Recommendations for the management of
premature ejaculation: BASHH Special Interest
Group for Sexual Dysfunction
Daniel Richardson BSc MRCP, David Goldmeier MD FRCP,
John Green PhD, Harpal Lamba BSc MRCP and J R W Harris FRCP, FRCPI,
on behalf of the BASHH Special Interest Group for Sexual
Dysfunction
Jane Wadsworth Clinic, Jefferiss Wing, St Mary’s Hospital, London W2 1NY, UK
Summary: We present the British Association for Sexual Health and HIV (BASHH),
Special Interest Group for Sexual Dysfunction updated recommendations for the
management of premature ejaculation. The recommendations outline the physiology,
prevalence, definitions, aetiological factors and patient assessment for this common
sexual problem. Behavioural, local and systemic pharmacological treatments are
discussed along with general recommendations and auditable outcomes.
Introduction
Orgasm and ejaculation constitute the final stage of
the sexual response in men. There are three basic
mechanisms involved in the normal antegrade
ejaculation: emission, ejection and orgasm.1
Ejaculation is a reflex comprising sensory receptors
and areas, afferent pathways, cerebral sensory areas,
spinal motor areas and efferent pathways (Figure 1).
The ejaculation reflex is controlled by a complex
interplay between central serotonergic and dopaminergic
neurons, with a secondary involvement of
cholinergic, adrenergic, nitrergic, oxytocinergic and
GABA (gamma aminobutyric acid)-ergic neurons.2
Seminal emission and ejaculation are integrated into
the complex pattern of copulatory behaviour by
several forebrain and midbrain structures (Figure 1).3
Prevalence of premature ejaculation
Premature ejaculation is one of the most frequently
reported sexual dysfunctions seen in clinical
practice. Varying rates have been estimated from
different populations. A systematic review of 28
studies suggested a prevalence of 15%.4 A large
representative sample of American men, aged
between 18 and 59 years, found that 31% of men
admitted to premature ejaculation occurring for
at least one month over the past 12 months.5
However, a more detailed study in the UK of 5000
16–44-year-old men found that 11.7% said that they
had experienced premature ejaculation for at least
one month in the past year, but only 2.7% hadexperienced the problem for at least six months in
the past year, suggesting that the problem affects
many men some of the time.6 Data from a large
observational study show overlapping distributions
of ejaculation times in men, who subjectively
had premature ejaculation compared with those
who were subjectively normal (Figure 2).7 A
substantial number of men who do not have
premature ejaculation have short ejaculation times
and conversely some men who complain of
premature ejaculation appear to have long ejaculation
times. This suggests that other features of
premature ejaculation have to be considered, as
well as time, i.e. degree of control and distress.
Definition
A universally accepted definition has yet to be
established. Masters and Johnson proposed that
premature ejaculation is the inability of a man to
delay ejaculation long enough for the woman to
reach orgasm 50% of the time.8 Some authors have
defined premature ejaculation as the number of
vaginal thrusts the man makes before ejaculation.
9–11 Clinical studies have used intravaginal
ejaculation times as measured by a stopwatch to
define premature ejaculation. Standardized inventories
may be available in the future, which will
generate individual data on the subjective perception
of lack of control and associated distress. The
DSM IV (American Association of Psychiatrists)
define premature ejaculation as: ‘persistent or
recurrent ejaculation with minimal sexual satisfaction
before, or shortly after penetration and before
the person wishes’.12 The disorder should result in
