Rapid ejaculation: a review of nosology, prevalence and treatment

Information concerning the epidemiology, etiology and treatment of premature (rapid) ejaculation is reviewed. Evidence concerning the prevalence of premature ejaculation indicates that subjective concern about rapid ejaculation is a common concern worldwide. Hypotheses concerning the pathogenesis of premature ejaculation include: (1) that it is a learned pattern of ejaculation maintained by interpersonal anxiety, (2) that it is the result of dysfunction in central or peripheral mechanisms regulating ejaculatory thresholds and (3) that it is a normal variant in ejaculatory latency. Current evidence based treatment interventions include behavioral psychotherapy and the use of pharmacological agents, including topical anesthetic agents and selective serotonin reuptake inhibitors.

Treatment of premature ejaculation

Premature ejaculation (PE) is a common problem, the treatment of which has received an increasing interest in recent years. Traditional management continues to be psychotherapy, with techniques such as the 'squeeze' and 'stop-start' most commonly employed. The application of local anaesthetics to the glans to delay ejaculation, first described over 60 years ago, continues to be used both in medical practice and as an 'over-the-counter' remedy. Over the years, a variety of psychopharmacological agents, especially antidepressants, have been described as treatments for PE. At the present time, the selective serotonin re-uptake inhibitors, licensed for other indications, emerge as the most effective agents to delay ejaculation, but none are licensed for the treatment of PE. There appears to be a high relapse rate irrespective of the mode of therapy used.

A placebo-controlled comparison of the effects on sexual functioning of bupropion sustained release and fluoxetine

BACKGROUND

Many antidepressants are associated with sexual dysfunction, a side effect that may lead to patients' dissatisfaction and noncompliance with treatment.

OBJECTIVE

This study compared the efficacy, tolerability, and effects on sexual functioning of bupropion sustained release (bupropion SR) and the selective serotonin reuptake inhibitor fluoxetine.

METHODS

In this multicenter, randomized, double-blind, double-dummy, parallel-group study, patients with recurrent major depression were treated with bupropion SR 150 to 400 mg/d, fluoxetine 20 to 60 mg/d, or placebo for up to 8 weeks. Depression and sexual-functioning status were assessed by site-specific trained investigators at weekly clinic visits; tolerability was assessed primarily by monitoring adverse events.

RESULTS

Four hundred fifty-six patients participated in the study, 150 receiving bupropion SR, 154 fluoxetine, and 152 placebo. The majority of patients in each group completed the study (63% each, bupropion SR [n = 94] and fluoxetine [n = 97]; 67%, placebo [n = 102]). Bupropion SR and fluoxetine were similarly effective in the treatment of depressive symptoms. Beginning at week 2 and continuing throughout the study, significantly more fluoxetine-treated patients experienced orgasm dysfunction than did patients receiving bupropion SR or placebo (P < 0.001); similar results were seen in patients defined as clinical responders (> or =50% decrease from baseline in 21-item Hamilton Rating Scale for Depression [HAM-D] total score) (P < 0.001) and in those experiencing remission of depression (HAM-D total score <8) (P < 0.05). At various time points, worsened sexual functioning, sexual desire disorder, sexual arousal disorder, and dissatisfaction with sexual functioning in those satistied at baseline were more frequently associated with fluoxetine treatment than with bupropion SR or placebo. Both active treatments were well tolerated.

CONCLUSIONS

Bupropion SR and fluoxetine were similarly effective and well tolerated in the treatment of depression. Fluoxetine, however, was more frequently associated with sexual dysfunction compared with bupropion SR. Bupropion SR may be an appropriate initial choice for the treatment of depression in patients concerned about sexual functioning.

Bupropion sustained release (SR) for the treatment of hypoactive sexual desire disorder (HSDD) in nondepressed women

This article describes the results of the first report of bupropion sustained release (SR) in nondepressed females with hypoactive sexual desire disorder (HSDD). Eligible females entered a 4-week, single-blind, placebo baseline phase. Subjects, all of whom did not respond to placebo, continued in a single-blind active treatment phase where they received bupropion SR for up to 8 additional weeks. We assessed HSDD by using investigator ratings of sexual desire and sexual functioning. Of the 51 evaluable subjects who entered the active treatment phase, 29% responded to treatment with bupropion SR. Bupropion SR was generally well tolerated. Pending the results of further study, bupropion SR may offer a treatment option for women with HSDD.

New treatment for erectile dysfunction

Numerous advances have been made in our understanding of the evaluation and treatment of erectile dysfunction. Numerous treatment options are currently available. Treatment of this disorder was revolutionized by the introduction of sildenafil, an oral vasoactive agent that has a peripheral mechanism of action, blocking the degradation of cyclic guanosine monophosphate, and thus augmenting the erectogenic effect of sexual stimulation. This agent has proven efficacy in a variety of patient populations, including psychiatric patients. Clinical series suggest that this agent will reverse erectile dysfunction induced by psychoactive agents. Thus, it may play a role in decreasing treatment noncompliance associated with drug-induced sexual dysfunction. Another novel agent that is in development may be of special interest to psychiatrists. Apomorphine is a central dopamine agonist that is believed to act at the level of the paraventricular nucleus of the hypothalamus. As new agents are evolving, our understanding of the neurobiology of sexual function is advancing.

Evaluation of sexual functioning in depressed outpatients: a double-blind comparison of sustained-release bupropion and sertraline treatment

Sexual dysfunction is a frequently reported side effect of many antidepressants, including serotonin reuptake inhibitors. Bupropion, an antidepressant of the aminoketone class, is relatively free of adverse sexual effects. In a randomized, double-blind, multicenter trial, sustained-release bupropion (bupropion SR) and sertraline, a selective serotonin reuptake inhibitor, were found to be similarly efficacious in the treatment of outpatients with moderate to severe depression. This report describes the results of a double-blind comparison of the sexual side effect profiles of bupropion SR and sertraline. Two hundred forty-eight patients who had received a diagnosis of moderate to severe major depression were randomly assigned to receive treatment with bupropion SR (100-300 mg/day) or sertraline (50-200 mg/day) for 16 weeks. Eligible patients were required to be in a stable relationship and to have normal sexual functioning. Sexual functioning was assessed by the investigator at each clinic visit using investigator-rated structured interviews. A significantly greater percentage of sertraline-treated patients (63% and 41% of men and women, respectively) developed sexual dysfunction compared with bupropion SR-treated patients (15% and 7%, respectively). Sexual dysfunction was noted as early as day 7 in sertraline-treated patients at a dose of 50 mg/day and persisted until the end of the 16-week treatment phase. Four patients, all of whom were treated with sertraline, discontinued from the study prematurely because of sexual dysfunction. Given the similar efficacy of the two drugs in treating depression, bupropion SR may be a more appropriate antidepressant choice than sertraline in patients for whom sexual dysfunction is a concern.

Report of the international consensus development conference on female sexual dysfunction: definitions and classifications

PURPOSE

Female sexual dysfunction is highly prevalent but not well defined or understood. We evaluated and revised existing definitions and classifications of female sexual dysfunction.

MATERIALS AND METHODS

An interdisciplinary consensus conference panel consisting of 19 experts in female sexual dysfunction selected from 5 countries was convened by the Sexual Function Health Council of the American Foundation for Urologic Disease. A modified Delphi method was used to develop consensus definitions and classifications, and build on the existing framework of the International Classification of Diseases-10 and DSM-IV: Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association, which were limited to consideration of psychiatric disorders.

RESULTS

Classifications were expanded to include psychogenic and organic causes of desire, arousal, orgasm and sexual pain disorders. An essential element of the new diagnostic system is the "personal distress" criterion. In particular, new definitions of sexual arousal and hypoactive sexual desire disorders were developed, and a new category of noncoital sexual pain disorder was added. In addition, a new subtyping system for clinical diagnosis was devised. Guidelines for clinical end points and outcomes were proposed, and important research goals and priorities were identified.

CONCLUSIONS

We recommend use of the new female sexual dysfunction diagnostic and classification system based on physiological as well as psychological pathophysiologies, and a personal distress criterion for most diagnostic categories.

Psychiatric illness and sexual function

Impaired sexual function has been noted to occur in various psychiatric illnesses. In affective disorders, disturbances of libido, erection and orgasm have been reported. Disordered sexual behavior has also been noted in patients with schizophrenia and anorexia nervosa. Clinical speculation suggests that anxiety disorders may also be associated with a higher prevalence of sexual problems.

Definitions and classification of male sexual dysfunction

The definitions and classifications of male sexual dysfunction as described by the diagnostic and statistical manual of the American Psychiatric Association are reviewed. The absence of clear operational criteria for these diagnoses and the varying definitions used by current investigators are highlighted.

Antidepressant-induced sexual dysfunction

This article reviews current evidence regarding sexual side effects of antidepressant drugs. Controlled studies have demonstrated that some antidepressant drugs have adverse effects on orgasm and libido. Orgasmic dysfunction and ejaculatory delay appear to be common sexual side effects of the serotonin selective reuptake inhibitors (SSRIs). A variety of treatment options are available if a patient experiences antidepressant-induced sexual dysfunction. Often, modification of the pharmacologic regimen will restore sexual function while maintaining antidepressant activity. The frequency of sexual side effects reported with the SSRIs mandates that the clinician inquire about sexual function if these agents are used. Bupropion and nefazodone appear to have an unusually low incidence of sexual side effects.

Double-blind comparison of bupropion sustained release and sertraline in depressed outpatients

BACKGROUND

A sustained-release formulation of bupropion (bupropion SR), developed with an improved pharmacokinetic profile to permit less frequent dosing than the immediate-release form, has not been evaluated in active comparator trials. This randomized, double-blind, parallel-group trial was conducted to compare the efficacy and safety of bupropion SR and sertraline.

METHOD

Outpatients with moderate to severe major depressive disorder (DSM-IV) received bupropion SR (100-300 mg/day) or sertraline (50-200 mg/day) for 16 weeks. Psychiatric evaluations, including the Hamilton Rating Scale for Depression (HAM-D), the Hamilton Rating Scale for Anxiety (HAM-A), the Clinical Global Impressions scale for Severity of Illness (CGI-S), and for Improvement (CGI-I) were completed, and adverse events were assessed in the clinic periodically throughout treatment. Patients' orgasm function was also assessed.

RESULTS

Mean HAM-D, HAM-A, CGI-I, and CGI-S scores improved over the course of treatment in both the bupropion SR group and the sertraline group; no between-group differences were observed on any of the scales. Orgasm dysfunction was significantly (p < .001) more common in sertraline-treated patients compared with bupropion SR-treated patients. The adverse events of nausea, diarrhea, somnolence, and sweating were also experienced more frequently (p < .05) in sertraline-treated patients. No differences were noted between the two treatments for vital signs and weight.

CONCLUSION

This double-blind comparison of bupropion SR and sertraline demonstrates that bupropion and sertraline are similarly effective for the treatment of depression. Both compounds were relatively well tolerated, and orgasm dysfunction, nausea, diarrhea, somnolence, and sweating were reported more frequently in sertraline-treated patients.

The biology of sexual function

This article provides a selective overview of the physiologic substrates of sexual desire, arousal, and orgasm, and reviews their changes with age. The effect of pharmacologic agents on sexual physiology is discussed, highlighting both the clinical significance and underlying neurophysiologic mechanisms of these agents.

Antidepressant-induced orgasm disorder

Most of the antidepressants approved for use in the United States, with the possible exceptions of bupropion and nefazodone, have been associated with drug-induced anorgasmia. Common strategies to overcome this drug side effect include waiting for tolerance to develop, dose reduction, change of dosing regimen, substitution of an alternative antidepressant, and coadministration of another drug. Current evidence suggests that antidepressant-induced anorgasmia may be mediated by 5HT2 antagonism of adrenergic mechanisms that underlie normal orgasm.

Clomipramine versus placebo in the treatment of premature ejaculation: a pilot study

This study evaluated clomipramine as a possible treatment for premature ejaculation. Twenty patients with premature ejaculation were randomly allocated to treatment with clomipramine or placebo in a double-blind study. Average estimated time to ejaculation after vaginal penetration increased to 6.1 minutes on 25 mg. of clomipramine and to 8.4 minutes on 50 mg. of clomipramine. These estimated times were significantly different from estimated time to ejaculation while on placebo. These findings suggest that low dose clomipramine may be useful in the treatment of premature ejaculation.

Effect of apomorphine on penile tumescence in men with psychogenic impotence

In a double-blind study using physiological recording of penile tumescence, brachial subcutaneous apomorphine hydrochloride injections elicited penile erections in men with psychogenic impotence. This observation is compatible with the hypothesis of central dopaminergic involvement in human penile erection. Since apomorphine is believed to induce erections by its effect on brain monoamine pathways, apomorphine response may have diagnostic use in evaluating the etiology of erectile failure.

Effects of psychotropic drugs on human erection and ejaculation

Evidence concerning pharmacological effects on human sexuality suggests that dopaminergic receptor activation may be associated with penile erection. Erection also appears to involve inhibition of alpha-adrenergic influences and beta-adrenergic stimulation plus the release of a noncholinergic vasodilator substance, possibly vasoactive intestinal peptide. Ejaculation appears to be mediated primarily by alpha-adrenergic fibers. Serotonergic neurotransmission may inhibit the ejaculatory reflex. An understanding of the neurobiological substrate of human sexuality may assist clinicians in choosing psychotropic agents with minimal adverse effects on sexual behavior and may also contribute to the development of pharmacological interventions for sexual difficulties.

Sexual side-effects of psychiatric drugs

Clinical case reports, clinical series, and a small number of controlled studies provide evidence that many commonly prescribed psychiatric drugs may have untoward effects on sexual function. Both heterocyclic antidepressants and monoamine oxidase inhibitors appear to be associated with ejaculatory impairment. Erectile dysfunction and retarded ejaculation have been associated with neuroleptics. Several benzodiazepines have been reported to interfere with ejaculation. This information has clear significance for the prescribing physician.

Psychiatric treatment of erectile dysfunction in urology outpatient clinic

This study examined the feasibility of establishing a satellite psychiatry service in a urology outpatient clinic for the express purpose of engaging men with inhibited sexual excitement in psychiatric treatment. This approach appeared to be more successful as judged by complete referrals and symptom remission than referral to a psychiatry clinic.

Serum testosterone and prolactin levels in erectile dysfunction

Serum testosterone and prolactin levels were determined in 52 impotent patients. Fifteen percent were found to have abnormally low testosterone levels. Low testosterone levels were related to clinical ratings of decreased libido and the absence of early morning erections. Suggestive relationships between testosterone levels and scales on the Derogatis Sexual Functioning Inventory were noted.

Referral of impotent patients to a sexual dysfunction clinic

The referral pattern of impotent men from a urology clinic to a sexual dysfunction clinic was investigated. Only 62% of referred patients made such recommended appointments. Of the patients for whom sex therapy was recommended, only 32% accepted this recommendation. Of those accepting a recommendation for treatment, 57% prematurely terminated treatment against medical advice. The implications of this for referring physicians and alternative treatment approaches are discussed.

Three cases of female anorgasmia associated with MAOIs

Monoamine oxidase inhibitors have been associated with male retarded ejaculation and impotence. The authors describe three cases of female anorgasmia secondary to this class of antidepressants. To the author's knowledge only one incidental finding of this kind has been reported.

Analysis of 122 unselected impotent men subjected to multidisciplinary evaluation

Erectile impotence is not a simple problem and it is important to recognize that the presence of a possible organic cause does not rule out emotional difficulties or sexual maladjustment. Behavioral therapy and surgery have an important role in treating this symptom. By careful pre-treatment evaluation the most appropriate therapy can be selected. It has been our general rule that when neither clear organic nor psychogenic problems lie at the root of the difficulty, a trial of behavioral therapy is the most appropriate procedure. If no success is achieved after an adequate trial of therapy re-evaluation and recommendation for a prosthetic implant can be made.

Characteristics of erectile dysfunction as a function of medical care system entry point

The scientific literature on the treatment of penile erectile dysfunction contains numerous contradictory reports on the relative frequency of organic causes of impotence and the treatment results of behavioral sex therapy. One explanation for these contradictory findings is the hypothesis that different investigators are studying different subsamples of the symptomatic population. This study investigated differences in characteristics of men who initially consulted a urologist with a complaint of impotence versus those who self-referred themselves to a sexual dysfunction clinic. Self-referred sexual dysfunction patients were more often white, more often had psychogenic etiologies to their difficulties, were more often of higher socioeconomic class, and had a much better response to psychological interventions. This study suggests that future studies concerning the etiology and treatment of impotence need to specify population characteristics such as referral source and screening criteria. It may be necessary to develop alternative treatment techniques for men who present to nonpsychiatric sources for help with psychogenic impotence.

Discrimination of organic versus psychological impotence with the DSFI: a failure to replicate

Patients with a presenting complaint of erectile dysfunction were extensively investigated by a research team consisting of a urologist, vascular surgeon, psychiatrist and psychiatric social worker. Patients were assigned to organic and psychogenic groups according to specified criteria. Multiple comparisons of psychogenic and organic impotence cases on scores derived from the Derogatis Sexual Functioning Inventory (DSFI) did not differentiate the two groups. This inventory did, however, manifest numerous relationships with demographic variables. Failure to identify a psychological profile characteristic of psychogenic impotence was attributed to the heterogenity of this diagnostic grouping and selection processes in seeking treatment for such disorders.

Marriage and mental health

Evidence linking psychiatric impairment with divorced marital status and the presence of marital discord is reviewed. Various theoretical models to explain these relationships are considered. Divorced marital status and marital discord are related to psychiatric impairment and mental health service utilization. Available evidence suggests that part of the impairment in these populations is secondary to factors involved in the breakdown of marital relationships and not completely explainable by premarital hypotheses. This has implications for mental health administrators.

Conjoint marital therapy: a cognitive behavioral model

This article presents an integrated cognitive-behavioral model for conjoint therapy of chronic marital discord. The model is based on eight empirically testable hypotheses that are clinically relevant and integrate contributions from general systems theory, behavioral marital therapy, and psychoanalysis. Disproof of cognitive schemas for the perception of the opposite sex (transference reactions) is hypothesized to be a common therapeutic mechanism in the dissimilar models of marital therapy.

Concurrent psychotherapy and behavior therapy. Treatment of psychoneurotic outpatients

The feasibility and effects of treating psychoneurotic outpatients with concomitant but separate treatment programs of psychoanalytically oriented psychotherapy and behavior therapy was investigated in three cases, utilizing detailed clinical observations and questionnaire responses. The two treatment regimens appeared to have synergistic effects, and anticipated difficulties, such as a split therapeutic alliance, symptom substitution, or preciptious withdrawal from psychotherapy after symptom removal, did not occur. Although there was no evidence of symptom substitution after the behavioral removal of the "target symptom," both clinical observations and questionnaire responses indicated that successful behavior therapy had many unanticipated effects on the patient's nontarget behaviors and cognitions.

Personality and family history of disease

Personality structure has been linked with cancer, heart disease, and duodenal ulceration. Eysenck (1965) hypothesized that the association of personality with these diseases is the result of an association between the genetic factors influencing personality predisposition and disease susceptibility. As briefly discussed by the present author elsewhere (Segraves, 1970), Eysenck's hypothesis seems tenable, since both these personality dimensions and these diseases have been shown to have hereditary components and to be related to bodily habitus in analogous ways.

Personality, body build and adrenocortical activity

In recent years research workers have shown a relative lack of interest in the constitutional correlates of normal personality. However, recent findings in the field of psychosomatic medicine suggest the need for a careful reexamination of this field of research. Several studies have indicated that breast cancer, lung cancer, and myocardial infarction patients are more extraverted and less neurotic than hospital control group patients (Eysenck, 1965). Also, duodenal ulcer patients have been reported as being both introverted and neurotic (Kanter and Hazelton, 1964).