Premature and delayed ejaculation: two ends of a single continuum influenced by hormonal milieu

Similarities and differences between men with self-reported lifelong and acquired difficulty reaching ejaculation

Men with delayed ejaculation are often categorized into lifelong and acquired subtypes, yet little is known about similarities and differences between these groups. In this study, we examined whether delayed ejaculation subtypes differed on various demographic, diagnostic, relationship, and sexual activity/satisfaction variables. We drew 140 men reporting moderately-severe to severe difficulty reaching ejaculation during partnered sex (occurring during ≥75% of sexual events) from a convenience sample of over 3000 respondents obtained through an opt-in, multinational, online survey. Respondents were further classified as having lifelong or acquired delayed ejaculation based on self-report. A series of alpha-adjusted analyses of covariance were then made between subtypes on subsets of variables. In addition, the extent to which two potential confounding variables, age and erectile function, might have been responsible for subtype differences was explored. Results indicated that compared with men with acquired delayed ejaculation, men with lifelong delayed ejaculation were younger (28.6 vs 44.7 years, η2p = 0.30, P < 0.001), reported greater delayed ejaculation symptomology (4.31 vs 3.98, P < 0.01, η2p = 0.02), were less likely to attribute their problem to a medical issue or medication (1.7% vs 12.2%, P < 0.05), and more likely to masturbate for anxiety/distress reduction than for pleasure. In contrast, delayed ejaculation subtype differences related to masturbation frequency, pornography use during masturbation, and condom use disappeared when age and erectile functioning differences were statistically controlled. Overall, lifelong and acquired delayed ejaculation subtypes showed more similarities than differences. Findings worthy of clinical note were the lower level of endorsement of medical issues/medication by the lifelong subtype, their higher level of delayed ejaculation symptomology, and-despite a high level of anxiety/distress reported by both groups-their particular vulnerability to anxiety/distress as indicated by their strong motive to masturbate for anxiety/distress reduction (44.3% vs 19.6%, P < 0.05). Other differences between delayed ejaculation subtypes were better explained by group differences in age and erectile function than by subtype membership per se.

Comparing Western and traditional Chinese medicine for male sexual dysfunction: can Klotho represent a silk road?

Traditional Chinese medicine (TCM) and Western Medicine both have shown efficacy in treating male sexual dysfunction (MSD). The aim of this perspective paper is to discuss a possible link between Western medicine and TCM in the MSD field as represented by the entity of Klotho. Klotho is a recently discovered protein, mainly expressed in the kidney, encoded by the anti-aging gene klotho. Not only is Klotho significantly correlated with the development and progression of kidney diseases and their complications, but increasing evidence indicates that it is also closely related to MSD. A comprehensive search within PubMed database was performed to retrieve available evidence on Klotho's roles, particularly in kidney and in MSD. Indeed, in the TCM theory, the concept of the "kidney" is entirely different from the Western medicine: it is closely related to metabolism and to the reproductive, nervous, endocrine systems, being more than just a urinary organ. According to the "Kidney storing essence (jīng) and governing reproduction" (KSEGR) theory, a cornerstone in TCM, the treatment of MSD mainly consists of restoring the kidney's function. Signs of decreasing kidney essence show a consistent similarity to deficiencies of Klotho, also for what regards the male sexual function. Based on the current evidence, Klotho may represent a potential biological indicator for sexual desire and sexual function and a kind of new scientific Silk Road between TCM and Western medicine for MSD; nevertheless, there is a need to conduct further high-quality research to prove this hypothesis.

Peripheral platelet count is a diagnostic marker for predicting the risk of rapid ejaculation: findings from a pilot study in rats

Parameters of peripheral blood cell have been shown as the potential predictors of erectile dysfunction (ED). To investigate the clinical significance of hematological parameters for predicting the risk of rapid ejaculation, we established a rat copulatory model on the basis of ejaculation distribution theory. Blood samples from different ejaculatory groups were collected for peripheral blood cell counts and serum serotonin (5-HT) tests. Meanwhile, the relationship between hematological parameters and ejaculatory behaviors was assessed. Final analysis included 11 rapid ejaculators, 10 normal ejaculators, and 10 sluggish ejaculators whose complete data were available. The platelet (PLT) count in rapid ejaculators was significantly lower than that in normal and sluggish ejaculators, whereas the platelet distribution width (PDW) and mean platelet volume (MPV) were significantly greater in rapid ejaculators. Multivariate logistic regression analysis and receiver operating characteristic (ROC) curve analysis showed that the PLT was an independent protective factor for rapid ejaculation. Meanwhile, rapid ejaculators were found to have the lowest serum 5-HT compared to normal and sluggish ejaculators (P < 0.001). Furthermore, there was a positive correlation between the PLT and serum 5-HT (r = 0.662, P < 0.001), indicating that the PLT could indirectly reflect the serum 5-HT concentration. In addition, we assessed the association between the PLT and ejaculatory parameters. There was a negative correlation between ejaculation frequency (EF) and the PLT (r = -0.595, P < 0.001), whereas there was a positive correlation between ejaculation latency (EL) and the PLT (r = 0.740, P < 0.001). This study indicated that the PLT might be a useful and convenient diagnostic marker for predicting the risk of rapid ejaculation.

Acquired hypoprolactinemia in men, possible phenotype

The physiological role of prolactin (PRL) in men is still not well defined. The pathological increase is characterized by sexual function impairment along with possible negative consequences in body composition and metabolic profile. Conversely, the clinical significance of reduced PRL levels was only partially investigated or mainly neglected. The present paper aims to summarize and critically discuss possible phenotypes characterizing male subjects with reduced PRL levels. When possible, meta-analytic results were provided. Available data derived from patients seeking medical care for sexual dysfunction as well as from cross-sectional and longitudinal studies showed that low PRL in males is associated with a worse metabolic phenotype (including diabetes mellitus), mood disturbances (including anxiety and depression), and sexual dysfunctions (including psychogenic erectile and ejaculatory dysfunctions). Whether or not these features are direct consequences of reduced PRL levels or whether the latter reflect other pathway impairments such as serotoninergic failure cannot be clarified. The present data, however, emphasize that a deficiency of PRL should be taken into account and need further investigations.

A population analysis of delayed ejaculation using a claims database: characteristics and national trends in prevalence, incidence, and pharmacotherapy

We investigated the prevalence, incidence, and rates of pharmacological treatment of delayed ejaculation using the TriNetX Diamond Network. We included all men evaluated in the inpatient, outpatient, and emergency settings. Prevalence was determined by comparing the number of men diagnosed with delayed ejaculation to the entire population. Incidence was determined by comparing the number of men diagnosed with delayed ejaculation without a prior diagnosis to the overall population without a prior diagnosis. Rates of pharmacologic treatment were calculated by comparing the number of men who received a prescription to the total number of men with delayed ejaculation. Trends in prevalence and incidence were compared using six-month intervals, while trends in pharmacologic treatment were compared using one-year intervals. A total of 23,164 adult males were diagnosed with delayed ejaculation from 2013 to 2019. During the final six-month interval (July to December 2019), 2,747 of 16,496,744 men received a delayed ejaculation diagnosis, and 1,375 of 16,488,270 men without a prior diagnosis were diagnosed with delayed ejaculation. In 2019, only 916 of 4,733 (19.4%) men diagnosed with delayed ejaculation received any prescription, with the most common being testosterone (9.5%), bupropion (6.6%), and buspirone (2.3%). Prevalence, incidence and pharmacologic treatment all had increasing trends.

Bilateral orchiectomy deteriorates the structure and function of seminal vesicles in a rat model

The effects of hormone levels on ejaculation are known. In addition to thyroid hormone levels, testosterone levels are also associated with ejaculation, but no consensus has been reached on this issue. Thus, we investigated the effect of decreased testosterone levels due to bilateral orchiectomy on the chemical stimulation-induced ejaculation phases in rats. Twenty-one male Wistar rats were randomized into the orchiectomy, sham, and control groups, with seven rats in each group. Bilateral orchiectomy was performed. The ejaculation parameters were evaluated 5 days after the sham and bilateral orchiectomy operations and the waiting period in the control group. The seminal vesicle (SV) phasic contraction number and increase in basal pressure amplitude were significantly lower in the orchiectomy group (6.9 ± 3.3 and 0.6 ± 0.3 mmHg) than in the sham and control groups (11.2 ± 1.7 and 1.0 ± 0.4 mmHg, and 14.5 ± 6.6 and 1.1 ± 0.2 mmHg, respectively; p = 0.016 and p = 0.03, respectively). The interval between the SV contractions was significantly longer in the orchiectomy group (166.2 ± 104.3 s) than in the sham and control groups (76.0 ± 15.5 s and 63.1 ± 31.1 s, respectively; p = 0.014 (between groups), orchiectomy vs sham p = 0.040 and orchiectomy vs control p = 0.018). The SV weights of the rats were significantly lower in the orchiectomy group (0.14 ± 0.01 g) than in the sham and control groups (0.37 ± 0.05 g and 0.48 ± 0.03 g respectively; p < 0.0001 (between groups), orchiectomy vs sham p < 0.0001 and orchiectomy vs control p < 0.0001). The groups showed no significant differences in ejaculation time, SV basal pressure, SV maximum amplitude, and bulbospongiosus muscle contraction electromyographic activity. Our results partially clarified the relationship between decreased testosterone levels and ejaculation. Decreased testosterone levels caused statistically significant changes in SV functions and affected the ejaculation emission phase.

Male delayed orgasm and anorgasmia: a practical guide for sexual medicine providers

Delayed orgasm (DO) is defined as increased latency of orgasm despite adequate sexual stimulation and desire. Anorgasmia (AO) is characterized as the absence of orgasm. Etiologies of DO/AO include medication-induced, psychogenic, endocrine, and genitopelvic dysesthesia. Given the multifactorial complex nature of this disorder, a thorough history and physical examination represent the most critical components of patient evaluation in the clinical setting. Treating DO/AO can be challenging due to the lack of standardized FDA-approved pharmacotherapies. There is no standardized treatment plan for DO/AO, though common treatments plans are often multidisciplinary and may include adjustment of offending medications and sex therapy. In this review, we summarize the etiology, diagnosis, and treatment of DO/AO.

Sexual health and treatment-related sexual dysfunction in sexual and gender minorities with prostate cancer

Prostate cancer treatment has substantial effects on sexual health and function. Sexual function is a vital aspect of human health and a critical component of cancer survivorship, and understanding the potential effects of different treatment modalities on sexual health is crucial. Existing research has extensively described the effects of treatment on male erectile tissues necessary for heterosexual intercourse; however, evidence regarding their effects on sexual health and function in sexual and gender minority populations is minimal. These groups include sexual minority - gay and bisexual - men, and transgender women or trans feminine people in general. Such unique effects in these groups might include altered sexual function in relation to receptive anal and neovaginal intercourse and changes to patients' role-in-sex. Sexual dysfunctions following prostate cancer treatment affecting quality of life in sexual minority men include climacturia, anejaculation, decreased penile length, erectile dysfunction, and problematic receptive anal intercourse, including anodyspareunia and altered pleasurable sensation. Notably, clinical trials investigating sexual outcomes after prostate cancer treatment do not collect sexual orientation and gender identity demographic data or outcomes specific to members of these populations, which perpetuates the uncertainty regarding optimal management. Providing clinicians with a solid evidence base is essential to communicate recommendations and tailor interventions for sexual and gender minority patients with prostate cancer.

Neurons for Ejaculation and Factors Affecting Ejaculation

Simple Summary

Sexual dysfunctions are rarely discussed in our current society. Males experience different sexual dysfunctions, including erectile, infertility, and ejaculatory dysfunctions. In this review only the ejaculatory dysfunction will be discussed. Ejaculation is defined as the ejection of contents collectively from the vas deferens, seminal vesicle, prostate and Cowper’s glands. It is completely controlled by a population of neurons present in the lumbar spinal cord. The presence of lesion in these neurons ceases the ejaculatory behavior in males. This population of neurons was first identified in rats; however, recently it was confirmed that these neurons are present in human males as well. The issues are known as ejaculatory dysfunction. The following are the different types of ejaculatory dysfunctions: early ejaculation, ejaculation into the urinary bladder, late ejaculation and no ejaculation.

Abstract

Ejaculation is a reflex and the last stage of intercourse in male mammals. It consists of two coordinated phases, emission and expulsion. The emission phase consists of secretions from the vas deferens, seminal vesicle, prostate, and Cowper’s gland. Once these contents reach the posterior urethra, movement of the contents becomes inevitable, followed by the expulsion phase. The urogenital organs are synchronized during this complete event. The L3–L4 (lumbar) segment, the spinal cord region responsible for ejaculation, nerve cell bodies, also called lumbar spinothalamic (LSt) cells, which are denoted as spinal ejaculation generators or lumbar spinothalamic cells [Lst]. Lst cells activation causes ejaculation. These Lst cells coordinate with [autonomic] parasympathetic and sympathetic assistance in ejaculation. The presence of a spinal ejaculatory generator has recently been confirmed in humans. Different types of ejaculatory dysfunction in humans include premature ejaculation (PE), retrograde ejaculation (RE), delayed ejaculation (DE), and anejaculation (AE). The most common form of ejaculatory dysfunction studied is premature ejaculation. The least common forms of ejaculation studied are delayed ejaculation and anejaculation. Despite the confirmation of Lst in humans, there is insufficient research on animals mimicking human ejaculatory dysfunction.

Delayed ejaculation in men with depressive disorders

Delayed ejaculation belongs to the group of sexual disorders in men. The causes of delayed ejaculation or anejaculation are not exactly known. It is assumed that it can be caused by psychogenic or organic influences or their combinations. One of the causes of delayed ejaculation may be elevated prolactin levels, which may be increased by psychosocial stress, pituitary disorders or also treatment with selective serotonin reuptake inhibitors in the treatment of depression. We tested a selected group of 50 men who were diagnosed with a depressive disorder and whose antidepressant treatment lasted for at least 24 weeks. These patients reported long-term delayed ejaculation or, in some cases, anejaculation as comorbidity. The results showed significant Spearman's correlation between elevated prolactin levels and intravaginal ejaculation latency values (R = 0.45), as well as between Beck's Depression-II inventory and intravaginal ejaculation latency and latency values (R = 0.48).

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.

Systematic review and meta-analysis for the value of thyroid disorder screening in men with ejaculatory dysfunction

OBJECTIVE

To demonstrate evidence from available clinical studies to clarify the scientific points that have been achieved in relation to thyroid disorders and ejaculatory dysfunction (EjD).

DATA SOURCES

Clinical trial articles published in English on Medline.

ELIGIBILITY CRITERIA

Clinical studies that investigated the association of thyroid disorders with the ejaculatory function of subjects and the trials evaluating the effect of thyroid dysfunction treatment on the ejaculatory function of the subjects were eligible.

SYNTHESIS METHODS

We searched Medline with "ejaculation" and different combinations of "thyroid," "serum TSH," "serum T3," "serum T4" keywords in PubMed.

RESULTS

Standardised mean serum thyroid-stimulating hormone (TSH) levels in premature ejaculation (PE) sufferers differed from non-PE control subjects (P = .05). Hyperthyroidism was associated with increased odds among PE subjects (OR = 2.0, P = .03). Delayed ejaculation was seen with increased odds in hypothyroid patients compared with hyperthyroidism patients (OR = 57, P = .0001). Serum TSH and mean intra-vaginal ejaculation latency time (IELT) of the subjects showed a correlation both before and after treatment for thyroid disorder. Treatment of thyroid disorders improved the mean IELT measures of the subjects. The overall estimate of the effect of hyperthyroidism treatment on mean IELT was .64 (P = .0001) in the random-effects model.

LIMITATIONS

The low quality and quantity of evidence from available studies limited the interpretation of our study findings.

CONCLUSIONS

The causal relationship between EjD and thyroid disorders remains to be clarified. Sufferers of delayed ejaculation acquired PE subjects, and PE sufferers who have accompanying erectile dysfunction and/or anxiety may benefit from thyroid disorder investigation.

Premature ejaculation and stress

Recent findings indicate that men with premature ejaculation report more frequent sexual problems associated with increased anxiety and interpersonal difficulties. Bearing this in mind, the neuroendocrine changes were examined in men with premature ejaculation and compared to other indicators of stressful experiences to see whether there can be any correlation which could indicate how these factors may contribute to the aetiology of premature ejaculation. Our study comprised 60 male outpatients diagnosed as having secondary premature ejaculation. Clinical examinations were focused on biochemical analysis of cortisol and psychometric scoring using a diagnostic tool for premature ejaculation, traumatic stress and somatoform dissociation. The control group consisted of a 60 healthy men. The results showed significant Spearman correlations of the Premature Ejaculation Diagnostic Tool score with Trauma Symptom Checklist score (R = .86), cortisol level (R = .47) and Somatoform Dissociation Questionnaire score (R = .61). In the control group, the results did not reach statistical significance. Spearman correlations of the Premature Ejaculation Diagnostic Tool score with Trauma symptoms checklist score was (R = .21), cortisol (R = .27) and with Somatoform dissociation questionnaire score (R = .25). These results represent the first reported findings documenting the relationship of traumatic stress indicators with the experience of secondary premature ejaculation and cortisol levels.

When Ejaculation Becomes the Goal in Itself: A Psychodynamic Approach to Delayed Ejaculation

There are a group of men with delayed ejaculation (DE) where the etiology as well as the consequences of the dysfunction are unclear. The aim of the present study was to explore, from a psychodynamic perspective, personality traits among men seeking treatment due to DE. During a 2.5-year period, a consecutive series of 14 men with DE were seeking help at Karolinska University hospital, Sweden. Full medical history and physical examination, sexological case-history and psychological assessments were performed by physicians and a psychotherapist. The results found all patients to be healthy. Mean age was 34 years (range 20-43 years). No other sexual dysfunction occurred. With one exception, they were sexually active. The psychological assessment (The Karolinska Psychodynamic Profile; KAPP) found patients to have difficulties in areas of dependency and separation, control and impulse control, regression in the service of the ego, coping with aggressive affects, alexithymic traits, sexual function, and satisfaction. The results add a deeper understanding of personality traits among healthy patients with DE, which may be a tool for the case history, and offer new treatment strategies. We suggest that DE can be the physical manifestation of some specific personality difficulties, and thus, ejaculation becomes the goal in itself and not the climax of an enjoyable adventure.

Benefits of Sexual Activity on Psychological, Relational, and Sexual Health During the COVID-19 Breakout

BACKGROUND

The COVID-19-related lockdown has profoundly changed human behaviors and habits, impairing general and psychological well-being. Along with psychosocial consequences, it is possible that sexual behavior was also affected.

AIMS

With the present study, we evaluated the impact of the community-wide containment and consequent social distancing on the intrapsychic, relational, and sexual health through standardized psychometric tools.

METHODS

A case-control study was performed through a web-based survey and comparing subjects of both genders with (group A, N = 2,608) and without (group B, N = 4,213) sexual activity during lockdown. The Welch and chi-square tests were used to assess differences between groups. Univariate analysis of covariance, logistic regression models, and structural equation modeling were performed to measure influence and mediation effects of sexual activity on psychological, relational, and sexual outcomes.

OUTCOMES

Main outcome measures were General Anxiety Disorder-7 for anxiety, Patient Health Questionnaire-9 for depression, Dyadic Adjustment Scale for quality of relationship and a set of well-validated sexological inventories (International Index of Erectile Function, Female Sexual Function Index, and male-female versions of the Orgasmometer).

RESULTS

Anxiety and depression scores were significantly lower in subjects sexually active during lockdown. Analysis of covariance identified gender, sexual activity, and living without partner during lockdown as significantly affecting anxiety and depression scores (P < .0001). Logistic regression models showed that lack of sexual activity during lockdown was associated with a significantly higher risk of developing anxiety and depression (OR: 1.32 [95% CI: 1.12 - 1.57, P < .001] and 1.34 [95% CI: 1.15 - 1.57, P < .0001], respectively). Structural equation modeling evidenced the protective role of sexual activity toward psychological distress (β_males = -0.18 and β_females = -0.14), relational health (β_males = 0.26 and β_females = 0.29) and sexual health, both directly (β_males = 0.43 and β_females = 0.31), and indirectly (β_males = 0.13 and β_females = 0.13).

CLINICAL TRANSLATION

The demonstrated mutual influence of sexual health on psychological and relational health could direct the clinical community toward a reinterpretation of the relationship among these factors.

STRENGTHS AND LIMITATIONS

Based on a large number of subjects and well-validated psychometric tools, this study elucidated the protective role of sexual activity for psychological distress, as well for relational and sexual health. Main limitations were the web-based characteristics of the protocol and the retrospective nature of prelockdown data on psychorelational and sexual health of subjects recruited.

CONCLUSIONS

COVID-19 lockdown dramatically impacted on psychological, relational, and sexual health of the population. In this scenario, sexual activity played a protective effect, in both genders, on the quarantine-related plague of anxiety and mood disorders. Mollaioli D, Sansone A, Ciocca G, et al. Benefits of Sexual Activity on Psychological, Relational, and Sexual Health During the COVID-19 Breakout. J Sex Med 2021;18:35-49.

Construction and internal validation of a prediction nomogram for acquired premature ejaculation (APE) in PE patients

Background

A predictive model for acquired premature ejaculation (APE) in PE patients has not yet been established.

Objectives

This study was aimed at determining which factors were independently associated with the possibility of predicting APE in PE patients, and whether an effective pre‐treatment nomogram for predicting their individual chances of being APE in PE patients can be developed.

Materials and methods

We analyzed the medical histories of 915 PE patients diagnosed at Xijing Hospital (Xi'an, China) and Northwest Women's and Children's Hospital (Xi'an, China) between May 2019 and May 2020. The diagnostic nomogram was developed using a multivariate logistic regression model by integrating selected significant variables determined through univariate analysis. Receiver operating characteristic curves were used to measure the predictive accuracy of the nomogram and its constituted variables, and calibrations were performed by making a comparison of nomogram‐predicted probability with actual rate of APE.

Results

The independent predictors for APE that were identified include Age, Intra‐vaginal Ejaculation Latency Time (IELT), Frequency of sexual desire (FSD), and Eysenck Personality Questionnaire‐Revised Short Scale for Chinese (psychoticism) [EPQ‐RSC(P)] scores. The predictive accuracy of the nomogram was 0.782 (95% CI: 0.723–0.841). Also, excellent agreement was demonstrated between the nomogram‐predicted probability and the actual rate of APE.

Discussion and conclusion

We identified 4 independent predictors for APE and demonstrated the potential significant differences in psychoticism between LPE and APE patients. This was the first internally validated predictive APE nomogram where good discrimination and calibration were applied, and it offers a promising role in clinical practice. More studies are necessary for verification of its universal applicability.

Erectile Dysfunction in Young Men: Testosterone, Androgenic Polymorphisms, and Comorbidity With Premature Ejaculation Symptoms

BACKGROUND

The association between erectile dysfunction (ED), free testosterone (T), and androgenic genetic polymorphisms is still unclear. As most studies in the field have focused on older (>40 y.o.) men, data from young men is scarce. In addition, the clinically observed comorbidity between ED and premature ejaculation (PE) has not been explained.

AIM

The aim of the present study was 3-fold: to assess in a sample of young men (1) the association between ED and T; (2) the role of androgenic genetic polymorphisms in the aforementioned association; and (3) comorbidity between ED and PE symptoms.

METHODS

Statistical analyses were performed on a population-based sample of 2,302 Finnish men, (M_age = 26.8 years). Hormone samples were available from 317 men, and genotype information was available from a minimum of 1,144 men depending on genetic locus. For twin analyses, the sample contained 533 male individuals from opposite-sex fraternal twin pairs, 491 identical male individuals (110 complete pairs), 493 male individuals from male fraternal twin pairs (92 complete pairs), and 658 siblings of twins.

OUTCOMES

The main outcome measure includes association between levels of salivary T and ED, main effects of the androgen-related genetic polymorphisms on ED scores. Bivariate twin models of PE and ED were fitted to elucidate possible shared etiology.

RESULTS

We found no significant association between T levels and ED and no significant main effects of the androgenic genetic polymorphisms on ED. We found no evidence suggesting that any of the genetic polymorphisms would moderate the association between T and ED symptoms. We found shared unique environmental influences between PE and ED (r_E = .28).

CLINICAL TRANSLATION

Obtained data suggest that ED has T-independent causes and that any comorbidity between PE and ED is not explained by a set of genes affecting both phenotypes.

STRENGTHS & LIMITATIONS

First, the sample size for both parts of the study was relatively small, which may make some statistical analyses underpowered. Furthermore, as the sample was a population-based sample of relatively young men, the number of clinically relevant ED cases was low. Second, some concerns about T derived from saliva exist because saliva sampling comes with increased risks of error particularly because saliva samples are more vulnerable to contamination.

CONCLUSION

We found no significant association between free T levels, androgenic genetic polymorphisms, and ED in the younger age cohort. Twin analysis suggested a common nonshared environmental component in PE and ED. Zhuravleva1 ZD, Johansson A, Jern P. Erectile Dysfunction in Young Men: Testosterone, Androgenic Polymorphisms, and Comorbidity With Premature Ejaculation Symptoms. J Sex Med 2021;18:265-274.

Association between the serotonin transporter linked polymorphic region and lifelong premature ejaculation: An updated meta-analysis of case-control studies

Previous studies on the association between serotonin transporter linked polymorphic region (5-HTTLPR) polymorphism and premature ejaculation (PE) have led to inconsistent results. The purpose of the present meta-analysis was to examine whether 5-HTTLPR polymorphism is associated with PE susceptibility.All eligible studies were searched and acquired from PubMed, Embase, Science Direct, CNKI, and Wanfang databases according to inclusion and exclusion criteria. Odds ratios (ORs) with 95% confidence intervals (CIs) were computed to assess the strength of the association between 5-HTTLPR polymorphism and PE. In addition, heterogeneity test, publication bias and sensitivity analysis were also conducted.Firstly, the association were observed in 8 studies (L vs S: OR = 0.74, 95% CI = 0.63-0.87; LL vs SS: OR = 0.61, 95% CI = 0.44-0.83; SL vs SS: OR = 0.73, 95% CI = 0.55-0.96; LL + SL vs SS: OR = 0.67, 95% CI = 0.52-0.86; LL vs SL + SS: OR = 0.72, 95% CI = 0.55-0.92). When the 2 studies not in Hardy-Weinberg equilibrium (HWE) were omitted, a positive association could only be observed between the 5-HTTLPR polymorphism and PE in allele contrast model (L vs S: OR = 0.81, 95% CI = 0.67-0.98). In the stratified analysis by subgroup, significantly associations were also found between PE and 5-HTTLPR polymorphism in Caucasians but not Asians (L vs S: OR = 0.79, 95% CI = 0.63-0.98; LL + SL vs SS: OR = 0.67, 95% CI = 0.46-0.96).Our meta-analysis demonstrated that the 5-HTTLPR polymorphism was associated with the susceptibility to PE in the Caucasian population. Compared with S allele, L allele is likely to be less susceptible to PE.

Brain Functional Biomarkers Distinguishing Premature Ejaculation From Anejaculation by ALFF: A Resting-State fMRI Study

INTRODUCTION

Premature ejaculation (PE) and anejaculation (AJ) are 2 opposite disorders of male ejaculatory dysfunction. Recent studies have demonstrated that the process of ejaculation is mediated by certain neural circuits in the brain. However, different mechanisms between PE and AJ are still unclear.

AIM

Therefore, we used resting-state functional magnetic resonance imaging (fMRI) to explore the underlying neural mechanisms in patients with PE and AJ by measuring the amplitude of low-frequency fluctuations (ALFF).

METHODS

Resting-state fMRI data were acquired in 17 PE, 20 AJ patients and 23 matched healthy controls (HC).

MAIN OUTCOME MEASURE

Differences of ALFF values among the 3 groups were compared. We also explored the correlations between brain regions showing altered ALFF values and scores of Premature Ejaculation Diagnostic Tool (PEDT) in the PE group.

RESULTS

There were widespread differences of ALFF values among the 3 groups, which included left anterior cingulate gyrus, precentral and postcentral gyrus, paracentral lobule, superior temporal gyrus, calcarine fissure, putamen; right postcentral gyrus, paracentral lobule, middle temporal gyrus, putamen. Compared with HC, PE patients had greater ALFF in the right inferior frontal gyrus (opercular part), AJ patients had greater ALFF in the left postcentral gyrus. In addition, PE patients exhibited greater ALFF in the left Rolandic operculum, anterior cingulate gyrus, inferior frontal gyrus (orbital part), putamen, and right putamen when compared with AJ patients, as well as decreased ALFF in the right postcentral gyrus. Moreover, positive correlations were found between ALFF of left postcentral gyrus, inferior frontal gyrus (orbital part), right inferior frontal gyrus (opercular part), and PEDT scores.

CLINICAL IMPLICATIONS

The differences in central pathophysiological mechanisms between PE and AJ might be useful for improving the clinical diagnosis of ejaculation dysfunction.

STRENGTH & LIMITATIONS

Our results showed that the method of fMRI could identify the differences of ALFF between PE and AJ and that these alterations in ALFF were related to clinical function. However, this was a relatively small sample study, and further multimodal neuroimaging studies with large samples were needed.

CONCLUSION

The findings demonstrated that altered ALFF of frontal, parietal cortex, and putamen might help distinguish premature ejaculation from anejaculation. Abnormal function of these brain regions might play a critical role in the physiopathology of ejaculatory dysfunction of patients. Chen J, Yang J, Huang X, et al. Brain Functional Biomarkers Distinguishing Premature Ejaculation From Anejaculation by ALFF: A Resting-State fMRI Study. J Sex Med 2020;17:2331-2340.

Moving Toward Empirically Based Standardization in the Diagnosis of Delayed Ejaculation

BACKGROUND

Criteria for delayed ejaculation (DE) rely on a long ejaculation latency (EL) time, lack of control/advancement regarding ejaculation, and associated bother/distress; yet, few studies have investigated these criteria in men who indicate the desire to ejaculate sooner during partnered sex.

AIM

To help standardize criteria for DE by better understanding characteristics of men who desire to ejaculate sooner during partnered sex in terms of their EL, reported ejaculatory control, and level of bother/distress, as well as their perceptions of typical and ideal ELs for men in general and of ELs for men with premature ejaculation (PE).

METHODS

A total of 572 men recruited through social media responded to an online survey regarding their EL, as well as typical, ideal, and PE ELs of men in general. They also rated (i) their ability to control and/or advance ejaculation and (ii) their level of associated bother/distress. 4 comparison groups were then established: men with probable DE (with [DE1] and without [DE2] ejaculatory control issues), a reference group with no ejaculatory disorders, and men who identified as having PE.

OUTCOMES

To demonstrate differences in EL, ejaculatory control, and bother/distress between men with delayed ejaculation and the control and PE reference groups.

RESULTS

ELs for men with probable DE were twice as long as those with no ejaculatory disorders. When probable DE men were further subdivided into DE2 and DE1, differences were greater for the DE2 group. DE2 men also differed significantly from the reference group on ejaculatory control/advancement but not on bother/distress. Both DE and reference groups differed from the PE group.

CLINICAL IMPLICATIONS

Using both EL and ejaculatory control are useful in distinguishing men with delayed ejaculation from men without delayed ejaculation.

STRENGTHS & LIMITATIONS

A sizable sample drawn from a multinational population powered the study, whereas the use of social media for recruitment limited the generalizability of findings.

CONCLUSION

Both EL and ejaculatory control differentiate men with probable DE from a control reference group having no ejaculatory disorders. Differences in bother/distress did not emerge as significant. Implications for diagnosing men with DE are presented. Rowland DL, Cote-Leger P. Moving Toward Empirically Based Standardization in the Diagnosis of Delayed Ejaculation. J Sex Med 2020;17:1896-1902.

Different levels of estradiol are correlated with sexual dysfunction in adult men

Ejaculatory dysfunction, including premature ejaculation (PE) and delayed ejaculation (DE), as well as erectile dysfunction (ED), constitute the majority of male sexual dysfunction. Despite a fair amount of data on the role of hormones and erection and ejaculation, it is inconclusive due to controversy in the current literature. To explore the correlation of male sexual dysfunction with hormonal profile, 1,076 men between the ages of 19–60 years (mean: 32.12 years) were included in this retrospective case–control study; 507 were categorized as ED, PE and DE groups. Five hundred and sixty-nine men without sexual dysfunction were enrolled in the control group. The background characteristics and clinical features of the four groups were collected and analyzed. The estradiol value was significantly elevated in the ED group than the control group (109.44 ± 47.14 pmol/L vs. 91.88 ± 27.68 pmol/L; P < 0.001). Conversely, the DE group had significantly lower level of estradiol than control did (70.76 ± 27.20 pmol/L vs. 91.88 ± 27.68 pmol/L; P < 0.001). The PE group had similar level of estradiol (91.73 ± 31.57 pmol/L vs. 91.88 ± 27.68 pmol/L; P = 0.960) but significantly higher level of testosterone (17.23 ± 5.72 nmol/L vs. 15.31 ± 4.31 nmol/L; P < 0.001) compared with the control group. In conclusion, elevated serum testosterone concentration was an independent risk factor for PE. Besides, there was a progressively increasing graded-distribution of estradiol values from DE to PE and ED groups.

Ejaculatory Dysfunction in Patients Presenting to a Men's Health Clinic: A Retrospective Cohort Study

Introduction

Prevalence and bother of ejaculatory dysfunction (EjD) has yet to be evaluated in a men's health referral population.

Aim

To evaluate the prevalence and associated risk factors of EjD in men presenting to a men's health clinic.

Methods

A retrospective review examined patients presenting to an outpatient men's health clinic who completed the Sexual Health Inventory for Men and the Male Sexual Health Questionnaire Ejaculatory Dysfunction (MSHQ-EjD) Short Form. Patient factors including demographics, comorbidities, and medication were examined. Descriptive statistics and multivariable logistic regression were used.

Main Outcome Measures

The main outcomes of this study are Sexual Health Inventory for Men and MSHQ-EjD scores.

Results

A total of 63 (24%) of patients presenting to the urology clinic were characterized as having EjD based on questionnaire responses. The mean age for men with EjD was 53.8 years, while those without was 42.6 years (P < .001). Of men with EjD, 74.6% were at least moderately bothered (MSHQ-EjD ≥3). Men with EjD were more likely to have erectile dysfunction (77.8%) compared with those without (21%, P < .001) as well as a history of a pelvic cancer (20.6% vs 6%, P = .001). On multivariable regression, erectile dysfunction (odds ratio: 15.04, 95% confidence interval: 6.76–35.92, P < .0001) and alpha inhibitor prescription (odds ratio: 6.82, 95% confidence interval: 1.57–30.16, P = .01) were associated with a higher odds of EjD. ED was found to be a mediator of the relationship between EjD and age, as the age association was lost in the ED population on multivariable regression compared with the non-ED population where it remained significant.

Conclusions

EjD is common among patients presenting to a men's health clinic and may present at varying ages, though it is more common in those aged 50 years or older; it is independent of age and race. EjD is associated with erectile dysfunction, pelvic cancer history, and use of alpha inhibitors, presenting a population that could be considered for screening.

Kasman AM, Bhambhvani HP, Eisenberg ML. Ejaculatory Dysfunction in Patients Presenting to a Men's Health Clinic: A Retrospective Cohort Study. J Sex Med 2020;8:454–460.

Ejaculatory and Orgasmic Dysfunction Following Prostate Cancer Therapy: Clinical Management

The majority of sexual health research has focused on erectile dysfunction following prostate cancer treatment. Ejaculatory and orgasmic dysfunction are significant side effects following the treatment of prostate cancer. Orgasmic dysfunction covers a range of issues including premature ejaculation, anorgasmia, dysorgasmia, and climacturia. This review provides an overview of prevalence and management options to deal with orgasmic dysfunction. A Medline Pubmed search was used to identify articles relating to these problems. We found that orgasmic dysfunction has a very large impact on patients’ lives following prostate cancer treatment and there are ways for physicians to treat it. Management of patients’ sexual health should be focused not only on erectile dysfunction, but on orgasmic dysfunction as well in order to ensure a healthy sexual life for patients and their partners.

Effect of Thyroid Hormone Derangements on Sexual Function in Men and Women

INTRODUCTION

Sexual dysfunction affects many people, with 33‒60% of women reporting sexual dysfunction and 8‒52% of men with erectile dysfunction or premature ejaculation. In an effort to determine the constellation of factors responsible for sexual dysfunction, the effect of thyroid hormone derangements has been of recent interest.

AIM

To investigate the associations between thyroid hormones and sexual dysfunction in women and men.

METHODS

Literature was reviewed to examine the effects of hypo- and hyperthyroidism on sexual function.

MAIN OUTCOME MEASURE

We present a summary of the effects of thyroid dysfunction on domains of sexual functioning.

RESULTS

Most studies demonstrate that men with hypo- and hyperthyroidism have increased rates of sexual dysfunction, including erectile dysfunction in men with hypothyroidism. However, studies vary on the strength of correlation between hormonal derangement and level of sexual dysfunction. In both men with hyper- and hypothyroidism, treating the thyroid disorder at least partially reverses sexual dysfunction. In contrast, the current literature provides no consensus on the effect of hypothyroidism, hyperthyroidism, or Hashimoto's thyroiditis on female sexual function. In studies that observed increased rates of sexual dysfunction in women with thyroid disorders, correction of the thyroid derangement resulted in resolution of some sexual dysfunction. Studies are also conflicted on whether there is a relationship between the degree of sexual dysfunction and the degree of hormone derangement in women. However, prior work has demonstrated a relationship between thyroid autoantibodies and sexual dysfunction in women.

CONCLUSION

Thyroid dysfunction is an important factor in the pathogenesis of sexual dysfunction in men and possibly women. Evidence suggests a reversibility of sexual dysfunction with correction of thyroid dysfunction, although the exact pathophysiology of thyroid-mediated sexual dysfunction remains unknown. However, current evidence supports thyroid derangements rather than autoantibodies as the causative factor in men, whereas autoantibodies appear to play a more prominent role in women. Bates JN, Kohn TP, Pastuszak AW. Effect of Thyroid Hormone Derangements on Sexual Function in Men and Women. Sex Med Rev 2020;8:217-230.

Serotonergic polymorphisms in the control of ejaculation

Serotonin has long been implicated in the regulation of the processes that trigger the ejaculatory reflex. Most evidence of serotonergic involvement is, however, indirect, stemming either from studies on rodents or clinical trials investigating effects of serotonergic drugs. In the past decade, emerging evidence for heritability (i.e., genetic effects) of premature ejaculation (PE) symptoms has spawned a number of scholarly attempts to identify genes that regulate ejaculation, most of which have focused on candidate genes related to the serotonergic system. The aim of the present review article was to summarize the literature concerning genetic association studies of PE, with focus on serotonergic genes. However, methodological obstacles relating to the candidate gene approach predict that a priori hypotheses regarding candidate genes are likely to generate ambiguous and spurious results if samples (e.g., if samples are underpowered and/or stratified). Attempts to replicate reported novel associations between PE symptoms and serotonergic candidate genes have largely failed (thereby adding to the growing body of evidence casting doubt on the reliability of the candidate gene approach), and at present, it is not possible to determine with acceptable certainty which serotonergic genes, if any, are involved in ejaculatory function.

The efficacy of low-dose tadalafil in patients undergoing hemodialysis with end-stage renal disease

BACKGROUND

Erectile dysfunction (ED) is a disorder that is frequently observed in people with chronic kidney disease who undergo hemodialysis (HD). In the context of evidence-based medicine, we aimed to investigate the effect of low-dose tadalafil on sexual function in patients undergoing HD.

METHODS

The medical records of 30 males (aged 29-65 years) with end-stage renal disease (ESRD) on a HD program, and who had received 5 mg tadalafil twice weekly, were retrospectively evaluated. Changes in erectile and ejaculatory function were evaluated using the International Erectile Function Index questionnaire, the Erection Hardness Scale (EHS), and the Male Sexual Health Questionnaire (MSHQ).

RESULTS

The mean age of the patients was 47.6 ± 10.1 years, their mean body mass index was 24.3 ± 4.2 kg/m², their mean hemoglobin was 11.9 ± 0.9 g/dL, and their mean creatinine clearance was 5.8 ± 1.1 mL/min. At the third month of treatment, 36.6% of the patients had no ED, 40% had mild ED, 10% had mild-to-moderate ED, and 13.3% had moderate ED. The mean MSHQ scores (p < .05) and the mean EHS scores (p = .001) were significantly improved. There was no significant difference between Beck's Depression Inventory scores (p > .05), but Hamilton anxiety rate scores decreased significantly (p = .001). The quality-of-life score improved throughout the study period (p < .05).

CONCLUSIONS

Tadalafil therapy is an effective therapeutic option in patients with ESRD who undergo HD, not only for the treatment of ED, but also for ejaculatory function, with acceptable adverse effects.

Longer trinucleotide repeats of androgen receptor are associated with higher testosterone and low oxytocin levels in diabetic premature ejaculatory dysfunction patients

Background

Despite its worldwide high occurrence, the obscurity regarding the description, epidemiology and management of premature ejaculation remains provocative. It is well established that male premature ejaculatory dysfunction is an increasing problem due to spontaneous ejaculation across a variety of general and clinical subjects. The main goal of this study was to determine the relationships between trinucleotide repeats of the androgen receptor (AR), sex steroids, and pituitary hormones with sexual function in men with type 2 diabetes mellitus (DM) and reported with acquired premature ejaculation (PE).

Methods

A total of 150 normal and 250 PE + DM subjects were enrolled in this study. Each subject was invited to fill out an elaborative questionnaire to acquire precise selective information regarding BMI, duration of PE + DM, self-reported Intra-Vaginal Ejaculatory Latency Time (IELT), sexual and mental health status by using the premature ejaculation diagnostic tool (PEDT) and Beck Depression Inventory-II (BDI-II). Pearson's correlation analysis was used to analyze the relationship between clinical, hormonal, and genetic variables. Ward's minimum variance cluster analysis and principal component analysis were used for evaluation of dependence between genetic, clinical, and demographic parameters.

Results

The patients who have the lowest number of (≤21) (CAG)n repeats have higher serum oxytocin levels (114.2 pg/ml; n = 54, 43.2%) than the controls (69.18 pg/ml; n = 22, 17.6%) and the patients with the highest (≥26) number of (CAG)n repeats (62.9 pg/ml; n = 108, 43.2%).On the other hand, patients who have the highest numbers of (CAG)n repeats (≥26) have higher serum testosterone (6.1 ng/ml; n = 108, 43.2% of cohort) lower prolactin (3.01 ng/ml; n = 108, 43.2% of cohort) levels than the controls and patients with the lowest numbers (≤21) of (CAG)n repeats and their TSH (1.53 mIU/L, P < 0.05) levels are lower than those of controls. In the Pearson correlation model, self-estimated IELT demonstrated significantly negative correlation with both (CAG)n and (GCC)n repeats (r = - 0.16, p = 0.0001; r = - 0.19, p = 0.0001) respectively. These repeats have positive correlation with PEDT (r = 0.28, p = 0.0001: r = 0.24, p = 0.0001, whole model) and inversely correlated with BDI-II (r = - 0.25, p = 0.0001).

Conclusion

This study indicates that androgen receptor polymorphism modulates the endocrine effect on ejaculatory reflex and depends strongly on its "cofactors". Moreover, our results also confirmed an association between long tri-nucleotide repeats of androgen receptor, sex steroids, pituitary, and thyroid hormones in relation to  acquired premature ejaculatory dysfunction in diabetic patients. However, endocrine regulation of PE reflex is a complex phenomenon that requires further investigation.

Delayed Ejaculation: Pathophysiology, Diagnosis, and Treatment

Delayed ejaculation (DE) is a poorly defined and uncommon form of male sexual dysfunction, characterized by a marked delay in ejaculation or an inability to achieve ejaculation. It is often quite concerning to patients and their partners, and sometimes frustrates couples' attempts to conceive. This article aims to review the pathophysiology of DE and anejaculation (AE), to explore our current understanding of the diagnosis, and to present the treatment options for this condition. Electronic databases were searched from 1966 to October 2017, including PubMed (MEDLINE) and Embase. We combined “delayed ejaculation,” “retarded ejaculation,” “inhibited ejaculation,” or “anejaculation” as Medical Subject Headings (MeSH) terms or keywords with “epidemiology,” “etiology,” “pathophysiology,” “clinical assessment,” “diagnosis,” or “treatment.” Relevant sexual medicine textbooks were searched as well. The literature suggests that the pathophysiology of DE/AE is multifactorial, including both organic and psychosocial factors. Despite the many publications on this condition, the exact pathogenesis is not yet known. There is currently no single gold standard for diagnosing DE/AE, as operationalized criteria do not exist. The history is the key to the diagnosis. Treatment should be cause-specific. There are many approaches to treatment planning, including various psychological interventions, pharmacotherapy, and specific treatments for infertile men. An approved form of drug therapy does not exist. A number of approaches can be employed for infertile men, including the collection of nocturnal emissions, prostatic massage, prostatic urethra catheterization, penile vibratory stimulation, probe electroejaculation, sperm retrieval by aspiration from either the vas deferens or the epididymis, and testicular sperm extraction.

Assessment of hormonal activity in patients with premature ejaculation

Purpose

Premature ejaculation is considered the most common type of male sexual dysfunction. Hormonal controls of ejaculation have not been exactly elucidated. The aim of our study is to investigate the role of hormonal factors in patients with premature ejaculation.

Materials and Methods

Sixty-three participants who consulted our outpatient clinics with complaints of premature ejaculation and 39 healthy men as a control group selected from volunteers were included in the study. A total of 102 sexual active men aged between 21 and 76 years were included. Premature ejaculation diagnostic tool questionnaires were used to assessment of premature ejaculation. Serum levels of follicle stimulating hormone, luteinizing hormone, prolactin, total and free testosterone, thyroid-stimulating hormone, free triiodothyronine and thyroxine were measured.

Results

Thyroid-stimulating hormone, luteinizing hormone, and prolactin levels were significantly lower in men with premature ejaculation according to premature ejaculation diagnostic tool (p=0.017, 0.007 and 0.007, respectively). Luteinizing hormone level (OR, 1.293; p=0.014) was found to be an independent risk factor for premature ejaculation.

Conclusions

Luteinizing hormone, prolactin, and thyroid-stimulating hormone levels are associated with premature ejaculation which was diagnosed by premature ejaculation diagnostic tool questionnaires. The relationship between these findings have to be determined by more extensive studies.

Translational Perspective on the Role of Testosterone in Sexual Function and Dysfunction

INTRODUCTION

The biological importance of testosterone is generally accepted by the medical community; however, controversy focuses on its relevance to sexual function and the sexual response, and our understanding of the extent of its role in this area is evolving.

AIM

To provide scientific evidence examining the role of testosterone at the cellular and molecular levels as it pertains to normal erectile physiology and the development of erectile dysfunction and to assist in guiding successful therapeutic interventions for androgen-dependent sexual dysfunction.

METHODS

In this White Paper, the Basic Science Committee of the Sexual Medicine Society of North America assessed the current basic science literature examining the role of testosterone in sexual function and dysfunction.

RESULTS

Testosterone plays an important role in sexual function through multiple processes: physiologic (stimulates activity of nitric oxide synthase), developmental (establishes and maintains the structural and functional integrity of the penis), neural (development, maintenance, function, and plasticity of the cavernous nerve and pelvic ganglia), therapeutically for dysfunctional regulation (beneficial effect on aging, diabetes, and prostatectomy), and phosphodiesterase type 5 inhibition (testosterone supplement to counteract phosphodiesterase type 5 inhibitor resistance).

CONCLUSION

Despite controversies concerning testosterone with regard to sexual function, basic science studies provide incontrovertible evidence for a significant role of testosterone in sexual function and suggest that properly administered testosterone therapy is potentially advantageous for treating male sexual dysfunction.

The Role of Somatic Symptoms in Sexual Medicine: Somatization as Important Contextual Factor in Male Sexual Dysfunction

INTRODUCTION

An important feature of somatic symptom disorder is the subjective perception of the physical symptoms and its maladaptive interpretation. Considering that psychological distress is often expressed through somatic symptoms, it is possible that they underlie at least a part of the symptoms in subjects complaining of sexual dysfunction. Nevertheless, studies on the impact of somatoform disorders in sexual dysfunction are scanty.

AIM

To define the psychological, relational, and organic correlates of somatic symptoms in a large sample of patients complaining of sexual problems.

METHODS

A consecutive series of 2833 men (mean age 50.2 ± 13.5 years) was retrospectively studied.

MAIN OUTCOME MEASURES

Somatic symptoms were assessed using the "somatized anxiety symptoms" subscale of the Middlesex Hospital Questionnaire (MHQ-S). Several clinical, biochemical, psychological, and relational parameters were studied. Patients were interviewed with the previously validated Structured Interview on Erectile Dysfunction (SIEDY), and ANDROTEST (a structured interview for the screening of hypogonadism in patients with sexual dysfunction).

RESULTS

Among the 2833 patients studied, subjects scoring higher on somatic symptoms were older, more obese, reporting unhealthy lifestyle (current smoking, alcohol consumption), and a lower education (all P < .05). Moreover, they reported a general impairment of their sexuality more often, including erectile problems (spontaneous or sexual-related), low sexual desire, decreased frequency of intercourse, and perceived reduction of ejaculate volume (all P < .005). Interestingly, we observed a significant association between MHQ-S scoring with a reduced testosterone level and hypogonadism symptoms (both P < .05). Finally, we found a significant association between somatic symptoms and both SIEDY Scales 1 (organic domain of ED) and 3 (intrapsychic domain of ED) (both P < .0001).

CONCLUSION

The present study demonstrates that the presence of somatic symptoms can represent an important contextual factor in the determination of or in the exacerbation of male sexual dysfunction. High levels of somatic symptoms in subjects with sexual dysfunction can be related to the sexual symptom itself. The consequences of this pattern have great clinical relevance in a sexual medicine setting, considering their severe impact on sexuality.

Increased prevalence of premature ejaculation in men with metabolic syndrome

This prospective study aimed to investigate the relationship between metabolic syndrome (Met S) and premature ejaculation (PE) among men. The study included 300 consecutive male patients (53.6 y ± 8.7) who attended the urology clinic (December 2013-September 2014), mostly complaining of renal/ureteric calculi. A diagnostic approach was undertaken to include demographics, clinical features and laboratory investigations of the study subjects. Both erectile function and PE were evaluated using the International Index of Erectile Function (abridged form, IIEF-5) and Premature Ejaculation Diagnostic Tool (PEDT) questionnaires, respectively. Results identified 182 (60.7%) men had Met S. Prevalence of PE was significantly higher in the subjects with Met S than the controls (35.2% vs 7.6%, p < 0.001). Patients with Met S and PE had significantly higher PEDT scores (15.4 vs 6.7), smaller waist circumference (108.3 cm vs 111.5 cm) and higher fasting blood sugar (187 mg% vs 161 mg%) than those with no PE (p < 0.001, 0.047 and 0.019, respectively). The other variables including IIEF-5 score, body mass index, serum triglycerides and high-density lipoprotein (14.98 vs 16.8, 30.6 vs 31.5, 192.9 mg% vs 178.1 mg% and 37.4 mg% vs 36.2 mg%, respectively) did not reveal significant differences. Both systolic hypertension and erectile dysfunction (ED) had significant associations (p = 0.047 and <0.001, respectively) with PE in Met S. In conclusion, PE has a high prevalence in Met S. Patients with Met S should be questioned about PE. Both ED and systolic hypertension may be associated with PE. Prevention of Met S should be considered, and this may be of help to decrease the prevalence of PE.

The pathophysiology of delayed ejaculation

Delayed ejaculation (DE) is probably least studied, and least understood of male sexual dysfunctions, with an estimated prevalence of 1–4% of the male population. Pathophysiology of DE is multifactorial and including psychosexual-behavioral and cultural factors, disruption of ejaculatory apparatus, central and peripheral neurotransmitters, hormonal or neurochemical ejaculatory control and psychosocial factors. Although knowledge of the physiology of the DE has increased in the last two decade, our understanding of the different pathophysiological process of the causes of DE remains limited. To provide a systematic update on the pathophysiology of DE. A systematic review of Medline and PubMed for relevant publications on ejaculatory dysfunction (EjD), DE, retarded ejaculation, inhibited ejaculation, and climax was performed. The search was limited to the articles published between the January 1960 and December 2015 in English. Of 178 articles, 105 were selected for this review. Only those publications relevant to the pathophysiology, epidemiology and prevalence of DE were included. The pathophysiology of DE involves cerebral sensory areas, motor centers, and several spinal nuclei that are tightly interconnected. The biogenic, psychogenic and other factors strongly affect the pathophysiology of DE. Despite the many publications on this disorder, there still is a paucity of publications dedicated to the subject.

Epidemiology of delayed ejaculation

A large body of literature on diminished ejaculatory disorders has been generated without the use of a clear diagnostic definition. Many studies have not distinguished between the orgasm and ejaculation disorders leading to doubtful results. Delayed ejaculation (DE) is one of the diminished ejaculatory disorders, which range from varying delays in ejaculatory latency to a complete inability to ejaculate. The present review is aimed at providing a comprehensive overview of the current knowledge on the definition and epidemiology of diminished ejaculatory disorders. We focus on the acquired diseases, such as benign prostatic hyperplasia (BPH) and specific drug regimens that may cause an iatrogenic form of ejaculatory disorder. In addition, the impact of aging is discussed since the prevalence of DE appears to be moderately but positively related to age. Finally, we also focus on the importance of the hormonal milieu on male ejaculation. To date, evidence on the endocrine control of ejaculation is derived from small clinical trials, but the evidence suggests that hormones modulate the ejaculatory process by altering its overall latency.

Efficacy and safety of dapoxetine in treatment of premature ejaculation: an evidence-based review

BACKGROUND

Premature ejaculation (PE) is a major issue in male sexual health, with a global prevalence estimated to be between 20% and 40%, making it the most common sexual dysfunction in men. PE causes distress and reduced quality of life for patients and has a negative impact on interpersonal relationships. Historically, it has been treated with cognitive therapy, behavioural methods and off-label use of selective serotonin reuptake inhibitors (SSRIs) usually used to treat depression and other psychological disorders. Dapoxetine is the only SSRI specifically designed to treat PE.

MECHANISM OF ACTION

Dapoxetine hydrochloride is a potent inhibitor of serotonin reuptake transporters. Dapoxetine is suited for 'on-demand' treatment of PE because of its rapid absorption and short initial half-life.

EFFICACY

Evidence from published studies showed that dapoxetine 30 mg or 60 mg taken 'on-demand' results in a significant increase in intravaginal ejaculatory latency time (IELT) when compared with placebo. Most patient-reported outcomes are clearly improved relative to placebo following dapoxetine therapy, indicating greater control over ejaculation, more satisfaction with intercourse, less ejaculation-related distress and significantly reduced interpersonal difficulties.

SAFETY

The most common adverse events with dapoxetine are nausea, dizziness, somnolence, headache, diarrhoea and insomnia. Usually they do not lead to drug discontinuation.

CONCLUSION

Dapoxetine is the only effective and safe available on-label oral treatment for PE, and its use can result in better quality of life for the patient and their sexual partner.

The office management of ejaculatory disorders

Premature ejaculation (PE), delayed ejaculation (DE), anejaculation (AE) and retrograde ejaculation (RE) are four main ejaculatory disorders (EjDs) observed in clinical practice. Despite their high prevalence, EjDs remain underdiagnosed and undertreated. Primary care physicians should incorporate the discussion of sexual health topics into routine visits to facilitate EjD diagnosis and treatment. Because the causes of EjDs are multifactorial, the management of EjDs is etiology-specific and may require a holistic approach. Dapoxetine, a selective serotonin reuptake inhibitor, is the only drug approved for on-demand treatment of lifelong and acquired PE. In clinical practice, scheduled follow-up visits, risk factor treatment, appropriate dose escalation, adequate sexual attempts, patient education, and partner involvement are critical factors responsible for optimal overall management of PE and dapoxetine treatment outcomes.

Psychosexual therapy for delayed ejaculation based on the Sexual Tipping Point model

The Sexual Tipping Point(®) (STP) model is an integrated approach to the etiology, diagnosis and treatment of men with delayed ejaculation (DE), including all subtypes manifesting ejaculatory delay or absence [registered trademark owned by the MAP Educational Fund, a 501(c)(3) public charity]. A single pathogenetic pathway does not exist for sexual disorders generally and that is also true for DE specifically. Men with DE have various bio-psychosocial-behavioral & cultural predisposing, precipitating, maintaining, and contextual factors which trigger, reinforce, or worsen the probability of DE occurring. Regardless of the degree of organic etiology present, DE is exacerbated by insufficient stimulation: an inadequate combination of "friction and fantasy". High frequency negative thoughts may neutralize erotic cognitions (fantasy) and subsequently delay, ameliorate, or inhibit ejaculation, while partner stimulation (friction) may prove unsatisfying. Assessment requires a thorough sexual history including inquiry into masturbatory methods. Many men with DE engage in an idiosyncratic masturbatory style, defined as a masturbation technique not easily duplicated by the partner's hand, mouth, or vagina. The clinician's most valuable diagnostic tool is a focused sex history (sex status). Differentiate DE from other sexual problems and review the conditions under which the man can ejaculate. Perceived partner attractiveness, the use of fantasy during sex, anxiety-surrounding coitus and masturbatory patterns require meticulous exploration. Identify important DE causes by juxtaposing an awareness of his cognitions and the sexual stimulation experienced during masturbation, versus a partnered experience. Assist the man in identifying behaviors that enhance immersion in excitation and minimize inhibiting thoughts, in order to reach ejaculation in his preferred manner. Discontinuing, reducing or altering masturbation is often required, which evokes patient resistance. Coaching tips are offered on how to ensure adherence to this suspension, manage resistance and facilitate success. Depending on motivation level, masturbation interruption may be compromised and negotiated. Encourage a man who continues to masturbate to alter style ("switch hands") and to approximate the stimulation likely to be experienced with his partner. Success will require most men to be taught to learn bodily movements and fantasies that approximate the thoughts and sensations experienced in masturbation. Fertility issues, as well as patient/partner anger are important causational factors, which often require individual and/or conjoint consultation. Drug treatment would benefit men particularly with severe DE, regardless of concomitant psychosocial-behavioral and cultural complications. When and if a safe effective medication for DE becomes available, this author's transdisciplinary perspective supports appropriate medication use when integrated with counseling. This approach emphasizes the utility of a biopsychosocial-cultural perspective combined with special attention to the patient's narrative. Treatment is patient-centered, holistic and integrates a variety of therapies as needed.

Biallelic and Triallelic 5-Hydroxytyramine Transporter Gene-Linked Polymorphic Region (5- HTTLPR) Polymorphisms and Their Relationship with Lifelong Premature Ejaculation: A Case-Control Study in a Chinese Population

BACKGROUND This study aimed to explore the relationship between premature ejaculation (PE) and the serotonin transporter gene-linked polymorphic region (5-HTTLPR) with respect to the biallelic and triallelic classifications. MATERIAL AND METHODS A total of 115 outpatients who complained of ejaculating prematurely and who were diagnosed as having lifelong premature ejaculation (LPE) and 101 controls without PE complaint were recruited. All subjects completed a detailed questionnaire and were genotyped for 5-HTTLPR polymorphism using PCR-based technology. We evaluated the associations between 5-HTTLPR allelic and genotypic frequencies and their association with LPE, as well as the intravaginal ejaculation latency time (IELT) of different 5-HTTLPR genotypes among LPE patients. RESULTS The patients and controls did not differ significantly in terms of any characteristic except age. The results showed no significant difference regarding biallelic 5-HTTLPR. According to the triallelic classification, no significant difference was found when comparing the genotypic distribution (P=0.091). However, the distribution of the S, LG, and LA alleles in the cases was significantly different from the controls (P=0.018). We found a significantly lower frequency of LA allele and higher frequency of LG allele in patients. Based on another classification by expression, we found a significantly lower frequency of the L'L' genotype (OR=0.37; 95%CI=0.15-0.91, P=0.025) in patients with LPE. No significant association was detected between IELT of LPE and different genotypes. CONCLUSIONS Contrary to the general classification based on S/L alleles, triallelic 5-HTTLPR was associated with LPE. Triallelic 5-HTTLPR may be a promising field for genetic research in PE to avoid false-negative results in future studies.

Cabergoline in the Treatment of Male Orgasmic Disorder-A Retrospective Pilot Analysis

Introduction

Male orgasmic disorder is common, with few treatment options. Cabergoline is a dopamine agonist that acts centrally to normalize serum prolactin that could improve orgasmic dysfunction.

Aims

To determine whether cabergoline increases the potential for orgasm in men with orgasmic disorder.

Methods

A retrospective chart review of men treated in a single andrology clinic for delayed orgasm or anorgasmia in a pilot study using cabergoline 0.5 mg twice weekly was performed. Duration of treatment and response were noted. Medical records were examined for other factors including history of prostatectomy and concomitant androgen supplementation.

Main Outcome Measures

Subjective improvement in orgasmic function resulting from cabergoline treatment.

Results

Of 131 men treated with cabergoline for orgasmic disorder, 87 (66.4%) reported subjective improvement in orgasm and 44 (33.6%) reported no change in orgasm. Duration of therapy (P = .03) and concomitant testosterone therapy (P = .02) were associated with a significant positive response to cabergoline treatment. No differences were found between injectable and non-injectable testosterone formulations (P = .90), and neither age (P = .90) nor prior prostatectomy (P = .41) influenced the outcome of cabergoline treatment. Serum testosterone levels before (P = .26) and after (P = .81) treatment were not significantly different in responders vs non-responders.

Conclusion

Cabergoline is a potentially effective and easy-to-administer treatment for male orgasmic disorder, the efficacy of which appears to be independent of patient age or orgasmic disorder etiology. Prospective randomized trials are needed to determine the true role of cabergoline in the treatment of this disorder.