Premature ejaculation

Premature ejaculation has both medical and behavioural approaches. The doctor decides which one fits your case, without assumptions — from online consultation to ongoing follow-up, without leaving home.

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Diagnostic criteria

The DSM-5 defines premature ejaculation as a persistent pattern of ejaculation occurring within approximately one minute of vaginal penetration (or less, in severe cases), present for at least six months, and causing clinically significant distress or interpersonal difficulty. Onset is classified as lifelong (present from first sexual experiences) or acquired (developing after a period of normal control). The distinction matters because lifelong PE is more likely to have a neurobiological basis, whereas acquired PE may be secondary to prostatitis, thyroid dysfunction, psychological factors or another medication.

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Pathophysiology

Ejaculation is co-ordinated by a spinal generator at the T10–L2 and S2–S4 levels, modulated by descending serotonergic pathways from the brainstem. The key neurotransmitter is serotonin (5-HT): activation of 5-HT2C receptors inhibits ejaculation, whereas activation of 5-HT1A receptors facilitates it. A relative hyposensitivity of 5-HT2C receptors or an imbalance between the two receptor subtypes is thought to lower the ejaculatory threshold (Waldinger, World J Urol 2005; PMID 15889324). This model explains why selective serotonin reuptake inhibitors such as dapoxetine — which raise synaptic 5-HT levels and preferentially activate 5-HT2C receptors — can delay ejaculation. Dapoxetine is authorised in the EU for men aged 18 to 64. It is contraindicated in moderate-to-severe hepatic impairment and with potent CYP3A4 inhibitors (ketoconazole, ritonavir, telithromycin, nefadone) because dapoxetine is metabolised primarily by CYP2D6 and CYP3A4; co-administration can raise plasma concentrations substantially, especially in CYP2D6 poor metabolisers. Concomitant use with phosphodiesterase type 5 inhibitors is not recommended because of an increased risk of orthostatic hypotension. The EMA Article 29 referral (2011–2012) reviewed the dose-dependent risk of syncope: the higher tablet strength showed a higher incidence of syncope and prodromal symptoms than the lower strength. Treatment must be initiated at the lower strength and escalated only in patients who respond insufficiently and tolerate the lower dose. Re-evaluation of the benefit-risk balance is recommended at least every six months (EMA Article 29 referral procedure, 2012).

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Trial design for dapoxetine

The phase 3 programme for dapoxetine comprised two randomised, double-blind, placebo-controlled trials conducted at US sites among men in stable heterosexual relationships (Pryor et al., Lancet 2006; PMID 16677881). Both trials used stopwatch-measured intravaginal ejaculatory latency time (IELT) as the primary endpoint. The integrated analysis showed an increase in mean IELT across the available tablet strengths, with a larger increase at the higher dose. The trials did not measure partner-satisfaction outcomes. Dapoxetine is authorised in the EU for men aged 18 to 64.

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Your path to treatment

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How Hi-Doctor handles it

One consultation, one doctor, one decision. Your case is reviewed by an EU-licensed doctor, who issues an electronic prescription only if appropriate — with a full refund if not. If the doctor prescribes a medicine, it is paid for separately at the pharmacy you choose; Hi-Doctor does not sell medications. See pricing, how a consultation works, the treatment areas Hi-Doctor covers, and how eligibility is decided in safety.

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Related sexual health medicines

Hi-Doctor’s doctors review the full sexual health questionnaire before deciding on an approach. Dapoxetine (Priligy) is the medicine in this library indicated for premature ejaculation. Because the two often come up together, the doctor may also assess erectile dysfunction and the oral options covered there, such as vardenafil.

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