A new treatment for premature ejaculation: the rehabilitation of the pelvic floor

Efficacy of combination therapy with biofeedback and dapoxetine in lifelong premature ejaculation treatment: a prospective randomized study

PURPOSE

Premature ejaculation (PE) is a common sexual dysfunction that significantly affects the quality of life of the patient and their partner. We aimed to compare the efficacy and safety of the combination therapy with biofeedback-guided pelvic floor exercise therapy (BFT) and dapoxetine 30 mg.

METHODS

Sixty-five patients diagnosed with lifelong PE were included in the study. Patients were divided into three groups as BFT, dapoxetine 30 mg and a combination of BFT and dapoxetine 30 mg. The patients were compared with the intravaginal ejaculatory latency time (IELT) pre-treatment and post-treatment 1st and 3rd months.

RESULTS

The mean IELTs of the patients in Group 1 were 40 s in pre-treatment, 115 s at the end of the 4th week and 140 s at the end of the 12th week. The IELT values of the patients in Group 2 were 40 s in pre-treatment, 145 s in the 4th week and 170 s in the 12th week. The IELT values were calculated in Group 3 as 42.5 s in pre-treatment, 185 s in the 4th week and 205 s in the 12th week When the IELT was statistically compared between the groups at 1st and 3rd months, the duration in the combination group was found to increase significantly (p < 0.001).

CONCLUSION

Combination therapy with BFT and dapoxetine 30 mg in lifelong PE treatment is a good alternative with a low side effect profile and acceptable continuous efficiency.

Remediation Strategies for Performance Anxiety across Sex, Sport and Stage: Identifying Common Approaches and a Unified Cognitive Model

Strategies for addressing anxiety-related decrements in performance have been implemented across a variety of domains, including Sex, Sport, and Stage. In this review, we (1) iterate the dominant anxiety-related remediation strategies within each of these domains; (2) identify over-lapping and domain-specific strategies; and (3) attempt to unify the conceptualization of performance-related anxiety across these three areas under the information-processing framework of the Reflective/deliberative-Impulsive/automatic Model (RIM). Despite both diversity and similarity in remediation approaches across domains, we found that many strategies appear to share the common goal of maintaining a dominant automatic style of information processing in high performance demand situations. We then describe how various remediation strategies might hypothetically fit within the RIM framework and its subcomponents, identifying each intervention as falling into one or more broad categories related to achieving and/or maintaining dominance in automatic information processing. We conclude by affirming the benefit of adopting a unifying information-processing framework for the conceptualization of performance-related anxiety, as a way of both guiding future cross- and inter- disciplinary research and elucidating effective remediation models that share common pathways/mechanisms to improved performance.

The Effect of Pelvic Floor Rehabilitation on Males with Sexual Dysfunction: A Narrative Review

INTRODUCTION

Increasing evidence has suggested that pelvic floor exercises and manual physical therapy may improve premature ejaculation (PE) and erectile dysfunction (ED) in males.

OBJECTIVES

To examine the effects of pelvic floor physical therapy treatment in men suffering from PE and ED.

METHODS

We searched Google Scholar, PubMed, Medline, PEDro databases from inception till January 2020 applying the following keywords: pelvic floor, erectile dysfunction, impotence, physiotherapy, exercises, rehabilitation, and pelvic floor muscle exercises.

RESULTS

The review included 37 papers reporting on PE and ED, of which 5 were randomized controlled trials, 2 meta-analyses, and 4 observational studies. Pelvic floor physical therapy treatment included education and rehabilitation. The rehabilitation part encompassed manual therapy techniques that contribute to the normalization of muscle tone and improvement of muscle relaxation. Moreover, exercises, according to the patients' clinical assessment were presented. Most of the studies reported that by strengthening the pelvic floor muscles (PFMs), ED and PE can be improved if manual physical therapy treatments are combined with PFM training.

CONCLUSIONS

A multifaceted approach should be chosen by physical therapists when evaluating and treating ED and PE and contending with both musculoskeletal dysfunction and behavioral contributions. It is recommended that exercises be monitored and situations involving, that is, hyperactivity/increased tone of the PFMs should be avoided. PFM training is simple, safe, and noninvasive; therefore, it should be a preferred approach in the management of ED and PE. This paper presents narrative reviews with a potential bias that systematic reviews or meta-analyses do not have, however, we strove to be all-encompassing and unbiased. There is a demand for high-quality scientific reviews examining the effectiveness of PFM training, manual therapy, and the rationale of pelvic floor physical therapy, in general, in treating individuals with PE and ED.

"The Overactive Pelvic Floor (OPF) and Sexual Dysfunction" Part 1: Pathophysiology of OPF and Its Impact on the Sexual Response

INTRODUCTION

Overactive pelvic floor (OPF) muscles are defined as muscles that do not relax, or may even contract, when relaxation is needed, for example, during micturition or defecation. Conditions associated with OPF are multifactorial and include multiple possible etiologies and symptom complexes. The complex interplay between biological and psychosocial elements can lead to the persistence of OPF symptoms along with psychological and emotional distress.

OBJECTIVES

(1) To review and contextualize, from a pathophysiologic perspective, the evidence for OPF, (2) to provide an overview of common clinical presentations and comorbidities of OPF, and (3) to discuss the effect of OPF on sexual function in men and women.

METHODS

Review of the updated literature on the pathophysiology of OPF was carried out. OPF-associated conditions were overviewed, with special emphasis on the impact on sexual function in men and women.

RESULTS

Individuals with suspected OPF often present with a combination of gastrointestinal, gynecological, musculoskeletal, sexual, and urological comorbidities, mostly accompanied by psychoemotional distress. In both women and men, sexual function is significantly impaired by OPF and genitopelvic pain penetration disorders are often the primary manifestation of this condition. Women with OPF report less sexual desire, arousal, and satisfaction; more difficulty reaching orgasm; lower frequencies of intercourse; more negative attitudes toward sexuality; and more sexual distress than women without sexual pain. The most frequently reported sexual dysfunctions in men with OPF include erectile dysfunction, premature ejaculation, and ejaculatory pain.

CONCLUSION

The complex pathophysiology of OPF involving multisystemic comorbidities and psychosocial factors emphasize the importance of a biopsychosocial assessment for guiding effective and personalized management. Padoa A, McLean L, Morin M, et al. "The Overactive Pelvic Floor (OPF) and Sexual Dysfunction" Part 1: Pathophysiology of OPF and Its Impact on the Sexual Response. Sex Med 2021;9:64-75.

Pelvic muscle floor rehabilitation as a therapeutic option in lifelong premature ejaculation: long-term outcomes

The aim of the study was to evaluate the long-term outcomes of pelvic floor muscle (PFM) rehabilitation in males with lifelong premature ejaculation (PE), using intravaginal ejaculatory latency time (IELT) and the self-report Premature Ejaculation Diagnostic Tool (PEDT) as primary outcomes. A total of 154 participants were retrospectively reviewed in this study, with 122 completing the training protocol. At baseline, all participants had an IELT ≤60 s and PEDT score >11. Participants completed a 12-week program of PFM rehabilitation, including physio-kinesiotherapy treatment, electrostimulation, and biofeedback, with three sessions per week, with 20 min for each component completed at each session. The effectiveness of intervention was evaluated by comparing the change in the geometric mean of IELT and PEDT values, from baseline, at 3, 6, and 12 months during the intervention, and at 24 and 36 months postintervention, using a paired sample 2-tailed t-test, including the associated 95% confidence intervals. Of the 122 participants who completed PFM rehabilitation, 111 gained control of their ejaculation reflex, with a mean IELT of 161.6 s and PEDT score of 2.3 at the 12-week endpoint of the intervention, representing an increase from baseline of 40.4 s and 17.0 scores, respectively, for IELT and PEDT (P < 0.0001). Of the 95 participants who completed the 36-month follow-up, 64% and 56% maintained satisfactory ejaculation control at 24 and 36 months postintervention, respectively.

Current and Emerging Treatments for Premature Ejaculation

INTRODUCTION

Over the past 20-30 years, the premature ejaculation (PE) treatment paradigm, previously limited to behavioral 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).

AIM

The objective of this article is to review current and emerging PE interventions.

METHODS

Contemporary data on the treatment of PE were reviewed and critiqued using the principles of evidence-based medicine.

MAIN OUTCOME MEASURE

Integrated pharmacotherapy and cognitive behavioral therapy (CBT) may achieve superior treatment outcomes in some patients. Phosphodiesterase type 5 inhibitors alone or in combination with selective serotonin reuptake inhibitors (SSRIs) should be limited to men with acquired PE secondary to comorbid erectile dysfunction (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.

RESULTS

Multiple well-controlled evidence-based studies have demonstrated the efficacy and safety of 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 intravaginal ejaculation latency time compared with on-demand SSRIs. On-demand SSRIs are less effective but may fulfill the treatment goals of many patients.

CONCLUSIONS

Current evidence suggests that psychosexual CBT has a limited role in the contemporary management of PE and confirms the efficacy and safety of dapoxetine, off-label SSRI drugs, and topical anesthetics drugs. Treatment with tramadol, α1-adrenoceptor antagonists cannot be recommended until the results of large, well-designed randomized controlled trials 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 pharmacotherepeutic armamentarium. McMahon CG. Current and emerging treatments for premature ejaculation. Sex Med Rev 2015;3:183-202.

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.

Pelvic floor muscle rehabilitation for patients with lifelong premature ejaculation: a novel therapeutic approach

OBJECTIVES

Premature ejaculation is the most common male sexual disorder. The aim of the study was to evaluate the possible therapeutic role of pelvic floor muscle rehabilitation in patients affected by lifelong premature ejaculation.

METHODS

We treated 40 men with lifelong premature ejaculation, reporting, a baseline intravaginal ejaculatory latency time (IELT) ≤ 1 min, with 12-week pelvic floor muscle rehabilitation.

RESULTS

At the end of the rehabilitation, mean IELTs were calculated to evaluate the effectiveness of the therapy. At the end of the treatment, 33 (82.5%) of the 40 patients gained control of their ejaculatory reflex, with a mean IELT of 146.2 s (range: 123.6-152.4 s). A total of 13 out of 33 (39%) patients were evaluated at 6 months follow up, and they maintained a significant IELT (112.6 s) compared with their initial IELT (mean 39.8 s).

CONCLUSIONS

The results obtained in our subjects treated with pelvic floor rehabilitation are promising. This therapy represents an important cost reduction compared with the standard treatment (selective serotonin reuptake inhibitors). Based on the present data, we propose pelvic floor muscle rehabilitation as a new, viable therapeutic option for the treatment of premature ejaculation.

Evolving ideas about the male refractory period

The male refractory period (MRP) continues to be a topic of discussion and debate within the field of sexual medicine. To date explanations rely on central descending (efferent) influences involving specific neurotransmitter systems. Herein we explore the issue of the male refractory period, identifying problems with current explanations, specifying the parameters of an adequate model, and suggesting possible mechanisms mediating this phenomenon. We review the literature regarding existing explanations for the MRP and look to other systems of physiological regulation that might provide a model for the conceptualization of the MRP. Our approach differs from traditional explanations in that it emphasizes the possible roles of various peripheral, rather than central, feedback (afferent) systems that affect peripheral autonomic functioning and response. Yet our approach is consistent with other peripheral regulatory feedback systems controlling autonomic response related to such processes as heart rate, respiration, and gut motility. Although direct empirical research supporting our approach is lacking, sufficient evidence exists to support the idea that such processes are not only possible but likely with respect to the male refractory period. We suggest several lines of research that might provide empirical support for this approach.

Premature ejaculation: do we have effective therapy?

INTRODUCTION

Premature ejaculation (PE) is the most common sexual dysfunction, with the majority of PE patients remaining undiagnosed and undertreated. Despite its prevalence, there is a current paucity of data regarding available treatment options and mechanisms. The objective of the current investigation is to review and summarize pertinent literature on therapeutic options for the treatment of PE, including behavioral/psychologic, oral pharmacotherapy, and surgery.

METHODS

A pubmed search was conducted on articles reporting data on available treatment options for PE. Articles describing potential mechanisms of action were additionally included for review. Preference was given towards randomized, controlled trials, when available.

RESULTS

PE remains an underdiagnosed and undertreated disease process, with limited data available regarding potential underlying mechanisms and long-term outcomes of treatment options. Psychological/behavioral therapies, including the stop-start, squeeze, and pelvic floor rehabilitation techniques have demonstrated improvements in short-term series, with decreased efficacy with additional follow-up. Topical therapies, which are commonly utilized result in prolonged intravaginal ejaculatory latency time (IELT) at the expense of potential penile/vaginal Hypothesia. Oral therapies similarly demonstrate improved IELTs with variable side effect profiles and include selective serotonin reuptake inhibitors (daily or on demand), phosphodiesterase-5 inhibitors, alpha-1 adrenergic antagonists, and tramadol. Alternative therapies such as acupuncture have shown benefits in limited studies. Surgery is not commonly performed and is not recommended by available guidelines.

CONCLUSIONS

PE is a common condition, with limited data available regarding its underlying pathophysiology and treatment. Available therapies include topical, oral, behavioral/psychologic modification, or a combination thereof. Additional research is required to assess the optimal treatment strategies and algorithms as well as to better define the mechanisms for PE and its management.

REVIEWS: Pelvic Floor Involvement in Male and Female Sexual Dysfunction and the Role of Pelvic Floor Rehabilitation in Treatment: A Literature Review

INTRODUCTION

The sphincteric and supportive functions of the pelvic floor are fairly well understood, and pelvic floor rehabilitation, a specialized field within the scope and practice of physical therapy, has demonstrated effectiveness in the treatment of urinary and fecal incontinence. The role of the pelvic floor in the promotion of optimal sexual function has not been clearly elucidated.

AIM

To review the role of the pelvic floor in the promotion of optimal sexual function and examine the role of pelvic floor rehabilitation in treating sexual dysfunction.

MAIN OUTCOME MEASURE

Review of peer-reviewed literature.

RESULTS

It has been proposed that the pelvic floor muscles are active in both male and female genital arousal and orgasm, and that pelvic floor muscle hypotonus may impact negatively on these phases of function. Hypertonus of the pelvic floor is a significant component of sexual pain disorders in women and men. Furthermore, conditions related to pelvic floor dysfunction, such as pelvic pain, pelvic organ prolapse, and lower urinary tract symptoms, are correlated with sexual dysfunction.

CONCLUSIONS

The involvement of the pelvic floor in sexual function and dysfunction is examined, as well as the potential role of pelvic floor rehabilitation in treatment. Further research validating physical therapy intervention is necessary.

Male sexual function and its disorders: physiology, pathophysiology, clinical investigation, and treatment

This review is designed to help the reproductive endocrinologist integrate his or her professional activity with those of other disciplines including urology, radiology, neurology, and psychology in order to successfully manage all of the inseparable aspects of male sexual and reproductive functioning. Significant advances in the field of male sexual physiology and pathophysiology and new methods of investigation and treatment of male sexual disorders are outlined. The review synthesizes available data on the following: norms of sexual organs, aging and sexuality, role of central and peripheral neurochemicals in each stage of the sexual cycle, role of corporeal smooth muscles in the hemodynamic control of erection and detumescence, influence of psychological factors, drugs, and disease on all aspects of sexual functioning, and use of nocturnal penile tumescence monitoring, imaging investigations, and neurophysiologic studies in the diagnostic workup of males with sexual dysfunction. Clinical algorithms are presented where appropriate. Extensive discussions on newly developed strategies in psychological and behavioral counseling, drug therapy, tissue engineering, nonsurgical devices, and surgical treatments for all forms of sexual disorders are also provided. Lastly, the effect of sexual dysfunction and its treatment on quality of life in affected men is addressed, along with recommendations for future research endeavors.

Premature ejaculation: a psychophysiological approach for assessment and management

This article distinguishes several subtypes of biogenic and psychogenic premature ejaculation (PE) according to their etiologic features: the physiological PE types of (a) neurologic constitution, (b) acute physical illness, (c) physical injury, and (d) pharmacologic side effect; and the psychological PE types of (a) psychological constitution, (b) acute psychological distress, (c) relationship distress, and (d) psychosexual skills deficit. Attention is given to assessment and differential diagnosis, and to specific treatment of the types of PE, such as the pharmacologic management of difficult neurologic cases. Effective psychosexual treatment combines multiple strategies such as physiological relaxation, pubococcygeal muscle training, cognitive and behavioral pacing strategies, and the involvement of the partner in the therapy. Treatment should determine the specific type of PE and comprehensively address its particular features in order to improve long-term treatment effectiveness.

Conservative treatment of erectile dysfunction. 3: Literature review

This is the third of a three-part article addressing whether physiotherapy involving pelvic floor muscle exercises (PFMEs) is efficacious as a first-line treatment for erectile dysfunction (ED). The first part (Vol 9(11): 691-4) highlighted the prevalence of ED, associated risk factors, the anatomy of the penis and the physiology of erection. The second part (Vol 9(12): 755-62) concentrated on the published clinical trials investigating the treatment and prevention of ED. This part will critically analyse the literature. PFMEs using ischiocavernosus muscles (ICMs) and bulbocavernosus muscles (BCMs) seem to have merit as a treatment for ED due to mild or moderate venous leakage. Men suffering from ED due to other causes may also benefit. There is no strong evidence that electrical stimulation or electroacupuncture is effective or ineffective. No studies demonstrating preventive conservative treatments were found. There is evidence that the ICMs and BCMs increase penile rigidity in the tumescent penis, that pelvic floor muscle efficiency is higher in potent men than impotent men and that perineal muscle efficiency reduces with age in impotent men. There is limited evidence that pelvic floor exercises relieve ED due to venous leakage and are a realistic alternative to surgery. Randomized controlled trials are needed to explore the use of PFMEs as a first-line treatment for men with ED.

The mechanism of ejaculation: the glans-vasal and urethromuscular reflexes

To assist in the understanding of the pathogenesis of the various ejaculatory disorders, 9 healthy male volunteers (mean age 30.4 +/- 4.8 years) were studied. The EMG response of the bulbocavernosus (BCM) and ischiocavernosus (ICM) muscles and the external urethral sphincter (EUS) to ejaculation induced by glans penis (GP) vibration was recorded. The test was repeated with individual anesthetization of the GP, BCM, ICM, and EUS. During ejaculation, the BCM, ICM, and EUS showed a significant increase in the motor unit action potentials. The contractions were rhythmic with a mean duration of the contractile episode of 0.8 s and the noncontractile episode of 0.72 s, and with a total muscle activity of 4.2 s. GP vibration after anesthetization of the GP produced no ejaculation or increased EMG activity of the BCM, ICM, and EUS, GP vibration after individual anesthetization of the BCM or the EUS produced semen emission but no ejection, and GP vibration after ICM anesthetization produced ejaculation (emission and ejection). The results suggest that the ejaculatory mechanism consists of two reflexes: the glans-vasal and urethromuscular. The former seems to bring the semen to the posterior urethra (the emission stage of ejaculation) and the urethromuscular reflex ejects it to the exterior (ejection stage of ejaculation). A dysfunction of these two reflexes would seem to induce ejaculatory disorders, a point that needs further study.