Premature ejaculation (PE) is a common male sexual dysfunction defined as ejaculation occurring within approximately one minute of vaginal penetration, or a distressing reduction in the ability to delay ejaculation. For the majority of men, this condition is effectively managed through conservative approaches. First-line options typically involve behavioral techniques (such as the start-stop or squeeze methods) or pharmacological treatments like selective serotonin reuptake inhibitors (SSRIs) and topical local anesthetics. Surgical interventions for PE are invasive procedures that carry distinct risks and are generally reserved for a small subset of patients whose condition is refractory to all standard medical and therapeutic treatments.
Rationale for Considering Surgical Intervention
Surgical options are primarily based on the theory of glans hypersensitivity, suggesting that increased sensitivity to tactile stimulation triggers an accelerated ejaculatory reflex. Patients are selected for surgical consideration only after they have demonstrated a clear lack of satisfactory response to established first-line treatments, including oral medications and desensitizing topical creams.
Objective assessment of penile sensitivity may be performed using penile biothesiometry, which measures the penile vibratory threshold. This non-invasive test determines the minimum vibratory amplitude a patient can perceive on the glans penis, providing a quantifiable measure of sensory input. If results indicate a lower-than-average threshold, suggesting hypersensitivity, the patient may be deemed a candidate for surgery aimed at reducing sensory perception. Such interventions are typically restricted to men with lifelong PE who have realistic expectations and good overall health.
Description of Primary Surgical Procedures
Surgery for premature ejaculation is dominated by two approaches aimed at reducing glans sensitivity: nerve modulation and tissue augmentation. Both procedures dampen sensory signals transmitted from the highly innervated tissue of the glans penis. These methods seek to increase the intravaginal ejaculatory latency time (IELT), the measured duration from penetration to ejaculation.
Nerve Modulation (Selective Dorsal Neurectomy)
Selective Dorsal Neurectomy (SDN) is a procedure designed to permanently reduce the sensory input from the penis by surgically severing specific nerve branches. The underlying premise is that men with lifelong PE may have a greater number of dorsal penile nerve branches, contributing to increased sensitivity. The surgeon makes a small incision, typically near the coronal sulcus or base, to access the dorsal nerve bundle.
The technique involves microscopically identifying and selectively cutting a portion of the sensory nerve fibers running along the dorsal aspect of the shaft to the glans. The goal is to modulate the sensory feedback pathway without compromising erectile function or the remaining sensation necessary for pleasure, though there is no standardized protocol for the exact number of branches to be severed.
Glans Augmentation/Filler Injection
The second method involves injecting a filler, most commonly hyaluronic acid (HA) gel, into the soft tissue layer of the glans. This minimally invasive procedure, performed under local anesthesia, creates a physical barrier between the sensitive nerve endings and the external environment. The injected filler increases the thickness of the glans tissue, resulting in reduced tactile stimulation of underlying nerve receptors during intercourse.
Unlike SDN, this augmentation is temporary because the body gradually metabolizes the HA filler over time. To maintain the desensitizing effect, the procedure must be repeated at intervals, typically ranging from one to five years.
Specific Adverse Outcomes and Complications
Both SDN and glans augmentation carry specific risks that must be carefully considered. Complications associated with SDN are often more significant because the procedure involves permanent alteration of nerve tissue. The most frequently cited risk is permanent hypoesthesia (reduced sensation), which can sometimes progress to anesthesia (complete loss of feeling) in the glans.
This reduction can negatively impact sexual satisfaction and may contribute to erectile dysfunction, as lack of sensory input disrupts the neurovascular cascade necessary for a firm erection. General surgical risks include infection, bleeding (hematoma), noticeable scarring, and the potential for severed nerves to regenerate (leading to recurrence).
Risks specific to HA filler injections tend to be localized and temporary, though severe complications are possible. Common adverse effects include temporary pain, swelling, and ecchymosis (bruising) at the injection site, which usually resolve within days. A more concerning risk is the formation of palpable lumps or nodules as the filler material settles. The most severe, though rare, complication involves unintentional injection into a blood vessel, which can lead to vascular occlusion and subsequent tissue necrosis (death) of the glans. Filler migration, where the gel moves away from the intended location, is another specific risk that can alter the desired effect.
Long-Term Efficacy and Regulatory Acceptance
While preliminary studies report positive initial outcomes, long-term efficacy remains contentious. Immediately following the procedures, many patients experience a substantial increase in IELT. However, long-term data for SDN is limited, and HA filler effects are transient, requiring repeated sessions as the body breaks down the material.
A major concern is the lack of large-scale, randomized-controlled trials with long-term follow-up for either procedure. Consequently, major international urological bodies (ISSM, AUA, and EAU) do not endorse SDN or HA glans augmentation as standard treatment options, considering them highly controversial due to the permanent nature of SDN and the risk profile. Many of these surgeries are performed in unregulated clinics, often in certain Asian countries, where they are more widely practiced despite the lack of official endorsement from global medical associations.