The first step in the treatment of premature ejaculation is to establish the type
that the patient suffers from and the underlying causes as summarised below:

1. Primary life long premature ejaculation

The criteria for a patient to be classified as having Primary premature ejaculation
are the following:

• From the first sexual experience
• Intravaginal latency time IELT ≤ 1-2min (90% of patients will have IELT < 1min, 10% between 1-2 min)
• Inability to delay ejaculation on all or nearly all vaginal penetrations.
• Negative impact e.g distress, bother, frustration, and/or the avoidance of sexual intimacy.

Ante-portal ejaculation is the severest form of primary PE when IELT= Zero, which means that the patient ejaculates even before penetration.

Causes

Lifelong premature ejaculation is usually neuro-biologically rather than psychologically determined meaning that the patients suffering from this have genetic predisposition with environmental influences. Unfortunately, the exact neuro-biological mechanisms have not been established (hence multi-optional treatment rather than targeted treatment is recommended) although there are a number of theories in development.

2. Acquired or secondary premature ejaculation

The criteria for a patient to be classified as having Acquired or Secondary PE
are the following:

• PE symptoms beginning after a period of normal ejaculatory function causing a clinically significant reduction in the IELT
• IELT≤ 3min
• Inability to delay ejaculation on all or nearly all vaginal penetrations;
• Negative impact e.g distress, bother, frustration, and/or the avoidance of sexual intimacy.

Causes

Potential causes of Secondary PE
are the following:

• Neurological factors causing hypersensitivity of genital skin and hyper excitability of the ejaculatory reflex e.g increased sympathetic tone (Hypertension), Diabetes, metabolic syndrome and alcoholism
• Hormonal Causes such as Hyperthyroidism/ Hypothyroidism / reduced Prolactin/ increased Leptin
• Erectile Dysfunction causing secondary PE
• Tight Frenulum
• Phimosis / Balanoposthitis causing Dyspareunia
• Chronic Prostatitis
• Chronic Pelvic pain syndrome
• Psychological factors; e.g Anxiety/depression, partner issues, paranoia habituation through early sexual experiences, habituation via masturbation, negative early sexual experiences
• Recreational drugs
• Certain medication such sympathomimetics

3. Variable PE:

Variable premature ejaculation
will happen naturally in certain situations such as:

• Abstaining from sex for a long time
• Over sexually excited, e.g having sex for the first time
• New sexual stimulants: sexually exciting situations e.g special occasions, fantasy enactments

This should not be considered a pathology but a small variation in normal sexual performance.

4. Premature-like ejaculatory dysfunction (Subjective PE)

Subjective complaint of premature ejaculation
(SPE) in men with a normal IELT of more than 3min. SPE is characterized by one or more of the following:

• Subjective perception of consistent or inconsistent short IELT;
• Preoccupation with an imagined short ejaculatory latency or lack of control over the timing of ejaculation;
• IELT in the normal range or even of longer duration (i.e., an ejaculation that occurs after 5 minutes);and
• Ejaculation control that may be diminished or lacking.