oxytocin.

dopamine.

serotonin.

γ-aminobutyric acid.

noradrenalin.

Ejection also involves a parasympathetic spinal cord reflex on which there is limited voluntary control.

Emission is mediated by sympathetic nerves (T10 to L2).

The ejaculatory process comprises three phases: emission, ejection and orgasm.

Closure of bladder neck, rhythmic contraction of the bulbocavernosus, bulbospongiosus, and other pelvic floor muscles, and relaxation of the external urinary sphincter during emission prevents retrograde ejaculation.

Ejection is mediated by somatic nerves (S2 to S4).

5.5%.

11%.

< 1%.

20%.

2.5%.

Approximately 80% of heterosexual men seeking treatment for lifelong PE ejaculate within 1 minute after penetration.

Acquired PE is most often due to psychological factors or comorbid erectile dysfunction.

The consistent early ejaculations of lifelong PE suggest an underlying neurobiologic functional disturbance.

Men with subjective PE complain of PE, often due to psychological and/or cultural factors, but have a normal or even extended IELT.

The Diagnostic and Statistical Manual (DSM) IV definition of premature ejaculation (PE) is an operationalized multivariate definition that captures the key dimensions of latency, control, and bother.

This definition is applicable to all men regardless of their sexual orientation or type of sexual contact.

The main constructs in the ISSM definition of PE are time from penetration to ejaculation, inability to delay ejaculation, and the presence of negative personal consequences.

Acquired PE is, in part, defined by a clinically significant and bothersome reduction in latency time, often to about 3 minutes or less.

Lifelong PE is, in part, defined by an IELT less than about 1 minute.

The International Society for Sexual Medicine (ISSM) developed the first contemporary, evidence-based definition of lifelong and acquired PE.

Men with acquired PE tend to have lower IELT than men with lifelong PE.

Most men do not use cognitive or behavioral techniques to prolong intercourse and delay ejaculation.

Patient self-estimated IELT correlates poorly with stopwatch IELT.

Men with lifelong or acquired PE invariably experience a variety of negative psychological consequences such as bother, frustration, or the avoidance of sexual contact.

Men with PE had similar overall health-related quality of life, self-esteem, and confidence compared with non-PE groups.

Hypothyroidism is a common cause of PE.

Community-based stopwatch IELT studies demonstrate that IELT decreases with age and varies among countries.

There is a substantial disparity between the incidence of PE in epidemiologic studies that rely on patient self-reports of PE and/or inconsistent and poorly validated definitions of PE.

Community-based stopwatch IELT studies demonstrate that the distribution of the IELT is positively skewed, with a median IELT of 5.4 minutes (range, 0.55-44.1 minutes).

Some men may have a neurobiologic and genetic predisposition toward early ejaculation.

c and d

Intentionally "rushing" intercourse to prevent early detumescence of a partial erection is common.

The presence of vascular risk factors such as diabetes and hypertension is common.

PE is rarely compounded by the presence of high levels of performance anxiety related to their ED.

Limitation of arousal during foreplay to prevent early ejaculation may result in an incomplete erection.

Laboratory or imaging investigations are occasionally required based on the patient's medical history

The Index of Premature Ejaculation (IPE) was developed specifically for use as a screening questionnaire.

The presence of comorbid ED can be evaluated using a validated instrument such as the International Index of Erectile Function (IIEF) or the IIEF-5 (SHIM).

A physical examination is mandatory in an effort to identify the etiology of the PE.

A digital prostate examination, routine in an andrologic setting for all men older than 40 years, is useful in identifying possible evidence of prostatic inflammation or infection.

Psychological-behavioral strategies for treating PE are moderately successful in the long term.

All men seeking treatment for PE should receive basic psychosexual education or coaching.

Combining PE pharmacotherapy and psychological approaches may be especially useful and potentially prevent symptom relapses.

Present-day psychotherapy for PE is an integration of behavioral (e.g., the well known start-stop and pause-squeeze methods) and cognitive approaches within a short-term psychotherapy model.

Drawbacks to the psychological-behavioral approach are that it is it is time-consuming, requires substantial resources of both time and money, lacks immediacy, and requires the partner's cooperation.

Dapoxetine is a rapid acting and short half-life selective serotonin reuptake inhibitor (SSRI) taken 1 to 3 hours before sexual contact.

Daily dosing of SSRIs such as paroxetine, sertraline, fluoxetine, and citalopram are effective treatments for PE.

The use of on-demand clomipramine taken 4 to 6 hours before sexual contact is limited by the occurrence of nausea and dizziness.

SSRIs inhibit the postsynaptic 5-HT transporter system in the serotonergic neuron synapse.

Dapoxetine can be combined with sildenafil as a treatment for PE in men with comorbid ED.

(d) Many men with acquired DE can often masturbate to orgasm and may use idiosyncratic masturbation techniques that cannot be easily replicated during intercourse.

(a) The DSM-IV-TR definition of delayed ejaculation is evidence based on a small number of community-based IELT studies.

Both b and d

(c) An IELT of 40 to 45 minutes represents an IELT in excess of two standard deviations above the mean.

(b) Men with IELT more than two standard deviations above the mean who report distress and/or cease sexual intercourse due to fatigue or irritation are regarded as suffering from delayed ejaculation.

Hypothyroidism

Hypogonadism

All of the above

Multiple sclerosis

Antidepressants drugs such as SSRIs

(c) The ability to achieve an erection increases with descending levels of spinal injury.

(a) The ability to ejaculate increases with descending levels of spinal injury.

(d) Semen harvesting with electroejaculation or vibratory stimulation is associated with a significant risk of autonomic dysreflexia.

Both a and b

(b) Fewer than 5% of patients with complete upper motor neuron lesions retain the ability to ejaculate.

Both a and c

(a) Retrograde ejaculation can be confirmed by the presence of spermatozoa in postmasturbation first-void urine.

(d) Retrograde ejaculation in men with diabetic autonomic neuropathy is usually associated with hypogonadism.

(c) Retrograde ejaculation may occur in men with diabetic autonomic neuropathy.

(b) Retrograde ejaculation is more common following a bladder neck incision than transurethral resection of the prostate (TURP).