Surgical Treatments for Premature Ejaculation: Selective Dorsal Neurectomy and Cryoablation
When is surgery considered in resistant premature ejaculation? The rationale, patient selection and risks of selective dorsal neurectomy, dorsal cryoablation and glans filler applications explained.
The first steps in treating premature ejaculation are behavioural techniques, sex therapy and medication. A large proportion of patients gain sufficient benefit at these steps. However, there is a group of patients with lifelong (primary) and treatment-resistant complaints: behavioural methods, oral medication and topical applications have been tried, yet latency has not reached an acceptable level. Surgical options come onto the agenda at this point, with careful patient selection.
When is surgery considered?
Surgery is not, and should not be, the first step in premature ejaculation. The following conditions are generally sought before it is considered:
- The complaint is of the lifelong (primary) type, present since adolescence
- Behavioural treatment, oral medication and topical anaesthetic applications have been tried for an adequate period
- The complaint markedly affects the person's relationships and quality of life
- A correctable cause such as erectile dysfunction, chronic prostatitis or a thyroid disorder has been excluded
In acquired (secondary) premature ejaculation the priority is to find the underlying cause; turning directly to surgery is not appropriate in these cases.
What is selective dorsal neurectomy (SDN)?
Sensation from the glans is carried by branches of the dorsal nerve running along the upper aspect of the penis. Selective dorsal neurectomy rests on selectively dividing some of these branches to reduce the excessive sensory density of the glans. The aim is not to abolish sensation but to reduce, in a measured way, the stimulus load that triggers the ejaculatory reflex, thereby prolonging latency.
The critical word here is selective: which branches are divided and to what extent directly determines the outcome. Excessive reduction means loss of sensation and diminished orgasm quality; insufficient reduction means the expected benefit is not obtained. This balance is the aspect of the method that demands experience.
What is selective dorsal cryoablation and how does it differ?
Cryoablation aims to reach the same target through controlled cooling rather than division. Low temperature is applied to the targeted nerve branches, reducing conduction temporarily or lastingly. Its notable feature is that it disturbs tissue integrity less and that the degree of effect can be titrated more gradually. On the other hand, long-term data are more limited than for classic surgery; patient information must therefore set out an honest framework.
How does a glans filler work?
The third approach works without touching the nerve: a filler material applied to the glans creates a thin cushioning effect between the surface of the glans and the nerve endings, reducing the intensity of stimulus from friction. It is a non-surgical procedure that can be performed in outpatient conditions, and its effect may diminish over time depending on the material used, so repeat application may be needed. The fact that it involves no permanent intervention on the sensory nerves may make it preferable for hesitant patients.
Which method suits which patient?
The main factors determining the choice are:
- Type and duration of the complaint: primary, lifelong cases are more suitable candidates for surgery.
- Measurement of glans sensitivity: examination and sensory assessment show whether hypersensitivity is genuinely predominant.
- The patient's view on reversibility: for a patient who prefers a more reversible option to a permanent nerve procedure, filler or cryoablation may come to the fore.
- Coexisting problems: if erectile dysfunction is present it is addressed first; the two problems are planned together.
Risks and realistic expectations
None of these procedures is a formula whose outcome can be stated in advance. Possible risks include greater-than-expected reduction of glans sensation, changes in the sensation of orgasm, temporary numbness, swelling and, rarely, insufficient improvement of the complaint. The right approach is to explain to the patient not what is promised but what is aimed for: bringing latency to a level acceptable to the person and their partner.
For this reason expectations are set out clearly before surgery; the patient's decision should be an informed choice.
What is the post-procedure course?
These procedures are usually short and can be performed as day cases in most patients. Swelling and tenderness are normal in the first days; sexual activity is paused for the period specified by the surgeon. Because changes in sensation take time to settle, a period of several weeks is allowed before the result is assessed. Follow-up considers both latency and patient satisfaction together, and a behavioural support programme is continued where needed.
Assoc. Prof. Zülfü Sertkaya practises in the field of urology and andrology in Istanbul; premature ejaculation assessments are carried out with individualised planning and full confidentiality.