A 35-year-old man comes to the office due to sexual symptoms. The patient has normal libido and erectile function but has uncontrollable orgasm within a minute of vaginal penetration during intercourse. His symptoms started 6 months ago after his wife gave birth to their second child. The patient says his symptoms are distressing and are leading to considerable frustration in his relationship with his wife. Medical history and examination are unremarkable. Which of the following is the most appropriate next step in management of this patient's sexual symptoms?

Question

A 35-year-old man comes to the office due to sexual symptoms.  The patient has normal libido and erectile function but has uncontrollable orgasm within a minute of vaginal penetration during intercourse.  His symptoms started 6 months ago after his wife gave birth to their second child.  The patient says his symptoms are distressing and are leading to considerable frustration in his relationship with his wife.  Medical history and examination are unremarkable.  Which of the following is the most appropriate next step in management of this patient's sexual symptoms?

Quizplus · Accepted Answer

11ec25c8_d76f_fc8f_bc81_f9d61d6c3c0b_MD0003_00 This patient has premature ejaculation (PE), presenting with uncontrolled ejaculation and decreased ejaculatory latency (ie, time from vaginal penetration to ejaculation). PE can be present from a patient's initial sexual experiences or acquired later in life; stressful or life-changing events may trigger symptoms, although the etiology is variable and often unclear. It can occur as an isolated symptom or in association with other sexual disorders (eg, erectile dysfunction [ED]). Decreased ejaculatory latency is common in men and does not require treatment, unless it is causing distress for the patient and/or partner. Most patients respond to selective serotonin reuptake inhibitors (SSRIs) (eg, paroxetine, citalopram), which prolong ejaculatory latency and allow for extended coitus. Alternate options include topical anesthetics (eg, lidocaine-prilocaine) and tricyclic agents (eg, clomipramine). Patients may also benefit from psychotherapy to address concurrent anxiety, mood disorders, and relational issues. (Choice A) Finasteride is a 5-alpha-reductase inhibitor used in benign prostatic hyperplasia. Low dose finasteride is indicated for treatment of male-pattern hair loss. Adverse effects include decreased libido and ED. It is not used for PE. (Choice C) Hyperprolactinemia can be caused by prolactin-secreting pituitary adenomas, other hypothalamic or pituitary masses, or antidopaminergic medications (eg, antipsychotics). Symptoms in men include decreased libido, erectile dysfunction, gynecomastia, and infertility. PE is not a common symptom. (Choice D) Male hypogonadism (ie, low testosterone level) typically presents with fatigue, decreased libido, ED, gynecomastia, and decreased muscle mass. PE is not a common symptom. (Choice E) Phosphodiesterase inhibitors (eg, sildenafil) are indicated for ED and are sometimes useful for patients with concurrent PE and ED. They are not recommended for isolated PE. Educational objective: Premature ejaculation is characterized by uncontrolled ejaculation and decreased ejaculatory latency. Most patients respond to selective serotonin reuptake inhibitors, which prolong ejaculatory latency. Patients may also benefit from local anesthetics and/or psychotherapy to address concurrent anxiety, mood disorders, and relational issues. References: Premature ejaculation. (http://www.ncbi.nlm.nih.gov/pubmed/23781521)

A 35-Year-Old Man Comes to the Office Due to Sexual