The document discusses several topics related to sexual health and dysfunction. It begins with an introduction to the prevalence of sexual dysfunction among psychiatric patients and the general population. It then discusses the importance of neuropsychiatric disorders and their contribution to disability-adjusted life years worldwide. Several tables show leading causes of disability and the association between medical conditions and major depression. The document then discusses evaluation and treatment of premature ejaculation, including the use of selective serotonin reuptake inhibitors.

1. ‫الرح‬‫الرحمن‬‫هللا‬ ‫بسم‬‫يم‬
«‫إ‬‫علمتنا‬ ‫ما‬ ‫إال‬‫لنا‬ ‫علم‬ ‫ال‬ ‫سبحانك‬‫نك‬
‫الحكيم‬‫العليم‬‫انت‬»

2. “Anxious Patient and
Resolution
in Andrology Clinic''
By
Shedeed Ashour MD
Professor of Andrology, Sexology & STDs
Consultant Andrologist & Head of Andrology
Dr. Erfan & Bagedo general Hospital, Jeddah
KSA
2016

3. introduction
• No more classic knowledge
• Problem Solving
– Identify ??!!
• Restoration of:
– Man’s life
– Relationship

4. Sexual Equilibrium
• Seven sex Parameters:
– Identity
– Orientation
– Intention
– Arousal
– Orgasm
– Pleasure
– Satisfaction
DALYs

5. INTRODUCTION
• Sexual dysfunction is prevalent among psychiatric
patients and may be related to both the
psychopathology and the pharmacotherapy
• Sexual dysfunction is a common phenomenon in
the general population, affecting an estimated 43%
of women and 31% of men in the US 1.
Zvi Zemishlany Abraham Weizman Adv Psychosom Med. Basel, Karger, 2008, vol 29
{1} Laumann EO, Paik A, Rosen RC: Sexual Dysfunction in the United States Prevalence and
Predictors. JAMA, 1999

6. Neuropsychiatric disorders – the importance
Prince et al. Lancet 2007.
Contribution by different non-communicable diseases to
disability-adjusted life-years worldwide, 2005
Schizophrenia (1-2%)
Unipolar affective disorder (10%)
Bipolar affective disorder (2%)
Dementia (2%)
Substance-use and alcohol-
use disorders (4%)
Other mental disorders (3%)
Epilepsy (1%)
Other neurological disorders (2%)
Other neuropsychiatric disorders (3%)
Digestive
disorders (6%) Musculoskeletal
disorders (4%)
Endocrine (4%)
Neuropsychiatric
disorders (28%)
Cancer (11%)
Cardiovascular
disease (22%)
Sense organ
impairment (10%)
Other
non-communicable
diseases (7%)
Respiratory
disease (8%)

7. Ten Leading Causesof DALYs in 2020
(DisabilityAdjustedfor Life Years)In the World
Both sexes
Disease or injury
Males
Disease or injury
Females
Disease or injury
All causes All causes All causes
1-
Ischaemic heart
disease
Ischaemic heart
disease
Unipolar major
depression
2-
Unipolar major
depression
Road traffic
accidents
Ischaemic heart
disease
3-
Road traffic
accidents
Cerebravascular
disease
Cerebravascular
disease
4-
Cerebravascular
disease
Chronic
obstructive
pulmonary
disease
Chronic
obstructive
pulmonary
disease
5-
Chronic obstructive
pulmonary disease
Unipolar major
depression
Road traffic
accidents
Ustun et al (2004) Brit. J. Psychiat.

8. MedicalCondition FrequencyofMajorDepression
 Sexual dysfunctions 30-60%
 Emphysema 20-40%
 HIV infection 20-35%
 Hypothyroidism 10-30%
 Stroke 10-25%
 Diabetes Mellitus 10-20%
 Renal Failure 5-20%
Kaplan HI, 1994
The association between depression
and medical illness
 Coronary Artery Disease 30-60%

9. Co morbid major depression and anxietydisorders
INTRODUCTION TO ANXIETY DISORDERS
Lifetime co morbidity
1. Kessler et al (1995); 2. APA, DSM-IV; 3. Rasmussen & Eisen (1988);
4. Van Ameringen et al (1991); 5. Brawman-Mintzer & Lydlard (1996); 6. Stein & Kean (2000)
PTSD Panic
disorder
SAnD
GAD
OCD
48% of patients with PTSD1 50% to 65% of patients with PD2
34% to 70% of patients
with SAnD4, 6
67% of patients with OCD3
8% to 39% of patients
with GAD5
Major
depression

10. ANXIETY & first coital
attempts
• 1st night ED
• Promiscuity
• Virginity loss

11. ED Etiology: Psychogenic
Brain
Direct inhibition of
spinal centers
Excessive
sympathetic outflow
Anxiety
Depression
OCD
Sexual phobias
Stress
Inhibition of erection
Lue TF. In: Walsh PC, et al (eds). Campbell’s Urology. 1992:709–728
Krane RJ, et al. N Engl J Med 1989;321:1648–1659

12. Honeymoon Impotence:
Performance Anxiety
Adoption of a spectator role
 Attention focused on performance
rather than erotic stimulation
 Cognitive distraction from
sexual arousing cues
 Arousal disorder
 Spinal center inhibition
 ↑ peripheral catecholamines
 Cavernous smooth muscle contraction

13. A model of pathogenesis
Factor: Random failure---
Dysfunction
Persistent
dysfunction
Excessive
sympathetic
outflow
Anxiety
Inhibition of erection
Anxiety: of
performance

14. Contemporary sex therapy
• A) psycho-sexual counseling
• B) Drug therapy
– Oral erectogenic Drugs
• PDE5 Inhibitors
– ICI
• PGE1
• Tri-mix
–Anti-Anxiety & SSRIs

15. Cipralex®is moreeffectivethan
Paroxetinein GAD
Baldwin et al. Poster presented at ECNP, 2004
-20
-16
-12
-8
-4
0
1 2 4 6 8 10 12 LOCF
Treatment week
Adjustedmeanchangefrombaseline,
HAM-Atotalscore
PBO
ESC 5 mg
ESC 10 mg
ESC 20 mg
PAR 20 mg
*p <0.05 vs placebo
**p <0.01 vs placebo
***p <0.001 vs placebo
#p <0.05 vs paroxetine
**
**
****
***
*
***#
***
*
*** #

16. Background SSRIscomparison(i)
• Independently funded meta-analysis that compared the
efficacy and patient acceptability of 12 antidepressants
• 117 RCT (25 928 participants) from 1991 - Nov. 2007
• Included bupropion, citalopram, duloxetine, escitalopram,
fluoxetine, fluvoxamine, milnacipran, mirtazapine,
paroxetine, reboxetine, sertraline and venlafaxine
Cipriani et al., Lancet 2009

17. Cipralex® isthe true SRI
SRI
NRI
Fluoxetine1
SRI
Fluvoxamine1
DRI
SRISertraline1
SRI
Cipralex3
SRI
NRI
Paroxetine1
DRI
SRI
Venlafaxine2
Stahl SM. Using secondary binding properties to select a not so
selective reuptake inhibitor. J Clin. Psychiatry 1998;59:642n3

18. Studiesincluded
0
10
20
30
40
50
60
B
upropionC
italopramD
uloxetine
EscitalopramFluoxetine
Fluvoxam
ineM
ilnacipranM
irtazapineParoxetineR
eboxetineSertralineVenlafaxine
Numberoftrials
1991–
2007*
1993–
2007*
2002–
2007*
2000–
2007*
1991–
2007*
1993–
2006*
1994–
2003*
1997–
2005*
1993–
2007*
1997–
2006*
1993–
2007*
1994–
2007*
2 three-arm studies comparing fluoxetine,
paroxetine and sertraline were included
*Earliest to latest year of publication Cipriani et al., Lancet 2009

19. Primary outcome measures
• Response (proportion of patients who had a
reduction of at least 50% from baseline on
Scales.
• Acceptability (number of patients who
terminated the study early for any reason
during the first 8 weeks).
Cipriani et al., Lancet 2009

20. Cipralex® demonstrates remarkable efficacy in overall analysis
of efficacy results
Odds ratio >1 favours fluoxetine
*p<0.05
0.0
0.2
0.4
0.6
0.8
1.0
1.2
1.4
1.6
B
upropionC
italopramD
uloxetine
EscitalopramFluvoxam
ineM
ilnacipranM
irtazapineParoxetineR
eboxetine
SertralineVenlafaxine
Efficacy(responserate)
oddsratio:drugvsfluoxetine
* *
*
* *
Cipriani et al., Lancet 2009

21. Cipralex® showedthe best profile of acceptability, leading to
significantly fewer discontinuation
Odds ratio <1 favours fluoxetine
*p<0.05
0.0
0.2
0.4
0.6
0.8
1.0
1.2
1.4
Bupropion
Citalopram
DuloxetineEscitalopramFluvoxam
ineM
ilnacipranM
irtazapine
Paroxetine
Reboxetine
Sertraline
Venlafaxine
Acceptability(dropoutrate)odds
ratio:drugvsfluoxetine
Cipriani et al., Lancet 2009

22. Escitalopram – the best combination of
efficacy and acceptability
Adapted from Cipriani et al. Lancet 2009; 373 (9665): 746–758
(Source: Patrick et al. J Fam Pract 2009; 58 (7): 365–369)
OR=odds ratio, using fluoxetine as the reference medication
0.80
0.85
0.90
0.95
1.00
1.05
1.10
1.15
1.20
1.25
0.8 0.9 1.0 1.1 1.2 1.3 1.4
Acceptability(OR)
Efficacy (OR)
Fluvoxam
ine
Citalopra
m
Bupropio
n
Venlafaxi
ne
Mirtazapi
ne
Sertraline
Escitalopra
m
Paroxetine
Fluoxetine
Duloxetin
e
●

23. Prevalence of ED prior to the
initiation of Antidepressant therapy
By
AM Saad *and SA Shedeed**
*From the Department of Psychaitry, Faculty of Medicine Ain Sham s
University.
From the Department of Andrology, Sexology & STDs, Faculty of Me
dicine, Cairo University,
Current Psych. 2001,8.3: 1-10.

24. patients & methods: Participants
• 184 consecutive out-patients treated for
Major depression (MD), at the psychiatric
dept. of two private hospitals in jeddah,
Saudi Arabia
• Those who met the criteria of DSM-IV for
non psychotic MD & scored 16 or greater
on the Hamilton rating scale for
depression were referred to the
Andrologist.
HRSD, hamilton, 1960

25. Results
Table.2 Item endorsment frequency of sexual dysfunction in depressed male
patients:
Patients % (n)
DriveDesire items (n=77)
Decrease in sexual desire 42.8%(33)
Decrease in interest in explicit material 33.7%(26)
Reduced fantasizing 40.2%(31)
Reduced frequency of masturbation 44.1%(34)
ArusalOrgasm items (n=107)
Less vigiorous erections 33.6%(36)
Inability to sustain an erection 45.7%(46)
Fewer spontaneous erections 22.4%(24)
Premature ejaculation problem 12.1%(13)
Delayed ejaculation problem 22.4%(24)

26. Treatment of AD induced sexual
dysfunction
General strategies
• Decreasing Dose.
• Waiting.
• Switching.
• Transient
discontinuation.
Specific treatment
• Drugs blocking 5HT2
receptors (buspirone,
cyproheptadine,
Mianserin, nefazodone.)
• Drugs augmenting
catecholamine activity
(Amantadine, Yohimbine)
• Sildenafil.

27. Prevalence of PE in Representative
Epidemiological Studies
151239Internet populationHo (2003)
181320US men (40+ yrs)Carson et al (2003
42810Swedish (18–74 yrs)Fugl-Meyer (1999)
293159US men (18–59 yrs)Laumann (1999)
14439DanishSolstad (1993)
36423English studentsEysenck (1983)
42100US couplesFrank (1976)
PE (%)nType (age)Study
Adapted from Simons JS, Carey MP. Arch Sex Behav 2001;30(2):177–219.

28. Premature ejaculation (PME).
• Drugs used extensively in the treatment of
PME:
– SSRIs
– TCAs
– PDE5I
– Local anesthetics (sprays creams & Gels).
– Other Medicines
Bernard Fallon. Off label drug use in sexual medicine. Int J Impot Resc. 20(2):127-134,2008

29. Dapoxetine (PriligyTM)
• 10th of Feb. 2009 received the first
regulatory approval in Finland and Sweden.
• Now its approved in 7 European countries
(EMEA).
• FDA approval is still bending for more
studies as asked in 2006.

30. Premature ejaculation (PME).
– Antidepressants SSRIs:
• Different types
• Efficacy
– Onset of action.
– For how long
– Acquired Vs life-long PME.
– Relapses1 and tachyphylaxis.2
– On-demand Vs Daily dosing.
Tolerability:
• Side effects.{common, uncommon and discontinuation syndrome}.
1-Arafa M, Shamloul R. Efficacy of sertraline hydrochloride in treatment of premature ejaculation: a placebo-controlled study using a validated
questionnaire. Int J Impot Res. 2006.
2-Waldinger et al. Relevance of methodological design for the interpretation of efficacy of drug treatment of premature ejaculation: a systematic
review and meta-analysis. Int J Impot Res 2004.

31. Premature ejaculation (PME).
– Antidepressants SSRIs:
Usual daily dose
(mg)
Drug
20—40Paroxetine
50—100Sertraline
5—40Fluoxetine
5—20Citalopram
20—50Clomipramine
20—50Duloxetine
Bernard Fallon. Off label drug use in sexual medicine. Int J Impot Resc. 20(2):127-134,2008

32. Pt. Co of PME
Establish co
IELT
Ejaculatory control
Onsetduration
psychosocial history
Medical history
Physical examination
1st line
Behavioral therapy
Start-Stop
Squeeze
Sensate focus
Relationship counseling
2nd line
Pharmacotherapy
SSRI
Topical
Combinations
1st line
Pharmacotherapy
SSRI
Topical
Combinations
2nd line
Behavioral therapy
Start-Stop
Squeeze
Sensate focus
Relationship counseling
2ry to ED or other SD
Yes
NO
Acquired PME Life long PME
I Sharlip,I J Sex Med suppl 4),2006:309-317

33. -10
-5
0
-15
-20
-25
-30
0 4 8 12 16 20 24
**
*
*
*
Escitalopram (n=228)
Paroxetine (n=223)
MeanchangefrombaselineinMADRS
Treatment week
*p<0.05 escitalopram versus paroxetine
(ANCOVA, two-sided test)
Boulenger et al., Curr Med Res Opin 2006; 22: 1331–1341
ITT, LOCF
Cipralex more effective than Paroxetine

34. Cipralex is more effective than Venlafaxine XR
*p <0.05
*
Bielski et al. ECNP, 2003
LOCF
-20
-15
-10
-5
0
1 2 4 6 8
Treatment Week
Mean
Change
from
Baseline
Cipralex 20 mg
Venlafaxine XR 225 mg

35. Cipralex10 mg is effectiveas Sertraline
144 mg
-20
-15
-10
-5
0
1 2 3 4 6 8
Treatment week
Meanchangefrombaseline
MADRStotalscore
Cipralex 10 mg/day (n.=104)
Sertraline 144 mg /day (n.=107)
LOCF
Alexopoulos, 2004

36. ORIGINAL RESEARCH—PSYCHOLOGY
A New Combination Treatment for Premature
Ejaculation: A Sex Therapist’s Perspective
Michael A. Perelman,
This article describes the diagnosis and treatment of
premature ejaculation (PE) from a sex therapist’s
perspective and proposes that combination therapy
integrating sex therapy and sexual
pharmaceuticals is frequently the best
treatment approach.
Perelman MA. A new combination treatment for premature ejaculation: A sex therapist’s perspective. J Sex Med
2006;3:1004–1012.

37. The Majority of Men with Lifelong Premature Ejaculation
prefer Daily Drug Treatment: An Observational study in a
consecutive Group of Dutch Men
• Rational:
– Both types of treatment ; the on-demand and regular
daily SSRI treatments had been studied separately,
but never together for the seek of preference.
• Aim
– To find the preference of pts with life-long PE
regarding the used of Antidepressants as an on-
demand or daily dosing and the topical treatment
modality. Preference Questionnaires are used for
evaluation.
Marcel D. et al., J Sex Med. 2007;4:1028-1037.

38. PREMATURE EJACULATION: NEW
COMBINATION THERAPEUTIC
APPROACH FOR COUPLE
SATISFACTION
By:
Shedeed Ashour Shedeed,M.D.
Professor of Andrology, Sexology & STDs.
Cairo University- Cairo, Egypt
Consultant Andrologist, Dr Erfan & Bagedo General
Hospital Jeddah, KSA
Published in the EJA, 2009, Accepted for Int. Publication in the
IJSM
PASSAM-2009

39. Aim of the work
• To evaluate the efficacy of the combination
therapeutic technique in treating PE.
• Also, to assess the effects of this approach on
the patient and Partner's satisfaction and
relationship.

40. Technique:
Foreplay is a mandatory part of TTT.
SSRI Distraction
Technique
Bringing the
Female
partner nearer
Start-Stop
Tech.
RE-CYCLE

41. Cipralex® is the true SRI
SRI
NRI
Fluoxetine1
SRI
Fluvoxamine1
DRI
SRISertraline1
SRI
Cipralex3
SRI
NRI
Paroxetine1
DRI
SRI
Venlafaxine2
Stahl SM. Using secondary binding properties to select a not so
selective reuptake inhibitor. J Clin. Psychiatry 1998;59:642n3

42. 1. Von Moltke et al. Drug Metab Dispos 2001;29:1102-9
2. Greenblatt et al. J Clin Psychiatry 1998;59:19-27
3. Albers et al. Psychiatry Res 2000;96:235-243
Lowpotentialfor drug-drug interactions
3A4 2D6 1A2 2C19 2C9
Escitalopram1
0 + 0 0 0
Citalopram2
0 + + 0 0
Fluoxetine2
++ +++ + ++ ++
Paroxetine2
+ +++ + + +
Venlafaxine3
+ + 0 0 0
Fluvoxamine2
++ + +++ +++ ++
Sertraline2
+ + + ++ +
0 = Negligible
+ = Very weak interaction
Cytochrome P450 Isozyme Inhibition In Vitro/In Vivo
++ = Moderate interaction
+++ = Strong interaction
•Ca+ antagonists
•Erythromycin
•Ketoconazole
•Lidocaine
•Cancer therapies
•Anti-Arrhythmic
•B-blockers
•Haloperidol
•Neuroleptics
•Caffeine
•Ciprofloxacin
•Theophylline
•Verapamil
•Diazepam
•Propranolol
•Moclobemide
•Imipramine
•Miconazole
•Phenytoin
•S-warfarin
•NSAIDs

43. Strategies for Refractory PME
Maximize dose
Sex Therapy + Maxi-dose
Two Drugs (Augmentation / Switch)
Augmentation
Combination SSRI and ????TCA
Alternatives Topical and remedies
Others, Future prospective ?

44. PME: Case #1
• A couple in their late 20s and married for three years was
concerned about the
• man’s ejaculation. For religious reasons, they had not attempted
intercourse before marriage. Since they were married, he regularly
ejaculated before attempts at vaginal entry. As a result, their union
had not been “consummated.” Her sexual desire diminished
considerably over the three years of their marriage.
• Apart from embarrassment and diminished sexual pleasure that
they both experienced, they wanted to have children and for her to
become pregnant in the “natural way.” Ejaculating quickly was
not a new problem for him. Since the first time he attempted
intercourse at the age of 14, he was unable to accomplish vaginal
entry except on one occasion, and, then, he ejaculated in a matter
of seconds. Since the “squeeze technique” described by Masters &
Johnson1 was tried and found not helpful, the couple felt
desperate and anticipated separation and divorce if another way to
help them could not be found.

45. International Society for Sexual Medicine’s Guidelines for the
Diagnosis and Treatment of Premature Ejaculation
jsm, 2011
Over the past 20 years our knowledge of premature
ejaculation (PE) has significantly advanced [1]. Specifically,
we have witnessed substantial progress in understanding:
• The physiology of ejaculation,
• Clarifying the real prevalence of PE in population-based
studies,
• Reconceptualizing the definition and diagnostic criterion of
the disorder,
• Assessing the psychosocial impact on patients and partners,
• Designing validated diagnostic and outcome measures,
proposing new pharmacologic strategies, and examining
the efficacy, safety, and satisfaction of these new and
established therapies.

46. Definitions
• A male sexual dysfunction characterized by
ejaculation that always or nearly always occurs prior
to or within one minute of vaginal penetration, and
the inability to delay ejaculation on all or nearly all
vaginal penetrations, and negative personal
consequences, such as distress, bother, frustration,
and/or the avoidance of sexual intimacy.
International Society of Sexual Medicine,2008
• Persistent or recurrent ejaculation with minimal
sexual stimulation, before, on, or shortly after
penetration and before the person wishes it. The
condition must also cause marked distress or
interpersonal difficulty and cannot be due exclusively
to the direct effects of a substance.
DSM-IV-TR, 2000

47. Types of PME
• Life long
• Acquired
• Ante-portal
• Vaginal
• Other non vaginal sex behaviors ?? LOE 5d
• Natural Variable PE
• Premature Like Disease

48. Ejaculatory continuum
• Premature
ejaculation
• lifelong
latency
• Acquired PE
• Acquired
DE
latency • Delayed
Ejaculation
• lifelong
latency
Waldinger MD., world Journal of Urology 2005 .

49. PME: case #2
• A couple in their mid-50s and married for 25
years was seen because of erectile and ejaculation
problems. Sexual difficulties began about five
years before and were gradually becoming worse.
The husband was aware of the association
between sexual dysfunctions and diabetes (a
disease with which he lived in the previous 20
years) but until recently had not volunteered
information to his physician about his sexual
difficulties. He believed that the onset of his
(generalized) erectile problems preceded his
ejaculation difficulty by about one year. He
described ejaculating rapidly after a frantic
process of gaining vaginal entry and before any
softening of his erection made continued
containment impossible.

50. PME: Case #3• A couple in their late 30s, married for 15 years, was
referred because the man regularly ejaculated immediately
after vaginal entry, a pattern that existed throughout all of
his life. In the process of initially talking with both
(together and separately) it became clear that she was angry
and “at the end of (her) rope.” She was seriously
considering separation for sexual and nonsexual reasons.
Sexually, her level of interest was similar to her husband’s
(i.e., substantial) but her sexual arousal was interrupted
continually by his ejaculation. She was orgasmic with
direct clitoral stimulation before intercourse but this was
irregular and unpredictable. Her animosity toward her
husband about nonsexual concerns related to his inclination
to continually avoid talking about contentious issues
(including their sexual troubles). It was evident that simply
delaying his ejaculation by using pharmacotherapy would
not circumvent the discord between the two. Thus
deliberate decision was made to treat this couple using
traditional counseling methods.

51. Dapoxetine
• Dapoxetine has received approval for the treatment of PE in Austria,
Germany, Italy, Finland, Mexico, New Zealand, Portugal, South Korea,
Spain, and Sweden.
• It is a rapid acting and short half-life SSRI with a pharmacokinetic profile
suggesting a role as an on-demand treatment for PE .
• No drug–drug interactions associated with dapoxetine, including
phosphodiesterase inhibitor drugs have been reported.
• In RCTs, dapoxetine 30 mg or 60 mg taken 1–2 hours before intercourse is
more effective than placebo from the first dose, resulting in a 2.5- and 3.0-
fold increases in IELT, increased ejaculatory control, decreased distress,
and increased satisfaction. Dapoxetine was comparably effective both in
men with lifelong and acquired PE .
• Treatment-related side effects were uncommon, dose dependent and
included nausea, diarrhea, headache, and dizziness. They were responsible
for study discontinuation in 4% (30 mg) and 10% (60 mg) of subjects.
There was no indication of an increased risk of suicidal ideation or suicide
attempts and little indication of withdrawal symptoms with abrupt
dapoxetine cessation.
 McMahon CG, Kim SW, Park NC, Chang C, Rivas D, Tesfaye F, Rothman M, Aquilina J. J Sex Med, 2010.
 Dresser MJ, Desai D, Gidwani S, Seftel AD, Modi NB. Int J Impot Res 2006.

52. EBM
• There is Level 1a evidence to support the
efficacy and safety of on-demand dosing
of Dapoxetine for the treatment of
lifelong and acquired PE. (LOE 1a)

54. Off-Label SSRIs and TCAs
.
• Daily treatment with off-label
– paroxetine 10–40 mg,
– clomipramine 12.5–50 mg,
– sertraline 50–200 mg,
– fluoxetine 20–40 mg, and
– citalopram 20–40 mg is usually effective in delaying ejaculation.
• A meta-analysis of published data suggests that paroxetine exerts
the strongest ejaculation delay, increasing IELT approximately
8.8- fold over baseline.
Waldinger MD, Zwinderman AH, Schweitzer DH, Olivier B. Int J Impot Res 2004.

55. EBM
• There is Level 1a evidence to support
the efficacy and safety of off-label daily
dosing of the SSRIs paroxetine,
sertraline, citalopram, fluoxetine, and
the serotonergic tricyclic, clomipramine,
and off-label on-demand dosing of
clomipramine, paroxetine, and sertraline
for the treatment of lifelong and
acquired PE. (LOE 1a)

56. Psychological/Behavioral,
Combined Medical and
Psychological, and Educational
Interventions
• There is level 2b evidence regarding
the efficacy of
psychological/behavioral interventions
in the treatment of PE.

57. Importance of Partners
• Inclusion of the partner in the treatment process is an important
but not a mandatory ingredient for treatment success.
• Some patients may not understand why the clinician wishes to
include the partner and some partners may be reluctant to join
the patient in treatment.
• However, if partners are not involved in treatment, they may be
resistant to changing the sexual interaction. A cooperative
partner can enhance the man’s self-confidence, skills, self-
esteem, sense of masculinity, and more generally assist the man
to develop ejaculatory control.
• Likely to lead to an improvement in the couple’s sexual
relationship, as well as the broader aspects of their relationship.
• There are no controlled studies on the impact of involving
partners in treating PE. However, a review of treatment studies
for ED demonstrated the important role of including a focus on
interpersonal factors on treatment success.

58. Take Home Message
• Psychiatric disorders and sexual Dysfunctions
are common and intermingled.
• The anti-psychiatric therapies have Sexual
Proved adverse events.
• We as clinicians “The Wisdom” are using the
Anti depressants but we sometimes can use
their side effects for treatment.
• SSRIs are one of the most important
modalities to treat PME.
• Sertraline and citalopram are among the most
save and beneficial medicines in this regard.

59. DISCUSSION
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