5 th Sexual Dysfunction Conference Queenstown NZ April 2012 Ejaculation Disorders Too Fast and Too...

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

[email protected] Men’s Health

EjaculationCOMPONENTS• Emission

• Ejaculation

• Orgasm

TYPES• Rapid/premature

• Delayed/inhibited

• Retrograde

Sydney Men’s Health


Limbic System

4Sydney Men’s Health

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



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



PE

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


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


Normal

ejaculation

time

Faster

ejaculation


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

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


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


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


Premature Ejaculation Diagnostic Tool


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


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)


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


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



J Sex Med 2012;9:576–584

38

Women with men who have PEWomen’s Sexual Function & Dysfunction


Stop/Start Technique


Dapoxetine - Priligy

• T max 1.2 hours• T ½ 18 hours• IELT 30mg 3.48x• IELT 60mg 3.68x• Side effects: nausea,

headache


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

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


Retrograde Ejaculation

• Common after benign prostate or bladder neck surgery

• Some disease conditions – diabetes, neurological

• Agonist medications may helpe.g. Sudafed, Periactin, Symmetrel


57 Sydney Men’s Health

5 th Sexual Dysfunction Conference Queenstown NZ April 2012 Ejaculation Disorders Too Fast and Too...

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