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PREMATURE EJACULATION: the less talked about sexual condition <ul><li>MMA Sabah </li></ul><ul><li>3 rd  SABAH GP CONFERENC...
48 yrs contractor, M, 6 +2  children, (real 12.5.11) <ul><li>Ejaculation within <10 thrusts ( ? How many mins ?), less vol...
Real Case  <ul><li>TREATMENT: </li></ul><ul><li>tried Levitra ( “others not so good for improving erection”), im Nebido 3x...
PREMATURE EJACULATION, PE <ul><li>Persistent or recurrent ejaculation with minimal stimulation before, on, or shortly afte...
Evidence-based  definition of lifelong PE:  T he International Society for Sexual Medicine <ul><li>PE is a male sexual dys...
Lifelong versus Acquired PE 1.  Palmer & Stuckey, 2008.
Estimated IELT Reported by Men with  “ Normal ”  Ejaculation and by their Partners Sotomayor M. J Sex Med 2 (Suppl 2): 110...
A MultiNational Survey of IELT 500 couples >age 18 in Netherlands, UK, Spain, Turkey and US Not selected for ejaculatory s...
There is a confusion between PE & ED <ul><li>65% of Malaysian men believe PE and ED are very similar, and the same medicat...
Up to 29% of Malaysian men suffer from PE at some point in their lives China Aust/NZ Taiwan Thailand Korea Hong Kong Malay...
Prevalence of PE is similar across countries 1.  Porst et al, 2007.  2. Janssen-Cilag Data On File 2009 PEPA (Premature Ej...
Prevalence of PE is Consistent Across Age Groups <ul><li>PEPA: Premature ejaculation perceptions and attitudes. Porst et a...
Normal Male Sexual Response Time Sexual interest/ stimulation Penile  tumescence High arousal / penile erection Plateau Or...
Premature Ejaculation Time Rapid ejaculation and associated orgasm with normal erection Normal response Adapted from  Dona...
  What percentage of men with PE  might want treatment?   Authors   Percent Rowland et al  ( JSexMed 1:225, 2004) 50% Cars...
Current Treatment Options ?
Pharmacological Treatment of PE, previous <ul><li>Topical (local) anesthetics eg Emla, Gambir Swak,  </li></ul><ul><li>PDE...
Topical PE Therapy ? <ul><li>Desensitizing creams use lidocaine (Emla) or lidocaine with prilocaine applied 20-30 minutes ...
New topical penile spray using a combination   of lidocaine and prilocaine to treat PE   DB PC phase 2 study of 43 men wit...
Efficacy of Sildenafil for Premature Ejaculation  and Post-Ejaculatory Refractory Time Double-blind placebo-controlled stu...
FIG 1 The mechanism of  ejaculation 2005 BJU International 95, 1181-1186 ejaculate
Neurophysiology of Ejaculation Motor supply to bulbospongiosus muscle Pudendal nerve Sensory inputs from genital areas Sup...
<ul><li>The following neurotransmitters are involved in the processing of emission  and ejaculation: </li></ul><ul><ul><li...
<ul><li>Nucleus ParaGiganto- cellularis (nPGi) and other centers have  projections to the lumbosacral spinal cord which ar...
Lifelong PE:  NOT  psychogenic ORGANIC CAUSE OF  PREMATURE EJACULATION  1   <ul><li>Serotonin in the CNS inhibits the ejac...
Indirect Evidence for a Genetic Explanation of PE <ul><li>(1) Dutch study in men with lifelong PE with IELT < 1 minute sho...
Dapoxetine (Priligy) A highly potent inhibitor of serotonin reuptake transporter  Following oral  administration, it is ra...
Dapoxetine <ul><li>Dapoxetine is the first compound specifically developed for the treatment of PE,  30-60mg ,  1-3 hrs be...
Dapoxetine Pharmacokinetics <ul><li>Dapoxetine undergoes rapid absorption (Tmax of 1.0 hours), rapidly achieves peak plasm...
Dapoxetine Phase III Studies Summary © J & J Pharmaceutical Services LLC, 2007 Study number Description Subjects enrolled ...
Dapoxetine IELT for ≤1min & ≤0.5min Pooled IELT values at endpoint for baseline IELT  ≤1min & ≤0.5min   †  McMahon et al. ...
Dapoxetine  Mean IELT  Results Over Time  (3x, NOT 3 hours) *P<0.001 vs. placebo ANCOVA * * * * * * * * Pooled study data:...
Dapoxetine:  Most adverse events mild to moderate in severity and  occurred within first 4 weeks of treatment 1. McMahon  ...
Dapoxetine - Most Common  Adverse Events Phase III Data - Pooled Discontinuation due to Nausea: 0.1% placebo, 0.9% 30 mg, ...
48 yrs architect,  <ul><li>? Give Priligy ? </li></ul>
48 yrs architect,  <ul><li>EHS  & TMT: DRE, normal (BS, LFT, RFT, cholesterol, testosterone) </li></ul><ul><li>Urine norma...
Summary (1) <ul><li>PE is a common male sexual dysfunction.  </li></ul><ul><ul><li>Both  psychological  and  physiological...
Summary (2) <ul><li>Manage  patient expectations  and involve  partners  (if possible) </li></ul><ul><ul><li>Patient ’s ne...
Summary (3) <ul><li>Patient presents with suspected PE </li></ul><ul><li>Establish PE diagnosis using ISSM definition </li...
Thank you ! (Damai Lagoon KUCHING)
Premature Ejaculation 1 Questions <ul><li>? </li></ul>
Medical Therapy Options for Treatment of PE  -  AUA Guidelines Oral Therapies   Trade Names Recommended Dose Nonselective ...
Effectiveness of SSRIs <ul><li>But successes limited by: </li></ul><ul><ul><li>Chronic dosing </li></ul></ul><ul><ul><li>A...
Slow onset of effect of SSRIs in PE sertraline washout placebo IELT (min) Weeks McMahon CG.  J Urol 159:1935-8, 1998
Evaluating the Patient on Dapoxetine Evaluating patient responses - Does the patient want to continue on treatment? - some...
Premature Ejaculation 2 Questions <ul><li>? </li></ul>
Premature Ejaculation Profile (PEP) <ul><li>1.Over the past month, was your satisfaction with sexual intercourse  </li></u...
PEP for Partners <ul><li>1.Over the past month, was your satisfaction with sexual intercourse  </li></ul><ul><li>2. Over t...
END <ul><li>Come again ! </li></ul>
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Premature ejaculation

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李長茂沙巴談少人啟齒的早洩問題
PREMATURE EJACULATION
Dr Clarence Lei Chang Moh
MMA Sabah
3rd SABAH GP CONFERENCE
Kota Kinabalu 15 May 2011

Published in: Health & Medicine
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Premature ejaculation

  1. 1. PREMATURE EJACULATION: the less talked about sexual condition <ul><li>MMA Sabah </li></ul><ul><li>3 rd SABAH GP CONFERENCE </li></ul><ul><li>Kota Kinabalu 15 May 2011 </li></ul><ul><li>CHAIRMAN: Datuk Dr Jayaram Menon </li></ul><ul><li>Chief Physician, Queen Elizabeth Hospital, KK </li></ul><ul><li>by Dr Clarence Lei Chang Moh, FRCS Urol </li></ul><ul><li>Consultant Urologist </li></ul><ul><li>email: clarencelei@gmail.com </li></ul><ul><li>kuchingurology.com </li></ul>
  2. 2. 48 yrs contractor, M, 6 +2 children, (real 12.5.11) <ul><li>Ejaculation within <10 thrusts ( ? How many mins ?), less volume, trickle instead of projectile, slight pain ejaculation last month </li></ul><ul><li>Since 1 st SI, better after few yrs (30min), deteriorated 2 nd yr 2n d wife (youngest child 1 yr) </li></ul><ul><li>Nocturia 3 x </li></ul><ul><li>DISTRESS, + partner “ can’t climax, I need just 1 -2 mins ”; came with wife (spacing outside room) ! </li></ul>
  3. 3. Real Case <ul><li>TREATMENT: </li></ul><ul><li>tried Levitra ( “others not so good for improving erection”), im Nebido 3x </li></ul><ul><li>stop start, (need coitus interruptus ? co-operate) </li></ul><ul><li>Prior masturbation, prior sex </li></ul><ul><li>foreplay, non penetrative (but ejaculates when he moves !) </li></ul><ul><li>internet, ? Local anaesthetic, partner mouth bitter taste & numb </li></ul><ul><li>? Medication, ? how ? safe </li></ul>
  4. 4. PREMATURE EJACULATION, PE <ul><li>Persistent or recurrent ejaculation with minimal stimulation before, on, or shortly after penetration, and before the person wishes it. </li></ul><ul><li>American Psychiatric Association ’s Diagnostic and Statistical Manual IV. </li></ul>
  5. 5. Evidence-based definition of lifelong PE: T he International Society for Sexual Medicine <ul><li>PE is a male sexual dysfunction characterized by: </li></ul><ul><ul><li>Ejaculation which always or nearly always occurs prior to or within about one minute of vaginal penetration 90% IELT, intravaginal ejaculatory latency time); and </li></ul></ul><ul><ul><li>Inability to delay ejaculation on all or nearly all vaginal penetrations; and </li></ul></ul><ul><ul><li>Negative personal consequences , such as distress, bother, frustration and/or the avoidance of sexual intimacy </li></ul></ul>McMahon CG, Althof SE, Waldinger MD, et. al. An Evidence-Based Definition of Lifelong Premature Ejaculation: Report of the International Society for Sexual Medicine (ISSM) Ad Hoc Committee for the Definition of Premature Ejaculation. J Sex Med 2008;5:1590–1606
  6. 6. Lifelong versus Acquired PE 1. Palmer & Stuckey, 2008.
  7. 7. Estimated IELT Reported by Men with “ Normal ” Ejaculation and by their Partners Sotomayor M. J Sex Med 2 (Suppl 2): 110-114, 2005. Estimated IELT (minutes) Men Women USA 13.6 11.2 UK 9.9 8.5 France 9.3 8.4 Germany 6.9 7.4 Italy 9.6 8.6
  8. 8. A MultiNational Survey of IELT 500 couples >age 18 in Netherlands, UK, Spain, Turkey and US Not selected for ejaculatory status or co-morbidities IELT measured by stop-watch for 4 weeks ----------------------------------------------------------------------------------------------- RESULTS by Country (Median IELT in minutes) Netherlands UK Spain Turkey US ALL 5.1 7.6 5.8 3.7 7.0 5.4 ----------------------------------------------------------------------------------------------- ----------------------------------------------------------------------------------------------- Waldinger MD, Quinn P, Dilleen M et al. J Sex Med 2:492-7, 2005.
  9. 9. There is a confusion between PE & ED <ul><li>65% of Malaysian men believe PE and ED are very similar, and the same medication can treat both conditions which in fact they can ’t </li></ul>ISSM Sept 2010 Seoul, Janssen Cilag: Data on file
  10. 10. Up to 29% of Malaysian men suffer from PE at some point in their lives China Aust/NZ Taiwan Thailand Korea Hong Kong Malaysia Indonesia Philippines Total <ul><ul><ul><ul><li>Malaysia : 15% self-reported vs 29% objective assessment </li></ul></ul></ul></ul><ul><li>. </li></ul>Champion: koreans !!
  11. 11. Prevalence of PE is similar across countries 1. Porst et al, 2007. 2. Janssen-Cilag Data On File 2009 PEPA (Premature Ejaculation Perceptions and Attitudes) Study * Men classified as having PE if low / absent control over ejaculation that is viewed as a problem by men or/ their partners ** Men classified as having PE or Probable PE by PEDT diagnosis ** ** * * * *
  12. 12. Prevalence of PE is Consistent Across Age Groups <ul><li>PEPA: Premature ejaculation perceptions and attitudes. Porst et al. (2007) Eur Urol 51:816–824 </li></ul>
  13. 13. Normal Male Sexual Response Time Sexual interest/ stimulation Penile tumescence High arousal / penile erection Plateau Orgasm Ejaculation accompanied by orgasm Penile detumescence Resolution Adapted from Donatucci (2006) J Sex Med 3(suppl 4):303–308 Excitement Penetration
  14. 14. Premature Ejaculation Time Rapid ejaculation and associated orgasm with normal erection Normal response Adapted from Donatucci (2006) J Sex Med 3(suppl 4):303–308 Short plateau phase Steep excitement phase with normal erection PE
  15. 15. What percentage of men with PE might want treatment? Authors Percent Rowland et al ( JSexMed 1:225, 2004) 50% Carson et al ( JUrol 169 Suppl 2003) 24% Brock et al ( JUrol 177 Suppl 2007) 38%
  16. 16. Current Treatment Options ?
  17. 17. Pharmacological Treatment of PE, previous <ul><li>Topical (local) anesthetics eg Emla, Gambir Swak, </li></ul><ul><li>PDE5 inhibitors </li></ul><ul><li>Tricyclic antidepressant (clomipramine) </li></ul><ul><li>Selective Serotonin Reuptake Inhibitors (SSRI ’ s) </li></ul><ul><li>Tramadol </li></ul>
  18. 18. Topical PE Therapy ? <ul><li>Desensitizing creams use lidocaine (Emla) or lidocaine with prilocaine applied 20-30 minutes prior to sexual activity </li></ul><ul><ul><li>Lessen penile sensitivity during foreplay and intercourse </li></ul></ul>
  19. 19. New topical penile spray using a combination of lidocaine and prilocaine to treat PE DB PC phase 2 study of 43 men with PE Drug Placebo Number of men 20 23 Baseline IELT (min) 1.0 0.9 Follow-up (min) 4.9 1.6 Dinsmore WW et al. BJU International 99:369-375, 2007 (Feb)
  20. 20. Efficacy of Sildenafil for Premature Ejaculation and Post-Ejaculatory Refractory Time Double-blind placebo-controlled study 157 men with PE ages 18-65 (mean 43 yrs) Compared flexible-dose sildenafil (50-100 mg) to placebo Results: No signficant difference between sildenafil and placebo in IELT Sildenafil-treated men had greater ejaculatory control and sexual satisfaction scores Sildenafil-treated men had decreased post-ejaculatory refractory time McMahon CG, Stuckey BGA, Andersen M, et al. J Sex Med 2: 368-375, 2005
  21. 21. FIG 1 The mechanism of ejaculation 2005 BJU International 95, 1181-1186 ejaculate
  22. 22. Neurophysiology of Ejaculation Motor supply to bulbospongiosus muscle Pudendal nerve Sensory inputs from genital areas Supraspinal Centres Spinothalamic cells L3-L4: Coordination of spinal nuclei Hypogastric Plexus ~ T12-L1: Emission Spinal Reflex S1-S3: Expulsion afferent efferent Giuliano & Clement (2005) Ann Rev Sex Res 16:190–216 Higher brain Centres Excitatory & inhibitory control Sympathetic supply to: Epididymis, Vas deferens Seminal Vesicles Prostate Pons: nPGi: Nucleus paragigantocellularis Dorsal nerve of penis
  23. 23. <ul><li>The following neurotransmitters are involved in the processing of emission and ejaculation: </li></ul><ul><ul><li>Serotonin (5-HT) </li></ul></ul><ul><ul><li>Dopamine (DA) </li></ul></ul><ul><ul><li>Gamma-aminobutyric acid (GABA) </li></ul></ul><ul><ul><li>Noradrenaline </li></ul></ul><ul><ul><li>Serotonin is considered to be the key inhibitory neurotransmitter involved in the processing of ejaculation </li></ul></ul><ul><ul><ul><li>There are multiple serotonin receptors in the hypothalamus, brainstem and the spinal cord </li></ul></ul></ul>Neurotransmitters Involved in Control of Ejaculation McMahon et al, Disorders of orgasm and ejaculation in men. In Sexual Medicine: Sexual dysfunctions in men and women. 2nd International Consultation on Sexual Dysfunctions, Paris, 2004
  24. 24. <ul><li>Nucleus ParaGiganto- cellularis (nPGi) and other centers have projections to the lumbosacral spinal cord which are thought to exert tonic inhibition of ejaculation </li></ul>Central Serotonin and PE Tonic descending serotonergic inhibition of ejaculation from NPGi nPGi (brainstem) MPOA (hypothalamus) PVN (hypothalamus) Sympathetic control of ejaculation in the lumbosacral cord Ejaculation reflex mediated by the L-S cord
  25. 25. Lifelong PE: NOT psychogenic ORGANIC CAUSE OF PREMATURE EJACULATION 1 <ul><li>Serotonin in the CNS inhibits the ejaculation reflex </li></ul><ul><li>With l ow CNS serotonin, ejaculation is not inhibited, setting the ejaculatory threshold at a lower point </li></ul><ul><li>PE seems to have a neurologic basis in some men </li></ul>1 Waldinger MD, Schweitzer DH and Olivier B. J Sex Med 2:121-131, 2005
  26. 26. Indirect Evidence for a Genetic Explanation of PE <ul><li>(1) Dutch study in men with lifelong PE with IELT < 1 minute showed </li></ul><ul><li>an increased familial occurrence of lifelong </li></ul><ul><li> PE in first degree male relatives 1 </li></ul><ul><li>(2) Finnish male twin questionnaire study showed a moderate genetic </li></ul><ul><li>influence on PE 2 </li></ul><ul><li>(3) Animal studies showed a subgroup of persistent rapidly ejaculating </li></ul><ul><li>Wistar rats 3-5 </li></ul><ul><li>1. Waldinger M, et al. Psychiatr Genet 1998;8:37-40 </li></ul><ul><li>2. Jern P, et al. J Sex Med 2007;4:1739-49 </li></ul><ul><li>3. Pattij T, et al Curr Pharm Des 2005;11:4069-77 </li></ul><ul><li>4. Waldinger M, et al. World J Urol 2005;23:115-8 </li></ul><ul><li>5. Pattij T, et al. Eur J Neurosci 2005;22:724-34 </li></ul>
  27. 27. Dapoxetine (Priligy) A highly potent inhibitor of serotonin reuptake transporter Following oral administration, it is rapidly absorbed After reaching T max, serum concentration declines rapidly At 60 mg dose: 1 T max = 1.2 hr T ½ initial = 1.5 hr Single dose and multiple dose pharmacokinetics are similar 1 No interaction when used with food 2 , alcohol 3 or PDE5 inhibitors 4 1 Dresser M, et al. Clin Pharmacol Therap 32:2004. Abstract Pl-113 2 Dresser M, et al. J Sex Med 3 (Suppl 1):25, 2005. Abstract 37. 3 Modi N, et al. J Urol 173 (Suppl):239, 2005. Abstract 879. 4 Dresser M, et al. J Urol 173 (Suppl):201, 2005. Abstract 739.
  28. 28. Dapoxetine <ul><li>Dapoxetine is the first compound specifically developed for the treatment of PE, 30-60mg , 1-3 hrs before, on demand, short acting </li></ul><ul><li>Approved in several EU countries, Mexico, Korea, New Zealand ,Malaysia (1.8.2010) with anticipated approval in other countries </li></ul><ul><li>Level 1A evidence to support the efficacy and safety of on-demand dosing of dapoxetine [1] </li></ul>1 . ICSD Paris 2009
  29. 29. Dapoxetine Pharmacokinetics <ul><li>Dapoxetine undergoes rapid absorption (Tmax of 1.0 hours), rapidly achieves peak plasma concentration (Cmax) and has a mean half-life after a single dose is 1.3 hours </li></ul><ul><li>Minimal accumulation with plasma concentration rapidly declining to about 5% of Cmax at 24 hours. </li></ul><ul><li>Dose-dependent pharmacokinetics with plasma concentrations and area under the curve (AUC) which are unaffected by multiple dosing </li></ul>
  30. 30. Dapoxetine Phase III Studies Summary © J & J Pharmaceutical Services LLC, 2007 Study number Description Subjects enrolled Sites 012 & 013 12 week phase III trials of dapoxetine in men with moderate to severe premature ejaculation (completed 2004) 2614 121 sites in USA 014 9 month open label extension of studies 012 & 013 (completed 2005) 1774 121 sites in USA 3001 24 week phase III trial of dapoxetine in men with moderate to severe premature ejaculation (completed 2007) 1162 143 sites in Europe, South Mexico, America, Canada, Israel and South Africa 3002 Withdrawal effects of chronic daily and as-needed dosing with dapoxetine in the treatment of PE (completed 2005) 1238 91 sites in USA and Canada 3003 12 week phase III trial of dapoxetine in men with moderate to severe premature ejaculation (completed 2007) 1349 52 sites in Asia and Australia
  31. 31. Dapoxetine IELT for ≤1min & ≤0.5min Pooled IELT values at endpoint for baseline IELT ≤1min & ≤0.5min † McMahon et al. (2008) Presented at ESSM/ISSM IELT≤Imin IELT≤0.5min * Fold-increase=geometric endpoint/geometric baseline, not model based. Values are unadjusted. † Week 12 (012, 013, 3001, 3003) or last observation carried forward Fold Increase=4.3 Fold Increase=3.4 Fold Increase=2.7 Fold Increase=3.4
  32. 32. Dapoxetine Mean IELT Results Over Time (3x, NOT 3 hours) *P<0.001 vs. placebo ANCOVA * * * * * * * * Pooled study data: C-2002-012, C-2002-013, PRE-3001, PRE-3003 * * Pooled Studies
  33. 33. Dapoxetine: Most adverse events mild to moderate in severity and occurred within first 4 weeks of treatment 1. McMahon et al., 2008 2. Casey et al., 2008 3. Giuliano et al., 2008 SSRI Class Effects are not evident: No deleterious effects on mood and anxiety symptoms, suicidal ideation or withdrawal syndrome, erectile function or libido
  34. 34. Dapoxetine - Most Common Adverse Events Phase III Data - Pooled Discontinuation due to Nausea: 0.1% placebo, 0.9% 30 mg, 3.0% 60 mg Pooled data: C-2002-012, C-2002-013, PRE-3001, PRE-3002, PRE-3003
  35. 35. 48 yrs architect, <ul><li>? Give Priligy ? </li></ul>
  36. 36. 48 yrs architect, <ul><li>EHS & TMT: DRE, normal (BS, LFT, RFT, cholesterol, testosterone) </li></ul><ul><li>Urine normal </li></ul><ul><li>US normal urinary tract, & prostate </li></ul><ul><li>Uroflow: 21 ml/sec (wants to show wife !) </li></ul><ul><li>Re-assure, Stress Mx, Exercise </li></ul><ul><li>Priligy 30 mg, 3 + 3 (kiv 60mg) </li></ul>
  37. 37. Summary (1) <ul><li>PE is a common male sexual dysfunction. </li></ul><ul><ul><li>Both psychological and physiological causes </li></ul></ul><ul><ul><li>Can be either lifelong or acquired </li></ul></ul><ul><ul><li>May cause serious psychological problems for patients and/ or their partners </li></ul></ul><ul><li>Be proactive about initiating PE conversation. </li></ul><ul><ul><li>High prevalence across age, nationality, ethnicity </li></ul></ul><ul><ul><li>Poor treatment seeking rates </li></ul></ul><ul><li>Diagnosis should be multidimensional and should assess </li></ul>Short time to ejaculation Inability to control ejaculation Negative personal consequences + +
  38. 38. Summary (2) <ul><li>Manage patient expectations and involve partners (if possible) </li></ul><ul><ul><li>Patient ’s needs and preferences </li></ul></ul><ul><ul><li>Set treatment goal </li></ul></ul><ul><li>Pharmacotherapy is the basis of treatment in lifelong PE </li></ul><ul><ul><li>All are off-label indications and not amenable to on-demand dosing </li></ul></ul><ul><ul><li>Dapoxetine is the first short-acting SSRI approved for on-demand, oral treatment of PE </li></ul></ul><ul><ul><li>Dapoxetine is shown to improve all components of PE – time, control and satisfaction with sexual intercourse </li></ul></ul>
  39. 39. Summary (3) <ul><li>Patient presents with suspected PE </li></ul><ul><li>Establish PE diagnosis using ISSM definition </li></ul><ul><li>Perform a sexual, medical and psychological history and physical examination </li></ul>NO Adapted from 1. McMahon et al, 2004. 2. Hatzimouratidis K et al, 2010 3. Althof et. al, 2010 PE management algorithm Patient preference
  40. 40. Thank you ! (Damai Lagoon KUCHING)
  41. 41. Premature Ejaculation 1 Questions <ul><li>? </li></ul>
  42. 42. Medical Therapy Options for Treatment of PE - AUA Guidelines Oral Therapies Trade Names Recommended Dose Nonselective serotonin reuptake inhibitor Clomipramine Anafranil ® 25 to 50 mg/day or 25 mg 4 - 24 hr pre-intercourse Selective serotonin reuptake inhibitors Fluoxetine Prozac ® , Sarafem ® 5 to 20 mg/day Paroxetine Paxil ® 10, 20, 40 mg/day or 20 mg 3 to 4 hr pre-intercourse Sertraline Zoloft ® 25 to 200 mg/day or 50 mg 4 to 8 hr pre-intercourse Topical Therapies Trade Name Dose Lidocaine/prilocaine cream EMLA ® Cream Lidocaine 2.5%, prilocaine 2.5% 20 to 30 minutes pre-intercourse
  43. 43. Effectiveness of SSRIs <ul><li>But successes limited by: </li></ul><ul><ul><li>Chronic dosing </li></ul></ul><ul><ul><li>Antidepressant stigma </li></ul></ul><ul><ul><li>Side effects </li></ul></ul>Waldinger MD, Hengeveld MW, Zwinderman AH, et al. J Clin Psychopharmacol 18:274‑81, 1998 IELT (seconds) 0 50 100 150 200 250 300 350 400 450 500 Baseline 6 weeks Placebo Fluvoxamine (100 mg/day) Fluoxetine (20 mg/day) Paroxetine (20 mg/day) Sertraline (50 mg/day)
  44. 44. Slow onset of effect of SSRIs in PE sertraline washout placebo IELT (min) Weeks McMahon CG. J Urol 159:1935-8, 1998
  45. 45. Evaluating the Patient on Dapoxetine Evaluating patient responses - Does the patient want to continue on treatment? - somewhat worse, the same, somewhat better or much better? What is a successful treatment? - A 3-fold increase in IELT is considered clinically significant and adequate for patient satisfaction Managing nausea and somnolence - Antacid - Timing of sexual activity
  46. 46. Premature Ejaculation 2 Questions <ul><li>? </li></ul>
  47. 47. Premature Ejaculation Profile (PEP) <ul><li>1.Over the past month, was your satisfaction with sexual intercourse </li></ul>2.Over the past month, was your control over ejaculation during sexual intercourse 3.Over the past month, how distressed were you by how fast you ejaculated during sexual intercourse? 4.Over the past month, to what extent did how fast you ejaculated during sexual intercourse cause difficulty in your relationship with your partner?
  48. 48. PEP for Partners <ul><li>1.Over the past month, was your satisfaction with sexual intercourse </li></ul><ul><li>2. Over the past month, was your partner ’s control over ejaculation during sexual intercourse </li></ul>3. Over the past month, how distressed were you by how fast your partner ejaculated during sexual intercourse? 4. Over the past month, to what extent did how fast your partner ejaculated during sexual intercourse cause difficulty in your relationship with your partner?
  49. 49. END <ul><li>Come again ! </li></ul>

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