"It's all about tweaking the equation" of biological and psychological factors, he said.
Pharmaceuticals have significant limitations, explained Dr. Perelman, co-director of the human sexuality program at the Payne Whitney Clinic, New York Presbyterian Hospital/Weill Cornell Medical Center, New York.
Although no prescription medicines are approved for PE, some are used off label, he explained, and topical treatments are cumbersome, messy, and may result in greater anxiety. Antidepressants require chronic dosing to achieve full effectiveness. They are slow to take effect and slow to clear, with risks of adverse reactions from abrupt withdrawal.
"If you look at the AUA guidelines, a strong point is made that if you discontinue medication, there is often a relapse," Dr. Perelman said.
Further, while phosphodiesterase type-5 inhibitors have been tried in uncontrolled and open-label trials, they don't address the mental and emotional issues that often underlie or accompany PE. Thus, even when sexual functioning can be restored, the patient may not feel satisfied.
But sex therapy has weaknesses as well, said Dr. Perelman. For example, the stop-start or squeeze technique is labor-intensive and requires the assistance of the partner. Some men find it burdensome, and the benefits often decline with time.
Studies of the time it takes men to ejaculate show a fairly normal distribution, with a few taking a long time, a few taking very little time, and most men averaging time in the middle of the two extremes. This suggests that genetics plays a role in PE, limiting the potential success of sex therapy.
While evidence suggests that both psychological and biological factors play a role in PE, researchers have historically emphasized one over the other, Dr. Perelman said. Researchers initially paid most attention to social and cultural elements, but, more recently, they have emphasized biological determinants of "oversensitivity." For example, investigators have measured electromyographic activity in the bulbospongiosus and ischiocavernous muscles during ejaculation. Others have focused on neurologic control of ejaculation, especially by serotonin modulation.
But all men with PE share the inability to recognize premonitory sensations or lack the ability to manage their body's response to these sensations, Dr. Perelman said. Often, by the time they know they are going to ejaculate, they are already ejaculating, so the key to treating PE, Dr. Perelman argued, is to teach men to recognize premonitory sensations and to "dial down" their response below the threshold for emission.
Pharmaceuticals can help raise this threshold enough that men have more time to become more aware of their premonitory sensations. Once they gain this awareness, they can learn to moderate their response, and they won't need to rely as much on medication.
Blueprint for recovery
To combine sex therapy with pharmaceuticals, Dr. Perelman proposed an integrated sex coaching technique that begins with a "Sex Status Exam," his term for a brief, focused sex history. It encompasses a detailed description of the patient's current sexual experience and the couple's erotic interaction in order to identify both biological and psychosocial factors, such as insufficient stimulation and awareness or the role of depression.
Second, Dr. Perelman recommends assessing the partner's capacity to participate or at least support the efforts of the patient and physician to address the problem. Third, he proposes scheduling a follow-up session to see whether a sexual pharmaceutical is being used correctly and whether the patient has learned to identify premonitory sensations. Fourth, Dr. Perelman says patients may be weaned from their medication bit by bit as they gain mastery over their "ejaculatory tipping point." If new stress or illness alters the situation, medication can be reintroduced.
Finally, he pointed out that some clinicians may not feel comfortable treating all of the psychosocial factors that have come into play in a patient's PE. In some cases, clinicians may want to refer the patient to another expert, such as a sex therapist.