Premature ejaculation: a psychophysiological approach for assessment and management

The impact of ejaculatory dysfunction upon the sufferer and his partner

Ejaculatory function cannot be evaluated outside the dyadic process and without taking into account the men’s and women’s cognition of the condition and how their subjective perception impacts on the evaluation of the relationship and sexual quality. Although the distress of the sufferer and his partner has been a motivating factor in leading men with ejaculatory dysfunction to seek medical help, few objective or prospective evaluations of the effects on the couple have been reported. Specialized literature has been dealing with ejaculatory disorders in a heterogeneous manner. Comparatively, there are far more studies on premature ejaculation (PE) than on delayed ejaculation (DE) and even fewer studies on other male orgasm disorders. Therefore, the review focuses on the literature of the two most studied ejaculatory disorders. The matter presented in this article can also be considered for other ejaculatory disorders, since all of them relate to a failure of control, changing the intravaginal ejaculatory latency time (IELT), with consequences for men and their partners. There are multiple psychological explanations as to why a man develops PE or DE. Unfortunately, none of the theories evolve from evidence-based studies. The common final pathway of these factors is the irrational fear of ejaculating intravaginally. These sexual disorders may also cause personal distress for the sexual partner and decreased sexual satisfaction for the couple. An association between pre-existing anxiety disorders and sexual performance anxiety has been found in men and couples with ejaculatory dysfunction. This could reflect a process in which pre-existing anxiety triggers sexual dysfunction, causing performance anxiety and leading to a vicious cycle: anxiety, sexual dysfunction, more anxiety. Men with DE are similar to men with other sexual dysfunctions. They show the same elevated level of sexual dissatisfaction and they also show lower levels of coital frequency. To a lower extent, they use more masturbatory activity relative to controls. The burden of PE for the patient is revealed in three different levels: the emotional burden, the health burden, and the burden on the relationship. In terms of the emotional burden, there is often a sense of embarrassment and shame at not being able to satisfy their partner, and patients often have low self-esteem, feelings of inferiority, anxiety, anger, and disappointment. Men feel frustrated about their PE and how it affects their intimacy with their partners and the sexual relationship. In conclusion, ejaculatory dysfunction has a negative impact on both the man and his female partner and, consequently, it has implications for the couple as a whole. Additionally, ejaculatory dysfunction extending beyond a year elevates the risk of depression in these patients. Although partner perceptions of PE generally indicated less dysfunction than those of subjects, partner outcomes measures play a part in the assessment of PE. Ejaculatory dysfunction involves the integration of physiological, psychobehavioral, cultural, and relationship dimensions. All these elements need to be considered in the treatment.

The design and methodology of premature ejaculation interventional studies

Large well-designed clinical efficacy and safety randomized clinical trials (RCTs) are required to achieve regulatory approval of new drug treatments. The objective of this article is to make recommendations for the criteria for defining and selecting the clinical trial study population, design and efficacy outcomes measures which comprise ideal premature ejaculation (PE) interventional trial methodology. Data on clinical trial design, epidemiology, definitions, dimensions and psychological impact of PE was reviewed, critiqued and incorporated into a series of recommendations for standardisation of PE clinical trial design, outcome measures and reporting using the principles of evidence based medicine. Data from PE interventional studies are only reliable, interpretable and capable of being generalised to patients with PE, when study populations are defined by the International Society for Sexual Medicine (ISSM) multivariate definition of PE. PE intervention trials should employ a double-blind RCT methodology and include placebo control, active standard drug control, and/or dose comparison trials. Ejaculatory latency time (ELT) and subject/partner outcome measures of control, personal/partner/relationship distress and other study-specific outcome measures should be used as outcome measures. There is currently no published literature which identifies a clinically significant threshold response to intervention. The ISSM definition of PE reflects the contemporary understanding of PE and represents the state-of-the-art multi-dimensional definition of PE and is recommended as the basis of diagnosis of PE for all PE clinical trials.

Emerging and investigational drugs for premature ejaculation

Over the past 20−30 years, the premature ejaculation (PE) treatment paradigm, previously limited to behavioural psychotherapy, has expanded to include drug treatment. Pharmacotherapy for PE predominantly targets the multiple neurotransmitters and receptors involved in the control of ejaculation which include serotonin, dopamine, oxytocin, norepinephrine, gamma amino-butyric acid (GABA) and nitric oxide (NO). The objective of this article is to review emerging PE interventions contemporary data on the treatment of PE was reviewed and critiqued using the principles of evidence-based medicine. Multiple well-controlled evidence-based studies have demonstrated the efficacy and safety of selective serotonin reuptake inhibitors (SSRIs) in delaying ejaculation, confirming their role as first-line agents for the medical treatment of lifelong and acquired PE. Daily dosing of SSRIs is likely to be associated with superior fold increases in IELT compared to on-demand SSRIs. On-demand SSRIs are less effective but may fulfill the treatment goals of many patients. Integrated pharmacotherapy and CBT may achieve superior treatment outcomes in some patients. PDE-5 inhibitors alone or in combination with SSRIs should be limited to men with acquired PE secondary to co-morbid ED. New on-demand rapid acting SSRIs, oxytocin receptor antagonists, or single agents that target multiple receptors may form the foundation of more effective future on-demand medication. Current evidence confirms the efficacy and safety of dapoxetine, off-label SSRI drugs, tramadol and topical anaesthetics drugs. Treatment with α1-adrenoceptor antagonists cannot be recommended until the results of large well-designed RCTs are published in major international peer-reviewed medical journals. As our understanding of the neurochemical control of ejaculation improves, new therapeutic targets and candidate molecules will be identified which may increase our pharmacotherapeutic armamentarium.

Event-level impact of Promescent on quality of sexual experience in men with subjective premature ejaculation

Promescent is a lidocaine-based ejaculation delaying spray that absorbs into the skin of the penis prior to sexual activity. This article aimed to evaluate the effect of Promescent on the experience of orgasm, ejaculatory latency time and quality of sexual experience (QSE). Additionally, we assessed ease of application of Promescent and the extent to which it enhanced or interrupted the sexual experience. The analytic sample consisted of 91 men with self-reported subjective premature ejaculation who were sent a sample of Promescent and completed a 14-day internet-based prospective daily electronic report. Average ejaculatory latency time was 11.16 min during product use events, compared with 6.81 min during product non-use events. Both members of the couple had an orgasm 65.6% of the time when they used the product, compared with 44.1% when they did not use the product. QSE was significantly improved on product use days (P<0.05). Quality also significantly improved each subsequent time the product was used (P<0.01). The product was reported as easy to use and did not interrupt the sexual experience. Findings suggest that the use of this topical spray significantly improves QSE and perception of partner experience, and that these improve with longer duration of use.

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.

Pelvic-floor muscle rehabilitation in erectile dysfunction and premature ejaculation

BACKGROUND

In men, involuntary or voluntary ischiocavernosus muscle contractions after erection lead to intracavernous blood pressures far higher than the systolic pressure, which builds and maintains penile rigidity. Thus, erectile dysfunction may be partly due to ischiocavernosus muscle atrophy and may be treated by rehabilitation interventions.

OBJECTIVE

The purpose of this study was to determine whether pelvic-floor muscle strengthening interventions could be associated with increases in intracavernous pressure that would increase penile rigidity.

DESIGN

An observational study was conducted.

METHODS

One hundred twenty-two men with isolated erectile dysfunction and 108 men with isolated premature ejaculation participated (no neuromuscular diseases or previous perineal rehabilitation). Thirty-minute sessions of voluntary contractions coupled with electrical stimulation were designed to increase ischiocavernosus muscle strength (monitored through intracavernous pressure increase). A linear mixed-effects model per group analyzed separately, then jointly, the maximum change in pressure (ΔP) and the maximum baseline (ie, respectively, the average contraction-generated difference in intracavernous pressure and the intracavernous pressure plateau at full erection, both measured during the highest moving average of the best 2 minutes of each session).

RESULTS

Over 20 sessions, the maximum ΔP increased in erectile dysfunction as well as in premature ejaculation (87% and 88%, respectively, in men with positive trends). The maximum baseline also increased (99% and 72%, respectively, in men with positive trends). The joint modeling indicated that the mean expected progressions of the intracavernous pressure after 5 sessions in erectile dysfunction and premature ejaculation were 62.85 and 64.15 cm H2O, respectively.

LIMITATIONS

Indirect measurements were obtained of intracavernous pressure and ischiocavernosus muscle force.

CONCLUSIONS

Pelvic-floor muscle rehabilitation was found to be beneficial in erectile dysfunction. However, its effects on symptoms of premature ejaculation, despite intracavernous pressure gains, were much more difficult to assess. The definitive proof of its benefits requires rather difficult-to-design clinical trials.

Self-Reported Prevalence of and Attitudes toward Premature Ejaculation in a Community-Based Study of Married Couples

PURPOSE

We evaluated the self-reported prevalence of and attitudes toward premature ejaculation (PE) in a community-based study of married couples.

MATERIALS AND METHODS

A community-based cross-sectional study of PE was conducted among married couples in Gwangju, Korea. Self-reported data were collected through the use of questionnaires, which included demographic questions, the Premature Ejaculation Diagnostic Tool (PEDT), the intravaginal ejaculation latency time (IELT), patient-reported outcome (PRO), and the Female Sexual Function Index (FSFI).

RESULTS

Of the 290 couples who completed the survey, the prevalence of PEDT-diagnosed PE including probable PE was 23.7% of men. By IELT measure, the prevalence of PE was 21.7% as reported by the men and 23.9% as reported by their partners, respectively. PRO responses indicated that control over ejaculation and severity of PE were not reported significantly differently by the men and their partners. Satisfaction with sexual intercourse was poorer for the men's partners than for the men. Personal distress and interpersonal difficulty were higher for the men than for their partners. The partners of men in the PE group had significantly lower FSFI scores than did the partners of men in the non-PE group.

CONCLUSIONS

The reporting of the prevalence of PE did not differ significantly between the men in this study and their partners. However, PE in men tended to impact their partners' sexual function.

Functional and psychological characteristics of belgian men with premature ejaculation and their partners

Physiological, behavioral, cognitive, and emotional factors are generally acknowledged to play a role in premature ejaculation (PE). However, the nature and the extent of their etiological impact remain largely imprecise. The present study examined functional and psychometric dynamics at work in a PE population. A total of 461 men with PE and 80 partners completed an online questionnaire. The main outcome measures were self-reported ejaculatory latency time, the feeling of control upon ejaculation, sexual satisfaction, distress related to PE, trait anxiety (STAI-B), sexual cognitions (Sexual Irrationality Questionnaire [SIQ]), social anxiety (Liebowitz's Social Anxiety Scale [LSAS] and Social Interaction Self-Statement Test [SISST]), and personality traits (Temperament and Character Inventory-Revised [TCI-R]). In our sample, the median latency time to ejaculation was between 1 and 2 min. Sexual satisfaction and distress correlated more strongly with the feeling of control than with the self-reported latency time. Men experienced more distress and dissatisfaction related to PE than did their partners, while overestimating their partners' distress and dissatisfaction. PE participants' scores differed significantly, albeit slightly, from STAI-B, SIQ, LSAS, and SISST norms. The differences were negligible on TCI-R. Some differences became stronger when subtypes were considered. Participants combining generalized and lifelong PE with self-reported latency times of <30 s reported lower sexual satisfaction and control, higher distress, higher social anxiety, and harm avoidance (TCI-R/HA) scores. By contrast, the situational subtype of PE was found to be characterized by a higher level of satisfaction, a greater feeling of control, less distress, and higher trait anxiety scores. However, the trends remained statistically discrete.

Dapoxetine: a new option in the medical management of premature ejaculation

Premature ejaculation (PE) is a common male sexual disorder which is associated with substantial personal and interpersonal negative psychological consequences. Pharmacotherapy of PE with off-label antidepressant selective serotonin reuptake inhibitors (SSRIs) is common, effective and safe. Development and regulatory approval of drugs specifically for the treatment of PE will reduce reliance on off-label treatments and serve to fill an unmet treatment need. The objective of this article is to review evidence supporting the efficacy and safety of dapoxetine in the treatment of PE. MEDLINE, Web of Science, PICA, EMBASE and the proceedings of major international and regional scientific meetings were searched for publications or abstracts published during the period 1993-2012 that used the word 'dapoxetine' in the title, abstract or keywords. This search was then manually cross referenced for all papers. This review encompasses studies of dapoxetine pharmacokinetics, animal studies, human phase I, II and III studies, independent postmarketing and pharmacovigilance efficacy and safety studies and drug-interaction studies. Dapoxetine is a potent SSRI which is administered on demand 1-3 h prior to planned sexual contact. It is rapidly absorbed and eliminated, resulting in minimal accumulation, and has dose-proportional pharmacokinetics which are unaffected by multiple dosing. Dapoxetine 30 mg and 60 mg has been evaluated in five industry-sponsored randomized, double-blind, placebo-controlled studies in 6081 men aged at least 18 years. Outcome measures included stopwatch-measured intravaginal ejaculatory latency time (IELT), Premature Ejaculation Profile (PEP) inventory items, Clinical Global Impression of Change (CGIC) in PE, and adverse events. Mean IELT, all PEP items and CGIC improved significantly with both doses of dapoxetine versus placebo (all p <0.001). The most common treatment-related adverse effects included nausea (11.0% for 30 mg, 22.2% for 60 mg), dizziness (5.9% for 30 mg, 10.9% for 60 mg), and headache (5.6% for 30 mg, 8.8% for 60 mg), and evaluation of validated rated scales demonstrated no SSRI class-related effects with dapoxetine use. Dapoxetine, as the first drug developed for PE, is an effective and safe treatment for PE and represents a major advance in sexual medicine.

Efficacy of dapoxetine in the treatment of premature ejaculation

Introduction

Premature ejaculation (PE) is a common male sexual disorder which is associated with substantial personal and interpersonal negative psychological factors. Pharmacotherapy of PE with off-label antidepressant SSRI drugs is common. Development and regulatory approval of drugs specifically for the treatment of PE will reduce reliance on off-label treatments and serve to fill a unmet treatment need.

Aim

To review evidence supporting the efficacy and safety of dapoxetine in the treatment of PE.

Methods

MEDLINE and the proceedings of major international and regional scientific meetings during the period 1994–2010 were searched for publications or abstracts using the word dapoxetine in the title, abstract or keywords. This search was then manually cross-referenced for all papers. This review encompasses studies of dapoxetine pharmacokinetics, animal studies, human phase 1, 2 and 3 efficacy and safety studies and drug-interaction studies.

Results

Dapoxetine is a potent selective serotonin re-uptake inhibitor, which is administered on-demand 1–3 hours prior to planned sexual contact. Dapoxetine is rapidly absorbed and eliminated, resulting in minimal accumulation and has dose-proportional pharmacokinetics, which are unaffected by multiple dosing. Dapoxetine 30 mg and 60 mg has been evaluated in 5 randomized, double-blind, placebo-controlled studies in 6081 men aged ≥18 years. Outcome measures included stopwatch-measured intravaginal ejaculatory latency time (IELT), Premature Ejaculation Profile (PEP) inventory items, clinical global impression of change (CGIC) in PE, and adverse events. Mean IELT, all PEP items and CGIC improved significantly with both doses of dapoxetine vs. placebo (P < 0.001 for all). The most common treatment related adverse effects included nausea (11.0% for 30 mg, 22.2% for 60 mg), dizziness (586% for 30 mg, 10.9% for 60 mg), and headache (5.6% for 30 mg, 8.8% for 60 mg), and evaluation of validated rated scales demonstrated no SSRI class-related effects with dapoxetine use.

Conclusion

Dapoxetine, as the first drug developed for PE, is an effective and safe treatment for PE and represents a major advance in sexual medicine.

An evidence-based definition of lifelong premature ejaculation: report of the International Society for Sexual Medicine Ad Hoc Committee for the Definition of Premature Ejaculation

OBJECTIVE

To develop a contemporary, evidence-based definition of premature ejaculation (PE).

METHODS

There are several definitions of PE; the most commonly quoted, the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders - 4th Edition - Text Revision, and other definitions of PE, are all authority-based rather than evidence-based, and have no support from controlled clinical and/or epidemiological studies. Thus in August 2007, the International Society for Sexual Medicine (ISSM) appointed several international experts in PE to an Ad Hoc Committee for the Definition of PE. The committee met in Amsterdam in October 2007 to evaluate the strengths and weaknesses of current definitions of PE, to critically assess the evidence in support of the constructs of ejaculatory latency, ejaculatory control, sexual satisfaction and personal/interpersonal distress, and to propose a new evidence-based definition of PE.

RESULTS

The Committee unanimously agreed that the constructs which are necessary to define PE are rapidity of ejaculation, perceived self-efficacy, and control and negative personal consequences from PE. The Committee proposed that lifelong PE be defined as a male sexual dysfunction characterized by ejaculation which always or nearly always occurs before or within about one minute of vaginal penetration, and the inability to delay ejaculation on all or nearly all vaginal penetrations, and negative personal consequences, such as distress, bother, frustration and/or the avoidance of sexual intimacy. This definition is limited to men with lifelong PE who engage in vaginal intercourse. The panel concluded that there are insufficient published objective data to propose an evidence-based definition of acquired PE.

CONCLUSION

The ISSM definition of lifelong PE represents the first evidence-based definition of PE. This definition will hopefully lead to the development of new tools and patient-reported outcome measures for diagnosing and assessing the efficacy of treatment interventions, and encourage ongoing research into the true prevalence of this disorder, and the efficacy of new pharmacological and psychological treatments.

Development and evaluation of the Arabic Index of Premature Ejaculation (AIPE)

OBJECTIVES

Our report describes the construction and evaluation of the Arabic Index Premature Ejaculation (AIPE) as a diagnostic tool for premature ejaculation (PE) and presents data supporting its validity.

METHODS AND MAIN OUTCOME MEASURES

Seventy-one men complaining of PE and 73 healthy subjects were asked to complete the seven-question AIPE. Diagnosis of PE was based on the criteria set by the second consultation on sexual dysfunctions. The seven items selected were based on assessment of erectile function, sexual desire, ejaculation latency, ejaculation control, patient satisfaction, partner satisfaction, and psychological distress. The AIPE was examined for sensitivity, specificity, and construct validity.

RESULTS

A receiver operating characteristic curve indicated that the AIPE is an excellent diagnostic test. A cutoff score of 30 (range of scores 7-35) discriminated best (sensitivity = 0.98, specificity = 0.88). Severity of PE ranged from none (31-35) to severe (7-13). A high kappa value (0.85) indicated existence of significant agreement existed between the predicted and "true" PE classes.

CONCLUSIONS

AIPE shows a potential to be a reliable aid to decrease the number of misdiagnosed cases of PE.

Antibiotic treatment can delay ejaculation in patients with premature ejaculation and chronic bacterial prostatitis

INTRODUCTION

Premature ejaculation (PE) is regarded as the most common male sexual disorder. Previous studies reported that prostatic inflammation was highly prevalent in PE. However, the effect of antibiotic treatment of cases with PE and chronic prostatitis has not been extensively investigated.

AIM

To examine the effect of antibiotic treatment in delaying ejaculation in patients with PE and chronic prostatitis.

METHODS

A total of 145 consecutive men attending of secondary premature ejaculation (SPE) were included in this study. Sequential microbiologic specimens were obtained from urine and prostatic fluid. Antibiotics were given for 1 month according to the results of their culture and sensitivity test. All patients were instructed to follow up with our clinic monthly for at least 4 months. At the end of the 4-month follow-up, another prostatic secretion analysis was performed.

RESULTS

Based on expressed prostatic secretion culture and white blood cell (WBC) count, 94 (64.8%) were having chronic bacterial prostatitis. The remaining 51 (35.2%) patients had negative WBC count. Of the 94 patients with SPE and chronic bacterial prostatitis, 20 patients were left untreated and considered as a control group. All 74 patients with PE and chronic prostatitis continued the 1-month treatment duration. Following 1-month antibiotic treatment, all 74 patients with initially positive cultures had sterile final cultures (P < 0.05). Sixty-two (83.9%) patients showed increases in their ejaculatory latency time and reported good control of their ejaculation and were considered treatment responsive. None of the control group patients experienced any improvement either in their prostatic infection condition or in their ejaculation time. The follow-up of treatment-responsive patients (N = 62) revealed no recurrence of PE with negative prostatic culture.

CONCLUSIONS

Successful eradication of causative organisms in patients with PE and chronic prostatitis may lead to marked improvement in intravaginal ejaculatory latency time and ejaculatory control.

Premature ejaculation

Premature ejaculation (PE) is a common male sexual disorder. Recent normative data suggests that men with an intravaginal ejaculatory latency time (IELT) of less than 1 minute have "definite" PE, while men with IELTs between 1 and 1.5 minutes have "probable" PE. Although there is insufficient empirical evidence to identify the etiology of PE, there is limited correlational evidence to suggest that men with PE have high levels of sexual anxiety and inherited altered sensitivity of central 5-HT (5-hydroxytryptamine, serotonin) receptors. Pharmacological modulation of the ejaculatory threshold using off-label daily or on-demand selective serotonin re-uptake inhibitors is well tolerated and offers patients a high likelihood of achieving improved ejaculatory control within a few days of initiating treatment, consequential improvements in sexual desire and other sexual domains. Investigational drugs such as the ejaculo-selective serotonin transport inhibitor, dapoxetine represent a major development in sexual medicine. These drugs offer patients the convenience of on-demand dosing, significant improvements in IELT, ejaculatory control and sexual satisfaction with minimal adverse effects.

Sexual sequelae of general medical disorders

That sexual symptoms can signal serious underlying disease confirms the importance of sexual enquiry as an integral component of medical assessment. Data on sexual function are sparse in some medical specialties. However, increased scientific understanding of the central and peripheral physiology of sexual response could help to identify the pathophysiology of sexual dysfunction from disease and medical interventions, and also to ameliorate or prevent some dysfunctions. Many common general medical disorders have negative effects on desire, arousal, orgasm, ejaculation, and freedom from pain during sex. Chronic disease also interferes indirectly with sexual function, by altering relationships and self-image and causing fatigue, pain, disfigurement, and dependency. Current approaches to assessment of sexual dysfunction are based on models that combine psychological and biological aspects.

Efficacy of type-5 phosphodiesterase inhibitors in the drug treatment of premature ejaculation: a systematic review

This review examines the role of nitric oxide (NO) as a neurotransmitter involved in the central and peripheral control of ejaculation, the methods of phosphodiesterase type 5 inhibitor (PDE5I) drug treatment studies for premature ejaculation (PE), the adherence of methods to the contemporary consensus of ideal PE drug trial design, the impact of methods on treatment outcomes and the role of PDE5Is in the treatment of PE. NO/cGMP transduction is involved in both the central and peripheral control of emission, but evidence for a direct central or peripheral effect of PDE5Is on ejaculation is speculative. Thirteen of the 14 studies reviewed failed to fulfil the evidence-based medicine criteria for ideal PE drug trial design. Limitations of the studies include inadequately defined study populations, the lack of a double-blind placebo-controlled study design, and the absence of consistent objective physiological measures or sensitive, validated outcome assessment instruments as study endpoints. The broad range of intravaginal ejaculatory latency time (IELT) fold-increases reported with PDE5Is, on-demand selective serotonin re-uptake inhibitor (SSRI) drugs, and combined PDE5I/on-demand SSRIs is testament to the unreliability of data and conclusions from methodologically flawed studies. The one study that fulfilled the evidence-based medicine criteria of an ideal clinical trial design reported that treatment with sildenafil failed to significantly increase baseline IELT, supporting our conclusion that there is no convincing evidence to support any role for PDE5Is in the treatment of men with lifelong PE and normal erectile function. However, there is limited evidence to support a potential role for PDE5Is alone or combined with daily or on-demand SSRIs in the treatment of acquired PE in men with comorbid erectile dysfunction. Further controlled studies adhering to the contemporary consensus of ideal clinical trial design are required to clarify the role of PDE5Is in this subgroup of men with acquired PE.

Chronic prostatitis in premature ejaculation: a cohort study in 153 men

INTRODUCTION

Premature ejaculation is a common male sexual dysfunction, affecting 30-40% of sexually active men in an age-dependent manner. Chronic prostatitis has been suggested as an important organic cause of premature ejaculation.

AIM

The aim of this study was to confirm previous data reported on the incidence of chronic prostatitis in a large cohort of patients with primary and secondary premature ejaculation.

METHODS

A total of 153 consecutive heterosexual men aged 29-51 years with premature ejaculation and another 100 male healthy subjects were included in this study. Sequential microbiologic specimens were obtained according to the standardized Meares and Stamey protocol. Nonbacterial prostatitis was defined by the evidence of prostatic inflammation but negative cultures of urine and prostatic fluids in men with various genitourinary symptoms.

RESULTS

There was no significant difference between patients and control subjects regarding age, education, or intercourse frequency. Prostatic inflammation was found in 64% and chronic bacterial prostatitis in 52% of the patients with premature ejaculation, respectively, showing statistical significance compared with control subjects (P < 0.05).

CONCLUSIONS

Results in our study showed a high prevalence of chronic prostatitis in patients with premature ejaculation. Examination of the prostate, physically and microbiologically, should be considered during assessment of patients with premature ejaculation.

Prevalence, characteristics and implications of premature ejaculation/rapid ejaculation

PURPOSE

Premature ejaculation/rapid ejaculation is a common but incompletely understood male sexual dysfunction. The purposes of this review are to 1) raise awareness of the prevalence and characteristics of PE/RE, its impact on the male and his partner, and the lack of approved medications indicated for its treatment, 2) encourage dialogue about PE/RE between physicians and patients, and 3) stimulate the development of appropriate new therapies.

MATERIALS AND METHODS

A MEDLINE search was performed to retrieve articles relating to PE/RE pathophysiology, etiology, impact, diagnosis and treatment. Sexual medicine journals not indexed in MEDLINE, sexual medicine texts and congress abstracts were also reviewed.

RESULTS

No universally accepted definition, licensed treatment, validated screening instrument or diagnostic criteria have been established for PE/RE, and its pathophysiology and etiology are incompletely understood. Additional barriers are the reluctance of patients and physicians to talk about PE/RE and the lack of knowledge regarding available treatments. Current pharmacological treatments include off label uses of antidepressants, topical anesthetics or phosphodiesterase-5 inhibitors. All are associated with drawbacks that limit their efficacy. Psychological counseling and behavioral therapy have a valuable role, although resources for this modality are limited.

CONCLUSIONS

Prevalence rates of 20% to 30% and negative effects on the quality of life of men and their partners illustrate the need for improved, standardized methods of PE/RE diagnosis, assessment and treatment. Medications indicated specifically for PE/RE and effective on an as needed basis are required. Behavioral therapies should emphasize pleasure, arousal, control, confidence and satisfaction, and they may have the best success when coupled with pharmacological approaches.

Prevalence of premature ejaculation: a global and regional perspective

The effort to determine the global burden of premature ejaculation (PE) has been impeded by the lack of a clear and universally accepted definition of the condition. Current diagnostic criteria are variable and rely, to a large degree, on subjective measurements. Moreover, the absence of a clear consensus on what constitutes a normal ejaculatory latency has impeded research into the prevalence of PE, although evidence is gradually accruing that may make this definition easier. Perception of "normal" ejaculatory latency varies by country and can differ when assessed either by the patient or their partner. Despite these limitations, information from the Global Study of Sexual Attitudes and Behaviors and other sources suggests a global prevalence of PE of approximately 30% across all age groups. The etiology underpinning this prevalence remains to be clarified, but current evidence reflects a shift from psychogenic theories to more neurobiological bases. While elucidation of the etiology of PE will undoubtedly aid the development of more effective therapies, it is clear that, whatever the cause of the condition, it is associated with a significant burden on psychological and overall health.

Diagnosis and Treatment of Premature Ejaculation: The Physician's Perspective

Premature ejaculation (PE) is a common condition associated with significant adverse effects on the sexual and overall quality of life of men with this condition. Behavioral therapies, such as the "squeeze" and "stop-start" techniques, and psychotherapy, have been the mainstay of PE management for many years. However, evidence of their short-term efficacy is limited while support for their long-term benefit is lacking. There are currently no medications licensed specifically for the treatment of PE. This paucity of pharmacological treatment may, in turn, contribute to the absence of systematic procedures for the identification, evaluation, and treatment of PE patients. Current "off-label" pharmacotherapeutic approaches include topical anesthetics, phosphodiesterase-5 inhibitors, and serotonin reuptake inhibitors. Of these, the serotonin reuptake inhibitors show the greatest efficacy and an increasing body of evidence is illuminating their mode of action. Nevertheless, all current "off-label" pharmacotherapeutic approaches fall short of the ideal therapy for PE. In the absence of a cure, such a treatment should be tolerable, inconspicuously used, effective from first dose, rapid in onset of action, and available as a prn-dosing regimen. It is anticipated that agents in development for the specific indication of PE will come closer to this ideal than existing pharmacotherapeutic approaches.

ORIGINAL RESEARCH—EJACULATORY DISORDERS: Premature Ejaculation: An Observational Study of Men and Their Partners

INTRODUCTION

Premature ejaculation (PE) is the most common male sexual dysfunction affecting men and their partners. Lack of community-based data describing this condition limits understanding of PE and its outcomes.

AIM

To characterize PE in a large population of men with and without PE using patient-reported outcome (PRO) measures elicited from men and their partners.

METHODS

4-week, multicenter, observational study of males (> or =18 years) and their female partners in monogamous relationships (> or =6 months). Screening, baseline, and follow-up visits scheduled at 2-week intervals. Clinicians diagnosed PE utilizing DSM-IV-TR criteria. Intravaginal ejaculatory latency time (IELT), measured by a stopwatch held by the partner, was recorded for each sexual intercourse experience. Subject and partner independently assessed PROs: control over ejaculation and satisfaction with sexual intercourse (0 = very poor to 4 = very good), personal distress and interpersonal difficulty (0 = not at all to 4 = extremely), and severity of PE (0 = none to 3 = severe). Results. Of the total study population (N = 1,587), 207 subjects were diagnosed with PE and 1,380 were assigned to the non-PE group. Median IELT (min) was 1.8 (range, 0-41) for PE and 7.3 (range, 0-53) for non-PE subjects (P < 0.0001). More PE vs. non-PE subjects gave ratings of "very poor" or "poor" for control over ejaculation (72% vs. 5%; P < 0.0001) and satisfaction with sexual intercourse (31% vs. 1%; P < 0.0001). More subjects in the PE vs. non-PE group gave ratings of "quite a bit" or "extremely" for personal distress (64% vs. 4%; P < 0.0001) and interpersonal difficulty (31% vs. 1%; P < 0.0001). Subject and partner assessments showed similar patterns and correlated moderately (0.36-0.57).

CONCLUSIONS

PE subjects reported significantly shorter IELT. Overlap in IELT distributions was observed between the PE and non-PE groups, indicating the need for additional PRO measures to characterize PE. Shorter IELT was significantly associated with reduced ejaculatory control and sexual satisfaction and increased distress and interpersonal difficulty.

Extensive Neurophisyological Evaluation in Primary Premature Ejaculation Patients

Pudendal nerve somatosensory evoked potentials (PN-SEPs), bulbo-cavernosus reflex (BC reflex) and perineal motor evoked potentials (BC MEPs) following transcranial magnetic cortical stimulation (TMS) were performed in patients with primary premature ejaculation (PPE), to investigate the somatic sensory and motor function of the genital area.

Methods

Fourteen patients with PPE underwent psychological counseling, urologic physical and trasnrectal ultrasound examination, laboratory data and Stamey test. Spinal and cortical PN-SEPs were recorded by dorsal nerve stimulaiton at penile shaft (DN-SEPs) in all patients, and at glans penis (GP-SEPs) in 3 of them. BC reflex was obtained by stimulating the basis of penis.

Results

Mean sensory thresold did not significantly differ between patients and normal subjects. Cortical DN-SEPs were normal in alla patients. Sensory central conduction was significantly smaller in patients than controls. In 3 patients and in 3 controls undergone both DN-SEPs and GP-SEPs, glans penis sensory threshold was lower than dorsal nerve one, and cortical GP-SEP latency longer than cortical DN-SEP latency. BC reflex was normal in most patients. BC MEPs were normal in all patients, but one.

Conclusions

We did not confirm either a faster conduction along the pudendal sensory pathway, or a greater cortical representation of the sensory stimuli from the genital area in oue patients. Moreover, we did not confirm an hyperexcitability of BC reflex in them. Our results suggest that the electrophysiological approach is probably not sufficient to clariphy the causes of PPE and more integrated investigation are requested.

Identifying physician-recognized depression from administrative data: consequences for quality measurement

BACKGROUND

Multiple factors limit identification of patients with depression from administrative data. However, administrative data drives many quality measurement systems, including the Health Plan Employer Data and Information Set (HEDIS).

METHODS

We investigated two algorithms for identification of physician-recognized depression. The study sample was drawn from primary care physician member panels of a large managed care organization. All members were continuously enrolled between January 1 and December 31, 1997. Algorithm 1 required at least two criteria in any combination: (1) an outpatient diagnosis of depression or (2) a pharmacy claim for an antidepressant Algorithm 2 included the same criteria as algorithm 1, but required a diagnosis of depression for all patients. With algorithm 1, we identified the medical records of a stratified, random subset of patients with and without depression (n = 465). We also identified patients of primary care physicians with a minimum of 10 depressed members by algorithm 1 (n = 32,819) and algorithm 2 (n = 6,837).

RESULTS

The sensitivity, specificity, and positive predictive values were: Algorithm 1: 95 percent, 65 percent, 49 percent; Algorithm 2: 52 percent, 88 percent, 60 percent. Compared to algorithm 1, profiles from algorithm 2 revealed higher rates of follow-up visits (43 percent, 55 percent) and appropriate antidepressant dosage acutely (82 percent, 90 percent) and chronically (83 percent, 91 percent) (p < 0.05 for all).

CONCLUSIONS

Both algorithms had high false positive rates. Denominator construction (algorithm 1 versus 2) contributed significantly to variability in measured quality. Our findings raise concern about interpreting depression quality reports based upon administrative data.

New OTC drugs and devices 2002: a selective review

OBJECTIVES

To create a heightened awareness of two consumer issues confronting pharmacists in the self-care arena--consumers' need for accurate information about over-the-counter (OTC) products and consumers' attitudes and beliefs about OTC drugs--and to educate pharmacists about newly introduced nonprescription products, home screening devices, and home accessories.

DATA SOURCES

Recently published clinical and pharmaceutical industry literature and survey results from the National Council on Patient Information and Education.

DATA SYNTHESIS

Although changes have been made to labeling for OTC products to heighten consumers' awareness of the dangers associated with misuse of these products, consumers need the expertise of the pharmacist to guide them toward effective and safe self-care. It remains critical that pharmacists be knowledgeable about the numerous nonprescription products that become available on the U.S. market each year and take the initiative to counsel patients appropriately on the benefits and risks associated with their use.

CONCLUSION

Patients will continue to place an increasing emphasis on self-care. To assist them, pharmacists must remain up-to-date on trends and have an understanding of the nuances of consumers' behavior and thinking in relation to OTC products and their use. The new nonprescription medications and diagnostic screening devices discussed in this review article represent valuable additions to the growing array of self-care products.

Neurophysiologic evaluation of central-peripheral sensory and motor pudendal pathways in primary premature ejaculation

OBJECTIVES

Pudendal nerve somatosensory evoked potentials (SEPs), the bulbocavernosus (BC) reflex, and BC perineal motor evoked potentials after transcranial magnetic cortical stimulation were performed in patients with primary premature ejaculation to investigate the somatic sensory and motor function of the genital area.

METHODS

Fourteen patients with primary premature ejaculation underwent psychological counseling, urologic physical examination, transrectal ultrasound examination, laboratory testing, and the Stamey test. The spinal and cortical pudendal nerve SEPs were performed by dorsal nerve stimulation at the penile shaft (DN-SEPs) in all patients and at the glans penis (GP-SEPs) in 3 of them. The BC reflex was obtained by stimulating the base of the penis.

RESULTS

The mean sensory threshold did not significantly differ between the patients and normal subjects. Cortical DN-SEPs were normal in all patients. The sensory central conduction time, calculated in 6 patients, was normal. The mean cortical DN-SEP amplitude was significantly smaller in patients than in controls. In 3 patients and in 3 controls who underwent both DN-SEP and GP-SEP testing, the glans penis sensory threshold was lower than the dorsal nerve threshold and the cortical GP-SEP latency was longer than the cortical DN-SEP latency. The BC reflex was normal in most patients. The BC motor evoked potentials were normal in all patients, but one.

CONCLUSIONS

We did not confirm either a faster conduction along the pudendal sensory pathway or a greater cortical representation of the sensory stimuli from the genital area in our patients. Moreover, we did not confirm hyperexcitability of the BC reflex in them. Our results suggest that the electrophysiologic approach is probably not sufficient to clarify the causes of primary premature ejaculation. A more integrated investigation could allow better results in this field.