Management of ejaculatory dysfunction

Abstract

Ejaculatory dysfunction is a common complaint and is often associated with a reduced quality of life for sufferer and partner. The spectrum of ejaculatory dysfunction extends from premature ejaculation (PE) to delayed ejaculation (DE) and anejaculation. Over the past 20-30 years, the PE treatment paradigm, previously limited to behavioural psychotherapy, has expanded to include drug treatment. Multiple well-controlled, evidence-based studies have demonstrated the efficacy and safety of selective serotonin re-uptake inhibitors in delaying ejaculation, confirming their role as first-line agents for the treatment of lifelong and acquired PE. More recently, there has been increased attention to the psychosocial consequences of PE, its epidemiology, its aetiology and its pathophysiology by both clinicians and the pharmaceutical industry. DE and anejaculation are probably the least common, least studied and least understood of the male sexual dysfunctions. However, their impact is significant as they may result in a lack of sexual fulfilment for both the man and his partner, an effect further compounded when procreation is among the couple's goals of sexual intercourse. The causes of DE, anejaculation and anorgasmia are manifold. Numerous psychotherapeutic treatments are described for the management of delayed or anejaculation. Although some appear to be effective, none has been properly evaluated in large-scale samples. Treatment of DE or anejaculation with pharmacotherapy has met with limited success. No drugs have been approved by regulatory agencies for this purpose, and most drugs that have been identified for potential use have limited efficacy, impart significant side-effects or are yet considered experimental in nature.Ejaculatory dysfunction is one of the most common male sexual disorders. The spectrum of ejaculatory dysfunction extends from premature ejaculation (PE) through delayed ejaculation (DE) to a complete inability to ejaculate, anejaculation, and includes retrograde ejaculation. Anatomy and physiology of the ejaculatory responseThe ejaculatory reflex comprises sensory receptors and areas, afferent pathways, cerebral sensory areas, cerebral motor centres, spinal motor centres and efferent pathways. Neurochemically, this reflex involves a complex interplay between central serotonergic and dopaminergic neurons, with secondary involvement of cholinergic, adrenergic, oxytocinergic and gamma aminobutyric acid (GABA) neurons. Serotonin, which inhibits emission/ ejaculation, and dopamine, which promotes seminal emission/ejaculation, have emerged as key neurochemical factors. 1 PEOver the past 20-30 years, the PE treatment paradigm, previously limited to behavioural psychotherapy, has expanded to include drug treatment. Animal and human sexual psychopharmacological studies have demonstrated that serotonin and 5-hydroxytryptamine (5-HT) receptors are involved in ejaculation and confirm a role for selective serotonin re-uptake inhibitors (SSRI) in the treatment of PE.2 Multiple well-controlled, evidenc...

2016 United Kingdom national guideline on the sexual health care of men who have sex with men

“…Psychological interventions for PE are generally effective but the evidence base for such interventions is not considered to be as clear or reliable as the findings from the research on ED (444) . Combining pharmacological and psychological treatments can be especially useful in men with acquired premature ejaculation where there is a clear psychosocial precipitant or lifelong cases where the individual or couple's responses to PE are likely to interfere in the medical treatment and ultimate success of therapy (445). NICE has recently issued guidance on the use of dapoxetine in the first line treatment of PE (446).…”

Epidemiology of delayed ejaculation

“…Based on the fact that the median value of intravaginal ejaculatory latency time (IELT) was 5.4 minutes (3) and 21–23 min represents about two standard deviations above the mean, we assume that men with latencies beyond 25 or 30 minutes suffer from DE (4,5). …”

The pathophysiology of delayed ejaculation

“…McMahon introduced a list of the main drug groups can cause DE, including alpha methyldopa, diuretics, tricyclic antidepressants, SSRIs, and phenothiazines as well as alcohol abuse (78). …”