Invited Lecture by Dr Sujoy Dasgupta in a webinar- COGNIZANCE 2021, by Perinthalmanna Ob-Gyn Society, Kerala Federation of Obgyn and FOGSI, held in June, 2021

1. Dr Sujoy Dasgupta
MBBS (Gold Medalist, Hons)
MS (OBGY- Gold Medalist)
DNB (New Delhi)
MRCOG (London)
Advanced ART Course for Clinicians (NUHS, Singapore)
Consultant: Reproductive Medicine, Genome Fertility Centre, Kolkata
Visiting Consultant, RSV Hospital, Kolkata
Bhagirathi Neotia Women and Child Care centre
Woodlands Multispeciality Hospital, Kolkata
Managing Committee Member, Bengal Obstetric & Gynaecological Society (BOGS)
Secretary, Subfertility and Reproductive Endocrinology Committee, BOGS
Executive Committee Member, Indian Fertility Society (IFS)- West Bengal Chapter
Executive Committee Member, Indian Society for Assisted Reproduction (ISAR)- Bengal
Winner, Prof Geoffrey Chamberlain Award, RCOG World Congress, London, 2019
Premature Ejaculation

2. Mr AC
• 30 year-old
newly
married man
came with c/o
“I cum too
early”

3. Confusions?
• Mr ID- I cum within 5 minutes. My wife said her
friend’s partner is able to hold for 30 minutes !!!!
(overdiagnosis of PE)
• Mr BM- I find it difficult to hold my hardness.
Even when I am hard, I cum quickly (ED
misdiagnosed as PE)
• Mr JS- I lose hardness immediately after the
discharge (PE misdiagnosed as ED)

4. Why we should treat PE?
• Low satisfaction with
their sexual relationship
• Low satisfaction with
sexual intercourse
• Difficulty relaxing during
intercourse
• Less frequent intercourse
• Detrimental effect on self-
confidence
• Relationship-conflict
• Mental distress, anxiety,
depression

5. If we are not confident
• Mr PB, 36 years-old came for infertility with
his partner.
• Asked to advise semen analysis
• Said he cannot ejaculate for last 2 years.
• Initially (5 yrs ago), he suffered from PE.
Taken “herbal medicines”. PE was cured
but……
• Abdel-Hamid et al., 2016- Herbal medicines
can cause delayed/ absent ejaculation

7. Pathophysiology of PE
• Ejaculation is retarded by 5HT2C
receptors
• Ejaculation is facilitated by
5HT1A receptors
PE happens if there are
1. hyposensitivity of the 5-HT2C
2. hypersensitivity of the 5-HT1A
3. low 5-HT neurotransmission
4. spinal command set at lower
threshold

8. LOFTI approach (Cowan and
Frodsham, 2015)
• Listening
• Observing
• Feeling
• Thinking
• Interpreting

9. Principles of treatment
• Discuss the patient’s expectations thoroughly.
• Treat them first, if present
1. ED
2. Chronic prostatitis
3. Hyperthyroidism
Lifelong PE
1. Pharnacotherapy is the basis
• Dapoxetine on demand is the ONLY
approved treatment for PE
2. Behavioural therapy- adjuct-
• time-intensive
• require the support of a partner
• difficult to perform
• long-term outcomes ?
Acquired PE
• Behavioural treatment first
• Add pharmacotherapy

10. Physical/ Behavioural Therapy
• Hypothesis- PE occurs
because the man fails to
appreciate the sensations
before feelings of
ejaculatory inevitability.
• Re-training- attenuates
stimulus-response
connections by
progressively more intense
and more prolonged
stimulation, just below the
threshold for triggering the
response.

12. Stop Start Technique
• Semans, 1956
• The partner stimulates the
penis until the patient feels the
urge to ejaculate.
• At this point, he instructs his
partner to stop, waits for the
sensation to pass
• Then stimulation is resumed
• 3 pauses before orgasm
Squeezing technique
• Masters and Johnson, 1970
• The partner applies manual
pressure to the glans just
before ejaculation until the
patient loses his urge.
• Squeeze for 15-20 sec
• 3 pauses before orgasm

13. Masturbation before coitus
• For younger men
• The penis is desensitised
resulting in greater
ejaculatory delay after the
refractory period is over.
Pelvic floor exercise
• Stop the flow of urine
(several times) while you
are peeing intentionally

14. Psychological counseling
• Particularly for “Premature like ejaculatory
dysfunction”
• Increase in the man’s confidence
• Lowered performance anxiety
• Increase in communication with the partner;
• Resolution of interpersonal problems

15. Outcome of behavioural therapy
• Short-term success rates of 50-60% (Grenier et
al., 1995; Metz et al., 1997)
• 8 fold increase in IELT than doing nothing (De
Carufel and Trudel, 2006)
• A double-blind, randomised, crossover study-
pharmacotherapy better IELT prolongation than
physical therapy (Abdel-Hamid et al., 2001)
• Combination with dapoxetine is better than
dapoxetrine alone in lifelong PE (Cormio et al.,
2015)
• Level 2b evidence (ISSM)

16. Mr MJ
• 24 yrs, single, thinks that he is having PE.
• Never had sexual intercourse

17. Homework assignment (Avasthi et al., 2020)

18. Dapoxetine hydrochloride
• Short-acting SSRI
• Rapid Tmax (1.3 hours) and a short half-life (95% clearance after 24
hours)
• On demand (1-2 hr before coitus)
• Dose 30 mg and 60 mg increases IELT by 2.5- and 3.0-fold
respectively (Macmahon et al., 2011; Porst et al., 2010).
• Effective from the first dose (Porst et al., 2010)
• Side-effects- dose-dependent - nausea, diarrhoea, headache, dizziness.
• Discontinuation because of side effects- 4% (30 mg) and 10% (60 mg)
• No increased risk of suicidal ideation or suicide attempts
• No withdrawal symptoms with abrupt cessation
• No drug interaction
• Level 1a evidence (ISSM)

19. How does Dapoxetine act?
• An abrupt increase in
extracellular 5-HT
following
administration that
might be sufficient to
overwhelm the
compensating
autoregulation
processes.
• Acts on 5HT2C
receptors

20. Long acting antidepressants
• To be given for 1-2 weeks before any benefit is seen
• Prolonged increases in synaptic cleft serotonin, which desensitises the 5-HT1A
receptors
• TCA- Clomipramine 12.5-50 mg
• SSRIs- Paroxetine (8.8 fold delay in IELT) > Sertraline.> fluoxetine >
Citalopram
• Tachyphylaxis (decreasing response to a drug following chronic
administration)
• Side effects- fatigue, drowsiness, yawning, nausea, vomiting, dry mouth,
diarrhoea and perspiration- gradually improve after two to three weeks
• Decreased libido, anorgasmia, anejaculation and ED
• Should not be stopped abruptly
• Avoided in men with depressive disorders and <18 yr age (suicidal ideation)
• Level 1a evidence (ISSM)

21. Desensitising agents
• Local anaesthetic gel- oldest pharmacological treatment of PE
• Reduce the sensitivity of the glans penis thereby delaying ejaculatory
latency, but without adversely affecting the sensation of ejaculation.
• Lidocaine-prilocaine cream- 20-30 min before intercourse
• Prolonged application (30-45 minutes) → loss of erection due to numbness
of the penis
• A condom will prevent diffusion of the topical anaesthetic agent into the
vaginal wall
• Alternatively, the condom may be removed prior to sexual intercourse and
the penis washed clean of any residual active compound.
• Contra-indicated in patients or partners with an allergy to any
ingredient in the product.
• Level of evidence 1b (ISSM)

22. Condom only

23. Tramadol
• Atypical opioid
• Activates opioid (µ) receptors centrally, inhibits serotonin
and noradrenaline uptake
• Readily absorbed after oral administration and has an
elimination half-life 5-7 hours
• On demand, like dapoxetine
• 62 and 89 mg increases IELT by 2.4 and 2.5 fold
respectively
• US-FDA, 2009- addiction, dyspnoea
• 15% discontinue- because of nausea, vomiting, dizziness
• Level of evidence 2d (ISSM)
• Not recommended for PE

24. Phosphodiesterase-5 inhibitors
• Sildenafil vs placebo- does not improve IELT, improves
satisfaction and confidence, reduces the refractory time to
achieve a second erection after ejaculation.
• Sildenafil + physical therapy- better than physical therapy
alone
• SSRI+sildenafil- better than monotherapy with SSRI
(paroxetine, sertraline)
• Sildenafil with chronic SSRI- prodromal symptoms,
vasovagal reaction
• Sildenafil + Dapoxetine- well tolerated
• Limited data on other drugs (Vardenafil, Tadalafil)
• Level 4d evidence
• Should NOT be used in PE without any evidence of ED

25. Role of surgery
• In refractory lifelong PE,
• Surgically induced penile hypo-anesthesia
1. Selective dorsal nerve neurotomy
2. Hyaluronic acid gel glans penis augmentation
• May be asso-ciated with permanent loss of
sexual function
• Needs further evidence
• Level 4 evidence (ISSM)
• NOT recommended

27. Combination of therapies
• Physical and Pharmaco-therapy
• Pharmacotherapy- quicker
results
• Physical therapy-
patient factors (performance anxiety,
self-confidence)
partner factors (partner sexual
dysfunction)
relationship factors (conflict, lack of
communication)
sexual factors in the relationship
(sexual scripts, sexual
satisfaction);
contextual factors (life stressors)
• Acquired PE-clear psychosocial
components
• Lifelong PE- patient and partner
factors
• Coexistent ED- with
psychosexual factors

29. Fertility issues and PE?
• Ho et al., 2019- overt PE 4.7%, probable PE 7.1%
• Lotti and Maggi, 2018- 16.67%
• Our study- 32%, more with timed intercourse

30. Anteportal Ejaculation
• Ejaculation prior to vaginal penetration
• Considered the most severe form of PE
• Typically present when they are having
difficulty conceiving children.
• 5% of lifelong PE men suffer from anteprotal
PE (De Carufel et al., 2006; Waldinger et al.,
1998; Pagani et al., 1996)

31. Mr SP
• 36 yr, businessman
• Apparently “unexplained
infertility”
• Multiple cycles of OI
• C/O inability to deposit
sperms in the vagina
• Multiple operations for
hypospadias
• Conceived after 1st cycle
of IUI (H), delivered