History
A guideline from the International Society of Sexual Medicine recommends asking patients the following questions to establish the diagnosis of premature ejaculation [19] :
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What is the time between penetration and ejaculation (cumming)?
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Can you delay ejaculation?
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Do you feel bothered, annoyed, and/or frustrated by your premature ejaculation?
Optional questions cover assessment of erectile function, impact of the problem on the patient's relationship with his partner, any previous treatment, and effect on quality of life. [19]
The history of the patient’s premature (early) ejaculation is helpful because it ultimately guides the treatment that is best suited to the patient (and his partner). One should determine whether premature ejaculation is lifelong (ie, primary) or acquired (ie, secondary) and assess the severity of the problem.
If the patient has always experienced premature ejaculation from the time he began coitus, then he has lifelong premature ejaculation. If he had successful coital relationships in the past, yet began experiencing premature ejaculation with the current relationship, then he has acquired premature ejaculation. In most cases, acquired premature ejaculation is easier to treat and has a better prognosis.
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 with subsequent fear of myocardial infarction during sexual activity, he may present with premature ejaculation, but the actual underlying problem is the cardiac disease and the attendant mental insecurity. Resolution of the cardiac problem usually suffices, with no specific therapy required for the premature ejaculation.
For the purposes of this discussion, it is assumed that the patient is healthy and that sexual dysfunction is the only significant problem.
Lifelong premature ejaculation
In addition to the general medical history, it is important to inquire about any previous psychological difficulties. Psychiatric conditions are more common in males with lifelong premature ejaculation than in the general population.
The history should include questions about the following:
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Early sexual experiences – Did the patient experience a traumatic sexual episode as a child or teenager (eg, discovery by a parent during masturbation, with subsequent feelings of guilt and perhaps threatened or actual punishment)?
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Family relationships during childhood and adolescence – How did the patient relate to his mother, father, brother(s), sister(s)? Does the 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
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Peer relationships – Did the patient have other male friends or any female friends? How does he regard himself in comparison with peers (eg, inferior, superior, more athletic, frailer, more intelligent, or less intelligent)?
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Work or school – Does the patient have any difficulties with work (or school, if still a student)?
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General attitude toward sex – Does the patient regard sex as dirty? What is his sexual preference, fantasy, and arousal pattern? Did the patient have a strict religious upbringing? If so, what was he taught about sex?
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Marital versus nonmarital context – 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, was there premarital noncoital sexual play between the partners?
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Sexual attitude and response of the female partner – If the female partner is having a problem (eg, dyspareunia), it could relate to the male’s problem or may have preceded it
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Nonsexual aspects of the current relationship – Does the couple fight, or are they going through a power struggle?
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Involvement of the sexual partner – If the patient’s sexual partner is not present for this interview, why not? Is the partner failing to support the man or blaming him?
Clues from these and similar questions usually point toward causative factors that may be specifically addressed with therapy.
Acquired premature ejaculation
In addition to a general medical history, the history should include details about the following:
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Previous relationships – Were there earlier relationships in which premature ejaculation was not a problem? Were there earlier relationships in which transient episodes of premature ejaculation occurred?
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Current relationship – Was premature ejaculation always a problem, or did it start after an initial time frame when coitus was satisfactory to both partners?
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Nonsexual aspects of the current relationship – Do the partners get along on most issues, or is conflict present? Who is dominant in the relationship, or is the relationship generally equal?
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Involvement of the sexual partner – If the patient’s female sexual partner did not accompany him to the clinic, why not? If she regards the problem as his alone, rather than theirs, this may be an important clue
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Impotence problems – If the patient has erectile dysfunction, did it begin after the premature ejaculation or before? If the patient does not have erectile dysfunction, what is the general timing for the male (ie, the typical time from commencement of intromission to climax)?
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Capacity for coitus – Can actual coitus be achieved, or does the premature ejaculation prevent it entirely?
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Sexual context – Is the patient experiencing premature ejaculation with self-stimulation (ie, masturbation), with nonintercourse stimulation by the partner, or just with coitus?
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Sexual response of partner – 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)?
If the patient has erectile dysfunction that began after premature ejaculation, treatment of both conditions may be required; in some cases, the erectile difficulty resolves once the patient gains confidence in his ability to control ejaculation. If erectile dysfunction developed first, premature ejaculation may be a secondary sexual dysfunction; it may resolve when the patient is confident of being able to maintain his erection.
Physical Examination
Physical examination findings are normal in males whose only presenting condition is premature ejaculation. If other relevant medical conditions are present, signs of these conditions will be noted.
