Disorders of Ejaculation: An AUA/SMSNA Guideline (2020) Flashcards

Question 1

Q

What percentage of men have self-reported Premature Ejaculation (PE)?
A) Less than 5%
B) 30%
C) 50%
D) 70%

Answer

A

B) 30%
Explanation: While up to 30% of men have self-reported PE, few of these men have an ejaculation latency time of less than two minutes, making the actual prevalence of clinical PE and DE less than 5%.

Question 2

Q

What is the primary role of the clinician in managing disorders of ejaculation?
A) To conduct appropriate investigation
B) To provide education
C) To offer available treatments based on sound scientific data
D) All of the above

Answer

A

D) All of the above
Explanation: The role of the clinician in managing PE and DE is to conduct appropriate investigation, to provide education, and to offer available treatments that are rational and based on sound scientific data.

Question 3

Q

What are Premature Ejaculation (PE) and Delayed Ejaculation (DE)?

Answer

A

Ejaculation and orgasm are distinct but simultaneous events that occur with peak sexual arousal. It is typical for men to have some control over the timing of ejaculation during a sexual encounter. Men who ejaculate before or shortly after penetration, without a sense of control, and who experience distress related to this condition may be diagnosed with Premature Ejaculation (PE). On the other hand, there also exists a population of men who experience difficulty achieving sexual climax, sometimes to the point that they are unable to climax during sexual activity; these men may be diagnosed with Delayed Ejaculation (DE).

Question 4

Q

What is the prevalence of clinical PE and DE?

Answer

A

While up to 30% of men have self-reported PE, few of these men have an ejaculation latency time of less than two minutes, making the actual prevalence of clinical PE and DE less than 5%.

Question 5

Q

What are the primary treatment options for PE and DE?

Answer

A

A number of psychological health, behavioral, and pharmacotherapy options exist for both PE and DE. However, none of these pharmacotherapy options have achieved approval from the United States Food and Drug Administration and their use in the treatment of PE is considered off-label. The role of the clinician in managing PE and DE is to conduct appropriate investigation, to provide education, and to offer available treatments that are rational and based on sound scientific data. It is also recommended to involve sexual partner(s) in decision making, when possible, to allow for optimization of outcomes.

Question 6

Q

What is the role of the clinician in managing disorders of ejaculation?

Answer

A

The role of the clinician in managing PE and DE is to conduct appropriate investigation, to provide education, and to offer available treatments that are rational and based on sound scientific data. The Panel recommends shared decision-making as fundamental in the management of disorders of ejaculation; involvement of sexual partner(s) in decision making, when possible, may allow for optimization of outcomes.

Question 7

Q

What is the definition of lifelong premature ejaculation?
a. Consistently poor ejaculatory control, associated bother, and ejaculation latency that is markedly reduced from prior sexual experience during penetrative sex.
b. Poor ejaculatory control, associated bother, and ejaculation within about 2 minutes of initiation of penetrative sex that has been present since sexual debut.
c. Lifelong, consistent, bothersome inability to achieve ejaculation or excessive latency of ejaculation despite adequate sexual stimulation and the desire to ejaculate.
d. None of the above.

Answer

A

b. Poor ejaculatory control, associated bother, and ejaculation within about 2 minutes of initiation of penetrative sex that has been present since sexual debut.

Explanation: Lifelong premature ejaculation is defined as poor ejaculatory control, associated bother, and ejaculation within about 2 minutes of initiation of penetrative sex that has been present since sexual debut. This is according to expert opinion.

Question 8

Q

What is the first-line pharmacotherapy recommended in the treatment of premature ejaculation?
a. Daily SSRIs; on demand clomipramine or dapoxetine (where available); and topical penile anaesthetics
b. α1-adrenoreceptor antagonists
c. Tramadol
d. Oral pharmacotherapy

Answer

A

a. Daily SSRIs; on demand clomipramine or dapoxetine (where available); and topical penile anaesthetics. Clinicians should recommend daily SSRIs; on demand clomipramine or dapoxetine (where available); and topical penile anaesthetics as first-line pharmacotherapies in the treatment of premature ejaculation. This is a strong recommendation according to evidence level: Grade B.

Question 9

Q

Define premature ejaculation and discuss the clinical evaluation of a patient with this condition.

Answer

A

Premature ejaculation is a condition characterized by poor ejaculatory control, associated bother, and ejaculation latency that is markedly reduced from prior sexual experience during penetrative sex. It is classified as either lifelong or acquired premature ejaculation. Lifelong premature ejaculation is present since sexual debut and acquired premature ejaculation is developed later in life.
When evaluating a patient with premature ejaculation, clinicians should assess their medical, relationship, and sexual history, as well as perform a focused physical exam. Validated instruments may be used to assist in the diagnosis of premature ejaculation. Additional testing is not recommended for the evaluation of a patient with lifelong premature ejaculation, but may be utilized for patients with acquired premature ejaculation if clinically indicated.

Clinicians may also consider referring patients to a mental health professional with expertise in sexual health, as combining behavioral and pharmacological approaches may be more effective than either modality alone. The first-line pharmacotherapy recommended in the treatment of premature ejaculation includes daily SSRIs, on demand clomipramine or dapoxetine (where available), and topical penile anaesthetics. If patients have failed first-line therapy, clinicians may consider on-demand dosing of tramadol or treating with α1-adrenoreceptor antagonists.

Question 10

Q

What is delayed ejaculation and what are the treatment options for this condition?

Answer

A

Delayed ejaculation is a condition characterized by the inability to achieve ejaculation or excessive latency of ejaculation despite adequate sexual stimulation and the desire to ejaculate. It is classified as either lifelong or acquired delayed ejaculation. Lifelong delayed ejaculation is present since sexual debut, while acquired delayed ejaculation is developed later in life.
Clinicians should assess the medical, relationship, and sexual history of patients with delayed ejaculation, as well as perform a focused physical exam. Additional testing may be utilized if clinically indicated. Patients diagnosed with lifelong or acquired delayed ejaculation may be referred to a mental health professional with expertise in sexual health.

Question 11

Q

What is the definition of premature ejaculation (PE)?
A. Ejaculation occurring less than 1 minute after penetration
B. Ejaculation occurring less than 3 minutes after penetration
C. Ejaculation occurring less than 5 minutes after penetration
D. Ejaculation occurring less than 10 minutes after penetration

Answer

A

A. Ejaculation occurring less than 1 minute after penetration

Explanation: PE is defined as ejaculation that occurs shortly after penetration and before the individual wishes it to occur, resulting in distress or dissatisfaction.

Question 12

Q

What is the definition of delayed ejaculation (DE)?
A. Ejaculation occurring more than 1 hour after penetration
B. Ejaculation occurring more than 30 minutes after penetration
C. Ejaculation occurring more than 15 minutes after penetration
D. Ejaculation occurring more than 10 minutes after penetration

Answer

A

B. Ejaculation occurring more than 30 minutes after penetration

Explanation: DE is defined as a delay or inability to achieve ejaculation during sexual activity, despite adequate sexual stimulation.

Question 13

Q

What are the potential causes of premature ejaculation (PE)?

Answer

A

There are several potential causes of PE, including psychological factors such as anxiety, stress, or depression, as well as biological factors such as abnormal hormone levels, genetic predisposition, or inflammation of the prostate gland. Additionally, certain medications, drug and alcohol use, and other medical conditions such as diabetes or multiple sclerosis can also contribute to PE.

Question 14

Q

What are the potential treatment options for delayed ejaculation (DE)?

Answer

A

Treatment for DE may include both psychological and physical interventions. Behavioral therapies such as the squeeze technique or stop-start method can be effective in managing DE. In addition, medications such as antidepressants or phosphodiesterase-5 inhibitors may be used to address underlying psychological or physical causes. Alternative treatments such as acupuncture or herbal remedies have also been explored, although their effectiveness remains unclear. In some cases, referral to a specialist in sexual medicine or therapy may be necessary to achieve optimal outcomes.

Question 15

Q

What is the definition of ejaculation?
a. Sensation of intense pleasure, relaxation or intimacy
b. Antegrade expulsion of semen from the urethra
c. A linear process of increasing sexual excitement
d. None of the above

Answer

A

b. Antegrade expulsion of semen from the urethra

Question 16

Q

What triggers ejaculation?

Answer

A

c. Both a and b

Question 17

Q

What is the spinal ejaculation generator (SEG)?
a. A structure responsible for integrating stimuli from peripheral and cerebral sources and triggering the ejaculatory reflex
b. A part of the brain involved in mediating the subjective experience of orgasm
c. A hormone responsible for the release of semen
d. None of the above

Answer

A

a. A structure responsible for integrating stimuli from peripheral and cerebral sources and triggering the ejaculatory reflex

Question 18

Q

What is the first phase of ejaculation?
a. Emission
b. Ejection
c. Orgasm
d. None of the above

Answer

A

a. Emission

Question 19

Q

What is the second phase of ejaculation?
a. Emission
b. Ejection
c. Orgasm
d. None of the above

Answer

A

b. Ejection

Question 20

Q

Describe the sexual response cycle in men.

Answer

A

The sexual response cycle in men is a linear process of increasing sexual excitement, starting with desire and followed by arousal, climax, and resolution. Sexual climax in men consists of two distinct physiological events: orgasm and ejaculation. Orgasm is a sensation of intense pleasure, relaxation, or intimacy that accompanies peak sexual arousal, while ejaculation is antegrade expulsion of semen from the urethra.

Question 21

Q

What triggers ejaculation and what is the spinal ejaculation generator (SEG)?

Answer

A

Ejaculation is triggered by integration of tactile and non-tactile stimuli in the brain. At some set point of arousal, a centrally-mediated action potential is triggered leading to ejaculatory and/or orgasmic inevitability. The spinal ejaculation generator (SEG) is a structure responsible for integrating stimuli from peripheral and cerebral sources and triggering the ejaculatory reflex. Lesion of this structure is strongly associated with ejaculatory failure.

Question 22

Q

What are the two distinct phases of ejaculation?

Answer

A

The two distinct phases of ejaculation are emission and ejection. Emission is a centrally-mediated action characterized by closure of the bladder neck and contraction of smooth muscles throughout the seminal tract. The emission phase also includes secretion of seminal fluid into the proximal urethra. The second phase is ejection, a reflex driven by the somatic nervous system, specifically the pudendal nerve. Ejection is characterized by repeated contractions of the bulbospongiosus and ischiocavernous muscles leading to forceful expulsion of seminal fluid from the urethral meatus.

Question 23

Q

What are the medical and surgical interventions that can alter ejaculatory function?

Answer

A

Medical and surgical interventions that alter function of the prostate and/or bladder neck often have noticeable and bothersome effects on ejaculation. Specific examples include decreased ejaculate volume and force in men using alpha blockers or 5-alpha reductase inhibitors for management of benign prostatic hyperplasia (BPH). Surgical interventions for BPH tend to cause pronounced and difficult to resolve alterations in ejaculatory function. A number of novel procedural approaches to BPH have been developed due in part to dissatisfaction with ejaculatory outcomes associated with conventional surgical BPH treatments. Surgical removal of the prostate and seminal vesicles for prostate cancer typically results in marked reduction or complete absence of ejaculation as these organs are responsible for the vast majority of seminal volume. Radiation therapy for prostate cancer is also commonly associated with loss of antegrade ejaculation. Disruption of ejaculation is associated with changes in subjective experience of orgasm for some men.

Question 24

Q

What are the factors that influence the subjective experience of orgasm?

Answer

A

The quality and intensity of orgasm may be influenced by a variety of factors that are incompletely understood. Orgasm is a transient neurological state characterized by intense feelings of pleasure, relaxation, and intimacy. It is mediated by and experienced in the brain, whereas ejaculatory reflexes are mediated by the putative SEG, making the subjective experience of orgasm an integration of numerous brain centers. The ventral medulla appears to exert an inhibitory effect on the SEG. In general, dopaminergic and oxytocinergic activation stimulates ejaculation and orgasm whereas serotonergic and gamma-aminobutyric acid (GABA)-ergic activation opposes ejaculation and orgasm. Agonists of opioid receptors, principally mu subtypes, are also associated with impairment of ejaculatory and orgasmic response.

Question 25

Q

What is the role of galaninergic neurons in ejaculation?
a. They have no role in ejaculation.
b. They play a minor role in ejaculation.
c. They play a critical role in ejaculation.
d. It depends on the individual.

Answer

A

c. They play a critical role in ejaculation.

Explanation: Galaninergic neurons are responsible for integrating stimuli from peripheral and cerebral sources and triggering the ejaculatory reflex. Lesion of these structures is strongly associated with ejaculatory failure.

Question 26

Q

What are galaninergic neurons?

Answer

A

Galaninergic neurons are a type of nerve cell that produce galanin, a neuropeptide that plays a critical role in the regulation of various physiological processes, including ejaculation. In the context of ejaculation, galaninergic neurons are responsible for integrating stimuli from peripheral and cerebral sources and triggering the ejaculatory reflex. Lesion of these structures is strongly associated with ejaculatory failure. These neurons are arranged in columns within the central spinal cord, and some experts have described this structure as the “spinal ejaculation generator” (SEG).

Question 27

Q

Describe the sexual response cycle.

Answer

A

The sexual response cycle consists of four phases: excitement, plateau, orgasm, and resolution. During the excitement phase, there is an increase in heart rate, blood pressure, and respiration. This phase is characterized by the onset of sexual arousal. During the plateau phase, sexual arousal continues to increase, but at a slower rate. This phase is characterized by increased muscle tension and vasocongestion. During the orgasm phase, there is a release of sexual tension and a feeling of intense pleasure. This phase is characterized by rhythmic contractions of the genital organs. During the resolution phase, there is a return to the pre-aroused state.

Question 28

Q

How is ejaculation triggered?

Answer

A

Ejaculation is triggered by the integration of tactile and non-tactile stimuli in the brain. At some set point of arousal, a centrally-mediated action potential is triggered leading to ejaculatory and/or orgasmic inevitability. The presence of galaninergic neurons arranged in columns within the central spinal cord is critical in this process. These neurons are responsible for integrating stimuli from peripheral and cerebral sources and triggering the ejaculatory reflex. Lesion of these structures is strongly associated with ejaculatory failure.

Question 29

Q

What are the two distinct phases of ejaculation?
A. Emission and Orgasm
B. Orgasm and Ejection
C. Emission and Ejection
D. Ejection and Ejaculation

Answer

A

. Emission and Ejection

Explanation: Ejaculation consists of two distinct phases, emission and ejection. The first phase is emission, characterized by closure of the bladder neck and contraction of smooth muscles throughout the seminal tract, mediated by the sympathetic nervous system. The second phase is ejection, a reflex driven by the somatic nervous system, specifically the pudendal nerve.

Question 30

Q

Which nervous system mediates the emission phase of ejaculation?
A. Parasympathetic Nervous System
B. Somatic Nervous System
C. Sympathetic Nervous System
D. Autonomic Nervous System

Answer

A

C. Sympathetic Nervous System

Explanation: The emission phase of ejaculation is mediated by the sympathetic nervous system. It is characterized by closure of the bladder neck and contraction of smooth muscles throughout the seminal tract, as well as secretion of seminal fluid into the proximal urethra.

Question 31

Q

What is the role of Onuf’s nucleus in ejaculation?

Answer

A

Onuf’s nucleus is a cluster of motor neurons in spinal segments S2-4 that appears to be of particular import for control of the striated muscles of the pelvis during ejaculation. This includes the bulbospongiosus and ischiocavernous muscles that contract during the ejection phase of ejaculation, leading to forceful expulsion of seminal fluid from the urethral meatus. The somatic nervous system, specifically the pudendal nerve, is responsible for driving this reflex during the ejection phase.

Question 32

Q

Which of the following medical interventions for BPH is most likely to cause a decrease in ejaculate volume and force?
a. Antibiotics
b. Antidepressants
c. Alpha blockers
d. Anticoagulants

Answer

A

c. Alpha blockers
Explanation: Alpha blockers are commonly used to manage benign prostatic hyperplasia (BPH), but they can cause decreased ejaculate volume and force due to their effect on prostate function.

Question 33

Q

What surgical procedure for BPH is known to cause pronounced and difficult to resolve alterations in ejaculatory function?
a. Transurethral resection of the prostate (TURP)
b. Prostatectomy
c. Prostate biopsy
d. Cystectomy

Answer

A

a. Transurethral resection of the prostate (TURP)
Explanation: TURP is a conventional surgical treatment for BPH that can cause pronounced and difficult to resolve alterations in ejaculatory function. This has led to the development of novel procedural approaches to BPH.

Question 34

Q

Which organs are responsible for the vast majority of seminal volume?
a. Prostate and bladder neck
b. Seminal vesicles and prostate
c. Bladder neck and urethra
d. Urethra and seminal vesicles

Answer

A

b. Seminal vesicles and prostate
Explanation: The seminal vesicles and prostate are responsible for the vast majority of seminal volume. Surgical removal of these organs for prostate cancer typically results in marked reduction or complete absence of ejaculation.

Question 35

Q

How does disruption of ejaculation affect subjective experience of orgasm for some men?

Answer

A

Disruption of ejaculation is associated with changes in subjective experience of orgasm for some men. Ejaculation is a key part of the male sexual response cycle, and its disruption can lead to decreased or altered sensation of orgasm. For example, men who have undergone surgical removal of the prostate and seminal vesicles for prostate cancer often report a decrease or absence of orgasmic sensation. The psychological and emotional impact of these changes can also be significant, and may require counseling or therapy.

Question 36

Q

Which of the following statements about orgasm is true?
A. Orgasm is characterized by intense feelings of pain, stress, and loneliness.
B. There is little variability in the subjective experience of orgasm between individuals.
C. Orgasm is typically experienced at peak sexual arousal.
D. The refractory period tends to become shorter with increasing age.

Answer

A

C. Orgasm is typically experienced at peak sexual arousal. Orgasm is a transient neurological state characterized by intense feelings of pleasure, relaxation, and intimacy. It is typically experienced at peak sexual arousal, which can vary between individuals and within a given person at different times.

Question 37

Q

What is the refractory period?
A. The time period following sexual arousal during which orgasm is not possible.
B. The time period following orgasm during which arousal and sexual climax are not possible.
C. The time period following sexual arousal during which only one orgasm is possible.
D. The time period following orgasm during which sexual arousal is heightened.

Answer

A

B. The time period following orgasm during which arousal and sexual climax are not possible.

Explanation: In men, orgasm is typically followed by a refractory period during which arousal and sexual climax are not possible. The duration of the refractory period tends to become longer with increasing age.

Question 38

Q

Which brain regions are thought to be intimately involved in central integration of stimuli germane to ejaculatory response?
a. The stria terminalis
b. The posterodorsal area of the medial amygdala
c. The parvicellular part of the supraparafascicular thalamus
d. All of the above

Answer

A

d. All of the above

Explanation: The stria terminalis, the posterodorsal area of the medial amygdala, and the parvicellular part of the supraparafascicular thalamus are all thought to be intimately involved in central integration of stimuli germane to ejaculatory response.

Question 39

Q

What is the putative SEG?

Answer

A

The putative SEG (spinal ejaculation generator) is a group of neurons located in the lumbosacral spinal cord that are responsible for the ejaculatory reflex.
Explanation: Understanding the role of the SEG is important in understanding disorders of ejaculation, as these disorders may involve dysfunction of the SEG.

Question 40

Q

Which neurotransmitters generally stimulate ejaculation and orgasm?
A) Serotonergic and GABA-ergic activation
B) Dopaminergic and oxytocinergic activation
C) Agonists of opioid receptors
D) None of the above

Answer

A

B) Dopaminergic and oxytocinergic activation

Explanation: In general, dopaminergic and oxytocinergic activation stimulates ejaculation and orgasm.

Question 41

Q

Which opioid receptor subtype is primarily associated with impairment of ejaculatory and orgasmic response?
A) Kappa
B) Delta
C) Mu
D) None of the above

Answer

A

C) Mu

Explanation: Agonists of opioid receptors, principally mu subtypes, are associated with impairment of ejaculatory and orgasmic response.

Question 42

Q

How do serotonergic and GABA-ergic activation oppose ejaculation and orgasm?

Answer

A

Serotonergic and GABA-ergic activation generally oppose ejaculation and orgasm. Serotonin is involved in mood regulation and is associated with feelings of calm and contentment, while GABA is the main inhibitory neurotransmitter in the brain. Activation of these neurotransmitters can decrease sexual arousal and inhibit ejaculation and orgasm.

Question 43

Q

Which of the following hormones is necessary for the initial maturation of sexual, including ejaculatory, reflexes?
a. Estrogen
b. Progesterone
c. Androgens
d. Prolactin

Answer

A

c. Androgens
Explanation: Experimental and observational data in animals and humans indicate that androgens are necessary for at least the initial maturation of sexual, including ejaculatory, reflexes.

Question 44

Q

What is the significance of galaninergic neurons in the L3 and L4 spinal segments in males?
a. They are not related to the ejaculatory process.
b. They suggest a sexually dimorphic developmental pathway.
c. They are responsible for the production of androgens.
d. They have no role in the sexual response cycle.

Answer

A

b. They suggest a sexually dimorphic developmental pathway.
Explanation: Male cadavers had a greater density of galaninergic neurons in the L3 and L4 spinal segments as compared to female cadavers, suggesting a sexually dimorphic developmental pathway likely mediated by differential exposure to androgens.

Question 45

Q

What is the significance of galaninergic neurons in the ejaculatory process?

Answer

A

Galaninergic neurons in the L3 and L4 spinal segments are thought to be essential to the ejaculatory process as evidenced by frequency of failure to ejaculate in response to penile vibratory stimulation in men with L3-5 spinal cord injury. These neurons are part of the putative SEG (spinal ejaculatory generator), which is responsible for the coordination of the motor activity necessary for ejaculation. The density of these neurons is greater in male cadavers as compared to female cadavers, suggesting a sexually dimorphic developmental pathway likely mediated by differential exposure to androgens.

Question 46

Q

Which of the following statements about serum testosterone levels is true?
a) Serum testosterone levels represent peripheral action of T in the tissues.
b) Variations in androgen receptor function do not affect the final action of T within target tissues.
c) Intracellular trafficking of T bound to the androgen receptor does not affect the final action of T within target tissues.
d) The balance among modulators of T receptors does not affect the final action of T within target tissues.
Answer: d) The balance among modulators of T receptors does not affect the final action of T within target tissues.

Answer

A

Serum testosterone levels do not represent peripheral action of T in the tissues, where T acts. Variations in androgen receptor function (e.g., number of CAG repeats), intracellular trafficking of T bound to the androgen receptor, and the balance among modulators of T receptors determine the final action of T within target tissues.

Question 47

Q

Which type of receptors carry out T action in the CNS?
a) Non-nuclear receptors only
b) Nuclear receptors only
c) Both nuclear and non-nuclear receptors
d) Neither nuclear nor non-nuclear receptors
Answer: c) Both nuclear and non-nuclear receptors

Answer

A

: T action in the CNS is carried out by nuclear receptors and possibly by non-nuclear G-protein coupled receptors.

Question 48

Q

How do variations in androgen receptor function affect T action within target tissues?

Answer

A

Variations in androgen receptor function, such as the number of CAG repeats, can affect T action within target tissues by altering the receptor’s sensitivity to T. This can result in different levels of T activity in different tissues, even when serum T levels are the same. Additionally, variations in intracellular trafficking of T bound to the androgen receptor and the balance among modulators of T receptors can also affect the final action of T within target tissues.

Question 49

Q

What is a common cause of disruption in ejaculation or orgasm?
a. Lack of sleep
b. Lack of exercise
c. Lack of sexual desire and/or erectile dysfunction
d. Lack of communication in a relationship

Answer

A

c. Lack of sexual desire and/or erectile dysfunction

Explanation: According to the guideline statements, one of the common causes of disruption in ejaculation or orgasm is failure of the earlier elements of sexual response such as lack of sexual desire and/or erectile dysfunction leading to inadequate genital and subjective excitement.

Question 50

Q

What condition can impair the subjective experience of orgasm but preserve ejaculatory reflexes?
a. Neurological lesions of the sympathetic nervous system
b. Retroperitoneal lymph node dissection
c. Cerebral lesions
d. Transurethral resection of the prostate

Answer

A

: c. Cerebral lesions

Explanation: According to the guideline statements, it is possible for ejaculatory reflexes to be preserved in the context of psychological, cerebral, or other neurologic lesions that may impair the subjective experience of orgasm.

Question 51

Q

Which historical term is associated with the clinical phenomenon of ejaculation which occurs earlier than a man wishes during a sexual encounter?
A. Rapid climax
B. Premature climax
C. Ejaculatio Praecox
D. Early orgasm

Answer

A

C. Ejaculatio Praecox

Question 52

Q

What was Masters and Johnson’s definition of premature ejaculation?
A. Ejaculation that occurs before penetration
B. Ejaculation that occurs before the female partner has experienced sexual climax during at least 50% of sexual encounters
C. Ejaculation that occurs within 15-30 seconds after penetration
D. Ejaculation that occurs within about 1 minute of vaginal penetration

Answer

A

B. Ejaculation that occurs before the female partner has experienced sexual climax during at least 50% of sexual encounters

Question 53

Q

Which diagnostic manual defines PE as a persistent or recurrent pattern of ejaculation occurring during partnered sexual activity within approximately 1 minute following vaginal penetration and before the individual wishes it?
A. DSM-IV-TR
B. DSM-V
C. ICD-10
D. ICD-11

Question 54

Q

According to the ISSM, what is the principle distinguishing feature between lifelong and acquired PE?
A. Chronicity and time of onset
B. Frequency of disturbance
C. Negative interpersonal consequences
D. Inability to delay ejaculation on all or nearly all vaginal penetrations

Answer

A

A. Chronicity and time of onset

Question 55

Q

What are the criteria for the diagnosis of premature ejaculation according to DSM-V?

Answer

A

According to DSM-V, premature ejaculation is diagnosed as a persistent or recurrent pattern of ejaculation occurring during partnered sexual activity within approximately 1 minute following vaginal penetration and before the individual wishes it. The disorder must be present in 75% or more of sexual encounters and persistent over at least the last 6 months. To qualify as a dysfunction, the man must experience personal distress related to the dysfunction and the condition cannot be better explained by a comorbid or concomitant diagnosis.

Question 56

Q

What is the strongest definition of premature ejaculation in terms of evidence basis?

Answer

A

he definition of premature ejaculation by the International Society of Sexual Medicine (ISSM) is the strongest in terms of evidence basis. The robust evidence basis is also a limitation in that the data used in its development were derived from studies of vaginal intercourse and hence it is explicitly specific to coitus.

Question 57

Q

What sub-types of premature ejaculation are recognized by the DSM-V?
A. Lifelong and acquired
B. Generalized and situational
C. Severe, moderate, and mild
D. All of the above

Answer

A

D. All of the above

Explanation: The DSM-V recognizes four sub-types of premature ejaculation - lifelong, acquired, generalized, and situational. Additionally, ejaculation that occurs before penetration or within 15 seconds, between 15-30 seconds after penetration, and from 30-60 seconds after penetration are categorized as severe, moderate, or mild PE, respectively.

Question 58

Q

What is the definition of premature ejaculation according to the ISSM?
A) Ejaculation that always occurs prior to vaginal penetration
B) A clinically significant and bothersome reduction in latency time, often to about 5 minutes or less
C) Ejaculation that occurs within 2 minutes of vaginal penetration
D) Ejaculation that always or nearly always occurs prior to or within about 1 minute of vaginal penetration (lifelong PE) or a clinically significant and bothersome reduction in latency time, often to about 3 minutes or less (acquired PE)

Answer

A

D) Ejaculation that always or nearly always occurs prior to or within about 1 minute of vaginal penetration (lifelong PE) or a clinically significant and bothersome reduction in latency time, often to about 3 minutes or less (acquired PE). This definition is to date the strongest in terms of evidence basis.

Question 59

Q

What is the definition of DE according to the DSM-V?
A) The inability to achieve an erection
B) The inability to attain orgasm after sufficient sexual stimulation
C) The inability to maintain an erection
D) The inability to achieve ejaculation

Answer

A

r: B) The inability to attain orgasm after sufficient sexual stimulation.

Question 60

Q

What is the difference between primary and secondary DE?
A) Primary is a lifelong experience while secondary is a distressing lengthening of ejaculatory latency that occurs after a period of normal ejaculatory function.
B) Primary is a distressing lengthening of ejaculatory latency that occurs after a period of normal ejaculatory function while secondary is a lifelong experience.
C) Primary and secondary DE are the same thing.
D) Primary DE is the inability to achieve ejaculation while secondary DE is the inability to maintain an erection.

Answer

A

A) Primary is a lifelong experience while secondary is a distressing lengthening of ejaculatory latency that occurs after a period of normal ejaculatory function.

Question 61

Q

What is the DSM-V criterion for a DE diagnosis?
A) The disorder must be present in 50% or more of partnered sexual encounters and persistent over at least the last 3 months.
B) The disorder must be present in 75% or more of partnered sexual encounters and persistent over at least the last 6 months.
C) The disorder must be present in 100% of partnered sexual encounters and persistent over at least the last 12 months.
D) The disorder must be present in 25% or more of partnered sexual encounters and persistent over at least the last 1 month.

Answer

A

B) The disorder must be present in 75% or more of partnered sexual encounters and persistent over at least the last 6 months.

Question 62

Q

What is DE and how is it defined in various guidelines?

Answer

A

DE stands for delayed ejaculation, which is the phenomenon of delay in ejaculation and/or orgasm. According to the 3rd International Consultation on Sexual Dysfunction in 2010, DE is defined as the persistent or recurrent difficulty, delay in, or absence of attaining orgasm after sufficient sexual stimulation, which causes personal distress. The DSM-V defines DE as the condition in which a man experiences “a marked delay in ejaculation” or “marked infrequency or absence of ejaculation.” The ICD-11 defines “male delayed ejaculation” as “inability to achieve ejaculation or an excessive or increased latency of ejaculation, despite adequate sexual stimulation and the desire to ejaculate. The 4th International Consultation on Sexual Medicine in 2015 developed new terminology for lifelong and acquired DE. Lifelong, alternatively classified as primary, delayed ejaculation was defined as a lifelong experience or inability to ejaculate in all of almost all (75%-100%) occasions of coital activity, associated with distress. Acquired, alternatively classified as secondary, DE was defined as a distressing lengthening of ejaculatory latency that occurs in most (>50%) coital experiences after a period of normal ejaculatory function or a clinically meaningful change that results in distress.

Question 63

Q

What are the DSM-V criteria for a DE diagnosis?

Answer

A

The DSM-V criteria for a DE diagnosis are as follows: The disorder must be present in 75% or more of partnered sexual encounters and persistent over at least the last 6 months. To qualify as a dysfunction, the patient must not desire delay of ejaculation and he must experience personal distress. Furthermore, the DE condition cannot be better explained by a comorbid or concomitant diagnosis or situation. The DSM-V definition permit categorization of DE into generalized versus situational sub-types and also includes an ordinal severity scale based on the degree of subjective distress (i.e., mild, moderate, and severe) rather than any quantitative measure.

Question 64

Q

What is the definition of hematospermia?
a. The absence or marked infrequency of the orgasm experience
b. The condition in which semen is not ejected antegrade but rather flows into the bladder during climax
c. The presence of blood in ejaculated semen
d. The absence of seminal ejaculation with sexual climax

Answer

A

c. The presence of blood in ejaculated semen

Explanation: Hematospermia is defined as the presence of blood in ejaculated semen. It may present as bright red blood, clots, or disintegrating blood products.

Answer 64

A

a. The absence or marked infrequency of the orgasm experience

Explanation: Anorgasmia may be conceptualized as an extreme variant of DE in which orgasm cannot be achieved.

Answer 65

A

c. The absence of seminal ejaculation with sexual climax

Explanation: Anejaculation refers specifically to the absence of seminal ejaculation with sexual climax.

Answer 66

A

Retrograde ejaculation is the condition in which semen is not ejected antegrade but rather flows into the bladder during climax. This is typically due to failure of the bladder neck to close during the emission phase and may be idiopathic or secondary to bladder neck surgery, pharmacological agents, or neurologic lesion. In most cases of retrograde ejaculation, orgasm occurs and feels pleasurable. Some men with retrograde ejaculation may report that their experience of orgasm is qualitatively different.

Answer 67

A

Anhedonic orgasm is the condition in which ejaculation occurs but is not associated with subjective feelings of pleasure, intimacy, or relaxation. This condition is poorly understood but may relate to medications (particularly antidepressants), neurologic lesions, or psychogenic causes.

Answer 68

A

Painful ejaculation, also known as dysejaculation, odynorgasmia, post orgasmic pain, dysorgasmia, or orgasmalgia, is a poorly understood condition that may have both psychogenic and organic elements. Pelvic lesion, traumas, or surgery may be contributing factors and painful ejaculation is often comorbid with other types of chronic pelvic pain syndromes. Men with painful ejaculation should be evaluated for lower urinary tract dysfunction and other causes of chronic pelvic pain.

Answer 69

A

Post Orgasmic Illness Syndrome (POIS) is a provisional diagnosis which has been applied to cases of somatic symptoms that occur in close association with sexual climax. POIS is distinguished from painful ejaculation by the presence of symptoms outside the pelvis, such as malaise, confusion, myalgias, fatigue, or other somatic concerns. The etiology of POIS is unclear but may be an autoimmune, cytokine-mediated, or allergic reaction to seminal components has been proposed. The condition may be empirically managed with antihistamines, selective serotonin reuptake inhibitors (SSRIs), and benzodiazepines although data to support these modalities is scant.35

Answer 70

A

b) 10%
Explanation: Similar data on the prevalence of DE are more limited; a substantial proportion of men in epidemiological studies report difficulty achieving orgasm, but the degree of associated distress is not reported.

Answer 71

A

c. Poor ejaculatory control, ejaculation within about 2 minutes of initiation of penetrative sex, and associated bother

Explanation: Lifelong premature ejaculation is defined as poor ejaculatory control, associated bother, and ejaculation within about 2 minutes of initiation of penetrative sex that has been present since sexual debut.

Answer 72

A

D. Over 70%

Explanation: Men with premature ejaculation frequently report poor ejaculatory control. Very poor to poor ejaculatory control is characteristic of over 70% of men who have premature ejaculation.

Answer 73

A

Treatment options for lifelong premature ejaculation may include behavioral therapy, such as the stop-start and squeeze techniques, as well as the use of topical anesthetics and oral medications, such as selective serotonin reuptake inhibitors (SSRIs) and phosphodiesterase-5 (PDE-5) inhibitors. Counseling may also be beneficial for addressing underlying psychological factors. It is important for individuals to discuss treatment options with their healthcare provider to determine the most appropriate course of action.

Answer 74

A

Self-efficacy is a psychological construct that refers to the perceived ability to be effective at a given task based on previous experiences. Lack of self-efficacy regarding ejaculatory control is a sine qua non for diagnosing PE. Men with PE often report poor ejaculatory control and lack of self-efficacy regarding ejaculation control. This lack of self-efficacy is central to both the diagnosis of PE and perceived treatment benefits. Men who have self-efficacy regarding ejaculation control or voluntarily ejaculate with short latency do not by definition have a sexual problem regardless of ELT.

Answer 75

A

Sine qua non is a Latin term that means “without which, there is nothing”. It refers to an essential or necessary condition or requirement without which something is not possible or cannot exist. In the context of disorders of ejaculation, lack of self-efficacy regarding ejaculatory control is a sine qua non for diagnosing premature ejaculation.

Answer 76

A

The ISSM definition for lifelong PE states that the criterion of 1 minute affords the clinician sufficient flexibility to also diagnose PE in the 10–20% of PE-treatment-seeking men who ejaculate within 1–2 minutes of penetration without unnecessarily stigmatizing the remaining 80–90% of men who ejaculate within 1–2 minutes of penetration but have no complaints of PE. Although the majority of men seeking treatment for lifelong PE are characterized by latencies of less than 60 seconds, about 20% of men seeking treatment for PE ejaculate after more than 60 seconds. An extended latency time of 120 seconds would capture most of the remaining 20%. This higher limit increases true positives (decreasing false negatives and Type 2 error), but also increases false positives (Type 1 error). Reliance on control and bother are essential elements for diagnosis.

Answer 77

A

B. Acquired premature ejaculation is defined as consistently poor ejaculatory control, associated bother, and ejaculation latency that is markedly reduced from prior sexual experience during penetrative sex.

Answer 78

A

D. Personal and psychological health issues, new environmental pressures, evolving relationship issues and dynamics, and partner-specific issues may be possible causes of acquired premature ejaculation.

Answer 79

A

Lifelong premature ejaculation refers to a man’s persistent and consistent inability to delay ejaculation, leading to distress and negative personal or interpersonal consequences. On the other hand, acquired premature ejaculation refers to a later onset of poor ejaculatory control, associated bother, and ejaculation latency that is markedly reduced from prior sexual experience during penetrative sex. Men with acquired PE experience a period of sufficient ejaculatory control and lack of distress prior to developing the distressing shortened latency.

Possible causes of acquired premature ejaculation may include medical comorbidities, health conditions, pain, surgery or trauma, erectile dysfunction, or medication. The latter condition may include personal and psychological health issues, new environmental pressures, evolving relationship issues and dynamics, and partner-specific issues. In some instances, no clear etiology is delineated (i.e., idiopathic acquired PE).

Diagnosis of acquired premature ejaculation requires that the man meets the criteria of poor ejaculatory control, diminished sexual satisfaction with intercourse, and negative personal or interpersonal consequences. The average estimated ejaculation latency time during partnered sex should fall under about 2-3 minutes, or ELT should be reduced by about 50% or more from prior estimations. However, these criteria are limited by lack of evidence and should be interpreted cautiously, and clinicians should exercise their own best judgement when making the diagnosis of acquired PE.

Answer 80

A

The questions that should be asked in the medical and sexual history to make the diagnosis of premature ejaculation include: concerns about ability to control ejaculation, ejaculating before wanting to, whether it is lifelong or not, feeling poor or no control of ejaculation, inability to postpone or delay ejaculation, negative interpersonal consequences, anxiety, depression, avoidance of sexual activity, self-estimated ejaculatory latency time, duration of premature ejaculation, occurrence with almost every sexual encounter, variations in ELT related to different sexual partners or circumstances, and history of prostatitis or other prostate conditions. These questions are important as they help in identifying the characteristics of premature ejaculation and its impact on the patient’s life, psychological health, and relationship with the partner.

Answer 81

A

Assessing the patient’s psychological health is important as it helps in identifying any underlying mood disorders or significant psychiatric problems that may contribute to the development of premature ejaculation or affect the patient’s response to treatment. Depression occurs in about 20% of men with premature ejaculation compared to 12% in men without, while anxiety occurs in 24% of men with premature ejaculation compared to 13% in men without. Studies have reported even higher prevalence rates for anxiety of up to one-third of men with premature ejaculation. A systematic review of 18,035 men in 8 studies determined that the odds ratio for depression was 1.63 in men with premature ejaculation versus without. Assessment by a mental health professional may be of benefit, or even a necessity, depending on the severity of the mood disorder. Mood disorders may or may not improve with initiation of effective premature ejaculation therapy.

Answer 82

A

Physical examination is an essential standard in medical practice; however, it seldom contributes to the evaluation of premature ejaculation. Although it rarely changes management, a focused physical examination is reassuring to patients and may identify issues meriting consideration. A brief genital exam should be considered when feasible. Particular areas of note include penile morphology, testicular size and consistency, and prostate size and consistency. The relevance of any of these factors to management of premature ejaculation is ambiguous, but evaluation may be informative in other ways and suggest other issues for discussion and management.

Answer 83

A

B) To facilitate a conversation about ejaculatory issues

Answer 84

A

B) Possible spectrum bias

Answer 85

A

Five studies evaluated the accuracy of validated questionnaires for diagnosing premature ejaculation, including the Premature Ejaculation Diagnostic Tool (PEDT), the Premature Ejaculation Profile (PEP), Index of Premature Ejaculation, the Multiple Indicators of Premature Ejaculation, the Checklist for Early Ejaculation Symptoms, and the Arabic Index for Premature Ejaculation. Despite limitations such as possible spectrum bias, these questionnaires have very good sensitivity and specificity scores and high discrimination.

Answer 86

A

While the clinical value of using validated questionnaires for diagnosing premature ejaculation is uncertain, they may be useful as an adjunct to diagnosis or as an “ice breaker” to facilitate a conversation about ejaculatory issues. They can also be useful for research purposes. However, their value in longitudinal measurement to assess change over time or in response to treatment has not been studied, and interpreting changes in scores is a challenge as minimal clinically important differences are unknown.

Answer 87

A

c. Clinicians should not use additional testing.

Answer 88

A

b. High serum T has been inconsistently associated with increased likelihood of premature ejaculation.

Answer 89

A

Biothesiometry is a technique used to measure the sensitivity of the penis to vibration. Lower penile vibratory sensation thresholds, indicative of greater sensitivity, have been noted in men with premature ejaculation compared to controls. However, a more recent study did not detect any significant difference in penile sensitivity between men with or without premature ejaculation. These findings suggest a possible etiology for some cases of lifelong premature ejaculation, but it is not clear if any particular intervention is preferred over another.

Answer 90

A

e. Erectile dysfunction. Men with acquired premature ejaculation often have comorbidities, including hypertension, sexual desire disorder, diabetes mellitus, chronic prostatitis, and erectile dysfunction.

Answer 91

A

a. Men with premature ejaculation have higher testosterone levels compared to men without premature ejaculation. However, it is unclear whether these high-normal testosterone levels were congenital or acquired.

Answer 92

A

B) Premature ejaculation

Answer 93

A

C) Thyroid function tests

Explanation: Laboratory tests related to the hypothalamic-pituitary-testicular axis, thyroid function, glucose metabolism, and prostatitis or chronic pelvic pain syndrome should be employed when there is clinical suspicion of these conditions in men with acquired premature ejaculation.

Answer 94

A

Laboratory tests, particularly tests related to the hypothalamic-pituitary-testicular axis, thyroid function, glucose metabolism, and prostatitis or chronic pelvic pain syndrome should be employed when there is clinical suspicion of these conditions in men with acquired premature ejaculation. Clinicians may utilize additional laboratory testing as clinically indicated and may treat such abnormalities accordingly. However, such tests are not a required element of evaluation for acquired premature ejaculation. The evidence regarding additional testing in men with acquired premature ejaculation is limited and inconsistent.

Answer 95

A

C. It has no significant impact on ejaculatory latency.

Explanation: According to the guideline statement 7, clinicians should advise patients that ejaculatory latency is not affected by circumcision status.

Answer 96

A

C. Circumcision has no significant impact on the risk of premature ejaculation.

Explanation: The systematic review of 12 studies on circumcision and premature ejaculation found no association between circumcision and increased risk of premature ejaculation (OR: O.90; 95% CI: 0.72-1.13).

Answer 97

A

A. Decreased emotional intimacy

Explanation: Psychological and interpersonal factors associated with premature ejaculation include depression, anxiety, history of sexual abuse, decreased emotional intimacy, and conflict within the relationship.

Answer 98

A

C. Behavioral therapy

Explanation: Behavioral therapy interventions include the stop-start technique, the squeeze technique, and sensate focus exercises. These interventions are designed to help men delay ejaculation while broadening their sexual scripts, increasing sexual self-confidence, and diminishing performance anxiety.

Answer 99

A

Psychological and behavioral interventions can be useful in treating premature ejaculation, even when no clear psychological or physiological etiology is apparent. These interventions have two overlapping goals: helping men develop sexual skills to delay ejaculation while broadening their sexual scripts, and resolving psychological and interpersonal issues that may have precipitated or resulted from premature ejaculation. Behavioral therapy interventions such as the stop-start technique, the squeeze technique, and sensate focus exercises can be helpful in achieving these goals. The potential advantages of these interventions include the ability to offer benefit without the need for pharmacological intervention, and the ability to be integrated into sexual encounters as part of the experience. The potential disadvantages of these interventions include the difficulty in studying their efficacy in a double-blind, controlled, randomized fashion, and the investment in time required, typically at least 5-10 sessions, which may not be covered by insurance carriers.

Answer 100

A

B. Depression, anxiety, history of sexual abuse, decreased emotional intimacy, and conflict within the relationship.

Explanation: Clinical experience suggests that psychological and interpersonal factors may precipitate premature ejaculation. These factors may also exacerbate premature ejaculation and generate additional psychological and interpersonal symptoms for the man, partner, and couple. Psychological and interpersonal factors associated with premature ejaculation include depression, anxiety, history of sexual abuse, decreased emotional intimacy, and conflict within the relationship.

Answer 101

A

B. Women in relationships with men who have premature ejaculation have lower scores for all domains of the Female Sexual Function Index except desire and pain.

Explanation: Women in relationships with men who have premature ejaculation have lower scores for all domains of the Female Sexual Function Index except desire and pain compared to women whose partners do not have premature ejaculation. One of the most troubling aspects of premature ejaculation for female partners may be the man’s focus on his ejaculatory performance; this may distract him from other salient aspects of a sexual encounter.

Answer 102

A

c. A way to train men to focus on excitatory sensations rather than avoiding them for fear of ejaculating quickly

Explanation: Sensate focus trains men to focus on excitatory sensations rather than avoiding them for fear of ejaculating quickly. By mastering these skills, men may learn to increase and control their ejaculatory latency.

Answer 103

A

D
Explanation: The use of topical local anaesthetics, such as lidocaine, prilocaine or benzocaine, alone or in association, to diminish the sensitivity of the glans penis is the oldest known pharmacological treatment for PE.

Answer 104

A

D
Explanation: The utilization of specific SSRIs (i.e., paroxetine, sertraline, fluoxetine, and citalopram) and the TCA clomipramine has revolutionized the treatment of PE. These drugs block axonal re-uptake of serotonin from the synaptic cleft of central serotonergic neurons by 5-HT transporters, resulting in enhanced 5-HT neurotransmission and stimulation of post-synaptic membrane 5-HT receptors.

Answer 105

A

The utilization of specific SSRIs (i.e., paroxetine, sertraline, fluoxetine, and citalopram) and the TCA clomipramine has revolutionized the treatment of PE. These drugs block axonal re-uptake of serotonin from the synaptic cleft of central serotonergic neurons by 5-HT transporters, resulting in enhanced 5-HT neurotransmission and stimulation of post-synaptic membrane 5-HT receptors. This results in a clinically meaningful patient-reported response from treatment that exceeds placebo response rates by about 40-60%.

Answer 106

A

c. Daily SSRIs and on-demand clomipramine or dapoxetine (where available)

Explanation: The AUA/SMSNA guideline recommends daily SSRIs, on-demand clomipramine or dapoxetine (where available), and topical penile anesthetics as first-line agents of choice in the treatment of premature ejaculation.

Answer 107

A

b. Headache

Explanation: Adverse effects from SSRI treatment of premature ejaculation have been reported in up to 54% of men using these medications, with headache being the most common. Other adverse effects include fatigue, yawning, mild nausea, diarrhea, perspiration, or decreased libido.

Answer 108

A

c. Clinicians may consider on-demand dosing of tramadol for treatment of premature ejaculation in men who have failed first-line therapy pharmacotherapy.

Explanation: According to Guideline Statement 10, clinicians may consider on-demand dosing of tramadol for treatment of premature ejaculation in men who have failed first-line therapy pharmacotherapy. This recommendation is a conditional recommendation with evidence level Grade C.

Answer 109

A

c. Low potential

Explanation: According to the guideline, the potential of tramadol for addiction or abuse appears low in most patient populations, but has not been assessed in men with premature ejaculation. The study by Adams et al. reported abuse rates of 0.7% for tramadol, which is lower than the rates for non-steroidal anti-inflammatory drugs and hydrocodone. However, caution should be exercised in prescribing an analgesic medication with opioid-like properties for management of premature ejaculation, especially in light of the ongoing opioid crisis in many nations.

Answer 110

A

Tramadol is a centrally acting synthetic opioid analgesic and weak inhibitor of re-uptake of GABA, norepinephrine, and serotonin. It has been reported to be effective in the treatment of premature ejaculation by several authors. However, most studies of tramadol for premature ejaculation are poorly designed open label trials with a wide range of efficacy. The only well-designed double-blind trial demonstrates superiority to placebo but a modest increase in IELT of 2.49-fold, consistent with the weak serotonin re-uptake inhibitor activity of tramadol. A large, international, prospective, randomized, placebo-controlled, double-blind trial of tramadol for the treatment of PE (NCT00983151) was recently stopped prematurely with no reason provided. There have been four meta-analyses of tramadol published clinical trial data, all of which conclude that tramadol appears effective in the treatment of premature ejaculation, but caution should be exercised given the observed levels of between-trial heterogeneity and the reporting quality of the available evidence.

Answer 111

A

Approximately 20% of patients receiving tramadol experience non-serious adverse effects including nausea, vomiting, dizziness, somnolence, tiredness, and headache. Serotonin Syndrome has been reported as an adverse effect of tramadol alone or in combination with SSRI drugs. The potential of tramadol for addiction or abuse appears low in most patient populations, but has not been assessed in men with premature ejaculation. Adams et al. reported abuse rates of 0.7% for tramadol, which is lower than the rates for non-steroidal anti-inflammatory drugs and hydrocodone, but caution should be exercised in prescribing an analgesic medication with opioid-like properties for management of premature ejaculation, especially in light of the ongoing opioid crisis in many nations.

Answer 112

A

C. α1-Adrenoceptor antagonists

Explanation: According to Guideline Statement 11, clinicians may consider treating men with premature ejaculation who have failed first-line therapy with α1-adrenoreceptor antagonists.

Answer 113

A

D. All of the above

Explanation: According to Guideline Statement 11, existing studies of α1-adrenoceptor antagonists are limited by flaws in sample size, inclusion criteria, premature ejaculation definitions, and outcome measures.

Answer 114

A

α1-adrenoceptor antagonists may induce ejaculatory dysfunction such as retrograde ejaculation and/or failure of emission. This is because these drugs also block the α1-adrenoceptors in the smooth muscle of the vas deferens, seminal vesicles, and prostate gland, which are essential for the process of ejaculation. The possible side effects of α1-adrenoceptor antagonists include dizziness, headache, orthostatic hypotension, nasal congestion, and abnormal ejaculation.

Answer 115

A

b. Determine which condition is more sexually disabling and/or primary and manage accordingly

Explanation: The guideline recommends determining which condition is more troublesome and managing accordingly. While management of ED should be primary in cases where acquired PE may be an adaptation to ED, a more nuanced approach is recommended.

Answer 116

A

c. PDE5is

Explanation: Several authors have reported experience using PDE5is alone or in combination with SSRIs as a treatment for PE. ED pharmacotherapy alone or in combination with PE pharmacotherapy may be considered for the treatment of lifelong and acquired PE in men with co-morbid ED.

Answer 117

A

ED pharmacotherapy alone or in combination with PE pharmacotherapy may be considered for the treatment of lifelong and acquired PE in men with co-morbid ED. Several authors have reported experience using PDE5is alone or in combination with SSRIs as a treatment for PE. PDE5i modulate activity of the NO/cGMP pathway, which is in turn a central and genital mediator of nitrergic neurotransmission that may influence ejaculatory responses. It is also conceivable that use of PDE5i improves sexual confidence and erection durability, enabling men with PE to focus on behavioural changes that help prolong ELT. In a study of 42 men with lifelong PE and no ED who were randomized to vardenafil vs placebo, Aversa et al. reported a 7.5-fold increase in geometric mean IELT following treatment with vardenafil (4.5±1.1 versus 0.6±0.3 minutes with placebo; P<0.01). Significant improvements were also noted in the IPE domains of ejaculatory control, confidence, overall sexual satisfaction, and distress. A recent meta-analysis of RCTs of PDE5i for management of PE indicated that PDE5i are effective compared with placebo and that a PDE5i combined with a SSRI is more effective in PE management than an SSRI alone. However, the efficacy of dapoxetine for PE was less robust in men with mild ED compared to men with no ED. Thus, clinicians should evaluate each patient individually and consider the potential benefits and risks of each pharmacotherapeutic option.

Answer 118

A

d. All of the above

Explanation: Behavioral strategies, including stop-start, squeeze, and sensate focus, have been studied in combination with pharmacological approaches to increase ejaculatory latencies and sexual satisfaction beyond that resulting from pharmacological treatment alone. Cognitive-behavioral therapy may also improve sexual satisfaction by expanding the couple’s sexual behavioral repertoire, improving communication, and addressing relationship dynamics.

Answer 119

A

c. Combination of behavioral and pharmacological approaches

Explanation: Clinicians should advise men with premature ejaculation that combining behavioral and pharmacological approaches may be more effective than either modality alone, according to the AUA/SMSNA guideline.

Answer 120

A

The behavioral strategies that can be used in combination with pharmacological approaches are start-stop, squeeze, and sensate focus techniques. Start-stop technique involves stopping sexual stimulation for a brief period when nearing ejaculation and then starting again. Squeeze technique involves squeezing the penis at the base when nearing ejaculation to reduce the sensation of orgasm. Sensate focus technique involves engaging in non-sexual touch to increase awareness of physical sensations and decrease performance anxiety.

Answer 121

A

Combination therapy, which includes both behavioral and pharmacological approaches, has been shown to increase ejaculatory latencies by about 1 minute over pharmacological therapy alone. In addition, combination therapy is associated with greater improvement in scores on validated instruments for assessment of premature ejaculation, such as the Premature Ejaculation Diagnostic Tool (PEDT). Patient-reported outcomes, such as sexual satisfaction, anxiety, and partner satisfaction, also improve with combination therapy.

Answer 122

A

Cognitive-behavioral therapy may also improve sexual satisfaction in men with premature ejaculation by expanding the couple’s sexual behavioral repertoire, improving communication, and addressing relationship dynamics. Incorporation of cognitive-behavioral therapy may result in an additional 1-3 minutes increase in ejaculatory latencies compared to pharmacotherapy alone. However, cognitive-behavioral therapy typically requires a specialist in psychosexual therapy and may not be covered by insurance.

Answer 123

A

b. Surgical management should only be considered in the context of an ethical board-approved clinical trial.

Explanation: According to the AUA/SMSNA guideline, surgical management (including injection of bulking agents) of premature ejaculation should be considered experimental and only be used in the context of an ethical board-approved clinical trial.

Answer 124

A

c. Selective dorsal penile neurectomy plus circumcision

Explanation: A recent study of 96 Chinese men with lifelong PE found that selective dorsal penile neurectomy plus circumcision was associated with longer post-surgical IELT than circumcision alone (4.29 versus 0.82 minutes; p=0.02).

Answer 125

A

Delayed ejaculation (DE) is a male sexual dysfunction that is characterized by a delay or absence of ejaculation and concomitant impairment of orgasm. It is of particular concern when procreation is desired, but the impact of failure to achieve orgasm is significant in that it typically results in a lack of sexual fulfillment for both the man and his partner. According to Guideline Statement 16, lifelong delayed ejaculation is defined as lifelong, consistent, bothersome inability to achieve ejaculation, or excessive latency of ejaculation, despite adequate sexual stimulation and the desire to ejaculate. On the other hand, acquired delayed ejaculation is defined as an acquired, consistent, bothersome inability to achieve ejaculation, or an increased latency of ejaculation, despite adequate sexual stimulation and the desire to ejaculate.

Answer 126

A

d) All of the above

Answer 127

A

The essential elements that should be assessed during the evaluation of a patient with delayed ejaculation include determining whether the patient’s delayed ejaculation is lifelong or acquired, global or situational, and the assessment of time of onset, chronicity, frequency, and associated factors. It is also important to establish whether a man can ejaculate during intercourse and the time elapsed between penetration and ejaculation. If ejaculation fails to occur, the duration of thrusting before suspension of intercourse, the reasons for suspension of intercourse, and whether ejaculation can occur during post-penetrative self- or partner-assisted masturbation must be determined. Variables that improve or worsen performance, the man’s ability to relax, sustain, and heighten arousal, and the degree to which he can concentrate on sensations should also be noted and documented.

Answer 128

A

A general medical history is important when evaluating a patient with delayed ejaculation as it can help to identify underlying medical conditions associated with neuropathy, metabolic derangements, or traumas to the nervous system or pelvis that may be contributing to the patient’s delayed ejaculation. Additionally, assessment for signs of metabolic disorders or decreased serum T can help to identify possible hormonal imbalances that may be causing delayed ejaculation.

Answer 129

A

b. Increases
Explanation: The prevalence of symptoms consistent with delayed ejaculation increases at progressively lower serum T levels.

Answer 130

A

a. Basic serum studies including electrolytes, lipids, and glycosylated hemoglobin
Explanation: Basic serum studies including electrolytes, lipids, glycosylated hemoglobin, and possibly others may be informative of medical conditions that could predispose to neuropathy or vascular disease, which may contribute to sexual dysfunction, including delayed ejaculation. Genetic tests have not been approved for use in the clinical context of delayed ejaculation.

Answer 131

A

B. Psycho-behavioral strategies

Explanation: While biomedical options for increasing the ejaculatory threshold are available (e.g., SSRIs), no clear options are available for lowering the threshold and thus decreasing ejaculation time. Psycho-behavioral strategies are unlikely to directly alter the ejaculatory threshold but may enhance psychosexual arousal and/or remove barriers and inhibitions that interfere with psychosexual excitement.

Answer 132

A

D. Age

Explanation: One of the most significant factors in DE is age, which likely combines psychological and physiological processes. Age-related increases in latency may be managed with psychological and behavioral approaches (e.g., increasing the repertoire of behaviors) aimed at increasing physical and psychological arousal.

Answer 133

A

The four major psychological approaches to managing delayed ejaculation are as follows:

a) The first approach is applicable to men in whom there is insufficient penile or psychological stimulation. These men may report having an insensate penis or diminished ability to experience penile sensations. A psychogenic etiology is strongly suggested when men report having normal penile sensation while masturbating, yet have diminished sensation when being stimulated by a partner. Psychological intervention aims to increase penile and psychological stimulation by using a vibrator, enhancing psychological arousal, or recommending vigorous pelvic thrusting while addressing the psychological factors that may inhibit ejaculation.

b) The second approach is applicable to men in whom there is a discrepancy between masturbatory patterns and fantasy life and the experience of partnered sex. Specifically, some men with DE report high-frequency masturbation, an idiosyncratic (i.e., referring to speed, pressure, and intensity that do not mimic sensations during intercourse) masturbation style, or a discrepancy between the reality of sex with a partner and sexual fantasy. In this context, the therapist recommends adaptation of the man’s masturbatory style to be more reflective of what is experienced during partnered sex and assists the man with reconciling fantasy and reality.

c) The third approach is applicable in the context of DE as a response to a preference for masturbation over partnered sex. Some men may prefer self-stimulation to stimulation by a partner. Psychological intervention aims to diminish the man’s focus on himself and enhance his ability to accept pleasure from his partner.

d) The last approach is applicable when there is psychological conflict regarding ejaculation and orgasm. This conflict may reduce arousal and inhibit orgasm. Possible sources of conflict include fear that semen loss will lead to health problems; fear of harm from female genitals; fear that ejaculation may hurt the partner; fear of impregnating a female partner; fear of defiling the partner with semen; hostility toward partner; unwillingness to give oneself; and guilt about sexuality in general, in many cases due to conservative religious upbringing. Psychological intervention focuses on resolving the psychological conflict, which may help normalize ejaculatory patterns.

Answer 134

A

b. Behavioral interventions

Explanation: Behavioral interventions, such as modifying sexual positions or practices to increase arousal, may help some men with DE enhance arousal and trigger orgasmic response.

Answer 135

A

b. Penile vibratory stimulation

Explanation: A limited evidence basis exists for the application of penile vibratory stimulation for management of acquired DE.

Answer 136

A

Behavioral interventions that can be recommended for men with delayed ejaculation include modifying sexual positions or practices to increase arousal, incorporating alternative sexual practices and scripts (such as oral or manual stimulation of the penis, use of alternative sexual positions, stimulation of other erogenous zones, and incorporation of fantasy or roleplay), and incorporating sexual enhancement devices (such as vibrators).
Explanation: Behavioral interventions are a low-risk option that may help some men with DE enhance arousal and trigger orgasmic response. This may include incorporation of alternative sexual practices and scripts (e.g., oral or manual stimulation of the penis, use of alternative sexual positions, stimulation of other erogenous zones, incorporation of fantasy or roleplay), and incorporation of sexual enhancement devices (e.g., vibrators). The specific nature of changes to sexual practice are dictated by what the couple is currently doing sexually, what each partner considers arousing, and what is physically and psychologically acceptable to both partners in terms of novel sexual practices. At a minimum, recommending a discussion about sexual needs and desires may help open lines of communication between partners and help facilitate treatment.

Answer 137

A

: b) Dose adjustment or substitution of the offending psychiatric drug

Explanation: Substitution of the offending psychiatric drug with an alternative agent may be the most medically feasible way to adjust therapy in patients with drug-induced delayed ejaculation.

Answer 138

A

c. Insufficient evidence to assess risk-benefit ratio

Explanation: The Guideline Statement 23 emphasizes that there is a scarcity of published studies on the pharmacotherapy for delayed ejaculation, and thus, there is a lack of evidence to evaluate the risk-benefit ratio of these medications.

Answer 139

A

Currently, there are no FDA-approved pharmacotherapies for delayed ejaculation, and the bulk of published studies consist of case reports and non-randomized, non-placebo-controlled case series. Some of the drugs that have been evaluated for the management of delayed ejaculation include bupropion, oxytocin, cabergoline, buspirone, sympathomimetics, imipramine, yohimbine, amantadine, and cyproheptadine. However, the Panel does not believe that existing evidence is robust enough to render an opinion on the actual risk/benefit ratio of these pharmacotherapies. The Guideline Statement 23 emphasizes that well-designed, appropriately powered studies are needed to better define efficacy and safety of pharmacotherapies for delayed ejaculation. Therefore, there is a lack of evidence-based recommendation for the use of these pharmacotherapies, and patients should be counseled on the weak evidence base and the potential for both known and unknown side effects.

Answer 140

A

The Panel recognizes the current needs of patients with delayed ejaculation and their partners for therapeutic options, which may include pharmacotherapy. Therefore, clinicians can offer appropriately selected and counseled patients pharmacotherapies that have a physiologic rationale for benefit in delayed ejaculation treatment. However, the Guideline Statement 23 emphasizes that patients should be counseled on the weak evidence base and the potential for both known and unknown side effects. The benefit of enhanced orgasmic function must be weighed by the patient against the potential risks, and an individualized decision can then be made based on the patient’s own personal values. The majority of these drugs are not commonly utilized in urological practice, and therefore, the urologist who is not comfortable prescribing these medications should consider referral of the patient for discussion of these management options.

Answer 141

A

C. Testosterone replacement therapy

Explanation: According to Guideline Statement 24, clinicians may offer treatment to normalize serum testosterone levels in patients with delayed ejaculation and testosterone deficiency.

Answer 142

A

B. Above 550 ng/dl

Explanation: Most experts recommend a target T level at or above the 50th percentile (>500-550 ng/dl) during treatment unless positive response is achieved with lower levels.

Answer 143

A

Testosterone is a hormone that plays a role in male sexual function, including ejaculation and orgasm. Although not all men with biochemically low testosterone levels suffer from delayed ejaculation, it is logical to hypothesize that the androgenic milieu has an influence on ejaculation and orgasm. In men with delayed orgasm and ejaculation and testosterone deficiency, clinicians may consider testosterone replacement therapy as per the 2018 AUA Guideline on the Management of Testosterone Deficiency. The target testosterone level during treatment should be at or above the 50th percentile (>500-550 ng/dl) unless positive response is achieved with lower levels. However, testosterone therapy is not indicated in men with delayed ejaculation and normal testosterone levels. Benefit from testosterone treatment should be evident within 90 days of the patient becoming eugonadal, and periodic follow-up is needed to gauge the need for continuing treatment. The choice of testosterone therapy should be patient-specific as available testosterone preparations in the USA differ in pharmacokinetics, costs, and side-effects profile.

Answer 144

A

D. Medications (e.g. SSRI, SNRI) are a common risk factor for both erectile dysfunction and delayed ejaculation.

Answer 145

A

B. When DE precedes the onset of ED, the focus should be on defining the etiologies of DE and trying to determine if they have played a role in the development of ED and address any etiological factors appropriately.

Answer 146

A

Common risk factors for delayed ejaculation include medications (e.g. SSRI, SNRI), endocrine conditions (e.g., T deficiency, hyperprolactinemia), penile sensation loss, and psychological factors (e.g., anxiety, depression, relationship stress). To address these risk factors in treatment, clinicians should first identify the underlying cause of delayed ejaculation and address it appropriately. For example, if the patient is taking medications that are known to cause delayed ejaculation, the clinician may consider adjusting the dosage or switching to an alternative medication. Similarly, if the patient has an endocrine condition that is contributing to their delayed ejaculation, such as low serum T, the clinician may recommend hormone therapy. Addressing psychological factors may involve counseling or therapy to help the patient manage anxiety or relationship stress that may be contributing to their delayed ejaculation.

Answer 147

A

d. None of the above. No published, peer-reviewed data exists supporting any of these approaches.

Answer 148

A

b. Penile sensation loss. Penile vibratory stimulation has been suggested as a potential management strategy in men with DE, particularly in men with a penile sensory deficit.

Answer 149

A

Guideline 1: 1. Poor ejaculatory control

Associated bother
Ejaculation within 2 minutes since sexual debut

Answer 150

A

Guideline 2: 1. Poor ejaculatory control

Associated bother
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

Answer 151

A

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?

Answer 152

A

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.

Answer 153

A

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.

Answer 154

A

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)

Answer 155

A

Guideline 7: Premature ejaculation is NOT affected by circumcision status

Answer 156

A

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.

Answer 157

A

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

Answer 158

A

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

Answer 159

A

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

Answer 160

A

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

Answer 161

A

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

Answer 162

A

Guideline 16: 1. Should be lifelong and consistent

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

Answer 163

A

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

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

Answer 164

A

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

Answer 165

A

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

Answer 166

A

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

Answer 167

A

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.

Answer 168

A

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.

Answer 169

A

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)

Answer 170

A

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

Answer 171

A

Patient and partner satisfaction

Answer 172

A

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
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
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)

Answer 173

A

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

Answer 174

A

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)

Answer 175

A

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

Answer 176

A

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

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Disorders of Ejaculation: An AUA/SMSNA Guideline (2020) Flashcards

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