Ejaculation latency times and their relationship to penile sensitivity in men with normal sexual function

Are the Criteria for the Diagnosis of Premature Ejaculation Applicable to Gay Men or Sexual Activities Other than Penile-Vaginal Intercourse?

Introduction

The criteria for premature ejaculation (PE) have generally been limited to the diagnosis of heterosexual men engaging in penile-vaginal intercourse and therefore the applicability of PE diagnostic criteria to gay men and to activities beyond penile-vaginal intercourse has yet to be explored in depth.

Aim

To compare the prevalence of PE in gay and straight men and to assess whether PE-related diagnostic measures (ejaculatory control, ejaculation latency [EL], and bother/distress) can be applied with confidence to gay men or to men engaging in sexual activities other than penile-vaginal intercourse.

Methods

Gay and straight participants (n = 3878) were recruited to take an online survey assessing sexual orientation, sexual function/dysfunction (including specific PE-related measures), sexual relationship satisfaction, and various other sexual behaviors during partnered sex or masturbation.

Outcomes

Comparison of ejaculatory control, EL, and bother/distress across gay and straight men, as well as across different types of sexual activities.

Results

A slightly lower PE prevalence among gay men became undetectable when other predictors of prevalence were included in a multivariate analysis (aOR = 0.87 [95% CI: 0.60–1.22]). Gay men with PE reported longer typical ELs (z_U = -3.35, P < .001) and lower distress (z_U = 3.68, P < .001) relative to straight men, but longer ELs and lower distress were also associated with anal sex.

Clinical Translation

Clinicians can feel confident about using existing criteria for the diagnosis of PE in gay men but should be aware of potentially longer ELs and lower PE-related bother/distress—probably related to the practice of anal sex—compared with straight men.

Strengths and Limitations

Although well-powered and international in scope, this study was limited by biases inherent to online surveys, the lack of a sizable sample of bisexual men, and a lack of differentiation between men with acquired vs lifelong PE.

Conclusions

Irrespective of sexual orientation, gay and straight men with PE reported shorter ELs, lower satisfaction, and greater bother/distress than functional counterparts. While PE-related diagnostic criteria (ejaculatory control, EL, and bother/distress) are applicable to gay men, accommodation for longer ELs and lower bother/distress in gay men should be considered.

McNabney SM, Weseman CE, Hevesi K, et al. Are the Criteria for the Diagnosis of Premature Ejaculation Applicable to Gay Men or Sexual Activities Other than Penile-Vaginal Intercourse?. Sex Med 2022;10:100516.

Premature Ejaculation Measures During Partnered Sex and Masturbation: What These Findings Tell Us About the Nature and Rigidity of Premature Ejaculation

Men with premature ejaculation (PE) during partnered sex (as defined by poor ejaculatory control) show significantly reduced PE symptomology during masturbation, but the reasons for this disparity are not clear. This study investigated the other two PE-related diagnostic criteria, namely ejaculatory latency (EL) and bother/distress, in order to explore possible explanations for this disparity between types of sexual activity. Specifically, 1,447 men with either normal or poor ejaculatory control were compared on EL parameters, bother/distress, and sexual satisfaction/pleasure during both partnered sex and masturbation. Results indicated that men with PE reported longer ELs during masturbation than partnered sex, in contrast with men without PE who reported shorter ELs during masturbation. Bother/distress was lower for both groups during masturbation, but bother/distress in men with PE during masturbation was comparable to that of men without PE during partnered sex. Minimal difference in these patterns was found across lifelong and acquired PE subtypes, whereas men with PE with comorbid erectile dysfunction appeared to represent a distinct group. These findings have implications for PE management or treatment as well as for the overall conceptualization of PE as a pathophysiological condition.

The Unfinished Business of Defining Premature Ejaculation: The Need for Targeted Research

INTRODUCTION

Fifteen years have passed since the International Society of Sexual Medicine first established the 3-pronged criteria for premature ejaculation (PE): a short ejaculation latency, lack of ejaculatory control, and bother/distress. Although the process of establishing valid criteria for any condition or disorder is an ongoing one, a dearth of targeted research on these criteria has hindered professional societies from updating and revising them.

OBJECTIVES

To review and critique existing criteria used in the diagnosis of PE, to identify specific problems with them, and to recommend studies that will address shortcomings.

METHODS

Each of the PE criteria was evaluated and compared against standard procedures for establishing validated measures. Following each analysis, targeted research to address the gaps has been recommended.

RESULTS

Each PE criterion has shortcomings and each can be improved by using standard validation procedures, as noted by the targeted research outcomes. Professional societies can play an important role by encouraging broad participation in research that generates new and relevant data supporting, validating, or challenging the existing criteria.

CONCLUSION

The concepts underlying the diagnostic criteria for PE have both broad consensus and functional utility. Nevertheless, much of the research investigating PE has uncritically adopted these criteria without concomitantly recognizing their limitations. These limitations prevent determining accurate prevalence rates, interpreting research findings with confidence, and establishing efficacious treatment outcomes. Rowland DL, Althof SE, McMahon CG. The Unfinished Business of Defining Premature Ejaculation: The Need for Targeted Research. Sex Med Rev 2021;XX:XXX-XXX.

Sensation-preserving clitoral reduction surgery: A preliminary report of our experience

BACKGROUND

The knowledge that preservation of clitoral sensation is essential for future sexual satisfaction gave rise to sensation-preserving clitoral reduction surgery. We present our results of sensation-preserving clitoral reduction procedure in the small group of patients.

AIMS AND OBJECTIVES

To show our technique and result of sensation-preserving clitoral reduction surgery.

MATERIALS AND METHODS

This is a retrospective study of cases with clitoromegaly, over a 5-year period, in which sensation-preserving clitoral reduction procedure was done by us at our centre. Demographics, indication for clitoral reduction, operative procedure, operative time, any intraoperative difficulty or problem, anaesthesia type, post-operative stay and outcome were analysed. Pre-operative and post-operative evaluation for clitoral viability done in all the cases, and evaluation for clitoral sensory testing and vibratory sensory testing done in selected cases.

RESULTS

A total of eight cases were operated in the last 5 years. Five were due to congenital adrenal hyperplasia. Immediate post-operative period was uneventful in all. Cosmetic appearance and viability were satisfactory in all the cases. In five cases, clitoral sensory testing and vibratory sensory testing were done, an average degree of sensation of 3.2 at the labia minora and 4.7 at the clitoris and an average values clitoral vibratory sensory testing for the introitus, clitoris, labia and thigh were 3.56, 1.61, 5.08 and 5.83, respectively.

CONCLUSIONS

Clitoral enlargement in girls is a rare problem. Sensation-preserving ventral clitoral reduction surgery leads to preservation of neurovascular bundles leads to acceptable cosmesis and preserved sensation.

Do the diagnostic criteria for premature ejaculation apply to non-straight men and to sexual activities other than penile-vaginal intercourse?

Professional standards committees have generally applied the diagnostic criteria for premature ejaculation only to situations involving (presumed) heterosexual men having penile-vaginal intercourse. This paper reviews the existing evidence supporting expansion of the criteria for use among non-straight men engaging in sexual activities that do not include vaginal intercourse. In brief, estimated ejaculation latencies appear similar across men identifying with different sexual orientations, and various partnered sexual activities (oral, vaginal, and manual) tend to be well correlated. In contrast, masturbation latency patterns are different between men with and without premature ejaculation, and ejaculatory control and bother/distress may be less critical to gay men than straight men during partnered sex. Finally, it should be noted that existing patient report outcomes (PROs) require modification for use with non-straight men.

Advantages and limitations of current premature ejaculation assessment and diagnostic methods: a review

Premature ejaculation (PE) is the most common male sexual dysfunction worldwide. Characteristic symptoms of PE are unexpected, rapid, complete ejaculation, which negatively impacts the sexual act for both sexual partners. Despite the existence of a definitive PE classification system and various diagnostic tools, diagnosing PE is still challenging due to the limitations associated with the assessment of this condition. Hence, it is necessary to review the diagnostic methods and processes of the physical examination that are currently performed in the medical setting. It is also important to analyze any controversial results of each main PE assessment method and propose novel diagnostic and assessment methods. To date, it is important to verify the accuracy of the PE evaluation method due to the ambiguity of previous definitions and proven invalidity of current examining techniques. Clinical diagnosis is based mainly on the patient history, patient-reported outcome scores, and diagnostic tools. Introduction of intravaginal ejaculatory latency time, penile biothesiometry, and the electrophysiological test provided objective means of evaluating PE. Due to the controversial and inconclusive findings in PE psychogenic and neurogenic etiology, utilizing a single parameter to describe and qualify PE using the aforementioned diagnostic methods provides valuable, but insufficient information for PE diagnosis. There is still a lack of a feasible and plausible means of objective measurement to evaluate the ejaculatory latency and control over ejaculation. Consequently, a comprehensive penile stimulation that simulates sexual intercourse could be useful to record intensity and duration parameters before the ejaculatory threshold, providing a more accurate method of describing and diagnosing PE versus a single chronological observation.

Cyberphysical Human Sexual Behavior Acquisition System (SeBA): Development and Implementation Study in China

Background

Sexual health is one of the principal components of human well-being. Traditional methods for observing human sexual behavior typically adopt manual intervention approaches (eg, interviews). However, the data obtained by such traditional approaches suffer from intrinsic bias and limited sample sizes. Sexual behavioral data that are more reflective of the actual situation can be collected by equipping sex toys with sensors.

Objective

To address the limitations of traditional human sexual behavior data observation methods, a novel cyberphysical system is proposed to capture natural human sexual behavior data in China at the nationwide level.

Methods

A cyberphysical human sexual behavior acquisition system (SeBA) was designed and implemented. SeBA jointly utilizes state of the art information and communication technologies such as smart sex toys, smartphones, and mobile social networks. Smart sex toys enable objective collection of data on human sexual behavior, while the mobile social network provides the possibility of partnered sex in a cyberphysical manner. The objectives and function settings are discussed, and the overall framework of the system architecture is presented.

Results

Operation and privacy policies are proposed and the technical solution of SeBA is described. The effectiveness of SeBA was verified based on analysis of users’ human sexual behavior data collected from January 2016 to June 2017. A total of 103,424 solo sexual behaviors were recorded involving 13,047 users, and 61,007 partnered sexual behaviors from 7,140 users were observed. The proportions of males and females in the solo and partnered sex groups were fairly consistent with recent statistics on unmarried individuals in China. We also found that only a small portion of individuals provided information on at least one other attribute besides the required input of gender, such as age, height, location, job, sex preferences, purposes, and interests.

Conclusions

To the best of our knowledge, this is the first study to analyze objective human sexual behavior data at the nationwide level. Although the data are restricted to China, this study can provide insight for further research on human sexual behavior based on the huge amount of data available from wireless smart sex toys worldwide. It is anticipated that findings from such objective big data analyses can help deepen our understanding of sexual behavior, as well as improve sexual health and sexual wellness.

Penile Sensory Changes After Plaque Incision and Grafting Surgery for Peyronie's Disease

INTRODUCTION

Plaque incision and grafting (PIG) for Peyronie's disease (PD) is not devoid of complications such as erectile dysfunction and penile sensory changes.

AIM

To define the rate and chronology of penile sensation loss after PIG surgery and to define predictors of such.

METHODS

The study population consisted of patients with PD-associated penile curvature who underwent PIG surgery with at least 6 months of follow-up. Demographics and PD factors were recorded. Patient had preoperative assessment of penile sensation and deformity. Postoperative follow-up occurred at 1 week, 1 month, 6 months, and 1 year after surgery. Neurovascular bundle elevation was conducted with loupe magnification.

MAIN OUTCOME MEASURE

Penile sensation was evaluated with a biothesiometer and graded on a patient-reported visual analog scale (0-10) in which 0 defined a completely numb area and 10 defined perfect sensation. The degree of sensation loss was defined as extensive (any 1 area >5 cm), major (2-5 cm), and minor (≤2 cm). The penile sensation loss distribution was defined as focal (1 site) or diffuse (>1 site).

RESULTS

63 patients were analyzed. Mean age was 56 ± 10 years. Mean duration of PD at the time of PIG was 15 ± 7 (12-38) months. 75% had curvature alone, and 25% had hourglass/indentation deformities. Mean primary curvature was 64˚ ± 28˚. The mean operation duration was 3.5 ± 1.8 hours. 21% had some degree of sensation loss at 1 week, 21% at 1 month, 8% at 6 months, and 3% at 12 months. Only 1 patient (1.5%) at 2 years continued to have extensive sensation loss on the glans and distal shaft with a very elevated sensitivity threshold. Using multivariable analysis, the only predictor of penile sensation loss ≥6 months was a duration of operation >4 hours (odds ratio = 2.1; 95% confidence interval = 1.2-3.0; P < .01).

CLINICAL IMPLICATIONS

The study highlights the need during patient consent to discuss penile sensation loss. Patients should be informed that rates of penile sensation loss ranges from 2-30% and most patients will have complete resolution of any sensation loss within one year of follow-up.

STRENGTH AND LIMITATIONS

To our knowledge no other studies have described the chronology and severity of penile sensation following PIG, our study demonstrates the utility of biothesiometry in measuring penile sensation before and after PIG. Number of patients and absence of control group represent a limitation.

CONCLUSION

Sensation loss is not uncommon after PIG surgery. It decreases in frequency and severity with time with only rare cases occurring >12 months. Longer operations appeared to be more likely associated with sensation loss. Terrier JE, Tal R, Nelson CJ. Penile sensory changes after plaque incision and grafting surgery for Peyronie's disease. J Sex Med 2018;15:1491-1497.

New Tools to Measure Ejaculatory Latency-Arousal to Ejaculation Time Interval and Erection to Ejaculation Time Interval: A Pilot Study

OBJECTIVE

The present study aimed to evaluate the proposed novel tools, namely, arousal to ejaculation time interval (AETI) and erection to ejaculation time interval (EETI), and to measure ejaculatory latency during different types of sexual encounters in a pilot study.

MATERIALS AND METHODS

The study period was from September 2016 to December 2016. After obtaining informed consent and institutional review board approval, the medical practitioners without any comorbidity and who volunteered to participate were asked to report their self-assessed AETI and EETI during a sexual activity. They were also asked to opine as to whether they consider themselves as normal ejaculators, delayed ejaculators, or premature ejaculators. Statistical data including mean, standard deviation, and P value were obtained.

RESULTS

The sample size was 60 with a mean age of 48.9 ± 10.8 years. A total of 48 participants reported themselves as normal. Their mean AETIs were 624.8 ± 83.6 seconds, 700 ± 79.1 seconds, and 420 ± 57.7 seconds, and their mean EETIs were 355 ± 82.6 seconds, 442.5 ± 46.6 seconds, and 240 ± 38.6 seconds during heterosexual vaginal intercourse, masturbation, and oral sex, respectively. Twelve participants reported premature ejaculation, and their mean AETIs were 122 ± 11.6 seconds, 73.33 ± 11.2 seconds, and 74 ± 12.3 seconds, and their mean EETIs were 106.7 ± 21.6 seconds, 70 ± 13.7 seconds, and 60 ± 11.8 seconds during heterosexual vaginal intercourse, masturbation, and oral sex, respectively. None of the participants reported themselves as delayed ejaculators. The differences between the means were statistically significant (P ≤.0001).

CONCLUSION

AETI and EETI can be used to measure ejaculatory latency in different types of sexual encounters.

Penile sensory thresholds in subtypes of premature ejaculation: implications of comorbid erectile dysfunction

Penile hypersensitivity plays an important role in premature ejaculation (PE), but differences in penile sensitivity among subtypes of PE are unknown. Therefore, we compared penile sensory thresholds in PE subtypes of lifelong and acquired PE, PE with and without erectile dysfunction (ED), PE with an intravaginal ejaculation latency time ≤1 min and >1 min, and PE with and without orgasmic pleasure perceptual dysfunction. During August 2014 to January 2016, 136 patients with PE were included. Penile warm, cold, and vibratory thresholds were measured. Data of clinical characteristics, sexual life, Premature Ejaculation Diagnostic Tool (PEDT) score, and the 5-item version of the International Index of Erectile Function (IIEF-5) score were collected. Vibratory thresholds of the PE with ED group were higher in the right coronal sulcus (median amplitude: 4.92 vs 3.65 μ m, P = 0.02) and the right penile shaft (median amplitude: 3.87 vs 3.30 μ m, P = 0.03), while differences in penile sensory thresholds between other subtypes were not significant. The median PEDT score was lower in the PE without ED group (12 vs 14, P < 0.001). The IIEF-5 and PEDT scores were negatively correlated (r = -0.29, P < 0.001). Patients with orgasmic pleasure perceptual dysfunction had a lower median IIEF-5 score (20 vs 21, P = 0.02). Patients with PE and ED had lower penile sensitivity, and ED was associated with more severe symptoms and weaker orgasmic pleasure perception. In men with PE, management of comorbid ED is necessary. In case of side effects in erectile function, topical anesthetics should be cautiously used in men with PE and ED.

Significance of penile hypersensitivity in premature ejaculation

To assess the correlation between penile hypersensitivity and premature ejaculation (PE), a total of 420 consecutive subjects attending our andrologic clinic for suspected PE were enrolled. The entire cohort was asked to complete the self-report intravaginal ejaculation latency time (IELT) by stopwatch. According to the IELT, the subjects were classified into 3 groups. Vibratory thresholds were recorded at the glans penis and penile shaft using a biothesiometer. We found that vibratory thresholds in the glans penis and penile shaft were significantly lower in both mild and severe PE group than in the control group (3.81 ± 0.57 and 3.54 ± 0.43 vs 4.73 ± 0.77 for glans penis p = 0.000; 3.64 ± 0.52 and 3.37 ± 0.50 vs 4.62 ± 0.69 for penile shaft p = 0.002). The vibratory threshold decreased as the disease aggravated. In the mild and severe PE groups, a significant positive correlation was detected between the mean values of IELT and the vibratory thresholds. Furthermore, in the receiver operating characteristics curve analysis, the area under the curve of the glans penis and penile shaft vibratory thresholds predicting severe PE were 0.852 and 0.893 respectively. Our study established a dose-dependent association between penile vibratory threshold and PE. Therefore, the vibratory threshold can serve as a potential marker for predicting the severity of PE.

Histological Correlates of Penile Sexual Sensation: Does Circumcision Make a Difference?

INTRODUCTION

The question of whether removal of sensory receptors in the prepuce by circumcision affects sensitivity and/or sexual pleasure is often debated.

AIMS

To examine histological correlates relevant to penile sensitivity and sexual pleasure.

METHODS

Systematic review of the scientific literature on penile structures that might affect sensitivity and sexual sensation. Articles were included if they contained original data on human male penile histology or anatomy. Individual articles, including reference lists, were evaluated. They were then considered in relation to physiological data from articles retrieved by a previous systematic review.

RESULTS

We retrieved 41 publications on penile structure. Considered in the light of 12 reporting physiological measurements, our evaluation finds that sexual response is unlikely to involve Meissner's corpuscles, whose density in the prepuce diminishes at the time of life when male sexual activity is increasing. Free nerve endings also show no correlation with sexual response. Because tactile sensitivity of the glans decreases with sexual arousal, it is unrelated to sexual sensation. Thermal sensitivity seems part of the reward mechanism of intercourse. Vibrational sensitivity is not related to circumcision status. Observations that penile sexual sensation is higher post circumcision are consistent with greater access of genital corpuscles to sexual stimuli after removal of the prepuce. This is based on the distribution of these corpuscles (which are located in the glans) and, in uncircumcised men, the position of the retracted prepuce during intercourse, rather than any change in the number of genital corpuscles. The scientific literature suggests that any sexual effect of circumcised men may depend solely on exposure of the glans and not on the absence of the prepuce.

CONCLUSION

Based on histological findings and correlates of sexual function, loss of the prepuce by circumcision would appear to have no adverse effect on sexual pleasure. Our evaluation supports overall findings from physiological measurements and survey data.

The effect of condoms on penile vibrotactile sensitivity thresholds in young, heterosexual men

INTRODUCTION

Investigating the ways in which barrier methods such as condoms may affect penile sensory thresholds has potential relevance to the development of interventions in men who experience negative effects of condoms on sexual response and sensation. A quantitative, psychophysiological investigation examining the degree to which sensations are altered by condoms has, to date, not been conducted.

AIM

The objective of this study was to examine penile vibrotactile sensitivity thresholds in both flaccid and erect penises with and without a condom while comparing men who do and those who do not report condom-associated erection problems (CAEP).

METHODS

Penile vibrotactile sensitivity thresholds were assessed among a total of 141 young, heterosexual men using biothesiometry. An incremental two-step staircase method was used and repeated three times for each of four conditions. Intra-class correlation coefficients (ICCs) were calculated for all vibratory assessments. Penile vibratory thresholds were compared using a mixed-model analysis of variance.

MAIN OUTCOME MEASURES

Penile vibrotactile sensitivity thresholds with and without a condom, erectile function measured by International Index of Erectile Function Questionnaire, and self-reported degree of erection.

RESULTS

Significant main effects of condoms (yes/no) and erection (yes/no) were found. No main or interaction effects of CAEP were found. Condoms were associated with higher penile vibrotactile sensitivity thresholds (F[1,124] = 17.11, P < 0.001). Penile vibrotactile thresholds were higher with an erect penis than with a flaccid penis (F[1,124] = 4.21, P = 0.042).

CONCLUSION

The current study demonstrates the feasibility of measuring penile vibratory thresholds with and without a condom in both erect and flaccid experimental conditions. As might be expected, condoms increased penile vibrotactile sensitivity thresholds. Interestingly, erections were associated with the highest thresholds. Thus, this study was the first to document that erect penises are less sensitive to vibrotactile stimulation than flaccid penises.

Standard operating procedures for neurophysiologic assessment of male sexual dysfunction

INTRODUCTION

Can neurophysiological testing in male patients with sexual dysfunction benefit the decision-making process? The answer remains unclear.

AIM

To provide standard operating procedures for the neurophysiologic assessment of male sexual dysfunction.

METHODS

Medical literature was reviewed and combined with expert opinion of the authors.

RESULTS

Bulbocavernosus reflex latency time, pudendal somatosensory evoked potentials, and sympathetic skin responses have been considered as potential candidates for the diagnosis and assessment of erectile dysfunction (ED). Currently, there is no consensus on a standardized methodology for these neurophysiological investigations in the overall assessment of ED. These procedures are unable to assess the integrity of the efferent parasympathetic proerectile penile innervation; accordingly, none of these assessment procedures is recommended for ED patients. Corpus cavernosum electromyography (CC-EMG) can detect abnormalities in cavernous smooth muscle although these alterations can be attributed both to damage to autonomic penile innervation and to degenerative processes of the cavernous smooth muscle. CC-EMG is still considered experimental. Evidence does not support that men with premature ejaculation (PE) are consistently characterized by penile hypersensitivity; accordingly, penile threshold determination is not recommended to in the diagnosis of PE. Neurophysiological investigation of other components of the penile sensory pathways in PE patients has not provided any definitive contribution to the diagnosis.

CONCLUSION

No neurophysiological assessment procedures yield additional information that consistently aids in the assessment of PE and ED.

Neuroanatomy and neurophysiology related to sexual dysfunction in male neurogenic patients with lesions to the spinal cord or peripheral nerves

STUDY DESIGN

Review article.

OBJECTIVES

The neuroanatomy and physiology of psychogenic erection, cholinergic versus adrenergic innervation of emission and the predictability of outcome of vibration and electroejaculation require a review and synthesis.

SETTING

University Hospital Belgium.

METHODS

We reviewed the literature with PubMed 1973-2008.

RESULTS

Erection, emission and ejaculation are separate phenomena and have different innervations. It is important to realize, which are the afferents and efferents and where the motor neuron of the end organ is located. When interpreting a specific lesion it is important to understand if postsynaptic fibres are intact or not. Afferents of erection, emission and ejaculation are the pudendal nerve and descending pathways from the brain. Erection is cholinergic and NO-mediated. Emission starts cholinergically (as a secretion) and ends sympathetically (as a contraction). Ejaculation is mainly adrenergic and somatic. For vibratory-evoked ejaculation, the reflex arch must be complete; for electroejaculation, the postsynaptic neurons (paravertebral ganglia) must be intact.

CONCLUSION

Afferents of erection, emission and ejaculation are the pudendal nerve and descending pathways from the brain. Erection is cholinergic and NO-mediated. Emission starts cholinergically (as a secretion) and ends sympathetically (as a contraction). Ejaculation is mainly adrenergic and somatic. In neurogenic disease, a good knowledge of neuroanatomy and physiology makes understanding of sexual dysfunction possible and predictable. The minimal requirement for the success of penile vibration is a preserved reflex arch and the minimal requirement for the success of electroejaculation is the existence of intact post-ganglionic fibres.

Perceived ejaculatory latency and pleasure in different outlets

INTRODUCTION

Ejaculatory latencies have been studied in coitus and with masturbation, but not with oral or manual stimulation by a partner.

AIM

The present study extended research on ejaculatory latency to these outlets, and investigated the effect of perceived pleasure on self-reported ejaculatory latency.

METHOD

A convenience sample of male college students, not selected for sexual dysfunction, completed questionnaires assessing the outcome measures.

MAIN OUTCOME MEASURES

Self-report measures of latency to ejaculation in, and perceived pleasure associated with, four different outlets (vaginal intercourse, oral intercourse, manual stimulation by a partner, and masturbation).

RESULTS

Ejaculatory latencies in partnered activities were predictive of each other. Masturbatory latencies were predictive of coital latencies but not oral or manual stimulation latencies; all the partnered activities were predictive of each other. There was no difference in time to ejaculation among any of the partnered outlets, although ejaculation occurred more quickly with masturbation than with coitus or manual stimulation. In terms of pleasure associated with the outlets, vaginal and oral intercourse were perceived as equally pleasurable, and both were rated as more pleasurable than manual stimulation or masturbation, which did not differ from each other.

CONCLUSIONS

These results suggest that rapidity of ejaculation is consistent across outlets for the partnered sexual activities, and that there is little unique-in terms of ejaculatory latency--about vaginal intercourse compared with oral or manual stimulation by a partner. Masturbation, however, does differ from the partnered activities. Although the average correlation, for individuals, between latency and pleasure for the different outlets is near zero, there are subgroups of men who have (i) a negative relation, (ii) a positive relation, or (iii) no relation. Results show that men, for whom greater pleasure is associated with shorter latency, are more likely to be dissatisfied with their intravaginal ejaculatory latencies, regardless of actual latency.

Premature ejaculation: current and future treatments

Premature ejaculation (PE) is recognized to be the most common male sexual disorder. PE provides difficulties for professionals who treat this condition because there is neither a universally accepted definition nor a medication approved by the Food and Drug Administration (FDA). Despite these shortcomings, physicians continue to diagnose their patients with PE according to major guidelines and treat them with either behavioral therapies or off-label medications. This review focuses on current and emerging treatment options and medications for PE. Advantages and limitations of each treatment option are discussed in the light of current published peer-reviewed literature.

The Role of Phosphodiesterase Type 5 Inhibitors in the Management of Premature Ejaculation: A Critical Analysis of Basic Science and Clinical Data

OBJECTIVES

To assess the usefulness of the phosphodiesterase type 5 inhibitors (PDE5-Is) in the treatment of premature ejaculation (PE) and to describe possible mechanisms to explain their effect.

METHODS

A MedLine search was performed for peer-reviewed articles on the role of PDE5-Is in managing PE. No meta-analysis method was used.

RESULTS

Five manuscripts that examined the efficacy of PDE5-Is in the treatment of PE were retrieved. Three studies used sildenafil as monotherapy and two used it in combination with a serotonin selective reuptake inhibitor (SSRI). Three studies demonstrated a beneficial effect of sildenafil in the treatment of PE, as measured by intravaginal ejaculatory latency time (IELT) and by different questionnaires assessing the patients' subjective feelings of ejaculatory control, sexual satisfaction, and anxiety. One study showed the superiority of sildenafil compared to other modalities. Two studies showed that combination therapy of paroxetine and sildenafil was better than paroxetine alone. One study did not demonstrate a beneficial effect of sildenafil in prolonging IELT, but showed that sildenafil improved patients' perception of ejaculatory control. Another study showed that topical anesthetics were better than sildenafil in the treatment of PE but did not use IELT or a validated questionnaire to measure the efficacy of treatment. Several possible mechanisms could explain effectiveness of the PDE5-Is for treatment of PE: centrally, through the effect on the nitric oxide/cyclic guanosine monophosphate pathway; peripherally by causing relaxation of smooth muscle in the vas deferens, seminal vesicles, prostate, and urethra and inhibition of adrenergic transmission; or locally by inducing peripheral analgesia. Another possibility might be prolongation of the duration of erection.

CONCLUSIONS

Encouraging evidence supports the role of PDE5-Is for treating PE. Possible therapeutic mechanisms of action of PDE5-Is are multiple and complex and include central and peripheral effects. A large population, multicenter, randomized, double-blind, placebo-controlled study is needed to elucidate the efficacy of PDE5-Is in the treatment of PE.

Nerve Sparing Ventral Clitoroplasty: Analysis of Clitoral Sensitivity and Viability

PURPOSE

Enlargement of the clitoris is often a prominent manifestation of virilizing congenital adrenal hyperplasia and other disorders of sexual development. Controversy persists regarding the viability and sensitivity of the clitoris following clitoroplasty. We present 51 consecutive cases of nerve sparing ventral clitoroplasty performed by a single surgeon.

MATERIALS AND METHODS

Nerve sparing ventral clitoroplasty was performed in all patients. Postoperative evaluation for clitoral viability included gross examination and capillary perfusion testing. Patients older than 5 years were evaluated for clitoral sensory testing and vibratory sensory testing.

RESULTS

A total of 51 patients 4 months to 24 years old (mean age +/- SD 4.6 +/- 6.8 years) with clitorimegaly underwent nerve sparing ventral clitoroplasty. Of the patients 41 had capillary perfusion testing of the clitoris, of whom all had a viable clitoris. Ten of the 41 patients underwent clitoral sensory testing. Patients reported an average degree of sensation of 3.6 +/- 0.9 at the labia minora and 4.8 +/- 0.4 at the clitoris. Nine of the 10 patients also underwent vibratory sensory testing. Average values for the introitus, clitoris, labia and thigh were 3.56, 1.61, 5.08, and 5.83, respectively. Mean time after surgery for the patients who underwent clitoral sensory testing/vibratory sensory testing was 2.0 +/- 0.8 years. No variations in the sensitivity results were reported at followup in 2 patients.

CONCLUSIONS

To our knowledge this is the largest report of followup testing of clitoral viability and sensation after clitoroplasty. Continued long-term followup is ongoing to document long-term sexual function using this nerve sparing ventral approach for clitoroplasty.

The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision as an Appropriate Diagnostic for Premature Ejaculation

INTRODUCTION

The Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision (DSM-IV-TR) criteria for premature ejaculation (PE) are multifactorial, and include concepts of latency, perceived control over ejaculation, and personal distress and interpersonal difficulty related to the condition. Recent publications have suggested that these criteria are not supported by empirical evidence, leading to the proposal that a PE diagnosis should be based solely on intravaginal ejaculatory latency time (IELT), while the presence of other factors (such as perceived lack of control over ejaculation) may be used to guide treatment decisions.

AIM

To examine the evidence supporting the elements of the DSM-IV-TR criteria for PE.

MAIN OUTCOME MEASURES

Literature searches on IELT, perceived control over ejaculation, and personal distress and interpersonal difficulty related to ejaculation.

RESULTS

From a historical perspective, there has been a lack of large observational studies that evaluated the contributions of the DSM-IV-TR components in men with PE. However, recently performed large observational studies have generated data supporting the inclusion of perceived control over ejaculation and personal distress related to ejaculation in the definition of PE. Furthermore, emerging evidence indicates that a perceived lack of control over ejaculation is directly associated with elevated personal distress related to ejaculation and decreased satisfaction with sexual intercourse, while the effects of IELT on these parameters are indirect, and mediated by perceived control over ejaculation. A key advantage of the DSM-IV-TR approach to the diagnosis of PE is that it firmly links PE to a negative outcome for the patient, which is an element common to diagnostic criteria for other conditions, including depression, hypertension, and osteoporosis.

CONCLUSIONS

This new evidence strongly suggests that the DSM-IV-TR criteria for PE encompass aspects of the condition that patients describe as important.