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Corona and Ricca equally contributed to the article.
© 2009 International Society for Sexual Medicine J Sex Med 2009;6:1259–1269
Results. Higher prolactin was observed only in patients using SSRIs, whereas no other
found after adjustment for confounders. Use of SSRIs was associated with a twofold risk for
desire and with a higher impairment of reported erectile function. However, no differenc
observed. A very high risk (sevenfold) for delayed ejaculation (DE) was observed in SSR
association with the mild, but not severe, form of DE was observed also in subjects using
(3.35 [1.48–7.59]; P < 0.005). Different life stressors and relational parameters were also
SSRI users reported less enjoyment with masturbation and decreased partner desire and
of significant association was observed among BDZ or non-SSRI antidepressant users an
life-stressors and relational parameters.
Conclusions. SSRIs can negatively affect all the steps of the male sexual response cycle (de
orgasm). SSRI-associated sexual dysfunction has a deleterious effect on both auto- and co
Conversely, other antidepressants and BDZ are less often associated with sexual impairm
Bandini E, Mannucci E, Lotti F, Boddi V, Rastrelli G, Sforza A, Faravelli C, Forti G,
serotonin reuptake inhibitor-induced sexual dysfunction. J Sex Med 2009;6:1259–1
Key Words. Erectile Dysfunction; Hypoactive Sexual Desire; Delayed Ejaculation; SS
NCEP-ATPIII = National Cholesterol Education Program-Third Adult Treatment Pane
Corona and Ricca equally contributed to the article.
© 2009 International Society for Sexual Medicine J Se
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– Autoerotisme
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P = notsignificant).Accordingly,nodifferencewas
observed in SIEDY scale 1 score after adjustment
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As expected, a higher risk for MMDE and
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use of SSRIs. Interestingly, the association with
MMDE, but not with ASDE, was observed also in
subjects using non-SSRI antidepressants (3.35
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J Sex Med 2009;6:1259–1269](https://image.slidesharecdn.com/5-220524024500-249c00a9/85/5-Pr_-Droupy-LIFE2015-DAY2_-Session6-3-pdf-24-320.jpg)
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- 1. Lebanese International FertilitySummit 2 – 3 October 2015 Hilton Beirut Habtoor Grand LIFE 2015 LIFE 2015
- 2. Ejaculatory Dysfunction Stéphane DroupyMD, PhD Professor of Urology, CHU de Nimes-Université Montpellier 1
- 3.
- 4. LIFE 2015 Male sexualresponse Excitation Plateau Orgasme Résolution Excitation/ Erection Tumescence Stimulation Ejaculation et orgasme Détumescence Penetration Phase réfractaire
- 5. LIFE 2015 The twophases of ejaculation • 1st phase: Emission ¡ Peristaltic contractions of epididymis and vas deferens ¡ Secretion of spermatic liquid by prostate and seminal vesicles ¡ Contraction of seminal vesicles, prostate and bladder neck ¡ Propulsion of spermatozoa and seminal/prostatic fluid into posterior urethra
- 6. LIFE 2015 The twophases of ejaculation • 2nd phase: Expulsion ¡ Rhythmic contractions of striated pelvic floor muscles (bulbospongiosus muscle) ¡ Bladder neck closure and relaxation of external urinary sphincter ¡ Propulsion of semen out of urethral meatus
- 7. LIFE 2015 Sympathic TL centers LStcells Parasympathic Sacral nucleus BS Muscle Prostate IMG N Pelv. N Hypog. MPG T12-L1 L3-L4 L5-S1 DM (VH) LumbarSpinothalamic neurons (L3-L4) (galanin- NK1) are connected with BS, prostate and SV. LSt neurons coordinate both emission and expulsion phases of ejaculation. Emission is not a prerequist for expulsion. N Pud. Ves Sem Spinal generator of ejaculation: LSt
- 8. LIFE 2015 BRAIN CONTROL of SEXUALRESPONSE INHIBITION / ACTIVATION OF SPINAL CONTROL Des influx nerveux activateurs avec comme neuromédiateur la DOPAMINE et Inhibiteurs comme la SEROTONINE vont converger vers le centre spinal de l’éjaculation. 1- Influx activateurs via l’hypothalamus (aire préoptique médiane (MPOA) et noyau paraventriculaire (PVN)) 2- Influx inhibiteurs via le noyau paragigantocelluaire (NPGi) du tronc cérébral.
- 9. LIFE 2015 Department ofUrology University of Copenhagen Physiology of Ejaculation Serotonergic Dopaminergic (Inhibitory) (Excitatory) Spinal innervation of ejaculation
- 10. LIFE 2015 Ejaculatory dysfunctions ¡ «Dry ejaculation » ¡ Anejaculation ¡ Aspermia ¡ Retrograde ejaculation ¡ Anorgasmia ¡ Partial ejaculations : hypospermia, asthenic ejaculation ¡ Emission or expulsion dysfunction ¡ Delayed ejaculations (> 25 min) ¡ Premature ejaculation (<3 min) (ante portas) ¡ Painfull ejaculation ¡ Orgasmuria
- 11. LIFE 2015 Anejaculation • Completeabsence of antegrade or retrograde ejaculation = Aspermia • Failure of semen emission from the seminal vesicles, prostate and ejaculatory ducts into the urethra • Anejaculation associated with a normal orgasmic sensation. ¡ Central or peripheral nervous system dysfunction ¡ Drugs ¡ Iatrogenic / surgery
- 12. LIFE 2015 Retrograde ejaculation • Total, or partial, absence of antegrade ejaculation as a result of semen passing backwards through the bladder neck into the bladder. Aspermia or hypospermia • Patients experience a normal or decreased orgasmic sensation. • The causes : ¡ neurogenic, ¡ pharmacological, ¡ urethral ¡ bladder neck incompetence
- 13. LIFE 2015 Delayed ejaculation • Prolonged stimulation of the erect penis is needed to achieve orgasm with ejaculation • Mild form of anorgasmia. • The causes ¡ Psychological, ¡ Organic: SCI ¡ Iatrogenic penile nerve damage, ¡ Pharmacological: selective serotonin re-uptake inhibitors (SSRIs), antihypertensives, or antipsychotics
- 14. LIFE 2015 Etiologies MALE INFERTILITY- UPDATE MARCH 2014 Colorectal and anal surgery Parkinson´s disease Urethral Bladder neck incompetence Ectopic ureterocele Congenital defects/dysfunction of hemitrigo Urethral stricture Bladder extrophy Urethral valves or verumontaneum hyperplasia Bladder neck resection (transurethral resect prostate) Congenital dopamine b-hydroxylase deficiency Prostatectomy 3L.1.5 Asthenic ejaculation Asthenic ejaculation is characterised by an altered propulsive phase, with a normal emission phase [ The orgasmic sensation is reduced and the typically rhythmical contractions associated with ejacula missing. Asthenic ejaculation does not usually affect semen quality. 3L.1.6 Premature ejaculation The International Society for Sexual Medicine (ISSM) has adopted the first evidence-based definition premature ejaculation (PE): “Premature ejaculation is a male sexual dysfunction characterised by eja which always or nearly always occurs prior to or within about one minute of vaginal penetration; and to delay ejaculation on all or nearly all vaginal penetrations; and negative personal consequences, su distress, bother, frustration and/or the avoidance of sexual intimacy”. Premature ejaculation may be organic (e.g., prostatitis-related) or psychogenic, partner-related or non-selective, and can be assoc EAU guidelines
- 15.
- 16. LIFE 2015 Iatrogenic aftersurgery • Cystoprostatectomy ¡ Bladder cancer • Radical prostatectomy ¡ Prostate Cancer • Endoscopic and simple prostatectomy ¡ BPH • Retroperitoneal ¡ Lymphadenectomies ¡ Aortic surgery ¡ Sigmoid and rectal surgery • EBR, Brachytherapy (Prostate cancer) ¡ Anejaculation 90% at 5 y ¡ IIEF-O: 7,4 to 2,8/10 at 3 y Sulivan JF et al J Sex Med 2013
- 17. LIFE 2015 Retroperitoneal lymphadenectomy L1 L2L3 VCI Ao Rein Dt Psoas Uretère VRG
- 18. LIFE 2015 Sexual dysfunctionsafter rectal surgery 0 10 20 30 40 50 60 70 80 90 100 Tous AAP Résection Antérieure Excison trans-anale Hendren et al Ann Surg 2005
- 19. LIFE 2015 Sexual dysfunctionsafter rectal surgery 0 10 20 30 40 50 60 70 80 90 100 Tous AAP Résection Antérieure Excison trans-anale Hendren et al Ann Surg 2005
- 20. Drug side effects onejaculation
- 21. LIFE 2015 Drug inducedejaculatory dysfunction • Delayed or suprressed ejaculation ¡ Alphablokers ¡ Antiandrogens ¡ Antidepressants ¡ Analgesic, Baclofen ¡ Antipsychotics, lithium ¡ Antihypertensive (alpha or betablockers and central) ¡ Cytotoxics (methotrexate, vincristine) ¡ Antiparkinsonians (bromocryptine) ¡ Recreational rugs except amphetamin and heroïne ¡ Alcoolism
- 22. LIFE 2015 Alpha-blockers • Anejaculation ¡ Silodosin> Tamsulosin> Alfusosin ¡ Anejaculation: ¡ 100% of healthy volunteers with silodosin (Kobayashi et al. J Sex Med 2008) ¡ 20-30% of treated pts in pivotal studies(Marks et al J Urol 2009) 0 40 80 120 Vehicle 3 10 *p <0.001 3 10 Tamsulosine (µg/kg) Alfuzosine (µg/kg) Pression de la vésicule séminale * *
- 23. LIFE 2015 Sexual sideeffects of drugs Classe& Thérapeutique& Priapisme/ES P/HS& Tr.&Libido& DE& Tr.& Orgasme/Ej& Les&médicaments&conseillés& Neuroleptiques& +" +" ±" +" Clozapine*(Leponex®),*Olanzapine* (Zyprexa®),*Quiétapine* (Seroquel®),*Arispiprazole* (Abilify®)" Antidépresseurs& +" +" +" +" Mirtazapine*(Norset®),*Tianeptine* (Stablon®),*Moclobémide* (Moclamine®),*Agomelatine* (Valdoxan®),*Duloxetine* (Cymbalta®)" Antiépileptiques& " +" " +" " Antalgiques& " +" +" ±" " Anxiolytiques& +" " +" +" Bupropion*et*Buspirone" *Classes thérapeutiques impliquées dans la survenue de dysfonctions sexuelles iatrogènes et médicaments conseillés afin d’éviter ou de limiter la survenue de ces effets indésirables. (ESP : Excitation sexuelle persistante, HS : hypersexualité, Tr. EJ : troubles de l’éjaculation,) S Droupy EMC 2005. Épidémiologie et physiopathologie de la dysfonction érectile ¶ 18-720-A-10
- 24. LIFE 2015 Corona andRicca equally contributed to the article. © 2009 International Society for Sexual Medicine J Sex Med 2009;6:1259–1269 Results. Higher prolactin was observed only in patients using SSRIs, whereas no other found after adjustment for confounders. Use of SSRIs was associated with a twofold risk for desire and with a higher impairment of reported erectile function. However, no differenc observed. A very high risk (sevenfold) for delayed ejaculation (DE) was observed in SSR association with the mild, but not severe, form of DE was observed also in subjects using (3.35 [1.48–7.59]; P < 0.005). Different life stressors and relational parameters were also SSRI users reported less enjoyment with masturbation and decreased partner desire and of significant association was observed among BDZ or non-SSRI antidepressant users an life-stressors and relational parameters. Conclusions. SSRIs can negatively affect all the steps of the male sexual response cycle (de orgasm). SSRI-associated sexual dysfunction has a deleterious effect on both auto- and co Conversely, other antidepressants and BDZ are less often associated with sexual impairm Bandini E, Mannucci E, Lotti F, Boddi V, Rastrelli G, Sforza A, Faravelli C, Forti G, serotonin reuptake inhibitor-induced sexual dysfunction. J Sex Med 2009;6:1259–1 Key Words. Erectile Dysfunction; Hypoactive Sexual Desire; Delayed Ejaculation; SS NCEP-ATPIII = National Cholesterol Education Program-Third Adult Treatment Pane Corona and Ricca equally contributed to the article. © 2009 International Society for Sexual Medicine J Se • Delayed ejaculation x7 • SSRI: younger and PRL • HSD: risk x2 • Less sexual intercourse • ED: idem non-SSRI • Deleterious effect – Autoerotisme – Partner P = notsignificant).Accordingly,nodifferencewas observed in SIEDY scale 1 score after adjustment for confounders (Figure 3). As expected, a higher risk for MMDE and ASDE was observed in subjects reporting the use of SSRIs. Interestingly, the association with MMDE, but not with ASDE, was observed also in subjects using non-SSRI antidepressants (3.35 ponent of ED) were o SSRIs even after adjust asage,useofBDZ,oro sants, patient’s HSD, te and S MHQ (Figure 3) between the use of BDZ sants, and all the aforem relational parameters, w Figure sympt logica patien select tor (S risk (a hood being of SS been founde age, non-S hypoa ostero J Sex Med 2009;6:1259–1269
- 25. LIFE 2015 Management ofsexual dysfunctions / SSRI • Inform and anticipate to prevent drug stop • Remplacement • Mirtazapine (Norset), Tianeptine (Stablon), Moclobémide (Moclamine), Zyban • ED : PDE5i • Ejaculation: • Periactine (cyproheptamine): 2 to 16 mg/d or on demand • Amantadine: 100mg 5h before SI Strategies for managing sexual dysfunction induced by antidepressant medication. Lisa R, Matthew JT, Keith H. Cochrane Database Syst Rev. 2004 Labbate et al. J Clin Psychiatry. 2003 Nurnberg et al.JAMA. 2003 and J Clin Psychiatry. 2003
- 26. ED and spinal cordinjury
- 27. LIFE 2015 Sexuality inSCI patients • 1 à 2 news case/ day • Young men • Quality of reinsertion is dependant of management of sexual dyfunctions Phelps Arch Sex Behav 2001 Why consider genital and sexual rehabilitation ? f 27% 13% Anderson J. Neurotrauma 2004 Why consider genital and sexual rehabilitation ? f 27% 13% Anderson J. Neurotrauma 2004 Anderson et al. J Neurotrauma 2004
- 28. LIFE 2015 Spinal cordinjury • Thoracolumbar Sympathic : ¡ Emission, • Sacral somatic and parasympathic ¡ Reflexogenic Erections, sensitivity ¡ Expulsion (perineal muscles contractions) • Level of the spinal lesion • Infralesional syndrom • Complete vs incomplete Ejaculation Erection Sensibilité
- 29. LIFE 2015 ED inSCI • Ejaculation depends on the intergrity the spinal cord between T12 et L2, • In SCI > T12, ejaculatory reflex remains intact and automatic ejaculation can be optain. • In SCI between T12 and L2 et complete, no ejaculation. • In SCI < L2, and integrity of sacral roots, psychogenic ejaculation is sometimes possible.
- 30. LIFE 2015 Management ofED in SCI • Urinary function • Anorectal function • Spasticity • Pain • Skin • Associated treatments • Reeducation of erection and recreative sexual life
- 31. LIFE 2015 Penile Vibratorystimulation • 22 studies since1954 • 2257 patients • 15% (0 et 52%) of patients are able to ejaculate without medical assistance • Vibratory stimulation of the penis: Ferticare Department of Urology University of Copenhagen Principle of PVS Spinal Cord PVS Pudendal nerve T12-L1 S2-S4 Seminal emission Projectile ejaculation Vibratory amplitude (N=66) 2.5 mm: 80% success rate 1.0 mm: 25% success rate Sønksen et al 1994 Sønksen et al 2001 Above T10 Intact BC reflex Sonkesen et al 1994 et 2001 Consequence of Amplitude S Development of t first medical vibra home use. FDA 510K registr Currently in use i more than 30 cou including US. University of Copenhagen & Multicept A/S Denmark
- 32. LIFE 2015 Ferticare® • Brackett,SØnksen. J. Urol, 1988. (653 essais chez 211 patients) ¡ C3-C7 66% ¡ D1-D5 54% ¡ D6-D10 41% ¡ D11-L3 36% • Efficacy 50 to 80% if Sci > T10 • First line treatment for ED in SCI • Home use for intravaginal inseminations • Association with: ¡ Midodrine :Gutron® (alpha +) ¡ iPDE5 to improve erection and sensitivity Courtois et al 2008, Soler et al 2008 Department of Urology Clinical Department of Urology Clinical use of PVS
- 33. LIFE 2015 Home insemination Departmentof Urology University of Copenhagen TMS (millions): 31 (1-426) 74/170couples: 100 pregnancies Outcome: 91 healthy babies (1 set of twins) Time to pregnancy: 1.2 years (0.1-8.2) Spontaneous abortion: 10 in 9 couples (10%) Results PVS and Home Insemination
- 34. LIFE 2015 Electroejaculation :100% Department of Urology University of Copenhagen Electroejaculation Procedure
- 35.
- 36. LIFE 2015 Obstruction ofseminal tract • CBAVD, at least one mutation of the CF gene in 82%. Dysgenesis of seminal vesicles. • Unilateral agenesis or a partial defect ¡ Contralateral seminal duct anomalies 80% ¡ Renal agenesis in 26% • Ejaculatory duct obstruction: 1-3% of OA ¡ Cystic obstruction: Mullerian cyst (central) ¡ urogenital sinus/ejaculatory duct cysts ¡ Post-inflammatory obstruction ¡ Lithiasis ¡ Painful ejaculation
- 37. LIFE 2015 Ejaculatory duct obstruction Phosphatesamorphes de Calcium Carbonatés + Protéines
- 38. LIFE 2015 MRI Curran Set al. AJR 2007;188:1373-1379
- 39. LIFE 2015 Treatment ofMullerian cyst • Mullerian cyst: ¡ US guided transrectal aspiration. ¡ TUR of cyst., laser resection ¡ Cryopreservation • Risks: ¡ Rectal perforation ¡ Retrograde ejaculation ¡ Urine reflux seminal tract ¡ Recurrence Goldstein - Surgery of Male Infertility – 1995, Fish World J Urol 2006, XU BJUInt 2011
- 40. LIFE 2015 Ejaculatory ductobstruction ¡ Stenosis /calculi of ejaculatory ducts ¡ Endoscopic incision (laser), ¡ Colliculus seminalis resection ¡ Per operative sperm retrieval ¡ Peroperative US ¡ Antibiotics, antiinflammtory a, repeated ejaculations ¡ Dilation 9 french vesiculoscopy free, and the scarred portion was removed, a drop of vasal fluid was examined for the presence of sperm. All patients were found to have sperm in the proximal vas bilaterally. Assisted laparoscopy was needed if the distal vas end was retreated into the pelvis and inaccessible at the inguinal area or if the distal (pelvic) vas end was found and dissected near the internal ring, but the defective vas was too long to anastomose with the proximal end of the vas. This procedure is similar to Shaeer pelviscrotal VV.4 A three-port transperitoneal approach is placed after artificial pneumoperitoneum. The initial 10 mm port was placed at the inferior umbilical crease and housed the laparoscope. Ports number 2 (5 mm) and number 3 (5 mm) were placed one fingerbreadth outside the lateral border of the rectus muscle and two fingerbreadths below the umbilicus. After an incision of the peritoneum on the internal ring, the distal end of the vas was easily identified and dissected distally, and 7–8 cm length of distal vas was dissected free. Another 5 mm trocar was placed on the external ring and created a new canal by penetrating the abdominal wall into the peritoneal cavity adjacent to the outside of the obliterated umbilical artery fold. This canal was a shortcut for a tension-free VV (Figure 3). The distal vas were delivered intact and then trimmed under direct vision of the microscope. The scarred end of the vas was cut-off until the vasal lumen appeared healthy. The distal vas was near the proximal vas, and VV was performed (the procedure used was similar to the previously reported technique5 ). The patients started to ejaculate 3 weeks after surgery. Microscopic vasoepididymostomy Patients who were presumptively diagnosed with vasal or epididymal obstruction underwent scrotum exploration under spinal anesthesia. The vas was transected at the site near the epididymis. The patency of the distal vas lumen was checked by injecting 10 ml of saline into the cannulated vas deferens. If saline could not pass through the vas Hong‐Tao Jiang et al. Asian Journal of Andrology (2014) 16, 912–916
- 41. LIFE 2015 Ballistic problems • Normalejaculatory sensation : no intravaginal semen emission • Hypospadias • Urethral stenosis • Congenitale or acquired penile curvature • Ejaculation prématurée ante-portas • Vaginism
- 42.
- 43. LIFE 2015 Premature ejaculation PE Normal response Etiologyof PE remains largely unknown Steep excitement phase Rapid ejaculation and associated orgasm Short plateau phase
- 44. LIFE 2015 Pathophysiology ofPE Adapted from Perelman, Atlas of Male Sexual Dysfunction, 2004 Biological Factors Psychological Factors Penile Hypersensitivity Hyperexcitability Genetic predisposition Central 5-HT sensitivity Early sexual experience Sexual conditioning Anxiety Psychodynamic Variable expression
- 45. LIFE 2015 Definitions Primary PE(1)Acquired PE Naturally variable PE(2) Pseudo-PE (2) Délai pour éjaculer après la pénétration vaginale: 1minute ou moins toujours ou presque. Incapacité de retarder l’éjaculation lors de toutes ou presque les pénétrations vaginales. Conséquences personnelles négatives: souffrances, gêne, frustration, évitement de l’intimité sexuelle Diminution significative du délai pour éjaculer après la pénétration vaginale: 3 minutes ou moins toujours ou presque. Incapacité de retarder l’éjaculation lors de toutes ou presque les pénétrations vaginales. Conséquences personnelles négatives: souffrances, gêne, frustration, évitement de l’intimité sexuelle Éjaculations précoces occasionnelles. Incapacité totale ou partielle à retarder une éjaculation imminente. Ejaculation parfois dans des délais normaux Perception subjective d’une éjaculation précoce lors des rapports sexuels. Ejaculation précoce imaginaire Le temps de latence pour éjaculer est dans la fourchette normale (3 à 25 min). La capacité à retarder l'éjaculation imminente est diminuée ou absente. 2- Waldinger MD. Recent advances in the classification, neuro- biology and treatment of premature ejaculation. Adv Psycho- som Med 2008;29:50–69. 1- McMahon CG, Althof SE, Waldinger MD, et al. An evidence-based definition of lifelong premature ejaculation: report of the Interna- tional Society for Sexual Medicine (ISSM) ad hoc committee for the definition of premature ejaculation. J Sex Med 2008;5:1590–606.
- 46. LIFE 2015 Management ofPE 1. Althof SE, et al. International Society for Sexual Medicine’s Guidelines for the Diagnosis and Treatment of Premature Ejaculation. J Sex Med 2010;7:2947-2969. Ejaculation Prématurée OUI EP secondaire à une DE ou autre dysfonction sexuelle OUI Prise en charge de la cause primaire EP acquise EP primaire Traitement Comportemental/Psychothérapie Pharmacothérapie Traitement combiné Traitement Pharmacothérapie Comportemental/Psychothérapie Traitement combiné Préférence du patient Tentative d’arrêt progressif du traitement pharmacologique selon les patients NON
- 47. LIFE 2015 Psycho-sexological approach § Sexothérapies comportementales 2, 3 Ø Technique Stop and Go Ø Squeeze Ø Sensate Focus Ø Thérapies cognitivo-comportementales Ø Jeux de rôle § Hypnose, relaxation, sophrologie 3 § Sexothérapies corporelles § Thérapie de couple 4 Ø Développer la communication Ø Gérer les émotions (négatives) § Thérapie psychodynamique 3 Ø Problèmes psychologiques et relationnels en amont du symptôme sexuel 2. Mohee A, et al. Medical therapy for premature ejaculation. Ther Adv Urol 2011;3(5):211︎-222. 3. Porto R, et al. L’éjaculation prématurée. Prog Urol 2013;23:647-656. 4. AIHUS. Recommandations aux médecins généralistes pour la prise en charge de première intention de la dysfonction érectile. 2010.
- 48. LIFE 2015 Pharmacological approach n=1,437( n=1,486( n=1,455( 1.6 2.5 3 0 1 2 3 4 5 Fold increase PlaceboPriligy30 mg Priligy60 mg n=1,437( n=1,486( n=1,455( Traitements per os An#dépresseurs hors AMM traitement quo#dien fluoxé#ne, paroxé#ne, citalopram, clomipramine Dapoxé#ne à la demande PriligyR Tramadol hors AMM à la demande seul ou associé (antalgique) Anesthésie locale Anesthésique local lidocaïne-‐prilocaïne crème (EmlaR) hors AMM Pryor et al. Lancet 2006; 368: 929-937. McMahon et al. (2008) Presented at ESSM/ISSM
- 49. Delayed ejaculation male orgasmic dysfunction Mediantime: 5.4 min (0,55- 44) + 2DS = 25 min
- 50. LIFE 2015 Delayed ejaculation • Persitant or recurrent difficulty or delay to reach an orgasm and obtain an ejaculation after suficient sexual stimulation. • > 25 minutes • Primairy (1,5/1000) or secondary (3-4%) • Permanent or situationnal • Seems interesing for the female partner • In fact: penible pour both
- 51. LIFE 2015 Causes • Inadequate stimulation ¡ Psychogenic ¡ Disparityfantasma /reality ¡ Affinity /partner ¡ Physical ¡ Masturbatory idiosyncrasism: ¡ Every day 35% ¡ auto-erotism > partner
- 52. LIFE 2015 Causes • Psychicconflicts: fear of semen, vagina, to hurt the partner or to have a child • Relational conflicts • Hyspoactive sexual desire / dysorgasmia • Organic: ¡ SSRi ¡ Hypogonadism : Testosterone ¡ Diabetes, hypothyroidism
- 53. LIFE 2015 Treatment ofdelayed ejaculation: Off-label • Alpha adrénergics sympathomimétics • Midodrine 5 to 30 mg 30 à 60 minutes before ejaculation. • Imipramine: 25mg x2-3 /jour. • Dopaminergiques agonists • Cabergoline (dostinex) • Apomorphine (Ixense, Uprima) • Periactine (cyproheptamine): 2 à 16 mg/jour ou à la demande (patients sous SSRI) • Amantadine: 100mg 5h avant le RS • Ocytocine (nasal) • Buspirone (buspar) • Bupropion (Zyban) • SSRI: efficacy 66% • Improve orgasm men and women
- 54. Painful orgasms /radical prostatectomy ¡ Pain: 14% ¡ Penis: 63% ¡ Rectum:24% ¡ Abdomen:9% ¡ elsewhere: 4% ¡ always: 33% ¡ Frequent: 13% ¡ sometimes: 35% ¡ Rare 19% ¡ Duration : <1min:55% , 1-5min: 33%, > 5min: 12%, >1H: 2,5% Barnas et al BJU Int 2004, 2005 Pathophysiology • Vas deferens obstruction Treatment: Alphablockers Silodosin
- 55. LIFE 2015 Climacturia, orgasmuria • Following radical prostatectomy • Urinary incontinence during sexual IC: ¡ 20 to 93% ¡ Techniques ou modalité d’évaluation ? ¡ Associated to painful orgasms and penile shortening ¡ A bothered problem for 50% patients • Prevention: preservation of bladder neck and nerve sparing technique . • Information, condoms Barnas et al BJU Int 2004, Lee et al J Urol 2006, Choi et al J Urol 2007
- 56. LIFE 2015 Conclusion • Ejaculatorydysfunctions are frequent in infertile men ¡ Cause of infertility ¡ Consequence of Infertility or ART • Aspermia or hypospermia need further investigations ¡ Clinical and Imaging (TRUS, MRI) • Surgical treatment of reversible cause of infertility • Psychological management of infertile men