2. Moderators:
Professors:
⢠Prof. Dr. G. Sivasankar, M.S., M.Ch.,
⢠Prof. Dr. A. Senthilvel, M.S., M.Ch.,
Asst Professors:
⢠Dr. J. Sivabalan, M.S., M.Ch.,
⢠Dr. R. Bhargavi, M.S., M.Ch.,
⢠Dr. S. Raju, M.S., M.Ch.,
⢠Dr. K. Muthurathinam, M.S., M.Ch.,
⢠Dr. D. Tamilselvan, M.S., M.Ch.,
⢠Dr. K. Senthilkumar, M.S., M.Ch.
Dept of Urology, GRH and KMC, Chennai. 2
3. What is the Problem about?
3
Dept of Urology, GRH and KMC, Chennai.
4. 3 Dimensions of the Problem
Jannini et al
⢠TIME Rapid Ejaculation
⢠CONTROL Patient not able to
control ejaculation
⢠STRESS Patient and the
partner feels stressed about
the above two.
4
Dept of Urology, GRH and KMC, Chennai.
5. How old is the Problem?
⢠Phenomenon of Premature
ejaculation is as old as Greek
Mythology.
⢠The Greeks called them âejaculatio
ante portasâ.
⢠First published case in 1887 by
Gross.
5
Dept of Urology, GRH and KMC, Chennai.
6. Human sexual response consists of 4 phases: (Masters and Johnson)
1. Excitation
2. Plateau
3. Orgasm
4. Resolution
To which may be added
Desire (Kaplan and Levin)
Normal Sexual Physiology
6
Dept of Urology, GRH and KMC, Chennai.
7. Normal Vs Premature Ejaculation
In PE:
⢠Rapid excitement
⢠Short Plateau
7
Dept of Urology, GRH and KMC, Chennai.
8. Definition of Premature Ejaculation
Multiple Definitions were
circulating for premature
ejaculation.
International Society for Sexual
Medicine (ISSM) gave the latest
Evidence based Definition of
Premature Ejaculation in 2013.
8
Dept of Urology, GRH and KMC, Chennai.
9. ISSM Unified Definition
⢠Ejaculation that always or nearly always occurs before or within about
1 min of vaginal penetration (lifelong premature ejaculation), or a
clinically significant and bothersome reduction in latency time, often
to about 3 min or less (acquired premature ejaculation).
⢠The inability to delay ejaculation on all or nearly all vaginal
penetrations.
⢠Negative personal consequences, such as distress, bother, frustration
and/or the avoidance of sexual intimacy
9
Dept of Urology, GRH and KMC, Chennai.
10. How big is the Problem?
Prevalence
24%
29%
30%
25%
20%
15%
10%
5%
0%
40%
35%
Overall
(US & EU)
USA Germany Italy Overall
(AP)
Malaysia
PEPA (Premature Ejaculation Perceptions and Attitudes) Study
31%
*
*
23%
*
*
20%
* 20%
*
10
Dept of Urology, GRH and KMC, Chennai.
12. What causes the Problem?
⢠The changing paradigms of Premature Ejaculation can be divided into
four periods.
⢠Starting with a Psychoanalytic approach, the knowledge now extends
into genetic origins of the disease.
12
Dept of Urology, GRH and KMC, Chennai.
13. The First Period (1917-1950)
Neuroses and Psychosomatic Disorder
⢠Karl Abraham-Ejaculatio Praecox, 1917.
⢠During the first decades of the 20th
century, PE was viewed,as a neurosis
linked to unconscious conflicts.
⢠Treatment consisted of classical
psychoanalysis.
13
Dept of Urology, GRH and KMC, Chennai.
14. Soil and Steal the Womanâs orgasm
⢠Narcissitic personality.
⢠Unconscious hatred for women.
Pitfalls:
⢠It could not explain premature
ejaculation in homosexuals.
⢠It gives prime importance to only
vaginal intercourse.
14
Dept of Urology, GRH and KMC, Chennai.
15. Is it just Mind? Or the Body too??
⢠Bernard Schapiro-Psycho somatic Disturbance.
⢠Caused by a combination of Psychologically over anxious constitution
with an inferior ejaculatory apparatus.
⢠Two types.
⢠Type B (the sexually hypertonic or hypererotic type), representing a
continuously present tendency to ejaculate rapidly from the first act
of intercourse, and
⢠Type A (the hypotonic type), leading to erectile dysfunction.
⢠Also noted, PE runs in the males of families.
15
Dept of Urology, GRH and KMC, Chennai.
16. The Second Period (1950-1990)
Learned Behaviour
⢠Masters and Johnson
⢠Rejected Psychoanalytic theory
⢠Rapid ejaculation was linked to initial
rapid intercourse(s) that led to
habituation and created performance
anxiety.
⢠Promoted Anxiety as the cause.
16
Dept of Urology, GRH and KMC, Chennai.
17. Anxiety causes Premature Ejaculation
⢠Risk of unwanted discovery (such as
copulating in a car),
⢠Experiences with prostitutes, and
⢠Anxiety due to poor sexual education
(e.g., absence of adequate
knowledge of contraceptive
methods)
⢠They worsen ejaculatory control.
17
Dept of Urology, GRH and KMC, Chennai.
18. Anti anxiety Drugs and PE
Clomipramine
In 1943, Eaton proposed in his study Clomipramine in the treatment of
Premature ejaculation.
Eaton H (1973) Clomipraminein the treatment of premature ejaculation. J Int Med Res 1:432â434
18
Dept of Urology, GRH and KMC, Chennai.
20. The Third Period (1990-2005)
Neurobiological Etiology
⢠For Lifelong Premature Ejaculation.
⢠In 1998, Waldinger et al. postulated
that lifelong PE is a neurobiologically
and genetically determined
dysfunction
⢠It is related to a diminished central
serotonergic neurotransmission and
activation or inhibition of specific 5-HT
receptors.
⢠He rejected pure Psychologic and
behaviouristic theories.
20
Dept of Urology, GRH and KMC, Chennai.
22. The Fourth Period (2005-Present)
Genetic Theory
DNA research in men with lifelong PE
and male twin genetic research show
that genetic polymorphisms of the
central serotonergic and
dopaminergic system, associated
with the duration of the IELT.
22
Dept of Urology, GRH and KMC, Chennai.
23. FineâŚ.What is it
then?
Is it Mind?
Is it Body?
Is it Behaviour?
Is it Genes?
The Truth IsâŚ
It is above All.
23
Dept of Urology, GRH and KMC, Chennai.
26. Genetic Factors
⢠Recent familial studies show that the
risk of PE co-occurring between
family members was higher than the
risk expected in the population1,2,3
1.Waldinger MD, Rietschel M, Nothen MM, Hengeveld MW, Olivier B. Familial occurrence of primary premature ejaculation. Psychiatr Genet 1998;8:37â
40.
2. Jern P, Santtila P,Witting K, Alanko K, Harlaar N, Johansson A, von der Pahlen B, Varjonen M, Vikstrom N, Algars M, Sandnabba K. Premature and
delayed ejaculation: Genetic and environmental effects in a population-based sample of Finnish twins. J Sex Med 2007;4:1739â49.
3. Jern P, Santtila P, Johansson A, Varjonen M, Witting K, von der Pahlen B, Sandnabba NK. Evidence for a genetic etiology to ejaculatory dysfunction. Int
J Impot Res 2009;21:62â7.
26
Dept of Urology, GRH and KMC, Chennai.
27. Neurobiological Factors
⢠Impairment of inhibitory serotonin
pathways are associated with
Lifelong PE.
⢠5-HTTLPR gene polymorphism has
been associated with shorter IELT
in men with lifelong PE.
⢠Certain Dopamine receptors are
also proposed.
27
Dept of Urology, GRH and KMC, Chennai.
28. Neurological Factors
⢠Multiple sclerosis,
⢠Peripheral neuropathies,
⢠Spinal cord tumors,
⢠Pelvic floor alterations
⢠Hypersensitivity of the glans
(Anecdotes)
⢠Accelerated conduction, and/or cortical
amplification of the genital stimuli
(Anecdotes)
28
Dept of Urology, GRH and KMC, Chennai.
29. Urological Factors
⢠Chronic prostatitis
⢠Chronic pelvic pain syndrome
⢠Short frenulum
29
Dept of Urology, GRH and KMC, Chennai.
30. Pharmacological Factors
⢠Opiod Withdrawal
⢠SSRI medications withdrawal
⢠Bupropion (Norephinephrine and
Dopamine Reuptake inhibitor)
30
Dept of Urology, GRH and KMC, Chennai.
32. Psychosocial and Relational Factors
⢠Performance anxiety
⢠Work stress or dissatisfaction
⢠Interpersonal Issues
⢠Social Phobia
⢠Alexithymia
32
Dept of Urology, GRH and KMC, Chennai.
33. Concomitant Erectile Dysfunction
⢠PE and ED may form a vicious cycle-
Control the ejaculation by
instinctively reducing his level of
excitation (which may lead to erectile
loss),
Then trying to achieve an erection by
increasing his excitation and arousal
(which leads to PE).
33
Dept of Urology, GRH and KMC, Chennai.
36. Clinical History Guidelines
⢠Should âexplicitly communicate the circumstances of the conditionâ
⢠Fundamental basis of assessment is with time to ejaculation (IELT).
⢠In addition to evaluation of IELT, the AUA recommends considerinig:
(1) the duration and frequency of PE,
(2) the rate of occurrence of PE with some or all sexual encounters and
partners,
(3) the degree to which sexual stimuli cause PE, and
(4) the nature and frequency of sexual activity including foreplay,
masturbation, and intercourse.
36
Dept of Urology, GRH and KMC, Chennai.
37. IELT
⢠IELT-Intravaginal Ejaculation
Latency Time.
⢠Measured using Stop Clock.
⢠Time between Intravaginal
penetration and intravaginal
ejaculation.
⢠Most objective measure of
premature ejaculation.
37
Dept of Urology, GRH and KMC, Chennai.
40. Medical Therapy
⢠Centrally acting agents
⢠Topical agents
⢠Intracavernosal Injection therapy
40
Dept of Urology, GRH and KMC, Chennai.
41. Medical Therapy-Centrally Acting Agents
Clomipramine
⢠Clomipramine is a tricyclic antidepressant (TCA)
⢠It inhibits the uptake of noradrenaline and 5-HT by adrenergic and 5-
HT neurons.
⢠Eaton (1973) published the first report on the use of clomipramine in
PE, and numerous subsequent publications have confirmed its
efficacy.
⢠Can be used on daily or on-demand basis.
41
Dept of Urology, GRH and KMC, Chennai.
42. Medical Therapy-Centrally Acting Agents
SSRIs
⢠Delayed ejaculation effect was
accidentally discovered in
1970s.
⢠Daily use is recommended.
⢠Effect noticed in 5-10 days
⢠Paroxetine has the strongest
effect in improving IELT
42
Dept of Urology, GRH and KMC, Chennai.
43. Medical Therapy-Centrally Acting Agents
SSRIs-Side Effects
⢠Yawning, mild nausea, excessive sweating,
⢠Fatigue and changes in bowel function.
⢠Loss of bone mineral density (Longterm Treatment).
⢠Reduced libido and erectile rigidity decrease (In some cases)
⢠SSRI discontinuation syndrome
⢠Serotonin syndroome
43
Dept of Urology, GRH and KMC, Chennai.
44. Medical Therapy-Centrally Acting Agents
SSRI Discontinuation syndrome
⢠Common with a sudden reduction or cessation of long-term
treatment of SSRIs.
⢠Symptoms include nausea, vomiting, dizziness, headache, ataxia,
drowsiness, anxiety and insomnia.
⢠Symptoms begin 1 to 3 days after the drug cessation and may
continue for a week or more.
⢠It is usually reversible by SSRI reintroduction.
⢠SSRI agents should be gradually withdrawn over a 2- to 4-week
period.
44
Dept of Urology, GRH and KMC, Chennai.
45. Medical Therapy-Centrally Acting Agents
Dapoxetine
⢠Short acting SSRI.
⢠Can be used On-demand basis, 1-4 hour before intercourse.
⢠Dose is 30-60 mg.
⢠4 fold increase in IELT.
⢠Side Effects: Nausea, Headache and Dizziness.
45
Dept of Urology, GRH and KMC, Chennai.
46. Medical Therapy-Centrally Acting Agents
Tramadol
⢠Synthetic opiod analogue.
⢠Mechanism of action not completely clear.
⢠On demand use of 50 mg, 2 hour before intercourse.
⢠Increase in IELT by 2-6 folds.
Side Effects: Nausea, Vomiting and giddiness.
46
Dept of Urology, GRH and KMC, Chennai.
47. Medical Therapy-Centrally Acting Agents
Sildenafil
⢠Phosphodiesterase 5 inhibitor.
⢠In patients with co-existing erectile dysfunction.
⢠To break the vicious cycle loop.
⢠Co-administered with an SSRI.
⢠Sildenafil 50 mg, on demand, with Paroxetine 20 mg, 1 hour with
intercourse.
⢠Monotherapy is of not much use.
47
Dept of Urology, GRH and KMC, Chennai.
48. Medical Therapy-Topical Agents
⢠Schapiro, in 1943, described local anesthetic agent use for PE.
⢠Currently, off-label topical treatment is widespread.
⢠Wide spread acceptancy due to preference of local treatment,
immediate effect and minimal systemic side-effect profile.
⢠Drawbacks:
Loss of penile sensitivity, (Penile hypostesia in some cases),
Erectile Dysfunction,
Female genital anesthesia, and skin irritation.
48
Dept of Urology, GRH and KMC, Chennai.
49. Medical Therapy-Topical Agents
Lignocaine
⢠Topical agent has been available for more than 25 years.
⢠Reliable data from clinical trials is absent.
⢠Its efficacy and safety cannot be assessed.
49
Dept of Urology, GRH and KMC, Chennai.
50. Medical Therapy-Topical Agents
Severance secret-cream (SS-cream)
⢠Developed at Yong-Dong Severance Hospital in Korea.
⢠It is made with the extracts of nine natural products.
⢠Applied 1 hour before intercourse and washed off before intercourse.
⢠Increase in IELT by 2 minutes.
⢠Drawback: Has an unpleasant odour.
50
Dept of Urology, GRH and KMC, Chennai.
51. Medical Therapy-Topical Agents
TEMPE/PSD 502
⢠A metered-dose aerosol delivery system.
⢠It delivers 7.5 mg lidocaine plus 2.5 mg prilocaine per spray.
⢠Incapable of penetrating keratinized skin, hence only anesthetizing
the glans.
⢠IELT increased by 8 fold.
⢠Low incidence of penile hyposthesia and erectile impairment.
51
Dept of Urology, GRH and KMC, Chennai.
52. Medical Therapy-Topical Agents
⢠Patients with low IELT groups
show maximum response to
the drug.
52
Dept of Urology, GRH and KMC, Chennai.
53. Medical Therapy-Topical Agents
Dyclonine-Alprostatil Spray
⢠A cream containing 0.5 % dyclonine (commonly used in dentistry) and
0.4 % alprostadil has been in development.
⢠Mild to moderate local side effects were noted in 17.5 % of subjects.
53
Dept of Urology, GRH and KMC, Chennai.
55. Behaviour Therapy
⢠Cognitive Behaviour therapy
⢠Psychodynamic approach therapy
55
Dept of Urology, GRH and KMC, Chennai.
56. Cognitive Behaviour Therapy
⢠Cognitive and Behavioural Pacing techniques
⢠Physiological relaxation technique
⢠Pubococcygeal Muscle control technique
⢠Pelvic floor rehabilitation technique
56
Dept of Urology, GRH and KMC, Chennai.
57. Stop-Start Technique
⢠The partner stimulates the
penis until the man feels a
sensation that is premonitory
to ejaculation.
⢠At this time, the partner ceases
stimulation until the sensation
disappears.
⢠This process is continued until
such time as ejaculation can be
delayed indefinitely
57
Dept of Urology, GRH and KMC, Chennai.
58. ⢠Partner to squeeze the frenulum of
the penis or glans for a few seconds
once the male has achieved ââfull
erectionââ and begins to sense the
urge to ejaculate.
⢠This results in an immediate partial
loss of erection and total loss of the
urge to ejaculate.
⢠This procedure is utilized until the
male has delayed ejaculating for a
period of 15â20 min.
Squeeze Technique
58
Dept of Urology, GRH and KMC, Chennai.
59. Cognitive Arousal Continuum Technique
The man systematically observes,
considers and distinguishes:
detailed thoughts,
actions,
feelings,
scenarios and
sequences that characterize his
individual arousal pattern.
59
Dept of Urology, GRH and KMC, Chennai.
60. Physiological Relaxation Techniques
⢠Ten to twenty minutes daily of quiet
focus on breathing, body awareness,
and muscle relaxation is
encouraged, to concentrate on
physical sensations, and to ease
bodily tensions.
⢠Satisfactory sexual functioning is the
result of this physiological relaxation
60
Dept of Urology, GRH and KMC, Chennai.
61. Sensate Focus
⢠Homework sessions begin with the
couple relaxing and pleasuring each
other until the man physiologically
relaxes.
⢠After that, he lies on his back while
the partner stimulates his penis very
gently as he concentrates on the
physical sensations he is
experiencing.
61
Dept of Urology, GRH and KMC, Chennai.
62. Intercourse Acclimatization-Quiet Vagina
⢠The man focus on relaxing the PC
muscle while the woman inserts
the penis into her vagina and
then he quietly rests inside.
⢠Then, he waits, expecting to reach
the physical pleasure saturation
point (a sensual dullness) in his
penis.
62
Dept of Urology, GRH and KMC, Chennai.
63. Psychodynamic Approach
⢠Psychoanalysis approach considers the
problem of premature ejaculation as
unconscious mental processes like inner
hatred for women.
⢠Though it is not for Life long PE, some
acquired cases may have psychoanalytic
processes involved.
63
Dept of Urology, GRH and KMC, Chennai.
64. Psychodynamic approach
⢠Increase communication between the couples
⢠Overcome barriers to intimacy
⢠Come to terms with feelings and thoughts that interfere with the
sexual function
⢠Lessen performance anxiety
⢠Resolve interpersonal issues
⢠Modify rigid sexual repertoires
64
Dept of Urology, GRH and KMC, Chennai.
66. Surgical Therapy-Circumcision
⢠Circumcision removes the sensitive
portions of the foreskin.
⢠Desensitizes the glans penis.
⢠After circumcision, the new surgical
margin becomes the region of
maximum sensitivity.
⢠Some studies show, incomplete
circumcision can aggravate the
condition.
66
Dept of Urology, GRH and KMC, Chennai.
