Michael A. Perelman

Disorders of Orgasm and Ejaculation in Men

INTRODUCTION Ejaculatory/orgasmic disorders are common male sexual dysfunctions, and include premature ejaculation (PE), inhibited ejaculation, anejaculation, retrograde ejaculation, and anorgasmia. AIM To provide recommendations and guidelines concerning current state-of-the-art knowledge for management of ejaculation/orgasmic disorders in men. METHODS An international consultation in collaboration with the major urology and sexual medicine associations assembled over 200 multidisciplinary experts from 60 countries into 25 committees. Committee members established specific objectives and scopes for various male and female sexual medicine topics. The recommendations concerning state-of-the-art knowledge of disorders of orgasm and ejaculation represent the opinion of seven experts from seven countries developed in a process over a 2-year period. MAIN OUTCOME MEASURE Expert opinion was based on grading of evidence-based medical literature, widespread internal committee discussion, public presentation and debate. RESULTS Premature ejaculation management is largely dependent upon etiology. Lifelong PE is best managed with PE pharmacotherapy (selective serotonin re-uptake inhibitor [SSRI] and/or topical anesthetics). The management of acquired PE is etiology specific and may include erectile dysfunction (ED) pharmacotherapy in men with comorbid ED. Behavioral therapy is indicated when psychogenic or relationship factors are present and is often best combined with PE pharmacotherapy in an integrated treatment program. Retrograde ejaculation is managed by education, patient reassurance, pharmacotherapy, or bladder neck reconstruction. Delayed ejaculation, anejaculation, and/or anorgasmia may have a biogenic and/or psychogenic atiology. Men with age-related penile hypoanesthesia should be educated, reassured, and instructed in revised sexual techniques which maximize arousal. CONCLUSIONS Additional research is required to further the understanding of the disorders of ejaculation and orgasm.

Low Testosterone Associated With Obesity and the Metabolic Syndrome Contributes to Sexual Dysfunction and Cardiovascular Disease Risk in Men With Type 2 Diabetes

Men with obesity, the metabolic syndrome, and type 2 diabetes have low total and free testosterone and low sex hormone–binding globulin (SHBG). Conversely, the presence of low testosterone and/or SHBG predicts the development of metabolic syndrome and type 2 diabetes. Visceral adiposity present in men with low testosterone, the metabolic syndrome, and/or type 2 diabetes acts through proinflammatory factors. These inflammatory markers contribute to vascular endothelial dysfunction with adverse sequelae such as increased cardiovascular disease (CVD) risk and erectile dysfunction. This review focuses on the multidirectional impact of low testosterone associated with obesity and the metabolic syndrome and its effects on erectile dysfunction and CVD risk in men with type 2 diabetes. Whenever possible in this review, we will cite recent reports (after 2005) and meta-analyses. ### Epidemiological studies of low testosterone, obesity, metabolic status, and erectile dysfunction Epidemiological studies support a bidirectional relationship between serum testosterone and obesity as well as between testosterone and the metabolic syndrome. Low serum total testosterone predicts the development of central obesity and accumulation of intra-abdominal fat (1–3). Also, low total and free testosterone and SHBG levels are associated with an increased risk of developing the metabolic syndrome, independent of age and obesity (1–3). Lowering serum T levels in older men with prostate cancer treated with androgen deprivation therapy increases body fat mass (4). Conversely, high BMI, central adiposity, and the metabolic syndrome are associated with and predict low serum total and to a lesser extent free testosterone and SHBG levels (1–3,5). Because obesity suppresses SHBG and as a result total testosterone concentrations, alterations in SHBG confound the relationship between testosterone and obesity. Low total testosterone or SHBG levels are associated with type 2 diabetes, independent of age, race, obesity, and criteria for diagnosis of diabetes (6,7). In longitudinal studies, low serum total and free testosterone …

Original ResearchDisorders of Orgasm and Ejaculation in Men

Introduction Ejaculatory/orgasmic disorders, common male sexual dysfunctions, include premature ejaculation, inhibited ejaculation, anejaculation, retrograde ejaculation and anorgasmia.

Drivers and barriers to seeking treatment for erectile dysfunction: a comparison of six countries

Associate Editor

An evidence-based definition of lifelong premature ejaculation: report of the International Society for Sexual Medicine Ad Hoc Committee for the Definition of Premature Ejaculation

To develop a contemporary, evidence‐based definition of premature ejaculation (PE).

Association of Sexual Dysfunction With Lower Urinary Tract Symptoms of BPH and BPH Medical Therapies: Results From the BPH Registry

OBJECTIVES The severity of lower urinary tract symptoms (LUTS) has correlated with erectile dysfunction (ED) and ejaculatory dysfunction (EjD) in large-scale epidemiologic studies. ED and EjD are also side effects of some medical therapies for LUTS suggestive of benign prostatic hyperplasia (LUTS/BPH). These relationships were examined in a physician office-based population of men enrolled in the BPH Registry. METHODS Enrolled men with LUTS/BPH who completed the International Prostate Symptom Score (IPSS), IPSS bother question, 5-item International Index of Erectile Function, and the 3 ejaculatory function items of the Male Sexual Health Questionnaire-EjD short form at baseline were eligible. The relationship between sexual dysfunction and LUTS/BPH and BPH medical therapies were examined using multivariate analyses. RESULTS Of 6924 men enrolled, 5042 (mean age 65 years) completed all 4 baseline assessments. Of 3084 sexually active men, age, total IPSS, IPSS bother score, hypertension, diabetes, and black race/ethnicity were independent predictors of both ED and EjD (all P < .05). For the subset of 1362 men receiving BPH medical therapy, a significant association (P < .0001) was demonstrated for ED and EjD with specific BPH medical therapies. The alpha(1A)-subtype nonsuperselective quinazoline alpha(1)-blockers alfuzosin, doxazosin, and terazosin appeared to be associated with better ejaculatory function than were the alpha(1A)-subtype superselective sulfonamide alpha(1)-blocker tamsulosin, 5alpha-reductase inhibitors, and alpha(1)-blocker plus 5alpha-reductase inhibitor combination therapy. CONCLUSIONS These results have provided additional evidence of the link between LUTS/BPH and sexual dysfunction in aging men and support clinical trial results indicating different rates of sexual side effects for BPH medical therapies.

Sex coaching for physicians: combination treatment for patient and partner.

Physicians dealing with sexual dysfunction (SD) must consider the psychological and behavioral aspects of their patients diagnosis and management, as well as organic causes and risk factors. Integrating sex therapy and other psychological techniques into their office practice will improve effectiveness in treating SD. This presentation provides information about the psychological forces of patient and partner resistance, which impact patient compliance and sex lives beyond organic illness and mere performance anxiety. Four key areas are reviewed: (1) ‘Sex coaching for physicians’ uses the ‘Cornell Model’ for conceptualizing and treating SD. A 5-min ‘sex status,’ manages ‘time crunch’ by rapidly identifying common causes of sexual dysfunction (insufficient stimulation, depression, etc). (2) Augmenting pharmacotherapy with sex therapy when treating erectile dysfunction (ED) specifically, or SD generally is stressed. Sex therapy is useful as a monotherapy or an adjunctive treatment and is often the ‘combination therapy’ of choice when treating SD. The following therapeutic integrations are highlighted: modifying patients initial expectations; sexual pharmaceuticals use as a therapeutic probe; ‘follow-up’ to manage noncompliance and improve outcome; relapse prevention. (3) Issues specific to the role of the partner of the ED patient are described. The physician must appreciate the role of couples issues in causing and/or exacerbating the ED and the impact of the ED on the patient/partner relationship. Successful treatment requires a supportive available sexual partner, yet partner cooperation may be independent of partner attendance during the office visit. Preliminary data from a survey of SMSNA members practice patterns, regarding partner issues, is presented and discussed. The importance of evoking partner support and cooperation independent of actual attendance during office visits is emphasized. (4) Finally, the need for more patient and partner educational materials to assist the physician in overcoming a patient/partners emotional barriers to sexual success in a time efficient manner are discussed.

Further evidence of the reliability and validity of the premature ejaculation diagnostic tool

This study details the further validation of the Premature Ejaculation Diagnostic Tool (PEDT), a five-item tool, developed to systematically apply the Diagnostic and Statistical Manual of Mental Disorders, revised version 4 (DSM-IV-TR), criteria in diagnosing presence or absence of premature ejaculation (PE). A total of 102 men completed the PEDT and were then interviewed by one of the seven clinical experts, who made a diagnosis of presence or absence of PE. The diagnoses from these two methods were compared to assess the convergent validity of PEDT. Retest reliability was also assessed, by men completing the PEDT a second time, approximately 2 weeks after the first administration. The level of agreement between clinical expert and PEDT diagnoses was very high (κ-statistic=0.80 (95% CI=0.68–0.92)), and retest reliability was very good – Intraclass correlation coefficient=0.88. In summary, the PEDT is extensively validated, self-report measure that can systematically assess DSM-IV-TR criteria to provide accurate diagnoses of PE/no-PE.

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

INTRODUCTION It is controversial whether or not the most frequent male sexual dysfunctions, premature ejaculation (PE) and erectile dysfunction (ED), share pathogenetic mechanisms and treatments. METHODS Three scientists (C.McM., J.C., and A.A.), together with the Controversys Editor (E.A.J.), with expertise in the area of medical treatment of PE, present different perspectives on the use of phosphodiesterase type 5 inhibitors (PDE5is) in PE. The psychological point of view is discussed by an expert in sexology (M.P.). MAIN OUTCOME MEASURE Outcome measures used are expert opinions supported by the critical review of the currently available literature. RESULTS This Controversy examines the role of nitric oxide (NO) as a neurotransmitter involved in the central and peripheral control of ejaculation, the adherence of methodology to the contemporary consensus of ideal PE drug trial design, the impact of methodology on treatment outcomes, and the role of PDE5i drugs (sildenafil, tadalafil, and vardenafil) in the treatment of PE. CONCLUSIONS While it is evident that PDE5is are the first choice in patients with comorbid ED and PE (where one may be secondary to the other), well-designed studies on the possible use of PDE5is in PE patients without ED are still limited. The issue will be less controversial when further evidence on the role of NO and PDE5 in the mechanism of ejaculation is available.

Erectile Dysfunction and Depression: Screening and Treatment

The comorbid conditions erectile dysfunction (ED) and depression are highly prevalent in men. Multiple regression analysis to control for all other predictors of ED indicate that men with high depression scores are nearly twice as likely to report ED than nondepressed men. Depression continues to be among the most common comorbid problems in men with ED, both in the community and in clinical samples. This article reviews the current knowledge about the relationship between ED and depression, the effect of treatments for depression on ED, ways to improve screening for depression, and treatment of ED in patients with this comorbidity.