5th Sexual Dysfunction Conference
Queenstown NZ April 2012
Ejaculation Disorders
Too Fast and Too Slow
Dr Michael Lowy
Sexual Health Physician
Sydney Men’s Health
Bondi Junction, Sydney
mlowy@sydneymenshealth.com.au
Sydney Men’s Health
Ejaculation
COMPONENTS
• Emission
TYPES
• Rapid/premature
• Ejaculation
• Delayed/inhibited
• Orgasm
• Retrograde
Sydney Men’s Health
Limbic System
Sydney Men’s Health
Sydney Men’s Health
5
Stages of normal ejaculatory
physiology
• Emission (sympathetic T10-L2)
– Bladder neck closure
– Deposition of seminal fluid into posterior urethra
• Ejection (parasympathetic S2-S4)
– Expulsion of seminal fluid from the urethra
– Relaxation of the external sphincter
– Co-ordinated pelvic floor, bulbospongiosis
contraction
• Orgasm
– A sensory experience via pudendal nerve
associated with all these events
Sydney Men’s Health
Hyposensitivity of MPO of hypothalamus – 5-HT2C
Hypersensitivity of MPO area of hypothalamus – 5-HT1A
Sydney Men’s Health
Arousal
Pudendal nerves
Spinothalamic tract
Thalamus/limbic system
Hypothalamus: MPOA, D1 & D2
Reticulospinal tracts
Sympathetic T10-L1
Parasympathetic S2,3,4
Ejaculation
Sydney Men’s Health
Sydney Men’s Health
PE
Biological
Young
age
Genes
Cultural
Sydney Men’s Health
Sydney Men’s Health
Sydney Men’s Health
Definition PE
• Lack of control of ejaculation
• Dissatisfaction of sexual
experience
• Distress to man and his partner
• Latency times (IELT)
• Often associated with a
secondary performance anxiety
• Erectile dysfunction is often
secondary to long term PE
Sydney Men’s Health
ISSM definition of PE
• Ejaculation which always or nearly always
occurs prior to or within about 1 minute
of vaginal penetration
• Inability to delay ejaculation on all or
nearly all vaginal penetrations
• Negative personal consequences, such as
distress, bother, frustration &/or the
avoidance of sexual intimacy
Sydney Men’s Health
Sydney Men’s Health
Normal
ejaculation
time
Faster
ejaculation
Sydney Men’s Health
Sydney Men’s Health
Ejaculatory Dysfunction
• 30% of men say they have a problem
controlling ejaculation
• 90% of ejaculation problems are PE
• 5-10% of men complain of severe PE
• Prevalence PE 8-31%, delayed 2-4%
Sydney Men’s Health
Sydney Men’s Health
Intra-vaginal ejaculation latency
time (IELT)
• PE level of distress depends if mild or severe
• IELT median time 5.4 minutes (range 1-45
min)
• IELT < 1 minute – definite PE
• IELT 1-1.5 minutes – probable PE
• Lifelong PE – 1.5 minutes 90% of intercourse
• Acquired PE – developed IELT < 1.5 minutes
Sydney Men’s Health
Sydney Men’s Health
Sydney Men’s Health
Taxonomy of PE
• Onset
JSM 2011;8(suppl 4):328-334
– 1° lifelong (from the first sexual experience)
– 2° acquired (after a period of normal ejaculation)
• Time
– Before vaginal penetration
– During vaginal penetration
• Type
– In all situations
– In specific situations
• Co-morbidities
– No other sexual symptoms
– Presence of other symptoms e.g ED
Sydney Men’s Health
PE SYNDROME
Marcel Waldinger
• Primary or lifelong (younger men)
– medication
• Secondary or acquired (older men)
– medication, counselling
• Natural Variable PE
– counselling
• PE like ejaculation syndrome
– counselling
Sydney Men’s Health
Sydney Men’s Health
Sydney Men’s Health
Sydney Men’s Health
Premature Ejaculation Diagnostic Tool
Sydney Men’s Health
Sydney Men’s Health
Sydney Men’s Health
30
Sydney Men’s Health
Treatment of Premature
Ejaculation
• Incorporate into sexual practice: "go with
the flow" - work on intimacy
• Sexual script change: extend foreplay,
modify rigid sex patterns, “partner first”
• Improve IELT, address relationship issues,
restore confidence
Sydney Men’s Health
Treatment PE cont’d
• Behavioural techniques - stop/start
(Seman), squeeze (Masters & Johnson)
• Oral medication - SSRI, clomipramine,
PDE5i
• Intra-cavernosal injections
• Anaesthetic spray (Stud Spray)
• Pelvic floor exercises
• Surgery to dorsal nerve (Brazil)
Sydney Men’s Health
PE issues
• Interview partner
– Obtain more accurate IELT
– Check issues of FSD
• Alcohol use delays ejaculation
• Acquired 2°PE factors – hyperthyroidism,
prostatitis, ED
• Assessment: history, stopwatch IELT, examination
(optional, not mandatory, reassuring)
• PE returns when medication is stopped
Sydney Men’s Health
Sydney Men’s Health
Sydney Men’s Health
36
Counselling for PE
Rowland D. JSM 2011;8(suppl 4):342-352
• Address physiological, psycho-behavioural,
cultural & relationship factors
• As PE is a couples problem, counselling best with
partner present
• Initial medical history: sexual, psychological,
relationship
• Psychotherapy domains: behavioural, cognitive,
affective, relational
• Pharmacotherapy can augment psychotherapy
Sydney Men’s Health
J Sex Med 2012;9:576–584
Sydney Men’s Health
Women with men who have PE
Women’s Sexual Function & Dysfunction
Sydney Men’s Health
39
Sydney Men’s Health
Sydney Men’s Health
Stop/Start Technique
Sydney Men’s Health
Sydney Men’s Health
Sydney Men’s Health
Sydney Men’s Health
Dapoxetine - Priligy
•
•
•
•
•
T max 1.2 hours
T ½ 18 hours
IELT 30mg 3.48x
IELT 60mg 3.68x
Side effects: nausea,
headache
Sydney Men’s Health
Sydney Men’s Health
Sydney Men’s Health
Sydney Men’s Health
Evidence-based research into both the
methodology, content, duration and intensity as
well as the short and long term results of
psychological treatment of PE is encouraged
Level 3 evidence to suggest that all men seeking
treatment for PE should receive basic
psychosexual education
Graded levels of patient and couple counselling,
guidance and/or relationship therapy, either
alone or ideally in combination with PE
pharmacotherapy should be offered as a
treatment option for most men with PE
Sydney Men’s Health
Sydney Men’s Health
Delayed Ejaculation
•
•
•
•
Often a normal part of ageing
Younger men - angry, withholding
Relationship issues – conception
Consider idiosyncratic masturbatory style
(traumatic masturbatory syndrome) –
conditioned inhibition
TREAT (enhance arousal)
• Pre & post masturbation/vibration
• Scrotal/perineal tickling
• Incorporate into normal practice
Sydney Men’s Health
Sydney Men’s Health
Sydney Men’s Health
Sydney Men’s Health
Retrograde Ejaculation
• Common after benign prostate or bladder
neck surgery
• Some disease conditions – diabetes,
neurological
• Agonist medications may help
e.g. Sudafed, Periactin, Symmetrel
Sydney Men’s Health
58
Sydney Men’s Health