This document discusses premature ejaculation (PE) and erectile dysfunction (ED). For PE, it defines it as early ejaculation causing distress. Most agree less than 1 minute is PE. It discusses epidemiology, potential causes including physiology and psychology, and treatments like behavioral therapy and medications. For ED, it defines it as inability to attain/maintain erection for sex. It discusses evaluation, causes like vascular issues and medications, and treatments including lifestyle changes, oral medications like PDE-5 inhibitors, injections, and devices.

1. PSYCHOSEXUAL
DISORDER II
BY
DR.(MAJ.)RAKESH SAXENA

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

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

19. Pharmacologic Interventions
■ Topical anesthetics
■ Tricyclic antidepressants (TCAs)
■ Selective Serotonin Reuptake Inhibitors (SSRIs)
■ Phosphodiesterase-5 (PDE-5) inhibitors

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

32. Anatomy of an Erection

33. Causes of Erectile Dysfunction
■ Physical Causes
■ Vascular (leading cause)
■ Cavernosal
■ Neurologic
■ Hormonal Causes
■ Psychological Factors

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

40. Treatments
■ Lifestyle modifications
■ Weight loss
■ Increase Exercise
■ Smoking Cessation

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

42. Older Treatments
■ Intracavernosal Injection
■ Vacuum Constriction Devices
■ Intraurethral Alprostadil Suppositories
■ Inflatable Prosthesis
■ Vascular Surgery

44. Oral Drug Therapies
■ Phosphodiesterase Type 5 (PDE-5) Inhibitors
■ Sildenafil (Viagra)
■ Tadalafil (Cialis)
■ Vardenafil (Levitra)
■ Yohimbe

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

46. Comparisons of Available Medications*
*Moore, et. al. BMC Urol (2005); 5:18

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

49. Side Effects
■ Headache
■ Indigestion
■ Flushing
■ Nasal congestion
■ Blue hue to vision

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

55. The Mental Health
Perspective
1. Premature Ejaculation
2. Erectile Dysfunction
3. College Health

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

58. PREMATURE EJACULATION
■ Conventional Treatments
a. “Stop-and-start” technique Semans (1955)
b. “Squeeze Method” Masters and Johnson
(1970)

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)