Post on 24-Dec-2015
5th Sexual Dysfunction ConferenceQueenstown NZ April 2012
Ejaculation Disorders Too Fast and Too Slow
Dr Michael LowySexual Health Physician
Sydney Men’s HealthBondi Junction, Sydney
mlowy@sydneymenshealth.com.auSydney Men’s Health
EjaculationCOMPONENTS• Emission
• Ejaculation
• Orgasm
TYPES• Rapid/premature
• Delayed/inhibited
• Retrograde
Sydney Men’s Health
Sydney Men’s Health
Limbic System
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Stages of normal ejaculatory physiology
• Emission (sympathetic T10-L2)– Bladder neck closure– Deposition of seminal fluid into posterior urethra
• Ejection (parasympathetic S2-S4)– Expulsion of seminal fluid from the urethra– Relaxation of the external sphincter– Co-ordinated pelvic floor, bulbospongiosis
contraction
• Orgasm – A sensory experience via pudendal nerve
associated with all these events
Sydney Men’s Health
Sydney Men’s Health
Hyposensitivity of MPO of hypothalamus – 5-HT2CHypersensitivity of MPO area of hypothalamus – 5-HT1A
Arousal Pudendal nerves
Spinothalamic tract
Thalamus/limbic system
Hypothalamus: MPOA, D1 & D2
Reticulospinal tracts
Sympathetic T10-L1
Parasympathetic S2,3,4
Ejaculation
Sydney Men’s Health
Sydney Men’s Health
Sydney Men’s Health
PE
Sydney Men’s Health
Sydney Men’s Health
Definition PE• Lack of control of ejaculation• Dissatisfaction of sexual
experience• Distress to man and his partner• Latency times (IELT)
• Often associated with a secondary performance anxiety
• Erectile dysfunction is often secondary to long term PE
Sydney Men’s Health
ISSM definition of PE
• Ejaculation which always or nearly always occurs prior to or within about 1 minute of vaginal penetration
• Inability to delay ejaculation on all or nearly all vaginal penetrations
• Negative personal consequences, such as distress, bother, frustration &/or the avoidance of sexual intimacy
Sydney Men’s Health
Sydney Men’s Health
Normal
ejaculation
time
Faster
ejaculation
Sydney Men’s Health
Sydney Men’s Health
Ejaculatory Dysfunction
• 30% of men say they have a problem controlling ejaculation
• 90% of ejaculation problems are PE• 5-10% of men complain of severe
PE• Prevalence PE 8-31%, delayed 2-
4%Sydney Men’s Health
Sydney Men’s Health
Intra-vaginal ejaculation latency time (IELT)
• PE level of distress depends if mild or severe• IELT median time 5.4 minutes (range 1-45
min)• IELT < 1 minute – definite PE• IELT 1-1.5 minutes – probable PE• Lifelong PE – 1.5 minutes 90% of intercourse• Acquired PE – developed IELT < 1.5 minutes
Sydney Men’s Health
Sydney Men’s Health
Sydney Men’s Health
Taxonomy of PEJSM 2011;8(suppl 4):328-334
• Onset– 1° lifelong (from the first sexual experience)– 2° acquired (after a period of normal ejaculation)
• Time– Before vaginal penetration– During vaginal penetration
• Type– In all situations– In specific situations
• Co-morbidities– No other sexual symptoms– Presence of other symptoms e.g ED
Sydney Men’s Health
PE SYNDROMEMarcel Waldinger
• Primary or lifelong (younger men)– medication
• Secondary or acquired (older men)– medication, counselling
• Natural Variable PE– counselling
• PE like ejaculation syndrome– counselling
Sydney Men’s Health
Sydney Men’s Health
Sydney Men’s Health
Sydney Men’s Health
Premature Ejaculation Diagnostic Tool
Sydney Men’s Health
Sydney Men’s Health
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Sydney Men’s Health
Treatment of PrematureEjaculation
• Incorporate into sexual practice: "go with the flow" - work on intimacy
• Sexual script change: extend foreplay, modify rigid sex patterns, “partner first”
• Improve IELT, address relationship issues, restore confidence
Sydney Men’s Health
Treatment PE cont’d
• Behavioural techniques - stop/start (Seman), squeeze (Masters & Johnson)
• Oral medication - SSRI, clomipramine, PDE5i
• Intra-cavernosal injections• Anaesthetic spray (Stud Spray)• Pelvic floor exercises• Surgery to dorsal nerve (Brazil)
Sydney Men’s Health
PE issues• Interview partner
– Obtain more accurate IELT– Check issues of FSD
• Alcohol use delays ejaculation• Acquired 2°PE factors – hyperthyroidism, prostatitis,
ED• Assessment: history, stopwatch IELT, examination
(optional, not mandatory, reassuring)• PE returns when medication is stopped
Sydney Men’s Health
Sydney Men’s Health
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Counselling for PERowland D. JSM 2011;8(suppl 4):342-352
• Address physiological, psycho-behavioural, cultural & relationship factors
• As PE is a couples problem, counselling best with partner present
• Initial medical history: sexual, psychological, relationship
• Psychotherapy domains: behavioural, cognitive, affective, relational
• Pharmacotherapy can augment psychotherapy
Sydney Men’s Health
Sydney Men’s Health
J Sex Med 2012;9:576–584
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Women with men who have PEWomen’s Sexual Function & Dysfunction
Sydney Men’s Health
Sydney Men’s Health
Sydney Men’s Health
Stop/Start Technique
Sydney Men’s Health
Sydney Men’s Health
Sydney Men’s Health
Sydney Men’s Health
Dapoxetine - Priligy
• T max 1.2 hours• T ½ 18 hours• IELT 30mg 3.48x• IELT 60mg 3.68x• Side effects: nausea,
headache
Sydney Men’s Health
Sydney Men’s Health
Sydney Men’s Health
Sydney Men’s Health
Sydney Men’s Health
Evidence-based research into both the methodology, content, duration and intensity as well as the short and long term results of psychological treatment of PE is encouraged
Level 3 evidence to suggest that all men seeking treatment for PE should receive basic psychosexual education
Graded levels of patient and couple counselling, guidance and/or relationship therapy, either alone or ideally in combination with PE pharmacotherapy should be offered as a treatment option for most men with PE
Sydney Men’s Health
Delayed Ejaculation• Often a normal part of ageing• Younger men - angry, withholding• Relationship issues – conception• Consider idiosyncratic masturbatory
style (traumatic masturbatory syndrome) – conditioned inhibition
TREAT (enhance arousal)• Pre & post masturbation/vibration• Scrotal/perineal tickling• Incorporate into normal practice
Sydney Men’s Health
Sydney Men’s Health
Sydney Men’s Health
Sydney Men’s Health
Retrograde Ejaculation
• Common after benign prostate or bladder neck surgery
• Some disease conditions – diabetes, neurological
• Agonist medications may helpe.g. Sudafed, Periactin, Symmetrel
Sydney Men’s Health
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