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. More on the Disconnect
■ Global Study of Sexual Attitudes and Behaviors
■ 9% of men reported that they had been asked about
their sexual health by an MD during a routine visit in
the last 3 years
■ 48% of men believe that an MD should routinely ask
about sexual health concerns
9. 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
10. 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
11. 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
12.
13.
14. Behavioral Theories of PE
■ Learned Behavior Conditioned from Early
Sexual Experiences (Masters and Johnson)
■ Role of Anxiety
15. 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
16. 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?
17. 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
18. Treatment for PE
■ Treat underlying cause (e.g. infection) if found
■ Pharmacologic Interventions
■ Behavioral interventions
20. 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
21. 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)
22. 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
23. 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)
24. 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
25. 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
26. 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
27. Which Option(s) for Patient
■ Consider co-morbidities
■ e.g. atopic dermatitis, anxiety
■ Side effects
■ Expense
■ Ultimately a shared decision between patient and
provider
28. 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
29. 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
30. Epidemiology of ED
■ Age dependent disorder
■ Rate depends on how it is defined
■ Expect the rates will increase as awareness of
the condition improves
31. 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
34. 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
35. 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?
36. Medications Known to Cause ED
■ Many medications linked to ED
■ Antihypertensives (thiazide diuretics and beta
blockers)
■ Antidepressants
■ Hormones
37. Physical Examination
■ Blood Pressure Measurement
■ Testicular Exam
■ Exam of Penis
■ Vascular and Neurologic Exam if indicated
38. 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
39. 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
41. 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
45. 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
47. 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
48. 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
50. 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
51. Follow-up
■ Recommended for all patients
■ Efficacy
■ Side Effects
■ Any significant change in health status (including
new medications)
52. Why Treatment Failures
■ Food or Drug interactions
■ Timing of Dose
■ ?Maximal Dose
■ Lack of Sexual Stimulation
■ Heavy Alcohol Use
■ Relationship Problems
53. 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
54. 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
56. 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
57. 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
59. 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.
60. 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)
61. Hypothetical Case Example
■ 21 y/o gay Chinese-American (Joe)
■ Referred by medicine due to difficulty
maintaining an erection
■ Serious relationship ended 3 months ago, but
they still share a suite
■ Low self-confidence, career indecision,
interpersonal anxiousness
■ Mood 6/10 Denies SI or HI
62. 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)
63. 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)
64. 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)
65. College Health
■ Male reluctance to seek help
■ “Sturdy Oak” Manliness = Not needing help
■ “The Stud” – “hook-ups”
■ Its just a sprain
Brannon (1976)
