Premature Ejaculation

Transcription

1 Understanding & Treating Premature Ejaculation David L. Rowland, PhD Peggy Rose, RN, MSN, CNS-BC, FNP-BC R ecent advances in sexual health have placed significant focus on erectile dysfunction (ED). Defined as a common medical problem affecting 35% of men 40 to 70 years of age, it is a problem for which a comprehensive model of care and management guidelines has been developed and recent medications (sildenafil, vardenafil, and tadalafil) have been approved. 1 Healthcare providers can now offer treatment options that have the potential to significantly impact quality-of-life and interpersonal relationships. Healthcare providers assessing the sexual health of men must now think beyond ED to the most common male sexual dysfunction, premature ejaculation (PE). Both national probability samples 2 and samples of convenience 3,4 estimate the prevalence of PE in the range of 15% to 30% across the lifespan. Furthermore, unlike ED, which is most frequently associated with increased age or pathophysiologic changes underlying that process, PE usually has no obvious pathophysiologic etiology and has a consistent prevalence over age cohorts. Yet PE, which may cause considerable anxiety and distress, is rarely discussed in the practitioner s office. PE has often been identified as a dysfunction with a psychological rather than a physical etiology, causing an element of shame. Unlike ED, men generally do not consult a healthcare provider for problems with PE or seek any type of treatment because of embarrassment, guilt, or discomfort. As awareness and interest in male sexual dysfunction has increased, it is increasingly likely that men with this dysfunction will seek treatment. Oral medications, including selective serotonin reuptake inhibitors (SSRIs), have been used successfully off-label for treatment of PE, 5 and new investigational drugs specifically designed for the treatment of PE are likely to be forthcoming. 6 It is important for primary care providers to have an understanding of this dysfunction, and how it is assessed, diagnosed, and treated. Sexual Response Cycle The sexual response cycle in men and women is usually conceptualized as having three interdependent phases: libido or The Nurse Practitioner October

2 Brief Lead-In Questions Are you still interested in having sex with your partner or have feelings of sexual desire? (A yes response eliminates lack of libido or desire as the problem.) Do you have trouble getting or keeping an erection? (A no response eliminates erectile dysfunction as the problem.) Do you ejaculate sooner than you or your partner would like? (A yes response raises the possibility of premature ejaculation.) 1. Do you usually ejaculate a minute or sooner after intercourse has begun? 2. Do you feel as though you have no control over when you ejaculate? 3. Does this condition bother you or your partner? (A yes response to all three items above indicates a high probability of premature ejaculation.) Does your partner seem to enjoy sex with you? (A yes response decreases the likelihood that the premature ejaculation results from a partner dysfunction.) arousibility, arousal, and orgasm. 7 Libido or arousibility a psychological concept that explains an individual s overall interest in sexual activity depends on a number of physiological, psychological, and relationship factors. In simple terminology, libido/arousibility refers to a person s readiness to respond sexually, given specific sexual stimuli and context. Arousal refers to the person s actual physiological and psychological response to erotic or sexual stimuli. In men, these responses include a state of subjective sexual excitement (usually related to central autonomic activation) and a number of peripheral physiological responses including erection, flushing of the skin, and increased heart rate and respiration. Under increasing levels of psychosexual stimulation and arousal, a man reaches the final stage, orgasm, which results in ejaculation. Ejaculation is a biological (procreative) and psychological (reward) endpoint that typically occurs during high sexual excitement in response to stimulation of the glans penis. This penile stimulation traverses the dorsal nerve, which is part of the larger pudendal nerve, to level S4 of the spinal cord. In the human male, cerebral ejaculatory control centers are currently putative, but animal studies have implicated dopaminergic fibers in the medial preoptic area and magnocellular fibers of the paraventricular nucleus of the hypothalamus. These centers presumably innervate descending serotonergic fibers in the region of the paragigantocellular reticular nucleus of the ventral medulla of the brainstem. 8 The efferent process of ejaculation consists of two distinct phases. The first is seminal emission, during which (1) the bladder neck is closed to prevent urination or retrograde 22 The Nurse Practitioner Vol. 33, No. 10 ejaculation, and (2) seminal fluid is deposited from the prostate gland into the urethral tract. Emission, under the control of sympathetic fibers in the spinal ejaculatory center located at the T12 and L1-L2 spinal levels, is associated with the feeling of ejaculatory inevitability reported by men prior to ejaculation. Partly in response to the seminal fluid in the urethra, the second phase reflex occurs, characterized by rhythmic contractions of the bulbocavernous and ischiocavernous muscles (proximal to the anus) responsible for semen expulsion. Expulsion, under the control of a second spinal center located at S2-S4, is mediated via pudendal innervation, which contracts the striate muscle, propelling seminal fluid through the urethra and out of the meatus. This latter reflex, although involving the striate muscle, is likely under the control of the parasympathetic nervous system. Finally, sensory receptors in the pelvic region are responsible for the subjective experience of orgasm associated with ejaculation. Given the complex somatic-autonomic peripheral and central components of the ejaculatory response, it is not surprising that dopaminergic, multiple serotonergic, gamma aminobutryic acid, cholinergic, and adrenergic receptors have all been identified as contributing to the ejaculatory response. 8 Although the conceptualization of the sexual response cycle suggests three discrete phases, men and women experience sexual response as a continuous, coordinated, and seamless process. Nevertheless, the three phases have clinical utility as they correlate well with the kinds of sexual dysfunctions healthcare providers typically encounter. In men, these problems include hypoactive sexual desire disorder, ED and (subjective) sexual arousal disorder,and problems with ejaculatory response, either PE or inhibited ejaculation. 9 What is PE? The American Psychiatric Association s Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) defines PE as persistent or recurrent ejaculation with minimal stimulation before, on, or shortly after penetration and before the person wishes. 9 The assumption is made that this condition does not result from novelty of partner or situation, age, or recent frequency of sexual activity. In addition, the disturbance causes marked distress or interpersonal difficulty and does not result from substance use. Consistent with this definition is the growing consensus that three criteria are necessary for PE. 10 These include the following: 1. Very short latency to ejaculation. Most men with PE ejaculate within seconds or after six penile thrusts following penetration, although a small number may ejaculate prior to entry (referred to as anteportal ejaculation). Generally, ejaculatory latencies of about 1.5 minutes or

3 less place a man at risk for PE, particularly when occurring in over 50% of his attempts. 2. Lack of control over the ability to delay the ejaculatory response. Men with PE are unable to delay their ejaculatory response even if they desire to do so. 3. Dissatisfaction with one s sexual response to the extent that it causes distress or anxiety for the man or his partner. Sometimes, men speak in general terms about their inability to keep their erection. In such situations, it is important that the healthcare provider ask further questions to differentiate a problem of losing an erection because of ejaculation from a man who is unable to maintain an erection to the point of ejaculation (see Brief Lead-In Questions). 11 Typical Etiological Factors Sources Physiological/ pathophysiological Psychological Relationship Potential Cause/Mechanism Chronic prostatitis: interferes with nerves adjacent to the prostate Direct effects of a substance - Withdrawal from opioids - Psychotropic drug induced, such as the anti- Parkinson's drug levodopa, the phenothiazine trifluoperazine, amphetamines, and heroin - Withdrawal from regular use of alcohol; used to delay orgasm Neuropathy from any source including pelvic surgery and transient ischemic accidents Stroke Hyperthyroidism Genital or lower urinary tract infection Concurrent erectile dysfunction Negative cognitive-affective states, such as anxiety about sexual intercourse Early sexual experiences reinforcing rapid ejaculation Novelty of the partner Dysfunctional sex partner: inorgasmia, dyspareunia (painful intercourse), and sexual aversion Effects Sexual dysfunctions, including PE, negatively impact both the man and his sexual partner. In fact, personal or partner distress is generally considered a necessary condition for a PE diagnosis. Although PE is not generally associated with major mental or psychological dysfunction, recent studies show that men with PE experience greater sexual dissatisfaction, lower confidence, and higher interpersonal difficulty with their partners than men without PE. 12,13 Negative effects are reported by partners as well as those who, in addition to indicating greater sexual avoidance and inorgasmia, report higher levels of dissatisfaction and distress than partners of men without PE. 14 Although long-term effects of such dyadic stress have not been well-documented through empirical studies, most clinicians are acutely aware that significant relationship problems are likely to develop from untreated sexual problems. Etiology The etiology of PE is poorly understood, and, unlike ED, the great majority of men with PE exhibit no underlying pathophysiology. Nevertheless, PE can be either a lifelong (primary) condition (the patient has always had the condition with all sexual partners), or it can be acquired (secondary) either through some pathophysiology or through learned experiences. Ejaculatory problems can arise from one or more of three sources: physiological/pathophysiological, psychological, and relationship (see Typical Etiological Factors). It follows that the better the understanding about the etiology of the patient s problem with PE, the more the treatment can be tailored to the specific needs of the individual or couple. However, neither the pathophysiological etiologies nor the psychosexual developmental etiologies are causal; rather, they should be viewed as risk factors associated with the occurrence of PE. 5,15 Because the physiology of ejaculation is less understood than the physiology of erection, physiological factors responsible for PE are not well understood. However, as with many biobehavioral responses, ejaculatory response latency shows natural variation among men. Some of these men have a tendency toward very short latencies, others toward long latencies, and so on. Specifically, a small proportion of men ejaculate prior to vaginal entry. The majority ejaculate 1 to 12 minutes after the start of coitus, with a median latency around 7 to 9 minutes, and another small proportion ejaculate only after prolonged stimulation or not at all. 4 Men at either end of the latency-to-ejaculation continuum are likely to report distress: men with very short latencies (premature ejaculation) terminate their sexual activity and the intimacy that accompanies it often before they or their partners wish. Men with very long latencies (inhibited ejaculation) are often frustrated by their inability to reach orgasm. Undoubtedly, ejaculation latency to some extent is hardwired into the man s physiology through genetics, maturation, and other developmental processes. Yet a man s The Nurse Practitioner October

4 ejaculatory latency varies from one situation to the next. 16 In other words, situation, context, and individual experience affect this response. Through various cognitivearousal-behavioral strategies, most men develop some capacity to alter their latency to ejaculation. For example, a man may attenuate or increase arousal by using various thought patterns, or by modifying his coital position to increase or decrease penile friction. For this reason, it is important to recognize that ejaculatory latency represents the interaction of biological predisposition and psychological relationship factors. A general discussion regarding the patient s and partner s needs and values with respect to various treatment options is essential. Diagnostic Strategy Discussion about one s private sexual life is usually not easy for anybody, but it is even more difficult for a person who feels stigmatized for having a sexual problem. Embarrassment and discomfort, particularly for a male patient interacting with a female healthcare provider, are likely to prevent an open and a frank discussion about sexual problems. So, it is incumbent for the clinician not only to broach the subject if a problem is suspected, but to do so in a manner that avoids invasion of privacy, embarrassment, stigmatizing, and guilt. Often, patients are relieved when the healthcare provider acts on subtle cues that give permission for the patient to discuss the issue. Although it is not likely that a complete sexual history can be garnered from a patient in the context of an office visit, some minimal background information can often help guide effective treatment. For example, the healthcare provider should inquire about the following: Severity of the problem. Is the problem occurring very frequently or all the time, and is it leading to significant problems with sexual intimacy. For example, is the man or couple beginning to avoid intimacy because of the anxiety that it causes? This information not only gives the healthcare provider the opportunity to verify the diagnosis, but also provides information of the distress the problem is causing for the man and his partner. Development of the problem. Has the problem been a lifelong one, or has it developed recently? If recent, what life events, diseases, or medical conditions were temporally related to the onset? This line of questioning might be subdivided into three areas: 1. Physical Exam and Medical History. Essential to an adequate diagnosis, a general physical exam to ascertain overall health and a specific medical history help identify potential pathophysiological problems that might account for PE. Prostatic problems, neuropathies (including ones resulting from pelvic region surgery or trauma), concomitant erectile dysfunction, stroke, genital and urinary tract infections, and hyperthyroidism tend to pose greater risk for PE. 2. Medications. If oral medications or herbal preparations are being used, their likelihood of affecting ejaculatory response should be investigated. Most medications are more likely to delay or inhibit ejaculation, and include a variety of psychotropic agents such as SSRIs and tricyclic antidepressants. Several prescription and recreational drugs have been reported to induce rapid ejaculation, including the anti-parkinsonism drug levodopa, the phenothiazine trifluoperazine, amphetamines, and heroin. However, each of these drugs has also been reported to increase ejaculatory latency in some men. 15 Withdrawal from opioids and alcohol, particularly when the latter has been used to delay ejaculatory response, is occasionally associated with PE. 3. Comorbid erection problems. About 30% of men with PE also report problems with erection, although this concomitant condition is most likely to appear when men reach their 50s. 17 In such men, PE may be secondary to ED, and therefore it may be best to treat the erection problem first as these men may ejaculate quickly from fear of losing their erection. Partner problems. Does the patient indicate that the partner shows signs of a sexual dysfunction? Partner problems that may exacerbate a tendency toward rapid ejaculation include inorgasmia, dyspareunia, and sexual aversion. Treatment Options and Strategies The goal of treatment of PE is to increase ejaculatory latency, and in doing so increase overall sexual satisfaction and relationship satisfaction. To this end, a general discussion regarding the patient s and partner s needs and values with respect to various treatment options is essential. In addition, the risks and benefits of each strategy must be delineated. Until recently, options for the treatment of PE were limited mainly to cognitive-behavioral therapies (CBT). Although short-term success rates for CBT have been typically reported at or above 70%, treatment effects assessed 1 to 3 years later indicate only about 60% of patients reported long-term satisfactory outcomes, 24 The Nurse Practitioner Vol. 33, No. 10

5 with one study reporting results as low as 25% Furthermore, this approach sometimes requires substantial investments of time and resources on the part of the man and his partner. Over the last decade, the offlabel use of tricyclic and SSRI antidepressants has been reasonably successful in delaying ejaculation in some men. A number of studies have documented the efficacy of the use of these drugs, both daily and on demand, in the treatment of PE (see Common Risks and Benefits of Cognitive-Behavioral Versus Medical Approaches). 5,15 As treatment strategies are considered, healthcare providers should be aware of the fact that men in particular tend to focus heavily on genital issues in resolving sexual problems, sometimes dismissing potentially relevant psychological and relationship issues. As a result, the automatic use of medication in the treatment of PE should be avoided. The patient and his partner should be fully aware of their options and of the possibility of combining options if it might better fit their needs. Biomedical approaches The off-label use of moderate doses of tricyclic and SSRI antidepressants as well as the use of topical anesthetic creams (such as lidocaine) have proven effective in helping men delay their ejaculatory response, with results indicating prolongation of intercourse anywhere from about 1 to 5 minutes. 5,15,21 Therapies that combine both approaches may represent an optimal strategy for the most severe cases of PE and may be the only viable approach for PE that has a clear and strong pathophysiological etiology. Stimulus reduction creams or gels (local topical anesthetics), particularly when used in conjunction with a condom, have demonstrated to be effective in increasing ejaculatory latencies by several minutes. However, if a condom is not used or if the cream or gel is not removed prior to coitus, vaginal numbness, irritation, and inorgasmia may occur in the partner. Oral medications have become an increasingly popular option in the treatment of PE. Meta-analytic comparisons among SSRIs have demonstrated that paroxetine may exert the strongest ejaculatory delay, although both sertraline and fluoxetine have shown to be clinically efficacious as well. Common Risks and Benefits of Cognitive-Behavioral Versus Medical Approaches Risks/Costs Benefits Cognitive-behavioral Requires cooperation Treatment specific to of partner problem Significant time and No negative side effects money Typically improves overall Lower level of evidence sexual satisfaction of efficacy Helps patient establish Positive effects wane control over ejaculation with time Once learned, techniques always available to patient and partner Oral medications Adverse effects likely Convenient and not time Medication not specific consuming to PE Typically low in cost Relapse if medication Well-documented efficacy is not used Adherence rates are unknown Requires anticipation of intercourse Fluvoxamine and citalopram appear to be less effective. The tricyclic clomipramine appears to be as effective as the best of the SSRIs, but tends to have more adverse effects. All these medications may also be associated with diminished libido and reduce erectile rigidity. If erectile function is a concern, concomitant treatment with a phosphodiesterase inhibitor (such as sildenafil) may be considered. As with any antidepressant medications, termination of daily dosing should be gradual to avoid withdrawal symptoms. 15 As needed, dosing 3 to 6 hours prior to anticipated intercourse has been implemented successfully with paroxetine, sertraline, and clomipramine. Given that many couples engage in intercourse only once or twice a week, this option provides an attractive alternative to daily dosing. However, in using this regimen, drug effects are diminished and more variable, and are less likely to be effective for the severest cases of PE. Unlike existing oral medications which require daily dosing or administration 3 to 6 hours prior to anticipated intercourse, forthcoming oral medications are likely to be taken as little as an hour prior to intercourse with effects continuing up to several hours thereafter. These medications, essentially SSRI variants, presumably work by inhibiting the central (brain or upper spinal cord) serotonergic trigger for ejaculation. 6 One of the disadvantages of oral medications for PE includes the symptomatic approach to treatment; that is, relapse occurs in the absence of medication use, as men do not develop better control over their ejaculatory response. The Nurse Practitioner October

6 Recommended Doses for Anesthetic Creams and Off-Label SSRI and Tricyclic Treatments 5 Drug Topical cream Lidocaine Prilocaine Dose 2.5%, 30 min prior to intercourse 2.5%, 30 min prior to intercourse SSRIs Fluoxetine 5 to 20 mg/day Paroxetine 10, 20, or 40 mg/day or 20 mg 3 to 4 hours prior to intercourse Sertraline 25 to 200 mg/day or 50 mg 4 to 8 hours prior to intercourse Tricyclic Clomipramine 25 to 50 mg/day or 25 mg 4 to 24 hours prior to intercourse In addition, as with any drug, unwanted adverse reactions might occur and the drugs are ineffective for an estimated 30% of patients. Data on long-term adherence are not available (see Recommended Doses for Anesthetic Creams and Off- Label SSRI and Tricyclic Treatment). Although the SSRIs in particular are well tolerated, adverse effects from these agents may occur and include gastrointestinal upset,insomnia,somnolence, tremor, dry mouth, sweating, anorexia, fatigue, and weight gain. Cognitive-behavioral approach Cognitive-behavioral and relationship factors are tied directly to levels of psychosexual arousal, and are likely to be involved in PE. Therefore, healthcare providers should be aware of and sensitive to such factors in the treatment of this disorder. Many elements of cognitive-behavioral strategies may be acquired through bibliotherapy. 22 However, the patient and his partner can also benefit from a counselor or a healthcare provider who can educate them about the sexual response cycle, facilitate communication about sexual issues, and give permission regarding an expanded repertoire of behaviors for greater sexual satisfaction. As examples, the healthcare provider might encourage the couple to enjoy intercourse a second time after a session involving a shortejaculation latency to take advantage of the decreased sexual arousal most men experience during the refractory period. Or, the couple could be encouraged to vary their intercourserelated behaviors to attenuate the patient s level of sexual arousal to keep it below the level of ejaculatory inevitability. Although education about the problem and facilitation of dyadic communication is central to therapy for any number of problems and usually can be achieved by any informed clinician, the employment of specific cognitive-behavioral strategies intended to increase ejaculatory latency is often facilitated through professional sex counseling. As such, referral to a sex therapist or a counselor versed in sexual problems for at least brief counseling may be an important option for the man or the couple, or an effective adjunct to a pharmacological approach. Standard behavioral strategies for the treatment of PE include the frenulum squeeze and start-pause techniques introduced several decades ago. 7,23 In addition, the couple could be encouraged to experiment with the partnersuperior or lateral positions, as these typically provide men with a greater sense of ejaculatory control. Couples could also be advised to engage in mutual masturbation and then oral sex prior to coitus (depending on the acceptability of the sexual behaviors to the couple). Other suggestions include slowing down during intercourse, breathing deeply, having shallower penile penetration, or moving the pelvis in a circular motion. 16 Relevant cognitive strategies include the man s increased attention to his somatic sensations so he might better monitor his level of physical arousal, and the use of sensate focus, which permit enjoyment of physical sensations without necessarily generating sexual arousal. 24 This latter procedure also deemphasizes the focus on intercourse and orgasm within the sexual relationship and may help reduce the man s performance anxiety, which, because it presumably operates through sympathetic pathways, may serve to prime the ejaculatory response prematurely. Important to any treatment plan is the substitution of counterproductive behaviors and beliefs with positive therapeutic strategies. Thus, strong emphasis on latency-toejaculation or on using distracting stimuli (at the cost of ignoring relevant body cues) can actually increase PE symptoms. As important, deliberate strategies to achieve relapse prevention, particularly by predicting the likelihood of occasional setbacks and preparing couples appropriately, and by using increased spacing between sessions as progress is noted, are typical. Depending on the level of PE severity, the above goals may be achieved in just two or three sessions. If significant relationship issues and partner dysfunction exist, it may take as many as 10 to 20 sessions. By itself, cognitive-behavioral treatment has a fairly high initial success rate; however, for reasons as yet undetermined, this drops off to about 50% or less by about a year posttreatment Although cognitive-behavioral therapy for PE has been criticized by some as lacking long-term efficacy, long-term success rates for PE treatment have not been adequately investigated, and the reasons for purported failures remain largely unknown. 26 The Nurse Practitioner Vol. 33, No. 10

7 Promoting an integrated biopsychosocial approach Treatment for PE is too often, and perhaps to the detriment of patient care, arbitrarily dichotomized into medical and psychological approaches. In fact, there is good reason to consider the full range of tools available for the treatment of premature ejaculation, rather than focusing on only one to the possible exclusion of others. The severity of the PE may suggest varied treatment approaches that combine oral medications and anesthetic creams (applied to the penis) with either brief or more extended cognitive-behavioral counseling. As with ED, these pharmacological strategies can assist the man in redeveloping self-confidence and selfefficacy, and afford the man the opportunity to develop and use cognitive-behavioral strategies as his response latency approximates a more typical pattern. Ideally, as the man and his partner gain a greater sense of self-efficacy, reliance on oral medications or anesthetizing creams could be reduced. Practice Implications Despite its significant prevalence and potential for causing distress, PE, the most common male sexual dysfunction, remains underreported and not well understood by healthcare providers. However, currently available treatment strategies offer significant amelioration of the condition. In general, it is important for the healthcare provider to convey to the patient a sense of optimism regarding a reasonably satisfactory solution. Essential to the treatment is accurate diagnosis. This is accomplished through the healthcare provider s frank discussion of sexual health, including but not limited to the development and severity of the dysfunction, history and physical exam, medication profile, comorbid erectile problems, partner sexual difficulties, and relationship issues. At the same time, the healthcare provider should recognize the fact that most instances of PE are not characterized by an obvious underlying pathophysiology. The goal of treatment for a patient with a diagnosis of PE is to increase ejaculatory latency, which presumably increases sexual satisfaction and thereby improves one s relationship. Treatment options and strategies for clients with a diagnosis of PE are varied, and discussion of various options is essential. The choice of treatment is best guided by taking into consideration the efficacy of the therapies, potential etiological factors that may be addressed, and the value and comfort level that the patient and his partner have for any particular strategy. The patient and his partner should be fully aware of the risks and benefits of each strategy as a decision is made regarding a treatment that best fits their needs. Currently available beneficial treatment strategies as well as possible forthcoming oral medications suggest that the practitioner offers an integrated biopsychosocial approach to the treatment of PE. REFERENCES 1. Albaugh J, Amargo I, Capelson R, et al. Health care clinicians in sexual health medicine: Focus on erectile dysfunction. Urol Nurs. 2002;22(4): Laumann EO, Pail A, Rosen RC. Sexual dysfunction in the United States: Prevalence and predictors. JAMA. 1999;281: Rowland DL, Perelman, Althof S, et al. Self reported premature ejaculation and aspects of sexual functioning and satisfaction. J Sex Med. 2005;1: Patrick DL, Althof SE, Pryor JL, et al. Premature ejaculation: an observational study of men and their partners. J Sex Med. 2005;2: Montague DK, Jarow J, Broderick GA, et al. AUA guideline on the pharmacologic management of premature ejaculation. J Urol. 2004;172(1): Pryor JL, Althof SE, Steidle C, et al. Efficacy and tolerability of dapoxetine in treatment of premature ejaculation: an integrated analysis of two doubleblind, randomized controlled trials. Lancet 2006; 368(9548): Kaplan H. The evaluation of sexual disorders: psychologic and medical aspects. New York, NY: Brunner/Mazel; Giuliano F, Clement P. Neuroanatomy and physiology of ejaculation. Annu Rev Sex Res. 2005;16: American Psychiatric Association. Diagnostic and statistical manual of mental disorders, Fourth Edition, Text Revision (DSM-IV-TR). Washington D.C.: American Psychiatric Association, Rowland DL, Cooper SE, Schneider M. Defining premature ejaculation for experimental and clinical investigations. Arch Sex Behav. 2001;30(3): Sadovsky R, Mulhall JP. The potential value of erectile dysfunction inquiry and management. Int J Clin Pract. 2003;57(7): Symonds T, Roblin D, Hart K. How does premature ejaculation impact a man s life? J Sex Mar Ther. 2003;29(5): Sotomayor M. The burden of premature ejaculation: the patient s perspective. J Sex Med. 2005;2 Suppl 2: Rowland DL, Patrick DL, Rothman M, Gagnon D. The psychological burden of premature ejaculation. J Urol. 2007;177(3): McMahon CG, Abdo C, Incrocci L, et al. Disorders of orgasm and ejaculation in men. In: Lue TF, Basson R, Rosen R, et al., eds. Sexual medicine: sexual dysfunctions in men and women. 2nd ed. International Consultation on Erectile and Sexual Dysfunctions, Health Publications; 2004: Rowland DL, Cooper SE. Behavioral and psychological models in ejaculatory function research. In: Mulhall J, ed. Current Sexual Health Reports. Philadelphia, PA: Current Science Inc: 2005;2(1): Grenier G, Byers ES. Operationalizing premature or rapid ejaculation. J Sex Res. 2001;38(4): DeAmicis LA, Goldberg DC, LoPiccolo J, et al. Clinical follow-up of couples treated for sexual dysfunction. Arch Sex Behav. 1985;14(6): Heiman JR, LoPiccolo J. Clinical outcome of sex therapy. Arch Gen Psychiatry. 1983;40: Hawton K, Catalan J, Martin P, Fagg J. Long-term outcome of sex therapy. Behav Res Ther. 1986;24(6): Waldinger M. The neurobiological approach to premature ejaculation. J Urol. 2002;168(3): Metz M, McCarthy BW. Coping with Premature Ejaculation. Oakland, Ca: New Harbinger Publications; Masters WH, Johnson VE. Human Sexual Inadequacy. Boston, MA: Little, Brown; 1970: Carey MP. Cognitive-behavioral treatment of sexual dysfunction. In: Caballo VE, ed. International Handbook of Cognitive and Behavioural Treatments for Psychological Disorders. Kidlington, Oxford: Pergamon; 1998: ABOUT THE AUTHORS David L. Rowland is a Professor of Psychology, Dean of the Graduate School, Valparaiso University, Valparaiso, Ind. Peggy Rose is an Assistant Professor of Nursing, Purdue University North Central, Westville, Ind. The Nurse Practitioner October