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
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Ejaculation
COMPONENTS
• Emission
TYPES
• Rapid/premature
• Ejaculation
• Delayed/inhibited
• Orgasm
• Retrograde
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Limbic System
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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
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Hyposensitivity of MPO of hypothalamus – 5-HT2C
Hypersensitivity of MPO area of hypothalamus – 5-HT1A
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Arousal
Pudendal nerves
Spinothalamic tract
Thalamus/limbic system
Hypothalamus: MPOA, D1 & D2
Reticulospinal tracts
Sympathetic T10-L1
Parasympathetic S2,3,4
Ejaculation
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PE
Biological
Young
age
Genes
Cultural
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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
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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
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Normal
ejaculation
time
Faster
ejaculation
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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%
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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
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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
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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
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Premature Ejaculation Diagnostic Tool
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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
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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)
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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
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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
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J Sex Med 2012;9:576–584
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Women with men who have PE
Women’s Sexual Function & Dysfunction
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Stop/Start Technique
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Dapoxetine - Priligy
•
•
•
•
•
T max 1.2 hours
T ½ 18 hours
IELT 30mg 3.48x
IELT 60mg 3.68x
Side effects: nausea,
headache
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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
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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
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Retrograde Ejaculation
• Common after benign prostate or bladder
neck surgery
• Some disease conditions – diabetes,
neurological
• Agonist medications may help
e.g. Sudafed, Periactin, Symmetrel
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