicts of interest related to this article or any devices/drugs mentioned in the text.

References

  1. Top of page
  2. ABSTRACT
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. References
  8. Appendix

Appendix

  1. Top of page
  2. ABSTRACT
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. References
  8. Appendix

SURVEY FOR MANAGEMENT OF PREMATURE EJACULATION

What is your practice setting?

________ Solo Practice ________ Group Practice ________ Academic Practice

________ HMO or other salaried position ________ Veteran's Administration or Military Practice

How large is the community in which you practice?

________ Rural ________ Suburban ________ Urban

In what region of the country do you practice?

________ Northeast Section ________ New England Section

________ Mid Atlantic Section ________ Southeast Section

________ North Central Section ________ South Central Section

________ Western Section

What is the approximate percentage demographic make-up of your patient population?

________% Medicare________% Private Insurance________% Medicaid________% Private Pay________% Uninsured

How long have you been in practice?

________ 1–5 years________6–10 years________11–15 years________16–20 years________21+ year

Have you done a fellowship? If yes, in what sub-discipline?

__________________________________________________

How do you make a diagnosis of premature ejaculation?

________ Patient Complaint

________ Partner Complaint

________ Patient and Partner Complaint

________ Objective Time Based Criteria

________ Other, please explain__________________________________

On average, how many patients do you see for evaluation of premature ejaculation?

________ None

________ Less than 1 a week

________ 1 a week

________ 2–3 a week

________ 4–5 a week

________ 6+ a week

What is your preferred initial management for a man who presents with a chief complaint of premature ejaculation? (Check only one)

________ Defer management and have patient follow-up later

________“Squeeze” Technique

________“Start/Stop” technique of Masters and Johnson

________ Topical Anesthetic

________ Oral SSRI, such as paroxetine (Paxil®)

 ________ On demand

 ________ Daily

 ________ Combined on demand and daily dosing

________ Referral to a psychologist/psychiatrist

________ Referral to another urologist

________ Other Therapy, please explain ___________________________

What is your management plan for men who fail initial management and continue to have premature ejaculation?

[Select all that apply, in the order in which you would prescribe them (1 = first choice, 2 = second choice, etc.)]

________ Defer management and have patient follow-up later

________“Squeeze” Technique

________“Start/Stop” technique of Masters and Johnson

________ Topical Anesthetic

________ Oral SSRI, such as paroxetine (Paxil®)

 ________ On demand

 ________ Daily

 ________ Combined on demand and daily dosing

________ Referral to a psychologist/psychiatrist

________ Referral to another urologist

________ Other Therapy, please explain___________________________

What is your preferred management for men who complain of both premature ejaculation and erectile dysfunction?

________ Treat PE first per management algorithm above

________ Treat ED first, using

[Check all that apply in the order in which you would use them [1 is first, 2 is second, etc]):

 ________ PDE 5-Inhibitor (Viagra, Levitra, Cialis)

 ________ Intracavernosal Injection Therapy

 ________ Intraurethral Prostaglandin (MUSE)

 ________ Vacuum Tumescence Device

 ________ Penile Prosthesis Placement

 ________ Psychological/Psychiatric Evaluation

Do you routinely inquire about the partner's sexual function and/or concerns about premature ejaculation?

________YES ________ NO

Do you evaluate the sexual partner?

________YES ________ NO

If so, do you offer treatment or do you refer them? If you offer treatment, what treatments do you recommend?

_____________________________________________________

_____________________________________________________

_____________________________________________________

Thank you for taking part in this survey

_________________________________________________________________

OPTIONAL: NAME and LOCATION