Advances in understanding and treating premature ejaculation

Daily intake of 30 mg duloxetine is effective in decreasing premature ejaculation severity: a prospective randomized placebo-controlled cross over clinical trial

BACKGROUND

Premature ejaculation (PE) is considered to be the most common male sexual disorder affecting 20% to 66% of sexually active men. Most of the patients had already tried on demand dapoxitine with no improvement. We aimed in the current study to assert the efficacy and safety profile of daily intake of 30 mg duloxetine in treating patients with lifelong premature ejaculation (LPE) as well as patients with acquired premature ejaculation (APE).

RESULTS

The current study showed significant improvement in intravaginal ejaculatory latency time (IELT) after intake of duloxetine. All participants had a median Arabic index of premature ejaculation (AIPE) of 26, median IELT of 180 s, median male sexual quality of life (SQOL) of 43 after being treated with duloxetine (p value < 0.001 for all). While median AIPE after placebo was 19, median IELT after placebo was 60 s and median male SQOL after placebo was 21. Paired comparison of AIPE, IELT (Secs), inter quartile range (IQR) and male SQOL in group (A) patients at baseline and after duloxetine intake showed statistically significant improvement among treated patients (p values < 0.001 for all). Paired comparison of AIPE, IELT (Secs), IQR and male SQOL in group (A) patients at baseline and after placebo treatment showed no significant improvement of male SQOL. Furthermore, AIPE and IELT returned to baseline scores after discontinuation of duloxetine (p values 0.729; 0.892, respectively). Paired comparison of AIPE, IELT (Secs), IQR and male SQOL in group (B) patients at baseline and after placebo treatment showed almost same scores of patients in group (A) who received placebo for 2 months after a 2 month washout period (p values 1.000 for all). Paired comparison of AIPE, IELT (Secs), IQR and male SQOL in group (B) patients at baseline and after duloxetine treatment showed statistically significant improvement among all treated patients (p values < 0.001 for all).

CONCLUSION

Duloxetine is an effective drug for treatment of LPE and APE patients. Further, larger studies are needed to compare duloxetine to different known therapeutic modalities for PE to assert it's efficacy and superiority.

A novel on-demand therapy for lifelong premature ejaculation using a miniature transperineal electrical stimulator-the vPatch: an as-treated analysis

BACKGROUND

While premature ejaculation (PE) is a common and disturbing sexual dysfunction in men, current available treatment modalities have limited efficacy and low treatment adherence.

AIM

To assess the feasibility, safety, and efficacy of the vPatch, a miniaturized on-demand perineal transcutaneous electrical stimulation device for treating PE.

METHODS

This prospective bicenter international first-in-human clinical study consisted of 2 arms, was sham controlled, and had a randomized double-blind design. In terms of statistical power calculation, 59 patients aged 21 to 56 years (mean ± SD, 39.8 ± 9.28) with lifelong PE were included. During the initial visit, intravaginal ejaculatory latency time (IELT) was measured over a 2-week run-in period. Eligibility was confirmed in visit 2, based on IELT values, medical and sexual history, and patients' individualized sensory and motor activation thresholds during perineal stimulation with the vPatch. Patients were randomized to the active (vPatch) and sham device groups in a 2:1 ratio, respectively. The vPatch device's safety profile was determined by comparing the incidence of treatment-emergent adverse events. During visit 3, IELTs, Clinical Global Impression of Change scores, and Premature Ejaculation Profile questionnaire outcomes were recorded. Primary end points assessed vPatch device efficacy as mean change in geometric mean IELT; each person was compared with himself, with and without the device, and the sham group was compared with the active group.

OUTCOMES

Outcomes included changes in IELT and Premature Ejaculation Profile before and after treatment, last visit Clinical Global Impression of Change scores, and vPatch safety profile.

RESULTS

Of 59 patients, 51 completed the study: 34 in the active group and 17 in the sham group. The baseline geometric mean IELT significantly increased from 67 to 123 seconds (P < .01) in the active group, as compared with an insignificant increase from 63 to 81 seconds (P = .17) in the sham group. The increase in mean IELT in the active group was significantly higher than in the sham group (56 vs 18 seconds, P = .01). IELT significantly increased by 3.1 times in the active vs sham group. The mean ratio of fold change (active:sham) was 1.4, significantly different from 1.0 (P = .02). No serious adverse events were reported.

CLINICAL IMPLICATIONS

Therapeutic use of the vPatch during coitus may become an on-demand, noninvasive, and drug-free treatment for PE.

STRENGTHS AND LIMITATIONS

To our knowledge, this is the first rigorous study investigating whether transcutaneous electrical stimulation during coitus could improve the symptoms of men with lifelong PE. The study is limited by the small number of patients, the exclusion of patients with acquired PE, the short-term follow up, and the use of a device based on a theoretic mechanism of action.

CONCLUSION

We demonstrated the possibility to treat lifelong PE by prolonging coitus on demand, using electric stimulation of ejaculation muscles with the vPatch.Clinical trial registration: NCT03942367 (ClinicalTrials.gov).

Changes of insular function in lifelong premature ejaculation patients before and after SSRI administration

OBJECTIVE

Lifelong premature ejaculation (PE) is regarded as one of the most common male sexual dysfunction. We aimed to detect whether insula-related brain functional networks are altered in lifelong PE patients and whether such alterations are "normalised" after selective serotonin reuptake inhibitors (SSRI) administration.

METHODS

Twenty-three drug-naive lifelong PE patients and 30 healthy controls (HC) were recruited in current study. All subjects underwent resting-state functional magnetic resonance imaging (fMRI) scan at first. One hour after dapoxetine administration, all patients underwent fMRI scanning again. The degree centrality (DC), amplitude of low-frequency fluctuations (ALFF) and regional homogeneity (ReHo) analysis, and ROI-based functional connectivity (FC) analysis were applied to calculate the abnormalities in insula-related functions among three groups.

RESULTS

Compared to HC group, PE patients at baseline showed significantly altered DC, ALFF, and ReHo value of the bilateral insula, which subsequently showed a "normalised" trend after dapoxetine administration. Additionally, compared to HC group, PE patients at baseline showed significantly decreased FC between insula and precentral gyrus, inferior frontal gyrus, middle/inferior temporal gyrus, and caudate, while patients after dapoxetine administration showed increased insula-related FC in anterior cingulate cortex and decreased FC in thalamus and middle/inferior temporal gyrus. The main effects of dapoxetine were located in precentral gyrus, inferior frontal gyrus, caudate, and limbic system.

CONCLUSIONS

Our findings report altered brain mechanism of insula in lifelong PE patients and also indicate that dapoxetine can "normalise" the abnormal function of the insula to certain extent in lifelong PE patients.

Current and emerging treatment options for premature ejaculation

Premature ejaculation (PE) is a prevalent male sexual dysfunction. Current standard treatment regimens include behavioural therapies, topical anaesthetics, dapoxetine and other selective serotonin reuptake inhibitors (SSRIs). Most of the pharmacotherapeutic options target neurotransmitters (such as serotonin and oxytocin) that have a role in the ejaculation mechanism. However, these treatments are mildly effective and only provide a temporary delay in the ejaculation latency time, and PE recurs when the treatment is stopped. Thus, a treatment for PE is urgently needed and research is ongoing to find the ideal PE therapy. The efficacy and safety of topical anaesthetics and SSRIs in delaying ejaculation have been confirmed in many well-designed controlled trials. Both preclinical and clinical studies on new-generation SSRIs are ongoing. Moreover, promising results came from clinical trials in which the efficacy of on-demand PE therapies targeting neurotransmitters other than serotonin, such as α1-adrenoceptor antagonists and oxytocin antagonists, was assessed. Surgical intervention and neuromodulation have been proposed as potential treatment options for PE; however, current PE guidelines do not recommend these treatments owing to safety concerns.

Premature Ejaculation and Endocrine Disorders: A Literature Review

Premature ejaculation (PE) is the most common male sexual dysfunction, with 30% of men experiencing PE worldwide. According to the generally accepted classification, there are two types of PE: lifetime PE and acquired PE. Various biological and psychological causes are known to be involved in the etiology of PE. However, due to the incomplete definition and etiopathogenesis of PE, there is no effective treatment. Although clinical and animal studies indicate that hormones play a role in controlling the ejaculation process, the precise endocrine mechanisms are unclear. In addition, little is known about the role of endocrine disorders in PE etiology. However, there is evidence that diabetes mellitus (DM), obesity, metabolic syndrome (MetS), thyroid gland disorders, pituitary gland disorders, and vitamin D deficiency affect the prevalence of PE. Moreover, it has been reported that the prevalence of PE decreases with treatment of these endocrine disorders. In this review, the relationship between PE and DM, MetS, obesity, vitamin D deficiency, and thyroid and pituitary gland disorders is summarized.

Reconfiguration of Dynamic Functional Connectivity States in Patients With Lifelong Premature Ejaculation

Purpose: Neuroimaging has demonstrated altered static functional connectivity in patients with premature ejaculation (PE), while studies examining dynamic changes in spontaneous brain activity in PE patients are still lacking. We aimed to explore the reconfiguration of dynamic functional connectivity (DFC) states in lifelong PE (LPE) patients and to distinguish LPE patients from normal controls (NCs) using a machine learning method based on DFC state features. Methods: Thirty-six LPE patients and 23 NCs were recruited. Resting-state functional magnetic resonance imaging (fMRI) data, the clinical rating scores on the Chinese Index of PE (CIPE), and intravaginal ejaculatory latency time (IELT) were collected from each participant. DFC was calculated by the sliding window approach. Finally, the Lagrangian support vector machine (LSVM) classifier was applied to distinguish LPE patients from NCs using the DFC parameters. Two DFC state metrics (reoccurrence times and transition frequencies) were introduced and we assessed the correlations between DFC state metrics and clinical variables, and the accuracy, sensitivity, and specificity of the LSVM classifier. Results: By k-means clustering, four distinct DFC states were identified. The LPE patients showed an increase in the reoccurrence times for state 3 (p < 0.05, Bonferroni corrected) but a decrease for state 1 (p < 0.05, Bonferroni corrected) compared to the NCs. Moreover, the LPE patients had significantly less frequent transitions between state 1 and state 4 (p < 0.05, uncorrected) while more frequent transitions between state 3 and state 4 (p < 0.05, uncorrected) than the NCs. The reoccurrence times and transition frequencies showed significant associations with the CIPE scores and IELTs. The accuracy, sensitivity, and specificity of the LSVM classifier were 90.35, 87.59, and 85.59%, respectively. Conclusion: LPE patients were more inclined to be in DFC states reinforced intra-network and inter-network connection. These features correlated with clinical syndromes and can classify the LPE patients from NCs. Our results of reconfiguration of DFC states may provide novel insights for the understanding of central etiology underlying LPE, indicate neuroimaging biomarkers for the evaluation of clinical severity of LPE.

Premature ejaculation: An investigative study into assumptions, facts and perceptions of patients from the Middle East (PEAP STUDY)

Objective: To determine the prevalence of premature ejaculation (PE) in Qatar as a representative of the Middle East region and the population perception of normal ejaculation.

Subjects and methods: This study was a cross-sectional, observational, non-interventional, epidemiological study, conducted from February 2012 to February 2013. Randomly selected married males were asked to answer two questionnaires in a direct interview. The first questionnaire assessed the PE complaint, the time between ejaculation and intromission (actual intravaginal ejaculatory latency time [IELT-a]), and the perceived normal average time between intromission and ejaculation (IELT-p). The second questionnaire used was the Arabic Index of Premature Ejaculation (AIPE).

Results: A total of 3042 subjects were included. The mean (SD) age was 37.09 (9.1) years. The prevalence of PE in Qatar using the self-report and AIPE score was 38.5% and 36.2%, respectively. The median (interquartile range) IELT-a and IELT-p were 5 (3–13.5) and 15 (5–15) min. In the AIPE-confirmed PE group, and according to the AIPE severity classification, the differences in IELT-a and IELT-p between the severity groups were highly significant, with the duration of both IELT-a and ILET-p being higher in AIPE-No-PE and mild-PE groups (P < 0.001 for both). A negative correlation was found between AIPE score and age in the PE group.

Conclusion: The prevalence of PE in Qatar is high. PE prevalence was found to increase with age. The IELT and perception of normal IELT were both correlated with the severity of PE.

Clinical use of hyaluronic acid in andrology: A review

Background

Hyaluronic acid is a glycosaminoglycan widely used in the fields of orthopedics, ophthalmology, and aesthetic medicine due to its significant ability to reduce the synthesis of pro‐inflammatory proteins and its activity against oxidative stress, a feature of many degenerative illnesses.

Objectives

The objective of the present review is to provide a comprehensive narrative review of the most recent literature on the use of hyaluronic acid in andrology in order to facilitate the use of this therapeutic device in the common clinical practice of many physicians. Specific conditions covered in the review are Peyronie's disease, premature ejaculation, and penile enlargement.

Materials and methods

A broad and comprehensive literature search included Medline, EMBASE, and the Cochrane Libraries, with no time restriction up to December 2020 and restricted to English language publications. Unpublished studies were not included. The study was registered as “The role of hyaluronic acid in andrology: A systematic review and meta‐analysis” in PROSPERO with the ID CRD42021223416.

Discussion and conclusion

Hyaluronic acid is a valid choice for the treatment of Peyronie's disease in terms of the resolution of the acute phase of the disease and of contributing to stabilizing the disease as a bridge to potential surgery. Data, furthermore, suggest that hyaluronic acid is frequently associated with an overall clinical improvement, allowing the patient to resume normal sexual activity.

With regard to premature ejaculation, data suggests hyaluronic acid‐based treatments were effective in prolonging intra‐vaginal ejaculation time. Furthermore, hyaluronic acid was found to be safe and well‐tolerated, with main adverse events limited to local discomfort, ecchymosis, papule formation, and glans numbness, all of which were reported to resolve spontaneously.

Last, with regard to penile enlargement, the overall perception of experts is that hyaluronic acid may be an extremely well‐tolerated compound with potential for application in specific areas of male sexual health that are often neglected as compared to more common, and relatively simpler to treat, conditions.

Self-Reported Shorter Than Desired Ejaculation Latency and Related Distress-Prevalence and Clinical Correlates: Results From the European Male Ageing Study

BACKGROUND

Few data have looked at the occurrence and clinical correlates of self-reported shorter than desired ejaculation latency (rapid ejaculation, RE) and its related distress in the general population.

AIM

To determine the prevalence and clinical correlates of self-reported RE and RE- related distress in middle age and older European men.

METHODS

Subjects were recruited from population samples of men aged 40-79 years across 8 European centers.

OUTCOMES

Self-reported RE and its related distress were derived from the European male Aging Study (EMAS) sexual function questionnaire (EMAS-SFQ). Beck's depression Inventory (BDI) was used for the quantification of depressive symptoms, the Short Form 36 health survey (SF-36) for the assessment of the quality of life, the International Prostate Symptom Score (IPSS) for the evaluation of lower urinary tract symptoms.

RESULTS

About 2,888 community dwelling men aged 40-79 years old (mean 58.9 ± 10.8 years) were included in the analysis. Among the subjects included, 889 (30.8%) self-reported RE. Among them, 211 (7.3%) claimed to be distressed (5.9% and 1.4% reported mild or moderate-severe distress, respectively). Increasing levels of RE-related distress were associated with a progressive worse sexual functioning, higher risk of ED and with couple impairment, along with a higher prevalence of depressive symptoms (all P < 0.05). Furthermore, a worse quality of life and higher IPSS score were associated with RE-related distress (all P < 0.05). The aforementioned results were confirmed even when patients using drugs possibly interfering with ejaculation or those without a stable relationship were excluded from the analysis.

CLINICAL IMPLICATIONS

RE is a frequent condition in men from the general population; however, its related distress is relatively modest. Nonetheless, men with any degree of self-reported RE show increasing levels of depression, worse quality of life and worse couple satisfaction.

STRENGTHS & LIMITATIONS

This is the first study estimating the prevalence of self-reported RE and its related distress, along with their biological and psychological correlates, in a population sample of European middle age and older men. However, is should be recognized that the diagnosis of RE was derived from patient reports and not supported by Intra-ejaculatory-Latency-Time (IELT) measurements.

CONCLUSION

Self-reported RE is relatively common in European men aged more than 40 years. The reported limited RE-related distress may explain the relatively low number of medical consultations for RE. RE-related distress is associated with worse sexual function, couple impairment, and more LUTS resulting in a worse quality of life and mood disturbances. Corona G, Rastrelli G, Bartfai G, et al. Self-Reported Shorter Than Desired Ejaculation Latency and Related Distress-Prevalence and Clinical Correlates: Results From the European Male Ageing Study. J Sex Med Rev 2021;18:908-919.

Relationship between atherogenic indices and acquired premature ejaculation

The aim of this study is to evaluate blood lipid parameters and level of atherogenic indices in acquired premature ejaculation (PE) patients. Between 2020 January and June 2020, 96 patients diagnosed with PE in our clinic and 84 control patients who applied to the urology outpatient clinic for other urological reasons were included in the study. Detailed medical and sexual histories of the patients were taken, and physical examination findings were recorded. In addition, 5-question premature ejaculation diagnostic tool (PEDT) was applied to patients and estimated intravaginal ejaculation latency times (IELT) were recorded. The mean values of lipid parameters; Risk Index of Castelli-1 (CRI-1 (Total cholesterol/ HDL)), CRI-2 (LDL/ HDL), Atherogenic Index of Plasma (AIP (log10 (triglyceride/ HDL)) and Atherogenic Coefficient (AC (HDL/ non-HDL)) were calculated. The average PEDT score was 7.68 + 5.05 (2-22), and the IELT arithmetic mean was 150.39 + 121.53 (5-900) seconds. In the APE group, triglyceride and AIP values were found to be higher than the control group (triglyceride: 188.75 + 76.39 versus 157.20 + 87.45; p = .049; AIP: 0.46 + 0.33 versus 0.35 + 0.35; p = .040). A fair positive correlation was found between PEDT scores and AIP values (r = .355, p < .001). AIP was found to be related to APE, and it was also found to be related to symptom severity.

Brain Cortical Complexity and Subcortical Morphometrics in Lifelong Premature Ejaculation

Premature ejaculation (PE) is the most common male sexual dysfunction. The brain disturbances that cause this disorder remain poorly understood. This study aimed to investigate how the morphology of cortical and subcortical brain structures differed in PE, how these morphologic differences were associated with severity measures of PE, such as intravaginal ejaculatory latency time (IELT), and how these cortical and subcortical structures were causally connected through mediation analysis. Anatomical MRI scans were acquired from 39 male participants, 23 with PE (28.78 ± 4.32 years), and 16 without PE (27.88 ± 3.65 years). We used a subcortical analysis package within FSL to perform subcortical shape segmentation and statistical analysis. The PE group was compared with the normal control (NC) group in the shapes of 15 subcortical structures with general linear models [p < 0.05, family-wise error (FWE)-corrected]. We analyzed the cortical complexity revealed by the gyrification index using the Computational Anatomy Toolbox (CAT12). Vertex-wise shape analyses revealed outward shape deformations (expansions) in the left hippocampus and bilateral thalamus. Gyrification index analyses revealed that the right orbital frontal cortex and the right nucleus accumbens had greater complexity in PE patients. The shape deformations were positively correlated with the IELTs in the NC group, while this relationship was interrupted in the PE group. PE is associated with outward deformations of the subcortical surfaces and more complexity of the cortical structures. These morphological differences may be the basis of the brain functional alterations underlying PE.

Progresses in pharmaceutical and surgical management of premature ejaculation

OBJECTIVE

Premature ejaculation (PE) is regarded as one of the most common male sexual dysfunctions. This review introduced several pharmaceutical and surgical methods for the management of PE. The definition, etiology, behavioral, and psychological therapy of PE were also discussed.

DATA SOURCES

"Premature," "ejaculation," or "sexual dysfuction" were used as the medical subject headings (MeSH) to obtain relevant articles before June 2019 on Pubmed, Google Scholar and CNKI. Most articles used were written in English and several Chinese articles were also cited.

STUDY SELECTION

Full-text articles of retrospective/prospective/randomized controlled trials were analyzed. Animal experiments and letters were excluded.

RESULTS

There are four PE sub-types: lifelong PE, acquired PE, natural variable PE, and subjective PE. Behavioral therapy, psychotherapy, medication, topical anesthetics, and surgery are currently used for the treatment of PE. However, all the above treatments have limitations. Therefore, novel ways should be investigated to more efficiently control PE.

CONCLUSIONS

The pharmaceutical therapy that is currently being used in clinical practice for the management of PE is still the main choice globally due to its good efficacy. Surgery may be a choice for patients who are resistant to medication. However, it should be performed cautiously.

Management Options for Premature Ejaculation and Delayed Ejaculation in Men

INTRODUCTION

Many men experience distressing issues regarding the timing of orgasm and ejaculation, such as premature ejaculation (PE) and delayed ejaculation (DE). Despite being highly prevalent, both PE and DE are poorly understood and present a management challenge for sexual medicine specialists.

AIM

To summarize existing data on the medical management of PE and DE.

METHODS

A comprehensive literature review pertaining to the management of PE and DE was conducted using PubMed and clinicaltrials.gov for data published up until May 2019. Our focus was on double-blind, placebo-controlled trials and meta-analyses of such studies.

MAIN OUTCOME MEASURE

Peer-reviewed studies on treatment options for PE and DE were critically analyzed for results and methodological rigor.

RESULTS

The peer-reviewed data on PE management continue to evolve. Psychotherapy, pharmacotherapy, and procedural interventions have all been associated with some degree of efficacy. A strong evidence base supports the off-label use of selective serotonin reuptake inhibitors and local anesthetics in PE given consistent increases in ejaculation latency time. Education and mental health assessments remain important components of PE management despite a dearth of peer-reviewed data on these interventions. Numerous treatment strategies have been evaluated for DE; limited data support psychotherapy, pharmacotherapy, and/or penile vibratory stimulation as management options.

CONCLUSION

A number of management options for PE or DE exist but none has been formally approved by the US Food and Drug Administration. New and novel treatments would be of great value in managing issues regarding the timing of ejaculation/orgasm. Martin-Tuite P, Shindel AW. Management Options for Premature Ejaculation and Delayed Ejaculation in Men. Sex Med Rev 2020; 8:473-485.

Transcutaneous functional electrical stimulation-a novel therapy for premature ejaculation: results of a proof of concept study

Premature Ejaculation (PE) is a very common and disturbing sexual dysfunction in men. Currently available treatment modalities are associated with limited efficacy and low treatment adherence. In this prospective, single-blinded, self-controlled study, we evaluated the efficacy and safety of transcutaneous electrical stimulation (TES) for the treatment of (PE). We included 23 patients aged 20-60 (mean: 38.7) with lifelong PE. On the first visit, we delivered either TES or sham treatment to the perineum, based on the enrollment order. For stimulation, we used a commercial neuromuscular electrical stimulation device. The patients were invited for the second visit after at least 7 days for receiving the alternating treatment. During the treatment sessions, the patients were left alone in a privet silent room to masturbate and a stopwatch was used to measure their masturbation ejaculatory latency time (MELT). The patients also filled-out safety questionnaires after each visit and on each of the 3 following days. Of the 20 patients who completed the study, 17 (85%) experienced prolonged MELT under TES compared with the sham treatment. Mean MELT values increased 3.5-folds under TES (p = 0.0009). We demonstrated a significant increase in MELT in lifelong PE patients using TES. This therapeutic option may have the potential to become an on-demand treatment option for PE. Future studies with wireless devices are needed to confirm the efficacy and safety of this treatment concept during intercourse.

Efficacy and safety of dapoxetine/sildenafil combination tablets in the treatment of men with premature ejaculation and concomitant erectile dysfunction-DAP-SPEED Study

Premature ejaculation (PE) and erectile dysfunction (ED) are the most prevalent sexual disorders in men. ED is commonly reported among patients with PE. Although recent guidelines recommend to treat ED first in men with both PE and ED, this recommendation is not based on evidence and there are limited data about the efficacy and safety of dapoxetine/sildenafil combination therapy for these patients. The aim of this study is to evaluate the clinical efficacy and safety of the dapoxetine/sildenafil combination (Dapoxil^® 30/50 mg film-coated tablet) in the treatment of patients with PE and concomitant ED. In a single-center, single-arm, open-label clinical study conducted between October 2016 and September 2017, 74 patients with lifelong or acquired PE and ED were included. All patients were instructed to record their intravaginal ejaculatory latency time (IELT) with a stopwatch for 4 weeks. After the screening, they were requested to complete Premature Ejaculation Diagnostic Tool (PEDT), Premature Ejaculation Profile (PEP), and International Index of Erectile Function-Erectile Function (IIEF-EF) questionnaires before the treatment. The patients received on demand Dapoxil^® 1-3 h before sexual intercourse for the next 4 weeks (2 days a week and no more than once a day). The patients were also assessed with global impression of change (GIC) question for the treatment satisfaction and the side effects were recorded. The study was completed with 53 patients (53/74, 71.62%). Mean age of the patients was 45.32 ± 10.05 years. At the end of the 4-week treatment period, the geometric mean IELT of the patients significantly increased (from 22.72 ± 15.16 to 68.25 ± 82.33 s; p < 0.001). Similarly, significant improvements were observed in the mean PEP index score (0.86 ± 0.72 vs. 2.36 ± 1.13; p < 0.001) and mean IIEF-EF domain score (13.17 ± 3.33 vs. 24.60 ± 3.96; p < 0.001). According to the GIC results, 81.13% of the patients were satisfied with the treatment. Non-serious adverse events occurred in 10 patients (18.87%) and 4 (7.55%) of these patients dropped out of the treatment. The most common adverse events were headache, palpitation, and flushing. The dapoxetine/sildenafil combination therapy significantly improves the IELT values and patient reported outcome measures of PE patients who also suffer from ED. Although several side effects were reported, these were mild and transient.

Hyaluronic acid injection in glans penis for treatment of premature ejaculation: a randomized controlled cross-over study

This randomized controlled cross-over study aimed to assess the efficacy and safety of glans penis injection with hyaluronic acid (HA) in treating premature ejaculation (PE). A total of 30 patients with PE were randomly allocated into two groups: group 1 (n = 15) which was subjected to glans penis HA injection and group 2 (n = 15) which was injected with saline as a control then both groups were subjected to follow-up at 1 week and 1 month after injection. These subjects were evaluated by intra-vaginal ejaculation latency time (IELT) and the Arabic validated index of premature ejaculation (AIPE). After a wash-out period, cross-over and re-evaluation of both groups were carried. Additionally, patients with reported improvement after 1 month of HA injection (n = 20) were subjected to extended evaluation by IELT at 3, 6, and 9 months intervals. Two-way repeated measures ANOVA indicated significant improvement after HA in comparison with saline across the follow-up periods (F(1.66: 91.37) = 24.85, p = 0.001). Post-hoc Bonferroni test indicated no significant difference after 1 week period in comparison with baseline IELT, but a significant difference after 1 month of injection in comparison with baseline IELT (p < 0.001) and after 1 week (p < 0.001). After 1 month of HA, IELT increased by a median of 2.6 folds while 1.1 folds increase was observed after 1 month of saline injection. Total AIPE scores improved significantly after HA injection compared with baseline (p = 0.003) and saline scores (p = 0.002). Reported adverse effects were minimal and self-limited. It could be concluded that glans penis injection with HA for treatment of PE is a safe method that ensures a modest but significant increase in IELT and improves couple sexual satisfaction.

Paroxetine in the treatment of premature ejaculation: a systematic review and meta-analysis

Background

Paroxetine is one of the selective serotonin reuptake inhibitors (SSRIs) used in the treatment of premature ejaculation (PE). However, this use is not approved in many countries. The purpose of this systematic review and meta-analysis is to review the efficacy and safety of paroxetine for PE patients.

Methods

We searched relevant randomized, controlled trials through May 2018, using PubMed, Embase and Cochrane Central Register. The main endpoint included intra-vaginal ejaculatory latency time (IELT) and side effects in the treatment of PE. Cochrane Collaboration’s Revman software, version 5.3, was used for statistical analysis.

Results

Out of 493 unique articles, a total of 19 randomized, controlled trials (RCTs) were reviewed. Quite a few RCTs were considered to have unclear risk of bias because of limited information. Pooled outcomes suggested that paroxetine was more effective than placebo, fluoxetine and escitalopram at increasing IELT (all p < 0.05). However, there existed a high level of heterogeneity in the paroxetine vs. fluoxetine groups and the paroxetine vs. placebo groups. Comparing paroxetine with tramadol, sertraline, phosphodiesterase 5 inhibitors (PDE5Is), local lidocaine gel, behaviour therapy or dapoxetine, we found that the increase in IELT was not statistically significant between groups. Paroxetine combined with tadalafil or behaviour therapy was more efficacious than paroxetine alone (all p < 0.05). Although the side effects in the combination group were more common than in the paroxetine alone group, the most common adverse events, such as nausea, muscle soreness, palpitation and flushing, were mild and tolerable. The main limitations of this systematic review and meta-analysis were the different definitions of PE and short follow-up times.

Conclusions

According to this systematic review and meta-analysis, paroxetine provided better efficacy than placebo, fluoxetine and escitalopram in the treatment of PE, with well-tolerated side effects. The combination group had better efficacy than the paroxetine alone group.

Trial registration

This review was reported in agreement with the PRISMA statement and was registered on PROSPERO 2018CRD42018097014.

[Effects of drug use and anxiety on premature ejaculation in a sample of Spanish drug addicts]

INTRODUCTION

Premature ejaculation may be due to many factors and one of them may be drug use.

AIMS

The main objective of this study is to show how drug abuse affects the ejaculatory response, keeping in mind the different substances consumed, the level of anxiety and the period of withdrawal.

METHOD

Two samples were used, one for men who were addicted to drugs (N=925) and one of non-consumers (N=82). Both samples were selected from 28 treatment centers. The Golombok Rust Inventory of Sexual Satisfaction (GRISS) questionnaire and the State Anxiety Trait Questionnaire (STAI) were used.

RESULTS

The results show that men with a history of consumption obtain higher percentages in premature ejaculation compared to non-users (44.3%> 15.9%) and also higher mean scores in anxiety (State Anxiety=19.83>11, 89; Trait Anxiety=25.66>12.39). These differences were statistically significant (P=.000). The results confirm that the withdrawal period does not improve ejaculatory response and having a partner does not work as a protective factor in premature ejaculation.

CONCLUSIONS

Men with a history of drug use are more likely to suffer from premature ejaculation and higher levels of anxiety, which does not improve during the period of withdrawal, leading to the belief that drug users have personality traits that facilitate premature ejaculation and/or that the neurological damages caused by the drugs contribute to a decrease in the intravaginal ejaculatory latency, issues that should be studied in future investigations.

Acquired premature ejaculation in Parkinson's disease and possible mechanisms

Premature ejaculation (PE) has been reported in 40.6-51.5% of men affected by Parkinson's disease (PD), however, this non-motor sexual complaint has not been studied in detail. We describe eight PD patients who asked for a sexological consultation between 2008 and 2014 because of a new-onset of PE. They were diagnosed with acquired PE (APE) according to the DSM-V criteria and the International Society for Sexual Medicine (ISSM) committee. Patients' demographic, medical and sexual related data were retrieved and studied. The average age of onset of PD was 53.3 ± 12.7 years (range 38-77 years) and the sexual problem appeared 4.0 ± 3.1 years later. The mean intravaginal ejaculation latency (IELT) before APE onset was 7.3 (range 2-20) min. Interestingly, the ejaculatory disorder appeared abruptly, characterized by a dramatically shortened IELT in all patients, while in three of the cases ejaculation occurred before vaginal penetration, hampering sexual intercourse. Some patients had 2 additional sexual problems, (four with erectile dysfunctions, five with libido changes: increased desire in four and reduced in one). In this case series of PD patients with APE, the ejaculatory dysfunction developed when patients were on antiparkinsonian medications, suggesting a possible medication effect.

Short- and long-range synergism disorders in lifelong premature ejaculation evaluated using the functional connectivity density and network property

This study was aimed to investigate brain function connectivity in premature ejaculation (PE) patients using the functional connectivity density (FCD) and network property of resting-state functional magnetic resonance imaging. Twenty PE patients (mean age: 27.95 ± 4.52 years) and 15 normal controls (mean age: 27.87 ± 3.78 years) with no self-reported history of neurologic or psychiatric disease were enrolled in this study. International Index of Erectile Function-5 and Chinese Index of Sexual Function for Premature Ejaculation-5 questionnaires and self-reported intravaginal ejaculatory latency time (IELT) were obtained from each participant for symptom assessment. Two-sample t-tests (intergroup comparison) were applied in the short-range FCD (SFCD) analysis, long-range FCD (LFCD) analysis, region of interest–based analysis, and network topological organization analysis. Pearson correlation analysis was performed to correlate IELT with FCD or the network property. The patients with PE showed significantly decreased SFCD in the bilateral middle temporal gyrus, left orbitofrontal cortex, nucleus accumbens, fusiform, caudate, and thalamus (p < 0.05, AlphaSim-corrected). Notably, all these aforementioned brain areas are located in the dopamine pathway. In contrast, increased LFCD was observed in the left insula, Heschl's gyrus, putamen, bilateral precuneus, supplementary motor area, middle cingulate cortex, and anterior cingulate cortex in PE patients (p < 0.05, AlphaSim-corrected). In addition, the network topological analysis found reinforced network connectivity between several nodes. The degree of hub nodes increased in the patients with PE. IELT was positively correlated with SFCD and negatively correlated with LFCD or the degree of hub nodes (p < 0.05, Pearson correlation). In summary, our results are important for understanding the brain network in PE patients. The present findings indicate that PE patients have a significant synergism disorder across the region of dopamine pathway, which implied neuronal pathological changes might be related with the change of dopamine. The FCD and network property can serve as new disease severity biomarkers and therapeutic targets in PE.

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PE patients have different patterns of FCD compared with normal controls.

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The functional brain network efficiency has changed in PE patients.

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The FCD and network property can serve as disease severity biomarkers.

Fortacin™ Spray for the Treatment of Premature Ejaculation

Premature ejaculation (PE) is a common complaint of male sexual dysfunction affecting men and their partners and consequently causing significant personal and interpersonal distress. Increased sensitivity of the glans penis and abnormalities of the afferent-efferent reflex pathway within the ejaculatory process are involved in the occurrence of PE. Drugs that either selectively reduce penile sensitization or modify the afferent-efferent reflex are well established therapeutic options for PE. Fortacin™ is the first topical treatment to be officially approved for the treatment of primary PE in adult men, and is mentioned as an experimental aerosol (as TEMPE) in the current European Association of Urology guidelines. It was approved for use in the European Union and launched in the United Kingdom in November 2016. Fortacin™ is a eutectic-like mixture of lidocaine 150 mg/mL and prilocaine 50 mg/mL that meets the requirements of an ideal treatment for PE because it is fast acting (within 5 minutes), has durable effects, can be easily used "on-demand", and shows minimal side-effects. The metered-dose spray delivery system allows the desensitizing agents to be deposited in a dose-controlled, concentrated film onto the glans penis consequently reducing its sensitivity. This is translated into a delaying of the ejaculatory latency time without adversely affecting the sensation of ejaculation and orgasmic pleasure. The efficacy and safety of Fortacin™ have been proven by means of increased ejaculatory latency, control, and sexual satisfaction in large scale studies demonstrating the significant benefits for both patients and their partners.

Transcutaneous neuromuscular electrical stimulation may be beneficial in the treatment of premature ejaculation

Approximately 20-30% of sexually active men suffer from Premature Ejaculation (PE), but the pathophysiology still remains unclear and the current available treatments for PE are unsatisfying. Considering the role of rhythmic bulbospongiosus and ischiocavernosus Muscles contractions on the ejaculatory reflex, we hypothesize that weakening this muscles via inhibiting it's contractions by Application of Neuromuscular Electrical Stimulation prior to the planned sexual activity, may have a beneficial effect in the treatment of PE. Using miniaturized perineal on-demand stimulation device, in a home setting during sexual intercourse may become the first line of treatment for PE.

Is there a place for surgical treatment of premature ejaculation?

Management of premature ejaculation (PE) has evolved tremandoulsy over the last 20 years. Selective serotonin reuptake inhibitor (SSRI) antidepressants and local anesthetics are the most and best studied treatments. This evidence has led to the establishment of an evidence-based definition of PE and the International Society for Sexual Medicine (ISSM) guidelines for the diagnosis and treatment of PE. The current treatment of choice for PE according to the ISSM guidelines is a centrally acting SSRI or peripherally acting topical anesthetics. Despite the progress in threating PE, the drawbacks of these medical treatments are controversial. Before the ISSM guidelines were established, selective dorsal neurectomy (SDN) and glans penis augmentation (GPA) using a hyaluronic acid (HA) gel were developed to decrease sensitivity of the glans penis but later ISSM guidelines do not recommend surgical treatment because of possible permanent loss of sexual function and insufficient reliable data. Despite the drawbacks of medical treatments and debates about the ISSM guideline, surgical treatment for PE has increased continuously in Asian countries for non-responders to medical treatment. In contrast to the concerns outlined in the ISSM guidelines, SDN has been reported as effective and safe with rare sensory loss. Percutaneous computed tomography-guided cryoablation of the dorsal penile nerve and neuromodulation of the dorsal penile nerve by pulsed radiofrequency are reported as effective and safe for PE. It is time to re-evaluate rather than ignore surgical treatments for PE because doctors and patients need surgical alternatives for patients with PE who are not satisfied with medical treatment. SDN has a definite role in the efficacy but needs more safety data to be used as standard surgical treatment for PE. SDN must be performed carefully and more well-designed studies are needed. GPA with a HA gel does not induce serious sensory loss in patients with ED erectile dysfunction and the recommendation should be re-evaluated by the ISSM after additional reliable studies are performed.

The epidemiology of premature ejaculation

Vast advances have occurred over the past decade with regards to understanding the epidemiology, pathophysiology and management of premature ejaculation (PE); however, we still have much to learn about this common sexual problem. As a standardized evidence-based definition of PE has only recently been established, the reported prevalence rates of PE prior to this definition have been difficult to interpret. As a result, a large range of conflicting prevalence rates have been reported. In addition to the lack of a standardized definition and operational criteria, the method of recruitment for study participation and method of data collection have obviously contributed to the broad range of reported prevalence rates. The new criteria and classification of PE will allow for continued research into the diverse phenomenology, etiology and pathogenesis of the disease to be conducted. While the absolute pathophysiology and true prevalence of PE remains unclear, developing a better understanding of the true prevalence of the disease will allow for the completion of more accurate analysis and treatment of the disease.

Attitudes of Sexual Medicine Specialists Toward Premature Ejaculation Diagnosis and Therapy

INTRODUCTION

Premature ejaculation (PE) is one of the commonest sexual dysfunctions in men. Because the definition of and guidelines for the management of PE have been revised in recent years, our understanding of PE has changed.

AIM

To investigate the clinical practice patterns of sexual medicine specialists regarding the diagnosis and treatment of PE.

METHODS

Attendees of the 17th Annual Congress of the European Society of Sexual Medicine, held in February 2015 in Copenhagen, Denmark, were asked to participate in a survey during the congress.

MAIN OUTCOME MEASURES

A 23-item, self-reported, closed-question questionnaire was distributed. Sociodemographic data, professional background, and personal practice patterns of the attendees were assessed in relation to PE.

RESULTS

In total, 217 physicians (median age = 47 years, range = 22-74) completed the survey. Most responders (79.3%) considered PE an important sexual dysfunction that should be treated. Almost half the participants stated there is insufficient information about PE for patients and physicians (46.1% and 45.2%, respectively). When asked about the main goal of treating PE, two thirds responded that main goal is to improve patients' sexual function and 35.9% responded that the main goal was to improve partners' satisfaction.

CONCLUSION

These findings confirmed that there are many differences among sex health experts in their understanding of PE. Educational activities are crucial in implementing the new guidelines on PE.

Classification and definition of premature ejaculation

Premature ejaculation (PE) is a poorly understood condition and is considered as the most common sexual disorder in men. The ambiguity surrounding PE is in part due to the difficulty in conducting and interpreting research in the absence of a standardised definition that adequately encompasses the characteristics of these patients. An enhanced awareness of sexual dysfunctions in the recent decades has lead to an increase in scientific research that has challenged the traditional paradigm regarding PE. This has also enabled to establish a universal definition and classification of the disease. A move to a more evidence based approach has improved the clinicians' ability to define those who need medical treatment, as well as perform further research in this complex condition.