5 th sexual dysfunction conference queenstown nz april 2012 ejaculation disorders too fast and too...
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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
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
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Sydney Men’s Health
Sydney Men’s Health
PE
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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
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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
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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
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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
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Sydney Men’s Health
Sydney Men’s Health
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Premature Ejaculation Diagnostic Tool
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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
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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)
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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
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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
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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
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Sydney Men’s Health
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Stop/Start Technique
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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
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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
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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
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