Premature Ejaculation
Doctor Information
Mr Jacob Arnold 28 years old
Past medical history:
Nill
Drug History:
No routine medication
Allergies:
None
Past medical history:
Nill
Drug History:
No routine medication
Allergies:
None
Patient Information
Jacob Arnold 28 years old
You do not act depressed for this station.
Opening line:
I want some antidepressants please doctor
Information you will reveal easily:
You tell the doctor that you would like antidepressants as you have read that they can make you feel ‘better’. The antidepressant you've read that might be best suited to you is dapoxetine. You don’t feel sad and you don’t have anhedonia, your sleep and appetite is good and undisturbed, you’re not anxious. You don’t feel depressed or hopeless, you’re stress levels are ok, work is good, home life is good. You do not feel suicidal, nor have you had any darker thoughts about the future.
Information to reveal only if asked directly:
If the doctor probes deeper and enquires why you want antidepressants, since you appear to have no signs of depression or anxiety, (or asks you in what way you want to feel ‘better) you will reluctantly tell them that it’s not really for depression or anxiety. You have recently started a new relationship with a really attractive colleague at work. It was really embarrassing for you as the first time you had sex a few days back you didn't last very long. At the time you made some excuse, saying that “that has never happened before”. However, you know yourself that you have never been able to last very long, so in the past you have tried all the techniques you've read up about on Google, and you've tried using thicker condoms, but nothing has helped. You don’t have any problems getting nor maintaining erections. No pain, no discharge, no testicular lumps / bumps. You have had no problems passing urine, not noticed any inflammation of your penis, and have not started taking any medications. You have no pelvic pains.
Your last relationship was over 2 years ago, you don't remember having this problem then. You're not sure what's different this time. You think it might be the fact that she is a work colleague, and you feel that there might be more "pressure" on you to perform.
So after some more google-ing you came across something that mentioned antidepressants can be used to help this problem, so you would like to try some please.
Social:
You don’t drink any alcohol, your Weight is stable at 75kg, your BMI is 23, you like to exercise regularly, and enjoy playing some football once a week. You don’t smoke and never have done. You don't take any illicit drugs.
Past Medical History:
You don't have any past medical history, and hardly ever visit a health professional. You take no routine medications, and have no allergies.
Ideas:
That this is life long problem, that needs fixing,
Concerns:
Your concern is that you have another date coming up soon, and if it happens again you’re worried that she wont want to continue the relationship, and word may get around your workplace about your inadequacies in the bedroom.
Expectations:
To get some antidepressants for this problem.
You do not act depressed for this station.
Opening line:
I want some antidepressants please doctor
Information you will reveal easily:
You tell the doctor that you would like antidepressants as you have read that they can make you feel ‘better’. The antidepressant you've read that might be best suited to you is dapoxetine. You don’t feel sad and you don’t have anhedonia, your sleep and appetite is good and undisturbed, you’re not anxious. You don’t feel depressed or hopeless, you’re stress levels are ok, work is good, home life is good. You do not feel suicidal, nor have you had any darker thoughts about the future.
Information to reveal only if asked directly:
If the doctor probes deeper and enquires why you want antidepressants, since you appear to have no signs of depression or anxiety, (or asks you in what way you want to feel ‘better) you will reluctantly tell them that it’s not really for depression or anxiety. You have recently started a new relationship with a really attractive colleague at work. It was really embarrassing for you as the first time you had sex a few days back you didn't last very long. At the time you made some excuse, saying that “that has never happened before”. However, you know yourself that you have never been able to last very long, so in the past you have tried all the techniques you've read up about on Google, and you've tried using thicker condoms, but nothing has helped. You don’t have any problems getting nor maintaining erections. No pain, no discharge, no testicular lumps / bumps. You have had no problems passing urine, not noticed any inflammation of your penis, and have not started taking any medications. You have no pelvic pains.
Your last relationship was over 2 years ago, you don't remember having this problem then. You're not sure what's different this time. You think it might be the fact that she is a work colleague, and you feel that there might be more "pressure" on you to perform.
So after some more google-ing you came across something that mentioned antidepressants can be used to help this problem, so you would like to try some please.
Social:
You don’t drink any alcohol, your Weight is stable at 75kg, your BMI is 23, you like to exercise regularly, and enjoy playing some football once a week. You don’t smoke and never have done. You don't take any illicit drugs.
Past Medical History:
You don't have any past medical history, and hardly ever visit a health professional. You take no routine medications, and have no allergies.
Ideas:
That this is life long problem, that needs fixing,
Concerns:
Your concern is that you have another date coming up soon, and if it happens again you’re worried that she wont want to continue the relationship, and word may get around your workplace about your inadequacies in the bedroom.
Expectations:
To get some antidepressants for this problem.
Examination Findings
Examination:
Pulse 80
Blood pressure: 120/70
RR 16
External genitalia: NAD
Pulse 80
Blood pressure: 120/70
RR 16
External genitalia: NAD
Mark scheme
Data Gathering
|
POSITIVE INDICATORS
Organised and systematic in gathering information from history taking, examination Identifies abnormal findings or results and/or recognises their implications Enquires about possible causes of premature ejaculation (see below) and enquires about erectile dysfunction. Does a quick depression screen Data gathering does appears to be guided by the probabilities of disease Undertakes physical examination competently |
NEGATIVE INDICATORS
Makes immediate assumptions about the problem Intervenes rather than using appropriate expectant management Is disorganised/unsystematic in gathering information Data gathering does not appear to be guided by the probabilities of disease. Fails to identify abnormal data or correctly interpret them Appears disorganised/unsystematic in the conduct of physical examinations |
Clinical Management Skills
|
POSITIVE INDICATORS Makes appropriate diagnosis Develops a management plan (including prescribing and referral) that is appropriate and in line with current best practice Makes appropriate prescribing decisions - in this case does prescribe something to help Manages risk effectively (with prescribing SSRI), safety netting appropriately |
NEGATIVE INDICATORS
Fails to consider common conditions in the differential diagnosis Does not suggest how the problem might develop or resolve Fails to make the patient aware of relative risks of different approaches Decisions on whether/what to prescribe are inappropriate or idiosyncratic. Follow-up arrangements are absent or disjointed |
Inter Personal Skills
|
POSITIVE INDICATORS
Identify patient’s agenda, health beliefs & preferences Works with the patient to develop a shared management plan or clarify the roles of doctor and patient Offers chaperone for examination Uses explanations that are relevant and understandable to the patient Shows sensitivity for the patient’s feelings in all aspects of the consultation including physical examination Does not allow own views/values to inappropriately influence dialogue |
NEGATIVE INDICATORS
Doesn't enquire about patients ICE Takes a doctor centered approach towards management Uses an explanation that is filled with jargon, or forgets to explain at all Fails to offer chaperone Doesn't show any sympathy / empathy towards the patient's situation Inappropriately influences patient interaction through own views/values |
Management
Explanation:
As you may already know from your online searches, premature ejaculation is the term given to the problem that you are experiencing. The term itself is used to describe the achievement of orgasm very soon after penetration, or even before. Many things can cause this, including stress, medication side effects, problems with the penis or prostate. Luckily there are many things that can be done to help ….
Assessment:
It’s important to rule out some common causes:
As you may already know from your online searches, premature ejaculation is the term given to the problem that you are experiencing. The term itself is used to describe the achievement of orgasm very soon after penetration, or even before. Many things can cause this, including stress, medication side effects, problems with the penis or prostate. Luckily there are many things that can be done to help ….
Assessment:
It’s important to rule out some common causes:
Anxiety about sex
Medicines (dopaminergic group)
Cocaine / amfetamine addiction
Chronic prostatitis
MS / peripheral neuropathy
Erectile dysfunction.
Management:
Self Help: [NHS uk]
masturbating 1-2 hours before sex
using thick condom, or local anaesthetic infused condom
taking a deep breath to briefly shut down the ejaculatory reflex
taking breaks during sex and think about something boring
Couples therapy / sexual therapy:
Techniques taught: ‘squeeze technique’ and ‘stop-go technique’
Taken directly from NHS UK:
“In the squeeze technique, the woman begins masturbating the man. When the man feels that he is almost at the point of ejaculation, he signals to the woman. The woman stops masturbating him, and squeezes the head of his penis for between 10 to 20 seconds. She then lets go and waits for another 30 seconds before resuming masturbation. This process is carried out several times before ejaculation is allowed to occur.
The stop-go technique is similar to the squeeze technique except that the woman does not squeeze the penis. Once the man feels more confident about delaying ejaculation, the couple can begin to have sexual intercourse, stopping and starting as required.
These techniques may sound simple, but they do require a lot of practice.”
Medications:
SSRI’s are used off license for the treatment of premature ejaculation. (However, if the cause is erectile dysfunction (ED), then treat the ED first.) Several types can be used: sertraline, paroxetine, fluoxetine, citalopram. Also PDE5 inhibitors can be used to inhibit ejaculation. There is no evidence that the effects of any of these medications continue following their cessation. [1] The afore mentioned SSRI’s can be used daily, or on an a PRN basis, however It has been suggested that for men with very short ejaculation times (under a minute) will only benefit from daily dosing.
There is now a newer, shorter acting SSRI: Dapoxetine, that has been specifically developed for the treatment of premature ejaculation. This is the only SSRI licensed for premature ejaculation, it acts much faster than regular SSRI, and is more successful on a ‘on demand’ basis, with patients taking the medication one to three hours before intercourse, but not more than once a day - please see here for side effects and contraindications. As a side not - Dapoxetine is currently listed as a "black" drug in our formulary, meaning that the CCG have not granted us permission to use it on the NHS. The same may be true elsewhere in the country, so please check before prescribing.
Self Help: [NHS uk]
masturbating 1-2 hours before sex
using thick condom, or local anaesthetic infused condom
taking a deep breath to briefly shut down the ejaculatory reflex
taking breaks during sex and think about something boring
Couples therapy / sexual therapy:
Techniques taught: ‘squeeze technique’ and ‘stop-go technique’
Taken directly from NHS UK:
“In the squeeze technique, the woman begins masturbating the man. When the man feels that he is almost at the point of ejaculation, he signals to the woman. The woman stops masturbating him, and squeezes the head of his penis for between 10 to 20 seconds. She then lets go and waits for another 30 seconds before resuming masturbation. This process is carried out several times before ejaculation is allowed to occur.
The stop-go technique is similar to the squeeze technique except that the woman does not squeeze the penis. Once the man feels more confident about delaying ejaculation, the couple can begin to have sexual intercourse, stopping and starting as required.
These techniques may sound simple, but they do require a lot of practice.”
Medications:
SSRI’s are used off license for the treatment of premature ejaculation. (However, if the cause is erectile dysfunction (ED), then treat the ED first.) Several types can be used: sertraline, paroxetine, fluoxetine, citalopram. Also PDE5 inhibitors can be used to inhibit ejaculation. There is no evidence that the effects of any of these medications continue following their cessation. [1] The afore mentioned SSRI’s can be used daily, or on an a PRN basis, however It has been suggested that for men with very short ejaculation times (under a minute) will only benefit from daily dosing.
There is now a newer, shorter acting SSRI: Dapoxetine, that has been specifically developed for the treatment of premature ejaculation. This is the only SSRI licensed for premature ejaculation, it acts much faster than regular SSRI, and is more successful on a ‘on demand’ basis, with patients taking the medication one to three hours before intercourse, but not more than once a day - please see here for side effects and contraindications. As a side not - Dapoxetine is currently listed as a "black" drug in our formulary, meaning that the CCG have not granted us permission to use it on the NHS. The same may be true elsewhere in the country, so please check before prescribing.