The Controversial Role of Phosphodiesterase Type 5 Inhibitors in the Treatment of Premature Ejaculation

The Italian Society of Andrology and Sexual Medicine (SIAMS), along with ten other Italian Scientific Societies, guidelines on the diagnosis and management of erectile dysfunction

PURPOSE

Erectile dysfunction (ED) is one of the most prevalent male sexual dysfunctions. ED has been in the past mistakenly considered a purely psycho-sexological symptom by patients and doctors. However, an ever-growing body of evidence supporting the role of several organic factors in the pathophysiological mechanisms underlying ED has been recognized.

METHODS

The Italian Society of Andrology and Sexual Medicine (SIAMS) commissioned an expert task force involving several other National Societies to provide an updated guideline on the diagnosis and management of ED. Derived recommendations were based on the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system.

RESULTS

Several evidence-based statements were released providing the necessary up-to-date guidance in the context of ED with organic and psychosexual comorbidities. Many of them were related to incorrect lifestyle habits suggesting how to associate pharmacotherapies and counseling, in a couple-centered approach. Having the oral therapy with phosphodiesterase type 5 inhibitors as the gold standard along with several other medical and surgical therapies, new therapeutic or controversial options were also discussed.

CONCLUSIONS

These are the first guidelines based on a multidisciplinary approach that involves the most important Societies related to the field of sexual medicine. This fruitful discussion allowed for a general agreement on several recommendations and suggestions to be reached, which can support all stakeholders in improving couple sexual satisfaction and overall general health.

Nomogram for stratifying patients with lifelong premature ejaculation before using the PHQ-9: An observational study

OBJECTIVE

A PHQ-9 score ≥ 15, represented as PHQ-9⁺ , indicates major depressive disorder (MDD). On using PHQ-9, the psychological burden of several patients with lifelong premature ejaculation (LPE) gets aggravated, which may lead to LPE development. We aim to construct a nomogram for predicting the individual risk of PHQ-9⁺ in patients with LPE and discerning those with low risks, who should avoid the PHQ-9.

METHODS

The nomogram was constructed by analysing data of 802 patients from Xijing Hospital and Northwest Women's & Children's Hospital. The LASSO and multivariable logistic regressions were used to identify independent predictors of PHQ-9⁺ , used for developing the nomogram. The discrimination, calibration and clinical usefulness of the nomogram were assessed in the derivation cohort and an independent validation cohort, which was composed of 505 prospectively enrolled patients from Daxing Hospital and Xijing Hospital.

RESULTS

The duration of PE, IELT, a history of PE exacerbation, IIEF-5 score, urinary frequency and physical pain score were identified as independent predictors. The nomogram showed excellent calibration, discrimination and clinical usefulness in the derivation and validation cohorts, with a predictive accuracy of 0.781 and 0.763, respectively. Based on this nomogram, patients were divided into not recommended, recommended and strongly recommended PHQ-9 filling groups, with PHQ-9⁺ rates of 3.5%, 9.3% and 30.7%, respectively.

CONCLUSION

A nomogram to discern LPE patients with low risks of PHQ-9⁺ was established. This tool can increase the positivity of MDD screening and may improve the therapeutic outcomes of those in the low-risk group.

The Inferto-Sex Syndrome (ISS): sexual dysfunction in fertility care setting and assisted reproduction

PURPOSE

Infertility represents a peculiar social burden affecting more than 15% of couples, provoking it a real threat to the general quality of life and to the sexual health. The medicalization (diagnosis, therapy and follow up) of the lack of fertility is frequently a challenge in term of personal and couple's involvement. In particular, while the Assisted Reproductive Technology (ART) has allowed many infertile couples to achieve pregnancy, the therapeutic process faced by the couple bears a strong psychological stress that can affect the couple's quality of life, relationship and sexuality. Despite infertility affects both female and male sexual health, only recently the interest in the effects of ART on the couple's sexuality has grown, especially for women.

METHODS

A literature research on the sexual dysfunction in fertility care and particularly in ART setting was performed.

RESULTS

Literature largely found that intimacy and sexuality appear specifically impaired by intrusiveness of treatments and medical prescriptions. Moreover, there is a close relationship between emotional, psychological and sexual aspects, which can be integrated in the new concept of Inferto-Sex Syndrome (ISS) that can impair the ART treatment outcomes. Evidence demonstrates that the assessment of sexual function is necessary in couples undergoing diagnosis of infertility and ART.

CONCLUSION

A close relationship between infertility and sexuality, both in the female and male partners, was detected. ART treatments may heavily impact on the couple's psychosexual health. A couple-centred program for the integrated management of psychological and sexual dysfunction should be considered in the context of ART programs.

Management of premature ejaculation: a clinical guideline from the Italian Society of Andrology and Sexual Medicine (SIAMS)

Premature ejaculation (PE) is the most prevalent male sexual dysfunction, and the most recently defined. PE is often mistakenly considered a purely psychosexological symptom by patients: the lacking awareness in regards to the pathophysiology and treatments often lead to resignation from the patients' side, making PE the most underdiagnosed sexual complaint. However, an ever-growing body of evidence supporting several organic factors has been developed in the last decades and several definitions have been suggested to encompass all defining features of PE. In the present document by the Italian Society of Andrology and Sexual Medicine (SIAMS), we propose 33 recommendations concerning the definition, pathophysiology, treatment and management of PE aimed to improve patient care. These evidence-based clinical guidelines provide the necessary up-to-date guidance in the context of PE secondary to organic and psychosexological conditions, such as prostate inflammation, endocrine disorders, and other sexual dysfunctions, and suggest how to associate pharmacotherapies and cognitive-behavioral therapy in a couple-centered approach. New therapeutic options, as well as combination and off-label treatments, are also described.

Redefining a sexual medicine paradigm: subclinical premature ejaculation as a new taxonomic entity

Premature ejaculation (PE) and poor ejaculatory control are multidimensional sexual symptoms estimated to affect almost one-third of men, severely impairing the overall quality of life of patients and their partners. However, patients who do not completely fulfil the definition criteria for PE rarely receive a diagnosis or adequate treatment, with the risk of subsequent progression from initial, subclinical symptoms to clinically overt PE, frequently with other sexual comorbidities. Thus, the current definitions of PE warrant review, in order to consider and propose a new taxonomy encompassing other unaddressed, crucial clinical aspects of PE. These newly proposed criteria include the recommendation for a primary screening for erectile dysfunction (ED), as PE and ED can be comorbid in up to 50% of patients but have never before been considered as a unified clinical entity. In order to facilitate clinical practice and improve clinical management of men with PE and comorbid conditions, we propose and define the new taxonomic clinical entities of subclinical PE (SPE) and loss of control of erection and ejaculation (LCEE). Application of these diagnoses to men who meet the criteria for SPE and/or LCEE, but not the overt conditions, could improve access to treatment for these patients and reduce progression to the more serious clinical disorder.

Practical Approaches to Treat ED in PDE5i Nonresponders

Erectile dysfunction (ED) is a common sexual disorder in adult males and one of the most important factors affecting their quality of life and that of their partners. Although PDE5 inhibitors (PDE5is) are the first choice for improving erectile function, there is a substantial proportion of ED patients, termed PDE5i nonresponders, who do not respond to PDE5is. Because of the lack of effective therapies, these patients always have serious social and psychological problems due to ED, which should be addressed. Here, we review the available literature about ED and PDE5is and propose several strategies for mitigating ED in PDE5i nonresponders.

Premature ejaculation in couples using contraceptive withdrawal and associations with characteristics of its use: A cross-sectional study

This study aimed to investigate the Premature Ejaculation Profile (PEP) and its related factors in couples using contraceptive withdrawal (WD). The study sample was composed of 108 participants including 54 males and 54 females (their partners) who used WD. The data were collected via a questionnaire and the male and female forms of the PEP. The mean total PEP index score of the couples (female (F); 1.69 ± 0.55 and male (M); 1.65 ± 0.36) was below the average possible score. Although both males and their partners generally rated control over ejaculation (F; 57.4%, M; 61.1%) and satisfaction with sexual intercourse (F; 63%, M; 79.7%) as good/very good, they rate personal distress related to ejaculation (F; 64.8%, M; 83.4%) and interpersonal difficulty related to ejaculation (F; 81.5%, M; 92.6%) as 'extremely/quite a lot'. As the time of using WD increased, male control over ejaculation increased (p = .019); as the marriage duration (p = .045) and ages (F; p = .012, M; p = .045) of the couples increased, their problems related to ejaculation increased. According to the results, couples who use WD experience PE-related problems, and the problems they experience vary depending on the period of WD use, marriage duration and age.

Phosphodiesterase-5 Inhibitors for Premature Ejaculation: Systematic Review and Meta-Analysis of Placebo-Controlled Trials

The purpose of this analysis is to assess the efficacy and safety of phosphodiesterase-5 inhibitors (PDE5Is) for the treatment of premature ejaculation (PE). A comprehensive search was performed to ascertain from trials about PDE5Is for the treatment of PE and compare the results, including intravaginal ejaculatory latency time (IVELT), score of sexual satisfaction scale, and side effects, between the group treated with PDE5Is and that treated with placebo. Seven studies involving a total of 471 patients were included in this meta-analysis. This analysis showed that patients who were treated with PDE5Is had significantly increased IVELT (mean difference [MD] 2.60; 95% CI [1.85, 3.36]; p < .00001) and score of sexual satisfaction scale (MD 2.04; 95% CI [0.78, 3.30]; p = .002) compared with the group on placebo. More patients had side effects while taking PDE5Is, such as headache, dizziness, flushing, and nasal congestion. PDE5Is were significantly more effective than placebo in the treatment of PE. Side effects were more common among patients who were treated with PDE5Is.

Lifestyles and sexuality in men and women: the gender perspective in sexual medicine

Sexual health is strictly related with general health in both genders. In presence of a sexual dysfunction, the expert in sexual medicine aims to discover the specific weight of the physical and psychological factors can cause or con-cause the sexual problem. At the same time, a sexual dysfunction can represent a marker of the future development of a Non-communicable diseases (NCDss) as cardiovascular or metabolic diseases.In the evaluation phase, the sexual health specialist must focus on these aspects, focusing especially on the risk and protective factors that could impact on both male and female sexuality.This article presents a review of researches concerning healthy and unhealthy lifestyles and their contribute in the development of sexual quality of life in a gender-dependent manner.Among the unhealthy lifestyle, obesity contributes mostly to the development of sexual dysfunctions, due to its negative impact on cardiovascular and metabolic function. Tobacco smoking, alcohol - substance abuse and chronic stress lead to the development of sexual dysfunction in a med-long term.In order to guarantee a satisfying sexual quality of life, sexual health specialists have the responsibility to guide the patient through the adoption of healthy lifestyles, such as avoiding drugs, smoke and excessive alcohol, practicing a regular physical activity, following a balanced diet and use stress-management strategies, even before proposing both pharmaco- and/or psychotherapies.

Evaluation of the Mistakes in Self-Diagnosis of Sexual Dysfunctions in 11,000 Male Outpatients: A Real-Life Study in An Andrology Clinic

Purpose: The aim of this study was to compare the initial request for sexual consultation with the final diagnosis and to evaluate the limits of the active andrological anamnesis concerning unclassified male sexual dysfunction. Methods: In this 12-year observational retrospective study, we collected data from patients referring to an andrological outpatient clinic, evaluating the requests, perceptions, needs, and self-diagnosis at their first visit and comparing them with the final diagnosis reached after a complete clinical, laboratory, and instrumental investigation. Results: A total of 11,200 patients were evaluated. The main request of andrological consultation was erectile dysfunction (ED) (52%), followed by premature ejaculation (PE) (28%), and low sexual desire (11.5%). Among the patients seeking help for ED, about 30% were ultimately found to have a different type of dysfunction and 24% were diagnosed with an “unmet need”, which included issues not present in the current nosography nonetheless affecting sexual and relational life. Among the patients referring for PE, the final diagnosis was lifelong PE for the large majority of them, regardless of whether initially they thought to have an acquired form. Several of those who sought consultation for acquired PE were frequently found to be able to compensate for lifelong PE by a subsequent coitus or were able to induce orgasm in the partner with different modalities. Among the patients referring for low sexual desire, only 57.5% were confirmed to have it; 23% had ED and 18.5% showed a raised threshold of penile sensitivity. Conclusions: The results of this study show that the reason for consultation is frequently misleading and raise the relevance of being aware of the so-called “unmet needs” and to discuss with the patient and the couple to explore the sexual history behind the self-diagnosis. These findings also suggest the need to expand the current taxonomy of male sexual dysfunctions.

Therapeutic Strategies for Erectile Dysfunction With Emphasis on Recent Approaches in Nanomedicine

This review addressed erectile dysfunction, regarding pathophysiology and therapeutic strategies. The line of treatment includes phosphodiesterase type-5 inhibitors and other types of therapy like topical and stem-cell transplant. Scientific literature was assessed to investigate the impact of nanotechnology on erectile dysfunction therapy. Various nanotechnology approaches were applied, like vesicular systems, lipid-based carriers, nanocrystals, dendrimers, liquid crystalline systems and nanoemulsions. Smart nano-systems can alter the landscape of the modern pharmaceutical industry by re- investigation of pharmaceutically suboptimal but biologically active entities for treatment of erectile dysfunction which were previously considered undeveloped.

The Sentiment Analysis of Tweets as a New Tool to Measure Public Perception of Male Erectile and Ejaculatory Dysfunctions

INTRODUCTION

Twitter is a social network based on "tweets," short messages of up to 280 characters. Social media has been investigated in health care research to ascertain positive or negative feelings associated with several conditions but never in sexual medicine.

AIM

To assess perceptions related to erectile dysfunction (ED) and premature ejaculation (PE) among Twitter users.

METHODS

Data collection was performed on a daily basis between May 24-October 9, 2018 (138 days) via an automated script. Data collection was then performed after data cleaning. The statistical software R and the rtweet packages were used in both phases.

RESULTS

We collected 11,000 unique tweets for PE and 30,546 unique tweets for ED. After data cleaning, we analyzed 7,020 tweets on PE and 22,648 tweets on ED by analyzing the most recurring words and the clusters describing word associations. The most popular words for ED were "Treatment," "Health," and "Viagra," whereas "Sex," "Sexual," and "Cure" were the top 3 for PE. Word clusters suggest the presence of some recurring themes, such as medical terms being grouped together. Additionally, tweets reflect the general feelings triggered by specific events, such as pieces of news pertaining to sexual dysfunctions.

CLINICAL IMPLICATIONS

Tweets on sexual dysfunctions are posted every day, with more tweets on ED than on PE. Treatment is among the chief topics discussed for both conditions, although health concerns differ between PE and DE tweets.

STRENGTH AND LIMITATIONS

This is the first analysis conducted on Tweets in the field of andrology and sexual medicine. A significant number of tweets were collected and analyzed. However, quantitative assessment of the sentiment was not feasible.

CONCLUSION

Sexual dysfunctions are openly discussed on social media, and Twitter analysis could help understand the needs and interests of the general population on these themes. Sansone A, Cignarelli A, Ciocca G, et al. The Sentiment Analysis of Tweets as a New Tool to Measure Public Perception of Male Erectile and Ejaculatory Dysfunctions. Sex Med 2019;7:464-471.

Efficacy of combined traditional Chinese medicine spray with premature ejaculation desensitization therapy for the treatment of primary premature ejaculation

Objectives

We recommend a new kind of spray made from eight kinds of traditional Chinese medicine, we aimed to investigate the safety and clinical efficacy of combined traditional Chinese medicine spray (TCMS) with premature ejaculation desensitization therapy (PEDT) for the treatment of primary premature ejaculation (PPE).

Methods

A total of 90 patients with PPE were randomly assigned to receive TCMS, PEDT monotherapy or TCMS plus PEDT combination therapy for 6 weeks. Intravaginal ejaculation latency time (IELT) and Chinese index of sexual function for premature ejaculation (CIPE-5) were measured to evaluate the effect of each treatment.

Results

Eighty six (86) participants completed the study voluntarily. Both IELT and CIPE-5 in these three groups increased after treatment when compared with baseline levels (p< 0.01). IELT and CIPE-5 after treatment in TCMS plus PEDT group were significantly higher than those in the other two groups (both p <0.05). Additionally, clinical efficacy in TCMS plus PEDT group (89.7%) was significantly higher than in TCMS (65.5%) and PEDT group (67.9%) (p< 0.01).

Conclusion

The self-made TCMS was safe and effective for the treatment of PPE, a combination of TCMS and PEDT therapy was more effective than the TCMS or PEDT monotherapy.

Phosphodiesterase Type 5 Inhibitors for Premature Ejaculation: A Systematic Review and Meta-analysis

CONTEXT

Phosphodiesterase type 5 inhibitors (PDE5-Is) are prescribed off-label for the treatment of premature ejaculation (PE).

OBJECTIVE

To systematically review the evidence from randomised controlled trials (RCTs) for PDE5-Is in the management of PE.

EVIDENCE ACQUISITION

Medline and other databases were searched through September 2015. Quality of RCTs was assessed. Intravaginal ejaculatory latency time (IELT) data were pooled in a meta-analysis. Heterogeneity was assessed.

EVIDENCE SYNTHESIS

Fifteen RCTs were included. The majority were of unclear methodological quality. Pooled IELT evidence suggests that PDE5-Is are significantly more effective than placebo (231 participants, p<0.00001), that there is no difference between PDE5-Is and selective serotonin reuptake inhibitors (SSRIs; 405 participants, p=0.50), and that PDE5-Is combined with an SSRI are significantly more effective than SSRIs alone (521 participants, p=0.001); however, high levels of statistical heterogeneity are evident (I2 ≥ 40%). Single-RCT evidence suggests that sildenafil is significantly more effective than the squeeze technique, but both lidocaine gel and tramadol are significantly more effective than sildenafil. Sildenafil combined with behavioural therapy is significantly more effective than behavioural therapy alone. Sexual satisfaction and ejaculatory control appear to be better with PDE5-Is compared with placebo and with PDE5-Is combined with an SSRI compared with an SSRI alone. Adverse events are reported with both PDE5-Is and other agents.

CONCLUSIONS

PDE5-Is are significantly more effective than placebo and PDE5-Is combined with an SSRI are significantly more effective than SSRIs alone at increasing IELT and improving other effectiveness outcomes; however, heterogeneity is evident across RCTs. The methodological quality of the majority of RCTs is unclear.

PATIENT SUMMARY

We reviewed phosphodiesterase type 5 inhibitors (PDE5-Is) for treating premature ejaculation. We found evidence to suggest that PDE5-Is are effective compared with placebo and that PDE5-Is combined with an SSRI are more effective than an SSRI alone. Adverse events are reported with PDE5-Is and other agents; however, the quality of the evidence is uncertain.

TRIAL REGISTRATION

PROSPERO registration number CRD42013005289.

Emerging and investigational drugs for premature ejaculation

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

The drug treatment of premature ejaculation

The management recommendation for both acquired premature ejaculation (APE) and lifelong PE (LPE) are similar, such as a behavioral/psychotherapy, a pharmacotherapy and a combination of these treatments. For the drug treatment for PE, gold standard is selective serotonin reuptake inhibitors (SSRIs) including dapoxetine or paroxetine. The drug treatment for PE is still developing and some new promising therapeutic options have been proposed. Topical anesthetics, tramadol, and alpha-1 blockers will be the next strategies of the drug treatment for PE in the future.

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.

Everything you ever wanted to know about phosphodiesterase 5 inhibitors and the heart (but never dared ask): How do they work?

INTRODUCTION

Phosphodiesterase 5 inhibitors (PDE5i) were developed while investigating novel treatments for coronary artery disease, but their andrological side effects shifted their indication toward the management of erectile dysfunction. Although PDE5i are now also indicated for pulmonary arterial hypertension and there are mounting preclinical and clinical evidences about their potentially beneficial cardiac effects, their use remains controversial and the involved mechanisms remain unclear.

MATERIALS AND METHODS

This review aimed to analyze the effects of PDE5i administration in various animal and humans models of cardiovascular diseases.

RESULTS

Animal studies have shown that PDE5i have protective effects in several models of cardiac disease. In humans, some studies showed that PDE5i improves microvascular and endothelial dysfunction and exerts positive effects in different samples of cardiovascular (CV) impairment. In contrast, other studies found no benefit (and no harm) in heart failure with preserved ejection fraction. The discrepancies in these findings are likely related to the fact that the mechanisms targeted by PDE5i in human disease are still poorly understood and the target population not yet identified. The mechanisms of actions herein reviewed suggest that hypertrophy, microvascular impairment, and inflammation, should be variably present for PDE5i to work. All these conditions frequently coexist in diabetes. A gender responsiveness has also been recently proposed.

CONCLUSIONS

Continuous PDE5 inhibition may exert cardioprotective effects, improving endothelial function and counteracting cardiac remodeling in some but not all conditions. A better patient selection could help to clarify the controversies on PDE5i use for CV disorders.

Interplay Between Premature Ejaculation and Erectile Dysfunction: A Systematic Review and Meta-Analysis

INTRODUCTION

The specific determinants and underlying factors linking erectile dysfunction (ED) and premature ejaculation (PE) have yet to be clearly identified.

AIM

The aim of this study was to review and meta-analyze all available data regarding the link between ED and PE.

METHODS

An extensive Medline Embase and Cochrane search was performed including the following words: "premature ejaculation" and "erectile dysfunction".

MAIN OUTCOME MEASURES

All observational trials comparing the risk of ED in relation to PE were included. Data extraction was performed independently by two of the authors (G.R, G.C.), and conflicts resolved by the third investigator (M.M.).

RESULTS

Out of 474 retrieved articles, 18 were included in the study for a total of 57,229 patients, of which 12,144 (21.2%) had PE. The presence of PE, however defined, was associated with a significant increase in ED risk (odds ratio: 3.68[2.61;5.18]; P < 0.0001). Meta-regression analysis showed that the risk of ED in PE subjects was higher in older individuals as well as in those with a lower level of education and in those who reported a stable relationship less frequently. In addition, subjects with PE and ED more often reported anxiety and depressive symptoms and a lower prevalence of organic associated morbidities, including diabetes mellitus, hypertension and dyslipidemia. All the latter associations were confirmed even after adjustment for age. Finally the risk of PE-related ED increased with the increased proportion of acquired ejaculatory problems (adj r = 0.414; P < 0.0001 after the adjustment for age).

CONCLUSIONS

In conclusion, the present data showed that ED and PE are not distinctly separate entities, but should be considered from a dimensional point of view. Understanding this dimensional perspective might help sexual health care professionals in providing the most appropriate therapeutic approach to realistically increase patient related outcomes in sexual medicine.

Erectile dysfunction and its management in patients with diabetes mellitus

Diabetes can be described as a syndrome of multiple closely related conditions induced by a chronic state of hyperglycaemia resulting from defective insulin secretion, insulin action or both. Chronic complications associated with diabetes (including neuropathy, vascular disease, nephropathy and retinopathy) are common, and of these, erectile dysfunction (ED) deserves special attention. ED and its correlation with cardiovascular disease require careful evaluation and appropriate treatment. PDE5 inhibitors (PDE5is) are an important tool for the treatment of ED, with new drugs coming onto the market since the late 90s. This review offers an overview of PDE5is and their use in treating ED in diabetes. We underline the differences between different types of PDE5i, focusing on available doses, duration of action, T ½, side effects and selectivity profiles in relation to patients with diabetes. We also discuss the link between diabetes and ED in presence of various associated cofactors (obesity, hypertension and its pharmacological treatments, atherosclerosis, hyperhomocysteinaemia, neuropathy, nephropathy, hypogonadism and depression). Finally a number of past and ongoing clinical trials on the use of PDE5is in patients with diabetes are presented to offer an overview of the appropriate treatment of ED in this condition.

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.

Clinical correlates of enlarged prostate size in subjects with sexual dysfunction

Digito-rectal examination (DRE) of the prostate provides useful information on the state of prostate growth and on the presence of suspected peripheral nodules. The aim of this study is to describe the clinical and biochemical correlates of finding an enlarged prostate size at DRE in subjects with sexual dysfunction (SD). A consecutive series of 2379 patients was retrospectively studied. The analysis was focused on a subset of subjects (n = 1823; mean age 54.7 ± 11.4) selected for being free from overt prostatic diseases. Several parameters were investigated. After adjusting for confounders, the presence of an enlarged prostate size at DRE was associated with a higher risk of metabolic syndrome (HR = 1.346 (1.129–1.759); P = 0.030), type 2 diabetes mellitus (HR = 1.489 (1.120–1.980); P = 0.006), increased LDL cholesterol (>100 mg dl⁻¹; HR = 1.354 (1.018–1.801); P = 0.037) and increased mean blood pressure (BP) values (HR = 1.017 (1.007–1.027) for each mmHg increment; P = 0.001). Accordingly, enlarged prostate size was also associated with a higher risk of arteriogenic erectile dysfunction (ED), as well as with other andrological conditions, such as varicocele and premature ejaculation (PE). PSA levels were significantly higher in subjects with enlarged prostate size when compared to the rest of the sample (HR = 3.318 (2.304; 4.799) for each log unit increment in PSA levels; P < 0.0001). Arteriogenic ED, according to different criteria, was also associated with increased PSA levels. In conclusion, our data support the need to examine prostate size either by clinical (DRE) or biochemical (PSA) inspection in subjects with SD, in order to have insights into the nature of the SD and the metabolic and cardiovascular (CV) background of the patient.

Relationship between premature ejaculation and chronic prostatitis/chronic pelvic pain syndrome

INTRODUCTION

Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) is a common etiology of premature ejaculation (PE). However, the current data are insufficient to explain this relationship and to support routine screening of men with PE.

AIMS

This study aims to evaluate the relationship between PE and CP/CPPS.

METHODS

A cross-sectional study was conducted that included 8,261 men who had participated in a health examination. The Premature Ejaculation Diagnostic Tool (PEDT), the National Institutes of Health-Chronic Prostatitis Symptom Index (NIH-CPSI), and the International Index of Erectile Function-5 (IIEF) were used for assessment of symptoms. A full metabolic work-up and serum testosterone level checks were also performed. We then investigated the relationship using the Spearman correlation test, multiple linear regression, and logistic regression analyses.

MAIN OUTCOME MEASURES

Associations of PEDT with NIH-CPSI.

RESULTS

The mean age was 50.4 ± 5.5 years. In total, 2,205 (24.9%) men had prostatitis-like symptoms (NIH-CPSI pain score of ≥4 and perineal or ejaculatory pain), and 618 (7.0%) men had moderate to severe symptoms (NIH-CPSI pain score of ≥8). Additionally, 2,144 men (24.2%) were classified as demonstrating PE (PEDT > 10). The PEDT score was found to have a significant positive correlation with the NIH-CPSI pain domain score (correlation coefficient = 0.206; P < 0.001). After adjusting for age, metabolic syndrome status, testosterone level, and IIEF score, there was no change in the positive correlation between the NIH-CPSI pain domain score and PEDT score (Beta = 0.175; P < 0.001). After adjusting for age, testosterone level, metabolic syndrome, and IIEF score, the odds ratio (OR) for PE significantly increased with the severity of pelvic pain (mild prostatitis-like symptoms, OR for PE: 1.269, 95% confidence interval: 1.113-1.447; moderate to severe symptoms, OR for PE: 2.134: 95% confidence interval: 1.782-2.557).

CONCLUSIONS

Our data showed a significant correlation between the PEDT score and the NIH-CPSI score. We suggest routine screening for CP/CPPS in men with PE and PE in men with CP/CPPS.

Relationships between intravaginal ejaculatory latency time and national institutes of health-chronic prostatitis symptom index in the four types of premature ejaculation syndromes: a large observational study in China

INTRODUCTION

Besides lifelong premature ejaculation (LPE) and acquired premature ejaculation (APE), Waldinger and Schweitzer proposed two addition PE syndromes (variable PE [VPE] and subjective PE [SPE]).

AIM

We assessed the associations between intravaginal ejaculatory latency time (IELT) and National Institutes of Health-Chronic Prostatitis Symptom Index (NIH-CPSI) in men with different PE syndromes.

METHODS

From September 2011 to September 2012, a total of 4,000 men were enrolled from the Anhui province of China. Subjects were required to complete a verbal questionnaire, including demographic information, medical and sexual history (e.g., IELT), and self-estimated scales (e.g., NIH-CPSI).

MAIN OUTCOME MEASURES

IELT; NIH-CPSI; the new classification of PE syndromes.

RESULTS

Of 3,016 of the men evaluated, 25.80% complained of PE. Distribution of the four PE syndromes among men with complaints of PE was as follows: LPE, 12.34%; APE, 18.77%; VPE, 44.09%; and SPE, 24.81%. Men with complaints of PE reported worse NIH-CPSI scores and lower IELT than men without complaints of PE (P < 0.001 for all). Moreover, total and subdomain scores of NIH-CPSI were higher in men with APE, and IELT was higher in men with SPE. IELT was negatively associated with NIH-CPSI scores in men with complaints of PE. Negative relationships between total and subdomain scores of NIH-CPSI and IELT were stronger in men with APE (total scores: adjusted r = -0.68, P < 0.001; pain symptoms: adjusted r = -0.70, P < 0.001; urinary symptoms: adjusted r = -0.67, P < 0.001; quality of life impact: adjusted r = -0.64, P < 0.001).

CONCLUSION

Men with complaints of PE reported worse NIH-CPSI scores than men without complaints of PE. Relationships between IELT and NIH-CPSI scores were strongest in men with APE.

Advances in treating premature ejaculation

In spite of its high prevalence and long history, the ambiguity regarding the definition, epidemiology and management of premature ejaculation continues. Topical anesthetic creams and daily or on-demand selective serotonin reuptake inhibitor (SSRI) treatment forms the basis of pharmacotherapy for premature ejaculation today, in spite of low adherence by patients. Psychotherapy may improve the outcomes when combined with these treatment modalities. Tramadol and phosphodiesterase type 5 inhibitors have a limited role in the management of premature ejaculation. Further research is required to develop better options for the treatment of this common sexual disorder.

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.

An Update of the International Society of Sexual Medicine's Guidelines for the Diagnosis and Treatment of Premature Ejaculation (PE)

INTRODUCTION

In 2009, the International Society for Sexual Medicine (ISSM) convened a select panel of experts to develop an evidence-based set of guidelines for patients suffering from lifelong premature ejaculation (PE). That document reviewed definitions, etiology, impact on the patient and partner, assessment, and pharmacological, psychological, and combined treatments. It concluded by recognizing the continually evolving nature of clinical research and recommended a subsequent guideline review and revision every fourth year. Consistent with that recommendation, the ISSM organized a second multidisciplinary panel of experts in April 2013, which met for 2 days in Bangalore, India. This manuscript updates the previous guidelines and reports on the recommendations of the panel of experts.

AIM

The aim of this study was to develop clearly worded, practical, evidenced-based recommendations for the diagnosis and treatment of PE for family practice clinicians as well as sexual medicine experts.

METHOD

A comprehensive literature review was performed.

RESULTS

This article contains the report of the second ISSM PE Guidelines Committee. It offers a new unified definition of PE and updates the previous treatment recommendations. Brief assessment procedures are delineated, and validated diagnostic and treatment questionnaires are reviewed. Finally, the best practices treatment recommendations are presented to guide clinicians, both familiar and unfamiliar with PE, in facilitating treatment of their patients.

CONCLUSION

Development of guidelines is an evolutionary process that continually reviews data and incorporates the best new research. We expect that ongoing research will lead to a more complete understanding of the pathophysiology as well as new efficacious and safe treatments for this sexual dysfunction. We again recommend that these guidelines be reevaluated and updated by the ISSM in 4 years. Althof SE, McMahon CG, Waldinger MD, Serefoglu EC, Shindel AW, Adaikan PG, Becher E, Dean J, Giuliano F, Hellstrom WJG, Giraldi A, Glina S, Incrocci L, Jannini E, McCabe M, Parish S, Rowland D, Segraves RT, Sharlip I, and Torres LO. An update of the International Society of Sexual Medicine's guidelines for the diagnosis and treatment of premature ejaculation (PE). Sex Med 2014;2:60-90.

An update of the International Society of Sexual Medicine's guidelines for the diagnosis and treatment of premature ejaculation (PE)

INTRODUCTION

In 2009, the International Society for Sexual Medicine (ISSM) convened a select panel of experts to develop an evidence-based set of guidelines for patients suffering from lifelong premature ejaculation (PE). That document reviewed definitions, etiology, impact on the patient and partner, assessment, and pharmacological, psychological, and combined treatments. It concluded by recognizing the continually evolving nature of clinical research and recommended a subsequent guideline review and revision every fourth year. Consistent with that recommendation, the ISSM organized a second multidisciplinary panel of experts in April 2013, which met for 2 days in Bangalore, India. This manuscript updates the previous guidelines and reports on the recommendations of the panel of experts.

AIM

The aim of this study was to develop clearly worded, practical, evidenced-based recommendations for the diagnosis and treatment of PE for family practice clinicians as well as sexual medicine experts.

METHOD

A comprehensive literature review was performed.

RESULTS

This article contains the report of the second ISSM PE Guidelines Committee. It offers a new unified definition of PE and updates the previous treatment recommendations. Brief assessment procedures are delineated, and validated diagnostic and treatment questionnaires are reviewed. Finally, the best practices treatment recommendations are presented to guide clinicians, both familiar and unfamiliar with PE, in facilitating treatment of their patients.

CONCLUSION

Development of guidelines is an evolutionary process that continually reviews data and incorporates the best new research. We expect that ongoing research will lead to a more complete understanding of the pathophysiology as well as new efficacious and safe treatments for this sexual dysfunction. We again recommend that these guidelines be reevaluated and updated by the ISSM in 4 years.

Integrating psychotherapy and pharmacotherapy in the treatment of premature ejaculation

OBJECTIVES

To describe the different approaches to the treatment of premature ejaculation (PE), with a final focus on integrated treatment, as conventional theories and therapies for PE are based on an organic or psychogenic dichotomy.

METHODS

We list the principal hypotheses of the causes and therapy of PE on the basis of psychological and medical perspectives, after identifying all relevant studies available on Medline up to 2012.

RESULTS

The cognitive feedback from PE can lead to a 'performance anxiety', which can combine with other conditions to further impair ejaculatory control. For these reasons, a psychological approach is always useful in treating PE, the most useful of which are sex therapy and behavioural therapy. For pharmacological treatment, reports suggest that dapoxetine (60 mg) significantly improves the control of the ejaculatory reflex, and it thus represents the first-line officially approved pharmacotherapy for PE.

CONCLUSIONS

A holistic approach which considers the biological, psychological and relational aspects is the advised treatment for PE. Integrated medical and psycho-sexological therapy requires a mutual understanding of and respect for the different disciplines involved in sexology. In this aspect two very important roles are those of the physician and the psychologist.

An update on pharmacological treatment of erectile dysfunction with phosphodiesterase type 5 inhibitors

INTRODUCTION

Phosphodiesterase type 5 inhibitors (PDE5-i) are used for the oral treatment of erectile dysfunction (ED). Since the launch of sildenafil more than 15 years ago, new molecules have become available. At present, in addition to tadalafil and vardenafil, there are three other drugs, udenafil, avanafil and mirodenafil, marketed in some countries which appear to be promising.

AREAS COVERED

The clinical pharmacological differences in dosage and side effects of all PDE5-i are evaluated.

EXPERT OPINION

All PDE5-i are equally effective and safe for the treatment of ED. On-demand use of any PDE5-i is also safe for patients with comorbid conditions. Tadalafil seems to be the preferred drug by patients and physicians, probably due to its peculiar pharmacological profile that makes sexual intercourse more spontaneous for the patients. Preliminary data suggest that the use of vardenafil may also be beneficial in cases of ED associated with premature ejaculation. Daily treatment is another option in men with ED and documented vascular or prostate disease. In geriatric or in difficult-to-treat populations, the evaluation of testosterone plasma levels will help to predict the efficacy of any PDE5-i. Remarkably, when such drugs are withdrawn for any reason, ED most often continues to occur because of the presence of an underlying disease.

The global online sexuality survey (GOSS): The United States of America in 2011 Chapter III--Premature ejaculation among English-speaking male Internet users

INTRODUCTION

The Global Online Sexuality Survey (GOSS) is a worldwide epidemiologic study of sexuality and sexual disorders. In 2010, the first report of GOSS came from the Middle East.

AIM

This report studies the prevalence rate of premature ejaculation (PE) in the U.S. as of 2011-2012 and evaluates risk factors for PE.

METHODS

GOSS was randomly deployed to English-speaking male web surfers in the USA via paid advertising on Facebook®, comprising 146 questions.

MAIN OUTCOME MEASURES

Prevalence of PE as per the International Society of Sexual Medicine's (ISSM) definition.

RESULTS

With a mean age of 52.38 years ± 14.5, 1,133 participants reported on sexual function. As per the ISSM definition of PE, the prevalence rate of PE in the USA as of 2011 was 6.3%. This is in contrast to 49.6% as per the Premature Ejaculation Diagnostic Tool (PEDT), 77.6% as per unfiltered subjective reports, and 14.4% as per subjective reporting on more consistent basis. 56.3% of the latter reported lifelong PE. 63.2% could be classified as having natural variable PE. Erectile dysfunction is a possible predisposing factor for acquired PE, while genital size concerns may predispose to lifelong PE. Age, irregular coitus, circumcision, and the practice of masturbation did not pose a risk for PE, among other risk factors. Oral treatment for PE was more frequently used and reported to be more effective than local anesthetics, particularly in those with lifelong PE.

CONCLUSION

Applying the ISSM definition, prevalence of PE is far less than diagnosed by other methods, 6.3% among Internet users in USA as of the year 2011. PEDT measures both lifelong and acquired PE, in addition to 35% men with premature-like ejaculatory dysfunction, making it inaccurate for isolating lifelong and acquired PE cases.

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.

Seminal vesicles and diabetic neuropathy: ultrasound evaluation after prolonged treatment with a selective phosphodiesterase-5 inhibitor

We have previously reported that infertile patients with diabetes mellitus (DM) have a particular ultrasound features of the seminal vesicles (SV) characterized by higher fundus-to-body ratio and lower pre- and post-ejaculatory difference in body antero-posterior diameter (APD). Based on these premises the aim of the present study was to investigate possible ultrasound SV changes in infertile patients with DM and diabetic neuropathy (DN), after prolonged administration of tadalafil (TAD) (a specific phosphodiesterase-5 inhibitor). To accomplish this, 20 infertile patients with symptomatic DN and erectile dysfunction were selected and arbitrarily divided into two groups which were assigned to: daily administration of 5 mg TAD for 3 months (Group A) (n = 10) and administration of placebo (Group B) (n = 10). All patients underwent to scrotal and prostate-vesicular transrectal ultrasound evaluation and semen analysis (Laboratory Manual for the Examination and Processing of Human Semen, WHO, 2010) before and after treatment. The following SV US parameters were recorded: (i) body APD; (ii) fundus APD; (iii) parietal thickness of the right and left SVs; and (iv) number of polycyclic areas within both SVs. We then calculated the following parameters: (i) fundus/body (F/B) ratio; (ii) difference of the parietal thickness between the right and the left SV and (iii) pre- and post-ejaculatory APD difference. In addition, we also evaluated the SV ejection fraction. Group A patients showed a significant reduction in F/B ratio and higher pre- and post-ejaculatory body SV APD difference compared with baseline or Group B after 3 months. These patients showed also a significant increase in SV ejection fraction and a significant improvement of the total sperm count, progressive motility, seminal levels of fructose, leucocytes and ejaculate volume. In conclusion, these results suggest that infertile DM patients with DN and erectile dysfunction had an improvement of ultrasound features suggestive of diabetic neuropathy after daily treatment with low doses of TAD.