2. Premature Ejaculation (PE)
■ Ejaculation that occurs sooner than desired
■ Loss of control over ejaculation
and
■ Causes distress to either one or both partners
3. What is too soon?
■ All agree Intravaginal Ejaculatory Latency Time
(IELT) of less than 60 seconds is PE
■ Most agree that less than 120 seconds is PE
■ May be dependent on culture and expectation
4. Perceived Normal Time to
Ejaculation
Montosori, J Sex Med (2005); 2 (suppl 2): 96-102
5. Overlap in IELT Distribution
Patrick, et. al, J Sex Med (2005); 2: 358-67
6. Premature Ejaculation
■ Epidemiology
■ Most common form of sexual dysfunction
■ Prevalence Rates vary from 4-39% ; most general
studies in 21-31% range
■ Rates generally not affected by age, marital status,
race, or country of residency
7. Disconnect Between Diagnosed and
Reported Prevalence of PE
■ Male patients don’t often “spontaneously” offer
up this problem as a complaint
■ Clinicians don’t inquire about this common
condition
8. Why don’t patients report PE
■ Embarrassment
■ Do not “medicalize” the problem
■ Perceive that their provider is not able or willing
to address the problem
9. Why don’t Provider’s Ask about PE
■ Lack of provider comfort in discussing sexuality
issues
■ Lack of provider knowledge about PE
■ Low prioritization by medical system of PE
■ No physical comorbidities
■ Time pressure
■ No FDA approved treatment options
10. What Causes PE
■ Exact etiology not fully known
■ Combination of Physiologic and Psychological
Factors
■ Primary PE – “more” neurophysiologic while
acquired PE “more” psychological or related to
a medical condition
11.
12.
13. Behavioral Theories of PE
■ Learned Behavior Conditioned from Early
Sexual Experiences (Masters and Johnson)
■ Role of Anxiety
14. PE’s Impact on Men
■ Symonds et. al study*
■ 68% said their confidence generally or in a sexual
encounter affected – low “self-esteem”
■ 50% had relationship issues – reluctant to form new
relationships or were distressed not satisfying current
partner
■ 36% reported being anxious
*Symonds et. al., J Sex Mar Ther (2003); 29: 361-370
15. Important Aspects of History
■ Age at onset of disorder
■ Frequency of PE (Consistent or Intermittent)
■ Circumstance(s) when PE occurs
■ Estimate of Intravaginal Ejaculatory Latency Time
(IELT)
■ Any other sexual problems (e.g. ED)?
■ How has it affected your relationship(s)?
■ How has it impacted your sense of well-being?
16. Physical Examination and “Tests”
■ Physical exam is not helpful in diagnosing
condition except in some secondary cases where
neurologic conditions or prostatitis are
entertained
■ No laboratory test available to confirm the
diagnosis
■ Can consider psychological tests to assess for
anxiety disorder
17. Treatment for PE
■ Treat underlying cause (e.g. infection) if found
■ Pharmacologic Interventions
■ Behavioral interventions
19. Topical anesthetics
■ Mode of Action: Desensitize penis and therefore
increase IELT
■ Example: Lidocaine/prilocaine cream
■ How to use: Apply to penis 20-30 minutes prior
to intercourse, wash off before sex
■ Potential problems
■ Loss of pleasurable sensation for male and partner
■ Contact skin reaction or allergy
20. TCAs
■ Mode of Action: presumed to act via neurotransmitters
involved to inhibit ejaculation
■ Example: Clomipramine
■ How to use: Can take on as needed basis before
intercourse or continuous basis
■ Potential problems
■ Side effects
■ Doses and regimens not standardized (Not FDA approved)
21. Daily vs As Needed Clomipramine
■ In a study* of on demand (OD) clomipramine
use in men with PE, 3 factors predicted likely
success of OD use
■ Men with IELTs of greater than 60 seconds
■ Men with higher self-reported sexual satisfaction
■ Men who ejaculated 2 or more times per week
*Rowland et. al., Int J Imp Res (2004); 16: 354-357
22. SSRIs
■ Mode of Action: Acts centrally through
serotonin receptors in inhibiting ejaculation
■ Example: Paroxetine
■ How to use: Can take OD, on a continuous
basis, or a combination of both
■ Potential problems
■ Side effects
■ Doses and regimens not standardized (Not FDA
approved)
23. Oral Therapies*
Fluoxetine 5- 20 mg/day
Paroxetine 10-40 mg/day or
20 mg 3-4 hrs before
intercourse (BI)
Sertraline 25-200 mg/day or
50 mg 4-8 hrs BI
Clomipramine 25-50 mg/day or
25 mg 4-24 hrs BI
*From Amer Urol Assn Guideline, J Urolog (2004); 172: 290-294
24. PDE-5 Inhibitors
■ Mode of Action: ?
■ having higher cGMP levels might prolong nitrous oxide
(NO) effect by delaying ejaculatory emission
■ Prolong erections – may reduce performance anxiety since
have improved erections
■ Example: Sildenafil
■ How to use: 25-100 mg 1 hour before sex
■ Potential problems
■ Limited benefit in many studies
■ Side effects
■ Expense
25. Comparison of Oral Medications
■ Multiple studies proving efficacy in delaying IELT in
many SSRIs and TCAs
■ For the SSRIs, paroxetine seems to work the best, with
sertraline and fluoxetine close behind
■ Although more efficacious in some studies, almost
twice as many adverse effects reported with
clomipramine compared with SSRIs
■ The evidence for sildenafil is the weakest, particularly
without concurrent erectile dysfunction
26. Which Option(s) for Patient
■ Consider co-morbidities
■ e.g. atopic dermatitis, anxiety
■ Side effects
■ Expense
■ Ultimately a shared decision between patient and
provider
27. Erectile Dysfunction (ED)
■ “the consistent or recurrent inability of a man to
attain and/or maintain an erection sufficient for
sexual performance”*
*First International Consultation on Erectile Dysfunction, WHO, 1999
28. Prevalence of ED
■ 5-35% of men have moderate to severe ED
■ Men’s Attitudes to Life Events and Sexuality
(MALES) study found prevalence of 16%, 22%
in US
■ In the MALES study 8% of men in their 20s
reported ED
29. Epidemiology of ED
■ Age dependent disorder
■ Rate depends on how it is defined
■ Expect the rates will increase as awareness of
the condition improves
30. What causes ED
■ Overall it is a neurovascular phenomenon
■ Sexual stimulation leads to
■ Parasympathetic nervous system enhancement of
production of cyclic guanosine monophosphate
(cGMP)
■ Smooth muscles relax and blood flows into the penis
■ Filling of the penis, compresses outflow of blood via
the veins
31. ■ Psychological impotence usually occurs acutely. The
early morning erections and erections during REM
sleep are usually preserved. Psychological factors are-
■ 1. ignorance regarding sexual act
■ 2.fear of failure and performance anxiety
■ 3.Marital conflict
■ 4.Anxiety disorder
■ 5.Mood disorder
■ 6.Masturbatory anxiety
■ 7.Fatigue
■ 8.Fear of pregnancy
■ 9.fear of damaging sexual partner or one self
32. ■ 10.Certain envoirmental factors like lack of
privacy
■ 11.Lack of consistent sexual partner
■ 12.Fear of commitment
■ 13.Poor self image or inferiority complex
■ 14.Sexual abuse in childhood
36. Evaluation of Patients with ED
■ Sexual history
■ Onset of Symptoms
■ Duration of Symptoms
■ Circumstances when ED occurs
■ Problems with having an erection
■ Problems with maintaining an erection
■ Libido
■ Concurrent premature ejaculation
37. Medical History in Patients with ED
■ Any comorbidities?
■ CV disease, Diabetes, Depression, Alcoholism
■ Smoker?
■ Pelvic surgery, radiation, or trauma?
■ Neurologic disease?
■ Other endocrine problems?
■ Recreational or prescribed medication use?
38. Medications Known to Cause ED
■ Many medications linked to ED
■ Antihypertensives (thiazide diuretics and beta
blockers)
■ Antidepressants
■ Hormones
39. Physical Examination
■ Blood Pressure Measurement
■ Testicular Exam
■ Exam of Penis
■ Vascular and Neurologic Exam if indicated
40. Laboratory Exam
■ Consider Testosterone if decreased libido
■ Older patients (or others where indicated) do
lipid panel and fasted blood glucose
■ Targeted tests in select patients
■ PSA
■ Prolactin
41. ■ Before making a diagnosis of sexual dys function, it is
of paramount importance to rule out an under lying
physical cause, which would need treatment. Although
the diagnosis is clinical, a detailed physical examination
and laboratory investigations (e.g. blood counts, blood
sugar, liver function tests, thyroid function tests,
hormonal profile, and rarely, routine exami nation and
culture of prostatic fluid) coupled with a good history
is a must in every patient to rule out an underlying
physical cause.
Diagnosis and Differential Diagnosis
42. ■ Certain laboratory techniques (e.g. penile
plethysmograph, penile tumescence moni toring during
sleep) may help in differentia ting organic and
nonorganic sexual dysfunctions. If NPT ( nocturnal
penile tumescence) is abnormal, then ancillary
investigations such as penile vascular investigations
(e.g. penile pulse pressure, penile Doppler, duplex ultra
sono graphy, diagnostic intracavernosal vasoactive
substance-papaverine injection test, arteriography,
DICC-dynamic infusion cavernosomatogram and
cavernosogram, and cavernosography) and penile
neurological investigations (e.g. penile sensory
threshold test or penile biothesiometry) may be
employed.
43. ■ Though searching for an organic factor responsible for
the sexual dysfunction is very impor tant, a large
majority of dysfunctions are psycho sexual in nature. A
detailed sexual and personal history is important in fi
nding out the underlying causes. The common
psychological causes of sexual dysfunction have been
discussed earlier.
■ It should be specified whether the sexual dysfunction
is psychogenic alone or biogenic factors co-exist;
whether the dysfunction is life-long or acquired; and
whether the dys function is situational or generalised.
44. Treatment of ED
■ Identify and Treat Organic Comorbidities and
other risk factors
■ Counsel and Educate the Patient and Partner
■ Identify and Treat any Psychosexual
Dysfunctions
■ Medications and Devices
■ Surgery
46. Mild 10/17 5/12 2/6
Mild to Mod 4/8 2/6 0/3
Moderate 5/19 2/16 0/7
Severe 0/6 0/8 0/10
Total 19/50 (38%) 9/34 (27%) 2/26 (8%)
Age Groups, Years
ED Grade 30-39 40-49 50-60
Improvement in ED of Ex-smokers
Pourmand, et. al. BJU Int (2004), 94: 1310-13
50. Use of PDE-5 Inhibitors
■ All three similarly effective
■ 75% of men on medications have satisfactory
erection to complete intercourse
■ No large head-to-head trials to compare the 3
available medications
■ Some patients prefer one over the others
51. Medication Standard
Dose
When to
Take (h)
Prior to Sex
Duration (h)
of Action
Cost per
pill*
Sildenafil 50-100 mg 1.0 < 4 $17.30
Tadalafil 10-20 mg 0.5 - 12 36 $18.50
Vardenafil 10-20 0.5-1.0 < 5 $16.90
Comparison Of Phosphodiesterase Type 5
(PDE-5) Inhibitors
*Based on average price reported
52. What to tell patients about PDE-5
Inhibitors Use
■ Still require sexual stimulation to have erection
■ Sildenafil’s absorption may be reduced by foods
– especially fatty foods
■ Expect maximal efficacy in 1 hour (2 hours after
tadalafil)
■ First few doses may not be successful – try 6-8
times before giving up
54. Contraindications
■ Not to use with nitrates (including amyl nitrate)
■ Not to use if severe CV disease
■ Cautious use of vardenafil if has prolonged QT
■ Care if on alpha blocking agents – may cause
significant hypotension
55. Follow-up
■ Recommended for all patients
■ Efficacy
■ Side Effects
■ Any significant change in health status (including
new medications)
56. Why Treatment Failures
■ Food or Drug interactions
■ Timing of Dose
■ ?Maximal Dose
■ Lack of Sexual Stimulation
■ Heavy Alcohol Use
■ Relationship Problems
57. Yohimbine for ED
■ Derived from the bark of the yohimbine tree in
Central Africa
■ Traditionally used to treat all forms of
impotence
■ Believed to work through the Central Nervous
System
■ An alpha2 adrenoreceptor blocker
58. Yohimbine for ED
■ Metaanalysis shows yohimbine superior to
placebo (Odds ratio of 3.85)*
■ Relatively safe medication
■ Low cost
■ Amer Urol Assn does not recommend its use at
this time
*Ernst, Pittler; J Urol (1998); 159: 433-436
60. Sexual History
■ In addition to intake process
■ First awareness of and feelings about anything
he considers related to sex
■ Childhood curiosity and exploration
■ Masturbation, including age of first experience,
fantasies
■ Student’s socialization based on attitudes and
behaviors of family or other significant figures
61. Sexual History (2)
■ Religious teachings about sexual behavior
■ The Coming Out Process
■ Dating History – “Losing virginity”
■ Relationships vs. “hook-ups” or “fuck buddies”
■ Sexually transmitted infections
■ Sexual experiences initiated by others/abuse
■ When specifically sexual difficulties began
63. Limitations
■ Some couples don’t want to interrupt sex after
starting.
■ Some students don’t have partners and some
partners unwilling to squeeze the penis
■ Techniques viewed as mechanical
■ The focus is on physiological processes and
neglect psychological dimensions such as
affective communication and sexual pleasure.
64. Functional-Sexological Treatment
■ First Goal of treatment: Keep the man’s sexual
excitement at a level of intensity below that which sets
off ejaculation.
■ Achieved by modulating sexual excitement, by
monitoring sexual stimulation as well as managing
breathing and the muscular tension deriving from
sexual activity.
■ (de Carufel, François and Trudel, Gilles (2006)
'Effects of a New Functional-Sexological Treatment for
Premature Ejaculation', Journal of Sex & Marital
Therapy ,32:2,97 — 114)
65. ERECTILE DYSFUNCTION
■ Normal to have occasional difficulty achieving
an erection
■ Men often feel emasculated and ashamed
■ How could “it” have happened to me?
■ Solitary or infrequently occurring erection
difficulty does not mean that a man has a sexual
dysfunction.
(Morris, 1998)
66. Erectile Dysfunction (2)
■ Cultural expectations
■ Fears and Myths
■ “Men are taught that their essence is linked to
their penis; it is not enough to just have a penis
but you must have a big one that stands ready at
all times to perform spectacular sexual feats.”
(Morris, 1998)
67. Sensate Focus
■ The cornerstone of sex therapy
■ Helping a couple to focus on sensation rather
than performance
■ Structured and flexible
■ Homework
■ Concerns regarding homework discussed in
couples session
Masters and Johnson (1970, 1986)
68. College Health
■ Male reluctance to seek help
■ “Sturdy Oak” Manliness = Not needing help
■ “The Stud” – “hook-ups”
■ Its just a sprain
Brannon (1976)
