Disorders of Ejaculation

Question 1

What 3 things need to be included in the history of a diagnosis of lifelong premature ejaculation?

Answer 1

Guideline 1: 1. Poor ejaculatory control

2. Associated bother
3. Ejaculation within 2 minutes since sexual debut

Question 2

What 3 things need to be included in the history to make the diagnosis of acquired premature ejaculation?

Answer 2

Guideline 2: 1. Poor ejaculatory control

2. Associated bother
3. Ejaculation latency that is markedly reduced from prior sexual experience

Note: This diagnosis does not have a specific time but is generally less than 2-3 minutes or reduced by ~50% from prior estimations

Question 3

What is needed to make a diagnosis of premature ejaculation? (besides short latency period, bother, and poor ejaculatory control)

Answer 3

Guideline 3: Assess the medical, relationship, sexual, and focused physical exam.

Make sure you ask about how long it’s been present? degree of bother? Any ejaculatory control? negative consequences? avoid sexual activity? with every partner? in different circumstances? self estimated time to ejaculation?

Question 4

Should you use any validated questionnaires to help with the diagnosis of premature ejaculation?

Answer 4

Guideline 4: You may use validated questionnaires for research or to use as an “ice breaker” to use to facilitate a discussion about ejacultaory issues.
Some questionnaires are: Premature Ejaculation Diagnostic Tool (PEDT), Premature Ejaculation Profile (PEP), Index of Premature Ejaculation, etc.

Question 5

Is any additional testing needed for LIFELONG premature ejaculation beyond history and physical exam?

Answer 5

Guideline 5: No, High serum T, hyperthyroidism, elevated glucose or Hgb A1c, and presence of inflammatory cells in urine or prostate secretions have been associated with premature ejaculation but its inconsistent data.

Question 6

Is any additional testing needed for ACQUIRED premature ejaculation beyond history and physical exam?

Answer 6

Guideline 6: You may utilize additional testing as needed for acquired PE. This may include questionnaires for ED (as ED may be associated- they speed up their ejaculation before they lose their erection), Hgb A1c, Serum T, testing for prostatic inflammation (urine culture, pyuria, etc)

Question 7

What should a person with premature ejaculation be told about circumcision status?

Answer 7

Guideline 7: Premature ejaculation is NOT affected by circumcision status

Question 8

What is the role of a mental health professional with sexual medicine experience in a patient with PE?

Answer 8

Guideline 8: Clinicians should consider referring all patients with premature ejaculation to a sexual mental health professional. They can help with relationship stress and give good behavioral health for treating PE such as stop-start technique, squeeze technique and sensate focus exercises.

Guideline 13: Combining behavioral with pharmacological treatment is likely more effective than either modality alone for treating PE.

Question 9

What are the first line medication treatment for premature ejaculation?

Answer 9

Guideline 9: Daily SSRI, on demand clomipramine, and/or topical penile anesthetics

Question 10

What is the second line pharmacotherapy treatment for premature ejaculation?

Answer 10

Guideline 10: If men fail first line therapy, you can consider on-demand dosing of tramadol

Guideline 11: You may consider treating men who fail first line therapy with alpha-1 adrenergic receptor antagonists

Question 11

What alternative natural therapies are effective for treated premature ejaculation?

Answer 11

Guideline 14: There is insufficient evidence for any alternative therapy use in ED.

Question 12

How should persons with ED and PE be treated?

Answer 12

Guideline 12: You should treat persons with ED and PE according to the ED guidelines first and foremost

Question 13

What surgery is approved for persons suffering from PE?

Answer 13

Guideline 15: surgical management is considered experimental only and should only be offered in a clinical trial.

Question 14

What is the definition of lifelong delayed ejaculation (4 components)?

Answer 14

Guideline 16: 1. Should be lifelong and consistent

2. Bothersome inability to achieve ejaculation or excessive latency of ejaculation (~ >21 minutes)
3. Adequate sexual stimulation
4. Desire to ejaculate

Question 15

What is the definition of acquired delayed ejaculation?

Answer 15

Guideline 17: 1. Should be acquired (new) and consistent

2. Bothersome inability to achieve ejaculation or excessive latency of ejaculation (~ >21 minutes)
3. Adequate sexual stimulation
4. Desire to ejaculate

Question 16

What is needed to evaluate a patient with delayed ejaculation?

Answer 16

Guideline 18: Access medical, relationship and sexual history along with a focused physical exam.
History: Make sure you ask about how long it’s been present? degree of bother? Any ejaculatory control? negative consequences? avoid sexual activity? with every partner? in different circumstances? self estimated time to ejaculation? Any neuropathy (or diabetes, myelopathy, neurological diseases, etc)?
PE: Access for signs of low T (hair distribution, minimal body hair, etc), metabolic disorders (obesity), clues of prior trauma (midline abd scar), penile morphology, sensation of the scrotum, size of testis (r/o XXY), and +/- DRE

Question 17

What additional testing should be used for delayed ejaculation, if any?

Answer 17

Guideline 19: morning serum T levels, electrolytes, lipids, Hgb A1c, biothesiometry to determine neuropathy of penis

Question 18

What is the role of a mental health professional with sexual medicine experience in a patient with delayed ejaculation?

Answer 18

Guideline 20: Refer patients to one. They may be able to help normalize or treat the underlying reason for delayed ejaculation.

Question 19

What therapies are approved for delayed ejaculation?

Answer 19

Guideline 20: Referral to a sexual mental health specialist.
Guideline 21: Recommend modifying sexual positions or practices to increase arousal may help (vibrators)
Guideline 22: suggest replacement or dose adjustment of medications that are known to cause sexual latency such as ETOH, SSRI, SNRI, TCA, opioids, CNS acting agents. Better meds would be Wellbutrin (bupropion)
Guideline 24: Normalize serum testosterone level if low
Guideline 25: Treat men with ED according to ED guidelines
Guideline 23 & 26: There are no known pharmacological or invasive treatments that are FDA approved for DE.

Question 20

Are there any medications that may be tried in delayed ejaculation patients?

Answer 20

Guideline 23: While there are no FDA approved medications, you can try oxytocin, pseudoephedrine, ephedrine, midodrine, bethanecol, etc

Must council the very limited evidence and potential SE may make it not worth it.

Question 21

Important factors to ask regarding premature ejaculation?

Answer 21

relationship of ejac to drug or ETOH use
relationship of ejac to specific partners
ED
occurrence of rapid ejac with all or some sexual attempts
quality of personal relationships and life
length of time between penetration and ejac (latency time) - 1 min
ability to control
lifelong (altered sensitivity of CNS serotonin receptors)
acquired (stress or medical condition)

Question 22

What are important elements of PE for premature ejac?

Answer 22

penile abnormality including plaque
inguinal hernia
testis
phallus size
body hair distribution
general appearance
scrotum, presence of varicocele

Question 23

Primary goal of tx of premature ejac?

Answer 23

Patient and partner satisfaction

Question 24

Name possible treatments for premature ejac? and advantages/disadvantages?

Answer 24

1. Psychotherapy/behavioral therapy is first
   
   1. can help with acquired PE, stress/relationships
   2. not as effective for lifelong PE
   3. behaviors: pause/squeeze little LT efficacy
2. Topical anesthetics
   
   1. topical lidocaine and/or prilocaine (2.5%) or EMLA applied inside condom, worn for 20-30, then washed off prior to sex
   2. loss of penile sensitivity, potential transfer, limit spontaneity, hypersensitivity
3. Oral antidepressants
   
   1. improvement in IELFT up to 70%, daily dosing vs. PRN (less effective)
   2. Clomipramine, Sertraline, Fluoxetine, Paroxetine (largest improvement)
   3. None FDA approved
   4. Not with MAOI (serotonin syndrome)

Question 25

A/E of oral antidepressants?

Answer 25

ED
insomnia
sleepiness
flushing
yawning
headache
decreased libido
dyspepsia
drowsiness
anxiety
delayed ejaculation
anejaculation
dizziness
nausea
anorexia
diarrhea
fatigue
dry mouth

Question 26

Dosing and type of SSRI for PE?

Answer 26

Fluoxetine (Prozac) 5-20 mg per day

Paroxetine (Paxil) 10, 20, 40 mg per day or 20 mg prior to coitus (3-4h)

Sertraline (Zoloft) 25-200 mg/day or 50 mg prior to coitus (4-8H)

non-SSRI Clomipramine 25-50 mg /day or 25 mg prior to coitus (4-24 h)

Question 27

Patient with ED and concomitant PE should have which testing?

Answer 27

serum lipids/triglycerides
fasting blood glucose
serum creatinine
UA
CBC
duplex US after PDE1 ICI
serum testosterone (if low LH, if low/normal, Prl)

Question 28

What is epidemiology of PE?

Answer 28

emotional problems/stress
DMII, poor control
poor overall health and simultaneous urologic condition
psychogenic and biogenic etiologies
ED
level of education (negative correlation)
30% prevalence in adult males
mc 18-59 yo