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Treatment of premature ejaculation: a new combined approach

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Background Selective serotonin reuptake inhibitors (SSRIs) are utilized to treat premature ejaculation (PE). However, their effect is moderate, with no universally adopted schedule. A possible role for pelvic floor dysfunction in the pathogenesis of PE was reported previously. Objective The aim of this study was to compare the efficacy of combined sertraline and pelvic floor rehabilitation with either line in patients with an unsatisfactory response to SSRIs. Design, setting, and participants From June 2009 to December 2012, 74 PE patients with an unsatisfactory response to sertraline 50 mg were enrolled and subjected to pelvic floor rehabilitation as an alternative therapy, and then a combination of both was tested on the same group. Outcome measurements and statistical analysis Relationships with outcome were analyzed using the Student t-test, Pearson′s correlation, and linear regression. Results and limitations The baseline intravaginal ejaculatory latency time (IELT) was 20-110 s (mean ± SD = 56.35 ± 21.67). With sertraline 50 mg therapy alone, IELT reached 90-180 s (mean ± SD = 121.69 ± 21.76, P = 0.0001). Of them, 44 (59.46%) patients failed to exceed an IELT of 120 s. With pelvic floor rehabilitation alone, IELT reached 90-270 s (mean ± SD = 174.73 ± 45.79, P = 0.0001). Of them, 13 (17.56%) patients failed to exceed an IELT of 120 s. Using a combination therapy of both, IELT reached 180-420 s (mean ± SD = 297.57 ± 59.19, P = 0.0001). This response was significantly higher than the baseline IELT and that of either lines alone (P = 0.0001, for all tests). Conclusion Pelvic floor rehabilitation is an important addition when treating PE, particularly in patients with pelvic floor dysfunction. We recommend this combination in patients with an unsatisfactory response to SSRIs. Patient summary Causes of PE differ considerably. In this paper, we compared the outcomes of two single treatment lines together with a combination of both. The combination therapy was more effective than either line alone.
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1110-161X © 2015 Egyptian Society for Rheumatology and Rehabilitation DOI: 10.4103/1110-161X.155649
Original article 39
Introduction
Premature ejaculation (PE) is the most common
male sexual disorder [1]. e prevalence of PE has
been ranging in literature between 5 and 30% [2–7].
is wide range is due to the fact that there was no
universally accepted standard denition for PE [1]. e
most recent denition of PE from the International
Society for Sexual Medicine (ISSM) in 2008 is a male
sexual dysfunction characterized by ejaculation which
always or nearly always occurs before or within about
1 min of vaginal penetration; and inability to delay
ejaculation on all or nearly all vaginal penetrations; and
negative personal consequences, such as distress, bother,
frustration and/or the avoidance of sexual intimacy [8].
Another denition that is frequently utilized in the
literature is the denition of PE in the Diagnostic and
Statistical Manual of Mental Disorders, 4th ed., text
revision criteria, for PE for at least 6  months, with
an intravaginal ejaculatory latency time (IELT) of 2
min or less in at least 75% of intercourse episodes at
baseline [9].
Historically, PE was thought of as a psychological
problem and was treated by behavioral treatment
and psychotherapy. However, there is increasing
evidence from pharmacological studies suggesting
that PE may be related to decreased serotonergic
neurotransmission [10]. Selective serotonin reuptake
Treatment of premature ejaculation: a new combined approach
Adel Kurkar
a
, Sherif M. Abulsorour
a
, Rania M. Gamal
b
, Ahmed M. Eltaher
a
,
Ahmed S. Safwat
a
, Mohammed M. Gadelmoula
a
, Ahmed A. Elderwy
a
,
Mahmoud M. Shalaby
a
, Abeer M. Ghandour
b
Background
Selective serotonin reuptake inhibitors (SSRIs) are utilized to treat premature ejaculation (PE).
However, their effect is moderate, with no universally adopted schedule. A possible role for
pelvic oor dysfunction in the pathogenesis of PE was reported previously.
Objective
The aim of this study was to compare the efcacy of combined sertraline and pelvic oor
rehabilitation with either line in patients with an unsatisfactory response to SSRIs.
Design, setting, and participants
From June 2009 to December 2012, 74 PE patients with an unsatisfactory response to sertraline
50 mg were enrolled and subjected to pelvic oor rehabilitation as an alternative therapy, and
then a combination of both was tested on the same group.
Outcome measurements and statistical analysis
Relationships with outcome were analyzed using the Student t-test, Pearson’s correlation,
and linear regression.
Results and limitations
The baseline intravaginal ejaculatory latency time (IELT) was 20–110 s
(mean ± SD = 56.35 ± 21.67). With sertraline 50 mg therapy alone, IELT reached 90–180 s
(mean ± SD = 121.69 ± 21.76, P = 0.0001). Of them, 44 (59.46%) patients failed to exceed
an IELT of 120 s. With pelvic oor rehabilitation alone, IELT reached 90–270 s (mean ±
SD = 174.73 ± 45.79, P = 0.0001). Of them, 13 (17.56%) patients failed to exceed an IELT
of 120 s. Using a combination therapy of both, IELT reached 180–420 s (mean ± SD =
297.57 ± 59.19, P = 0.0001). This response was signicantly higher than the baseline IELT
and that of either lines alone (P = 0.0001, for all tests).
Conclusion
Pelvic oor rehabilitation is an important addition when treating PE, particularly in patients with
pelvic oor dysfunction. We recommend this combination in patients with an unsatisfactory
response to SSRIs.
Patient summary
Causes of PE differ considerably. In this paper, we compared the outcomes of two single
treatment lines together with a combination of both. The combination therapy was more
effective than either line alone.
Keywords:
male sexual dysfunction, pelvic oor rehabilitation, premature ejaculation, selective serotonin
reuptake inhibitors
Egypt Rheumatol Rehabil 42:39–44
© 2015 Egyptian Society for Rheumatology and Rehabilitation
1110-161X
Departments of
a
Urology,
b
Rheumatology
and Rehabilitation, Assiut University Hospital,
Assiut, Egypt
Correspondence to Sherif M. Abulsorour,MD,
Department of Urology, Assiut University
Hospital, 71516, Assiut, Egypt
Tel: +20-882-324062; fax: +20-882-333327;
E-mail: abulsorour@rocketmail.com
Received 05 Decemeber 2014
Accepted 17 January 2015
Egyptian Rheumatology & Rehabilitation
2015, 42:39–44
[Downloaded free from http://www.err.eg.net on Sunday, June 07, 2015, IP: 197.32.9.79]
40 Egyptian Rheumatology & Rehabilitation
inhibitors (SSRIs), for example, dapoxetine,
uoxetine, paroxetine, and sertraline, are among
the recommended pharmacological treatment lines
currently used for treating PE [1,9]. However,
their eects can be best described as moderate. In
addition, there is no universal agreement regarding
the type, the dose, the administration protocol,
and the duration of therapy [11]. Dapoxetine may
alter this situation, showing preliminary promising
results [9].
Several reports in the literature suggest an important
role for pelvic oor dysfunction as a subtle confounding
factor that may account for pharmacological
treatment failure in many instances. ese studies
have utilized many techniques for rehabilitation, such
as electrostimulation, physiotherapy and biofeedback
therapy, with promising results. ese reports
refer to pelvic oor rehabilitation as a successful
treatment for PE, particularly in patients with pelvic
oor dysfunction, with a success rate approaching
57–61% [12–15].
Study objective
e objective of this study was to compare the value
of a combination therapy of both sertraline and pelvic
oor rehabilitation over either of them as a single
therapy in patients with an unsatisfactory response to
SSRI treatment alone.
Patients and methods
During the period from June 2009 to December
2012, 74 patients having PE (according to the PE
denition adopted from the Diagnostic and Statistical
Manual of Mental Disorders) were treated using on-
demand sertraline single therapy with a 50 mg dose
3 h before sexual intercourse for 8 weeks, and exhibited
an unsatisfactory treatment response. In all patients,
the baseline IELT was recorded before therapy, and
remeasured after stopping the treatment to assure
the return to the pretreatment baseline. Similarly,
IELT was recorded during sertraline therapy in each
intercourse, and the average IELT for each patient was
calculated. All patients gave their formal consent and
the protocol was approved by the Ethical committee.
After return to the baseline, all the patients were subjected
to a pelvic oor rehabilitation course for 8 weeks and
the IELT was measured at the end of the course for
each patient; then, 50 mg on-demand sertraline was
readministered together with continuing pelvic oor
exercise and the average IELT was measured again.
With respect to pelvic oor rehabilitation, all patients
received three weekly sessions of electrical stimulation
and pelvic oor exercise in addition to a daily exercise
at home for 1 month. Electrical stimulation was
performed using the interferential current therapy by
MEDECT model 3060 interferential therapy unit
(EMS). e frequency of the apparatus ranges from 0
to 50 Hz (rhythmic) and the current ranges from 0 to
100 mA.
e technical details of the procedure were as follows:
the swing was 50 Hz of 100 mA intensity and the swing
pattern was 6/6. e frequency of treatment sessions
was three sessions per week, the time of each session
was 20 min, for a total of 12 sessions over a period of 1
month, using four electrodes measuring 7.5 × 5.5 cm,
with two electrodes placed on the lower abdomen and
two electrodes on the inner thigh.
Regarding the pelvic oor exercise, the Kegel exercise
program was adopted as follows: the therapist ensured
at rst that the patient recognized the pubococcygeus
muscle (PC) by trying to stop the ow of urine during
micturition (and then was acquainted that the muscle
that contracts to stop the ow of urine is the PC muscle).
Two forms of exercise were performed for both slow-
twitching and fast-twitching muscle bers respectively:
a long-cycle exercise, which comprised sustained
submaximal contraction of the PC muscle for 10 s and
then relaxation for 10 s. e patient was instructed to
repeat the test 15 times, and rest for 30 s for slow-
twitching muscle bers thereafter, and then start over
again. e short-cycle exercise comprised contracting
the PC muscle maximally for 1 s, and then relaxation
for 1 s for fast-twitching muscle bers. e test was
repeated 10 times, with a 30-s relaxation period
thereafter before starting over again. Patients were
instructed to breath normally to avoid tensing other
muscles. Both short-cycle and long-cycle exercises
were repeated daily, eventually reaching 15 episodes of
each cycle per day.
e response of the patients to dierent treatment was
measured both subjectively and objectively. Objective
satisfaction with treatment was categorized into four
categories after asking both the patient and his partner
to put their results on a visual analog similar to that
of the pain analog, where a score from 0 to 3 implies
no satisfaction (N), a score of 4–7 implies modest
satisfaction (M) (associated interpersonal distress and
one partner dissatised), and a score of 8–10 implies
good satisfaction (S) (both partners).
Statistical analysis and graphical illustrations were
performed using SPSS program (version 19; SPSS
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Treatment of premature ejaculation Kurkar et al. 41
Inc., Chicago, Illinois, USA) and Microsoft Excel
2010 professional plus SPSS (version 14; SPSS Inc.,
Chicago, Illinois, USA). All tests were performed at a
condence level (CL) of 95%, and tests proven to be
signicant at a higher CL were reported separately. e
P value was considered signicant if 0.05 or less.
Results
e patients age range was 23–56 years (mean ±
SD = 37.53 ± 8.8). Of these 74 patients, 35 (47.3%) had
primary PE, whereas 39 (52.7%) had secondary PE.
e duration of PE in these patients was 1–10 years
(mean ± SD = 4.27 ± 2.14). e frequency of intercourse
episodes per week was one to three episodes (mean ±
SD = 2.04 ± 0.67). e patients were instructed to use
a stopwatch to record the IELT, and also not to change
the frequency of intercourse episodes per week all over
the study period. A summary of treatment results of all
groups is shown in Table 1.
Side eects reported with sertraline therapy were
nausea in 17 (22.97%) patients, vomiting in eight
(10.8%), dyspepsia in 13 (17.57%), insomnia in seven
(9.46%), somnolence in nine (12.16%), weak scanty
ejaculation in 13 (17.57%), and postmicturition
dribbling in 11 (14.86%). Both weak scanty ejaculation
and postmicturition dribbling improved with pelvic
oor exercise. Improvement started after the rst
week, with complete improvement of symptoms after
1 month of pelvic oor exercise.
Intervariable correlations were performed. e age
of the patients correlated signicantly and inversely
with both the IELT after pelvic oor rehabilitation
monotherapy [(IELTpf ): P = 0.0001, r = −0.7, CL 99%]
and the IELT after combined therapy [(IELTpfser):
P = 0.0001, r = −0.8, CL 99%] (Figs 1 and 2). In
addition, secondary PE was signicantly correlated
with a higher patient age (P = 0.0001, r = 0.7, CL 99%).
Similarly, the duration of PE in years, that is, PEdury,
correlated signicantly and inversely with both the
IELT after pelvic oor rehabilitation monotherapy, that
is, IELTpf (P = 0.0001, r = −0.6, CL 99%), and the IELT
after combined therapy, that is, IELTpfser (P = 0.0001,
r = −0.6, CL 99%) (Figs 3 and 4). In addition, secondary
PE was signicantly correlated with a longer PE
duration (P = 0.0001, r = 0.5, CL 99%).
In contrast, the baseline IELT, that is, IELTb, correlated
signicantly and positively with the IELT after sertraline
monotherapy (P = 0.0001, r = 0.6, CL 99%) (Fig. 5).
Moreover, primary PE exhibited a signicant positive
correlation with a longer IELT with pelvic oor
rehabilitation monotherapy (P = 0.0001, r = 0.5, CL
99%) and a longer IELT with combined therapy (P =
0.0001, r = 0.6, CL 99%).
Lastly, a multivariate regression analysis model was
applied to determine as to which variables had a
signicant impact on the treatment response with
both monotherapy and combined therapy lines. With
sertraline monotherapy, patients’ baseline IELT was
the only variable having a signicant impact on the
IELT (P = 0.0001). With pelvic oor rehabilitation
monotherapy, however, both the patient age and the
baseline IELT were found to have a signicant impact
on the IELT (P = 0.002 and 0.04, respectively). Finally,
Table 1 Treatment results among different treatment approaches
Treatment types Baseline IELT IELT after treatment Patients’ response P (CL = 95%) SS OS
Sertraline 50 mg 90–180 s
(121.69 ± 21.76 SD)
44 (59.46%)<120 s73 (98.65%)<180 s 0.0001 N N
PFE 20–110 s
(56.35 ± 21.67 SD)
90–270 s
(174.73 ± 45.79 SD)
13 (17.56%)<120 s40 (54%)<180 s 0.0001 M S
Combined 180–240 s
(297.57 ± 59.19 SD)
0 (0%)<180 s62 (83.78%)≥240 s 0.0001 S S
CL, condence level; IELT, intravaginal ejaculatory latency time; M, modest satisfaction (associated interpersonal distress and one partner
dissatised); N, no satisfaction; OS, objective satisfaction with treatment; PFE, pelvic oor exercise; S, good satisfaction; SS, subjective
satisfaction with treatment (both partners).
Figure 1
The correlation between age and intravaginal ejaculatory latency time
(IELT) after pelvic oor exercise monotherapy.
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42 Egyptian Rheumatology & Rehabilitation
only patients’ age had a signicant impact on the IELT
with combined therapy (P = 0.0001).
Discussion
PE is a common male sexual disorder [2,10,16–18].
Moreover, it is associated with sexual dissatisfaction
during intercourse for both sexual partners,
interpersonal distress, and a negative impact on the
male partners self-esteem [19–21].
e exact etiology of PE is not yet well-understood and
is believed to be due to neurobiological, psychological,
or penile hypersensitivity issues [1,10,22,23]. is is
one of the most important obstacles that hinders the
development of a denitive therapy for PE.
To our knowledge, this is the rst study to compare
SSRI therapy with pelvic oor rehabilitation and a
combination therapy of both. In this study, we utilized
mainly the denition of PE in the Diagnostic and
Statistical Manual of Mental Disorders, 4
th
ed., text
revision criteria for PE [9]. However, we did not ignore
the subjective issues included in the ISSM denition,
that is, bother, frustration, interpersonal distress, and/
or the avoidance of sexual intimacy [8], and we found
that at the level of an IELT of 2 min or less, the amount
of interpersonal distress and psychosocial bother was
considerable.
Both medical and psychological perspectives focus
mainly on the mere establishment of normal sexual
function, but fail to consider the patient himself, his
social perspectives, and the anxiety of accomplishing
his sex-determined role performance, in addition to
overlooking subjective erotic desire, intimacy, and
embodiment [24]. In our study, on a subjective basis,
Figure 3
The correlation between the premature ejaculation (PE) duration and
intravaginal ejaculatory latency time (IELT) after pelvic oor exercise
monotherapy.
Figure 4
The correlation between the premature ejaculation (PE) duration and
intravaginal ejaculatory latency time (IELT) after combined therapy.
Figure 5
The correlation between the baseline intravaginal ejaculatory latency
time (IELT) and the IELT after sertraline monotherapy.
Figure 2
The correlation between age and intravaginal ejaculatory latency time
(IELT) after combined therapy.
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Treatment of premature ejaculation Kurkar et al. 43
these problems tended to be more important to the
patient than a mere statistical or objective denition-
based improvement.
Despite a statistically signicant improvement of IELT
with sertraline 50 mg on-demand monotherapy, the
amount of patient-related distress and bother did not
improve suciently, and further analysis of the results
revealed that in reality, only about 40% of the patients
achieved an actual, yet marginal, improvement. We
assumed that another subtle cause may account for such
an unsatisfactory result in this patient population. Our
results with sertraline 50 mg on-demand monotherapy
are more or less similar to those reported by Tuncel
et al. [25], but are obviously lower than those reported
in the literature [1,16,26], which might be attributed
to the variation of the baseline IELT or the underlying
etiology of the PE in these studies.
We applied pelvic oor rehabilitation monotherapy at
rst to determine whether it is sucient alone for curing
these patients or, in case of unsatisfactory response, to
denote a mixed etiology of PE in this group of patients;
we made sure that the baseline IELT was subjectively
restored to its pretreatment values on an individual
level with a sucient silent no-treatment interval
between the various treatment strategies to avoid
overlapping of therapeutic eects. We also applied the
various therapeutic lines to the same patient group so
as to avoid any confounding dierences among groups
such as etiological and demographic factors.
With pelvic oor exercise monotherapy, the IELT
improvement was signicantly higher than that
of sertraline monotherapy. Similarly, on objective
denition-based assessment, the results were deemed
rather satisfactory. However, on a subjective basis, the
amount of distress remained remarkable, taking into
consideration that about 18% of the patients remained
below an IELT of 120 s and that about 60% of the
patients achieved just one minute, that is, 180 s, higher
than the cuto limit for PE in this study. Pastore et
al. [14] reported a lower success rate with pelvic
oor rehabilitation than ours, and a lower success
rate than dapoxetine monotherapy, but no previous
studies in the literature have compared sertraline with
pelvic oor rehabilitation monotherapy. Similarly, La
Pera [12] reported a lower success rate with pelvic
oor rehabilitation monotherapy, but their report
concentrated on the ability of the patients to control
the ejaculation reex with no reference to the cuto
limit for improvement they relied on.
e ndings from correlation and multivariate analyses
denote that the ecacy of either of the monotherapies
alone depend, at least in part, on a better baseline IELT.
In contrast, patients’ age played a signicant negative
impact on pelvic oor muscle function. e negative
correlation between the duration of PE duration and
IELT improvement in the pelvic oor rehabilitation
monotherapy group could be attributed to an
overshadowing eect of a higher patient age, which
might parallel a longer PE duration and/or possible
deterioration of baseline IELT with longer PE periods.
With combined therapy, that is, both sertraline on-
demand therapy plus pelvic oor exercises, the amount
of statistical, objective, and subjective improvement
was signicantly higher than either of the treatment
lines in the monotherapy approach. ese ndings
denote a denitive mixed etiology of PE in this patient
group and highlight the importance of understanding
the underlying factors in each individual PE patient.
Conclusion
Pelvic oor muscle rehabilitation is an important
addition to the treatment options of PE, whether as
a monotherapy or combined to SSRIs, particularly in
patients in whom pelvic oor dysfunction represents
an integral part of the etiology of PE. A better
understanding of the underlying mixed etiology of PE
plays a key role in denitive treatment.
Currently, we recommend investigating pelvic
oor dysfunction in patients with an unsatisfactory
preliminary response to SSRI monotherapy, and using
the aforementioned combined approach for treating
this patient subgroup.
Acknowledgements
Conicts of interest
None declared.
References
1 Hellstrom WJ. Update on treatments for premature ejaculation. Int J Clin
Pract 2011; 65:16–26.
2 Laumann EO, Paik A, Rosen RC. Sexual dysfunction in the United States:
prevalence and predictors. JAMA 1999; 281:537–544.
3 Dunn KM, Croft PR, Hackett GI. Sexual problems: a study of the
prevalence and need for health care in the general population. Fam Pract
1998; 15:519–524.
4 Reading AE, Wiest WM. An analysis of self-reported sexual behavior in a
sample of normal males. Arch Sex Behav 1984; 13:69–83.
5 Rowland D, Perelman M, Althof S, Barada J, McCullough A, Bull S, et al.
Self-reported premature ejaculation and aspects of sexual functioning and
satisfaction. J Sex Med 2004; 1:225–232.
6 Simons JS, Carey MP. Prevalence of sexual dysfunctions: results from a
decade of research. Arch Sex Behav 2001; 30:177–219.
7 Aschka C, Himmel W, Ittner E, Kochen MM Sexual problems of male
patients in family practice. J Fam Pract 2001; 50:773–778.
8 McMahon CG, Althof SE, Waldinger MD, Porst H, Dean J, Sharlip ID, et al.
An evidence-based denition of lifelong premature ejaculation: report of
[Downloaded free from http://www.err.eg.net on Sunday, June 07, 2015, IP: 197.32.9.79]
44 Egyptian Rheumatology & Rehabilitation
the International Society for Sexual Medicine (ISSM) ad hoc committee for
the denition of premature ejaculation. J Sex Med 2008; 5:1590–1606.
9 Buvat J, Tesfaye F, Rothman M, Rivas AD, Giuliano F. Dapoxetine for the
treatment of premature ejaculation: results from a randomized, double-
blind, placebo-controlled phase 3 trial in 22 countries. Eur Urol 2009;
55:957–967.
10 Xin ZC, Zhu YC, Yuan YM, Cui WS, Jin Z, Li WR, Liu T Current therapeutic
strategies for premature ejaculation and future perspectives. Asian J
Androl 2011; 13:550–557.
11 Wang WF, Chang L, Minhas S, Ralph DJ Selective serotonin reuptake
inhibitors in the treatment of premature ejaculation. Chin Med J (Engl)
2007; 120:1000–1006.
12 La Pera G. Awareness of the role of the pelvic oor muscles in controlling
the ejaculatory reex: preliminary results. Arch Ital Urol Androl 2012;
84:74–78.
13 La Pera G, Nicastro A. A new treatment for premature ejaculation: the
rehabilitation of the pelvic oor. J Sex Marital Ther 1996; 22:22–26.
14 Pastore AL, Palleschi G, Leto A, Pacini L, Iori F, Leonardo C, Carbone
A A prospective randomized study to compare pelvic oor rehabilitation
and dapoxetine for treatment of lifelong premature ejaculation. Int J Androl
2012; 35:528–533.
15 Piediferro G, Colpi EM, Castiglioni F, Scroppo FI Premature ejaculation. 3.
Therapy. Arch Ital Urol Androl 2004; 76:192–198.
16 Giuliano F, WJ Hellstrom. The pharmacological treatment of premature
ejaculation. BJU Int 2008; 102:668–675.
17 Porst H, Montorsi F, Rosen RC, Gaynor L, Grupe S, Alexander J The
Premature Ejaculation Prevalence and Attitudes (PEPA) survey:
prevalence, comorbidities, and professional help-seeking. Eur Urol 2007;
51:816–823; discussion 824.
18 Rosen RC. Prevalence and risk factors of sexual dysfunction in men and
women. Curr Psychiatry Rep 2000; 2:189–195.
19 Giuliano F, Patrick DL, Porst H, La Pera G, Kokoszka A, Merchant S, et
al.3004 Study Group Premature ejaculation: results from a ve-country
European observational study. Eur Urol 2008; 53:1048–1057.
20 Patrick DL, Althof SE, Pryor JL, Rosen R, Rowland DL, Ho KF, et al.
Premature ejaculation: an observational study of men and their partners. J
Sex Med 2005; 2:358–367.
21 Rowland DL, Patrick DL, Rothman M, Gagnon DD The psychological
burden of premature ejaculation. J Urol 2007; 177:1065–1070.
22 Morales A, Barada J, Wyllie MG. A review of the current status of topical
treatments for premature ejaculation. BJU Int 2007; 100:493–501.
23 Waldinger MD. Recent advances in the classication, neurobiology and
treatment of premature ejaculation. Adv Psychosom Med 2008; 29:50–69.
24 Steggall MJ, A Pryce. Premature ejaculation: dening sex in the absence
of context. J Men Health Gender 2006; 3:25–32.
25 Tuncel A, et al. Efcacy of clomipramine, sertraline and terazosin
treatments in premature ejaculation. Turk J Med Sci 2008; 38:59–64.
26 McMahon CG. Treatment of premature ejaculation with sertraline
hydrochloride: a single-blind placebo controlled crossover study. J Urol
1998; 159:1935–1938.
[Downloaded free from http://www.err.eg.net on Sunday, June 07, 2015, IP: 197.32.9.79]
... Of the ten included trials, five trials were focused on erectile dysfunction [19][20][21][22][23], with the other five focused on premature ejaculation [24][25][26][27][28]. These included one ran-domised controlled trial [19]; one prospective randomised trial [24]; five pre post-test studies [21][22][23]25,27]; one parallel study [20]; one retrospective study [28]; and, one crossover study [26]. ...
... Of the ten included trials, five trials were focused on erectile dysfunction [19][20][21][22][23], with the other five focused on premature ejaculation [24][25][26][27][28]. These included one ran-domised controlled trial [19]; one prospective randomised trial [24]; five pre post-test studies [21][22][23]25,27]; one parallel study [20]; one retrospective study [28]; and, one crossover study [26]. ...
... Of the five PE-based trials, three trials had no comparator [25,27,28]; one trial compared their PFMT intervention with Dapoxetine (a selective serotonin reuptake inhibitor (SSRI)) [24]; one trial had their participants act as their own controls in comparison to Sertraline (SSRI) [26], as both a monotherapy and combined approach ( Table 2). Frequency of physiotherapist supervision of PE-based PFMT programs ranged from 12 to 20 sessions, with intervention lengths ranging from between 4 and 12 weeks. ...
Article
Background: Erectile dysfunction (ED) and premature ejaculation (PE) often have underlying musculoskeletal abnormalities. Despite this, traditional management has focused on pharmaceutical prescription. Objective: To investigate the efficacy of pelvic floor muscle training in treating ED and PE. Data sources: A computerized literature search of CINAHL®, Cochrane, InFormit, Ovid Medline, Pedro, and Scopus (from inception until January 2018) was conducted of type of dysfunction and intervention. Secondary search strategies included Medical Subject Headings expansion, hand searching of conference abstracts, key authors, reference lists and forward citation searching via Web of Science. Study selection: All studies where participants were males greater than 18years with ED or PE, with no history of neurological injury or previous major urological surgery were included. Study appraisal: Two independent reviewers assessed methodological quality using the Crowe Critical Appraisal Tool. Disagreements between reviewers were resolved by consensus. Results: Ten trials were included for review. Among the measures of ED, all trials showed comparative improvement and cure rates in response to treatment. Within PE outcomes, the majority of trials showed comparative improvement rates, with a greater range in overall cure rates in response to treatment. Training protocols varied significantly in overall therapist contact, concurrent interventions, intervention length, training frequency and intensity. Limitations: The included studies were of low to moderate methodological quality with discrepancies in reporting. Study heterogeneity was not conducive to data pooling. Conclusion: Pelvic floor muscle training appears effective in treating ED and PE; however, no optimal training protocol has been identified. Systematic review registration number: PROSPERO CRD42016047261.
... In addition, participants were asked to breathe normally and complete 15 practice sessions per day. 37 CONCLUSIONS Current evidence is encouraging, even though, further highquality evidence is still necessary to attain a better understanding of the effectiveness of PFM training and the part that physical therapy plays in the management of PE and ED. Physical therapists choose a multifaceted approach when assessing and treating PFM dysfunction, focusing on musculoskeletal dysfunction and behavioral involvement. ...
Article
Introduction Increasing evidence has suggested that pelvic floor exercises and manual physical therapy may improve premature ejaculation (PE) and erectile dysfunction (ED) in males. Objectives To examine the effects of pelvic floor physical therapy treatment in men suffering from PE and ED. Methods We searched Google Scholar, PubMed, Medline, PEDro databases from inception till January 2020 applying the following keywords: pelvic floor, erectile dysfunction, impotence, physiotherapy, exercises, rehabilitation, and pelvic floor muscle exercises. Results The review included 37 papers reporting on PE and ED, of which 5 were randomized controlled trials, 2 meta-analyses, and 4 observational studies. Pelvic floor physical therapy treatment included education and rehabilitation. The rehabilitation part encompassed manual therapy techniques that contribute to the normalization of muscle tone and improvement of muscle relaxation. Moreover, exercises, according to the patients’ clinical assessment were presented. Most of the studies reported that by strengthening the pelvic floor muscles (PFMs), ED and PE can be improved if manual physical therapy treatments are combined with PFM training. Conclusions A multifaceted approach should be chosen by physical therapists when evaluating and treating ED and PE and contending with both musculoskeletal dysfunction and behavioral contributions. It is recommended that exercises be monitored and situations involving, that is, hyperactivity/increased tone of the PFMs should be avoided. PFM training is simple, safe, and noninvasive; therefore, it should be a preferred approach in the management of ED and PE. This paper presents narrative reviews with a potential bias that systematic reviews or meta-analyses do not have, however, we strove to be all-encompassing and unbiased. There is a demand for high-quality scientific reviews examining the effectiveness of PFM training, manual therapy, and the rationale of pelvic floor physical therapy, in general, in treating individuals with PE and ED.
Article
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Context While recent pharmacological advances have generated increased public interest and demand for clinical services regarding erectile dysfunction, epidemiologic data on sexual dysfunction are relatively scant for both women and men. Objective To assess the prevalence and risk of experiencing sexual dysfunction across various social groups and examine the determinants and health consequences of these disorders. Design Analysis of data from the National Health and Social Life Survey, a probability sample study of sexual behavior in a demographically representative, 1992 cohort of US adults. Participants A national probability sample of 1749 women and 1410 men aged 18 to 59 years at the time of the survey. Main Outcome Measures Risk of experiencing sexual dysfunction as well as negative concomitant outcomes. Results Sexual dysfunction is more prevalent for women (43%) than men (31%) and is associated with various demographic characteristics, including age and educational attainment. Women of different racial groups demonstrate different patterns of sexual dysfunction. Differences among men are not as marked but generally consistent with women. Experience of sexual dysfunction is more likely among women and men with poor physical and emotional health. Moreover, sexual dysfunction is highly associated with negative experiences in sexual relationships and overall wellbeing. Conclusions The results indicate that sexual dysfunction is an important public health concern, and emotional problems likely contribute to the experience of these problems.
Article
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Ten years of research that has provided data regarding the prevalence of sexual dysfunctions is reviewed. A thorough review of the literature identified 52 studies published in the 10 years since an earlier review by Spector and Carey (Arch. Sex. Behav. 19(4): 389–408, 1990). Community samples indicate a current prevalence of 0%–3% for male orgasmic disorder, 0%–5% for erectile disorder, and 0%–3% for male hypoactive sexual desire disorder. Pooling current and 1-year figures provides community prevalence estimates of 7%–10% for female orgasmic disorder and 4%–5% for premature ejaculation. Stable community estimates of the current prevalence of other sexual dysfunctions remain unavailable. Prevalence estimates obtained from primary care and sexuality clinic samples are characteristically higher. Although a relatively large number of studies has been conducted since the earlier review, the lack of methodological rigor of many studies limits the confidence that can be placed in these findings.
Article
Objective: To review and assess the update studies regarding selective serotonin reuptake inhibitors (SSRIs) in the treatment of premature ejaculation (PE) and then provide practical recommendations and possible mechanisms concerning state of the art knowledge for the use of SSRIs in alleviating PE. Data sources: Using the Medline, 48 articles published from January 1st, 1996 to August 1st, 2006 concerning the use of SSRIs and their possible mechanisms in alleviating PE were found and reviewed. Study selection: PE, rapid ejaculation, early ejaculation and SSRIs were employed as the keywords, and relevant articles about the use of SSRIs and their possible mechanisms in the treatment of PE were selected. Results: Many kinds of SSRIs, such as fluoxetine, sertraline, paroxetine and citalopram, have widely been employed to treat PE. However, their effects are moderate and there is no a universal agreement about the kind, dose, protocol and duration. Dapoxetine, as the first prescription treatment of PE, may change this bottle-neck situation. SSRIs are suggested to be used in young men with lifelong PE, and acquired PE when etiological factors are removed but PE still exists. Phosphodiesterase 5 inhibitors (PDE(5)-Is) are suggested to be employed alone or combined with SSRIs when SSRIs fail to treat PE or sexual dysfunction associated with SSRIs occurs. The protocol of taking drugs on demand based on taking them daily for a suitable period is proposed to be chosen firstly. The possible mechanisms include increasing serotonergic neurotransmission and activating 5-hydroxytryptamine 2C (5-HT(2C)) receptors, then switching the ejaculatory threshold to a higher level, decreasing the penile sensitivity and their own effect of antidepression. Conclusion: The efficacies of the current SSRIs are moderate in the treatment of PE and they have not been approved by the FDA, therefore new SSRI like dapoxetine needs to be further evaluated.
Article
Ten years of research that has provided data regarding the prevalence of sexual dysfunctions is reviewed. A thorough review of the literature identified 52 studies published in the 10 years since an earlier review by Spector and Carey (Arch. Sex. Behav. 19(4): 389–408, 1990). Community samples indicate a current prevalence of 0%–3% for male orgasmic disorder, 0%–5% for erectile disorder, and 0%–3% for male hypoactive sexual desire disorder. Pooling current and 1-year figures provides community prevalence estimates of 7%–10% for female orgasmic disorder and 4%–5% for premature ejaculation. Stable community estimates of the current prevalence of other sexual dysfunctions remain unavailable. Prevalence estimates obtained from primary care and sexuality clinic samples are characteristically higher. Although a relatively large number of studies has been conducted since the earlier review, the lack of methodological rigor of many studies limits the confidence that can be placed in these findings.
Article
50 mg sertraline nightly; and Group 4 (n: 25) 5 mg terazosin nightly. The medications were used for two months. After 8 sexual attempts, the patients' clinical responses were assessed using the patient self- description method. Clinical responses were classified as "no change", "improvement" and "under control". Success was described as improvement + under control. Results: Success rates were 36.3% in Group 1, 91.3% in Group 2, 90% in Group 3 and 76% in Group 4. Although the efficacy of each medical treatment was superior to placebo (P = 0.001), no significant difference in efficacy was found between the medical treatment groups (P = 0.537). Conclusions: Clomipramine, sertraline and terazosin are more efficient than placebo. No significant difference was observed in terms of efficacy among these three medical treatments.
Article
The difficulty in correctly identifying the etiologic factors of premature ejaculation (PE) could be due to the fact that the role of the pelvic floor muscles (PFMs) in the voluntary control of ejaculatory reflex has not been elucidated. The aim of the present investigation was to measure the prevalence of awareness of the role and use of PFM contraction in controlling the ejaculatory reflex among PE and non-PE participants. A total of 44 men with PE and 73 men without PE were recruited. In the first part of the study, we validated a test that rendered the participants aware of the PFMs through digital rectal examination and the PFM contraction. In the second part, we posed this multiple-choice question: "Which muscles do you use to delay ejaculation?". Men not answering correctly were considered not to be using the PFMs and also to be unaware that it is necessary to contract the PFMs to control the ejaculatory reflex. Only 3 of 44 subjects (6.8%) with PE and 60 of 73 subjects (82%) without PE answered correctly and used PFMs to control the ejaculatory reflex (Fisher test p < 0.0001). This test has a sensibility of 93%, a specificity of 82%, and an accuracy of 86%. The vast majority of PE subjects were unaware that to inhibit or delay ejaculation it is necessary to contract the PFMs. This association also raises the question whether the difficulties in defining PE and finding effective PE therapies could be due to a nonhomogeneous population of PE patients with different etiopathogenetic factors. More studies are required to confirm these data and to answer this question.
Article
Conflict of Interest. Dr. Rowland is a part-time consultant for ALZA Corporation. Drs. Bull, Jamieson and Ho are employees of the ALZA Corporation. Background. Although premature ejaculation (PE) is a common male sexual dysfunction, its relevant parameters have not been adequately studied in large community-based samples. Objective. To examine the diagnostic utility of two self-report questions based on the DSM-IV-TR definition of PE and to investigate the relationship between self-identified PE, sexual functioning, and sexual satisfaction in men. Methods. An Internet survey of general health and aspects of sexual functioning and satisfaction was conducted in 2056 males. Subjects were classified as having “probable” or “possible” PE, or as “non-PE” by survey responses. Results. A total of 1158 men met the selection criteria (sexually active in a stable heterosexual relationship), and 189 (16.3%) were classified as having probable PE by reporting they ejaculated before they wished and indicating it was “very much” or “somewhat” a problem. Another 188 (16.2%) men reported ejaculating before they wished but rated their distress lower and were classified as having possible PE. Compared to non-PE men, those with probable and possible PE reported significantly worse sexual functioning in 6 of 8 study measures. Concern about partner satisfaction was high in all groups. The importance of ejaculatory control and the ability to have intercourse for the desired time was significantly higher in men with PE as compared to non-PE men (P < 0.01). Conclusions. PE was a common problem, was characterized by a lack of ejaculatory control, and was associated with significant effects on sexual functioning and satisfaction. Additional research on the sensitivity and specificity of these self-report questions should be pursued.
Article
Medical and psychiatric literature defines premature, early or rapid ejaculation from diverse perspectives and provides explanations and treatment options that reflect their historical development. Medical discourse focuses on premature ejaculation as a neuro-biological phenomenon with a growing 'evidence' base emerging for both defining the condition and treating it with selective serotonin re-uptake inhibitors (SSRIs). Current definitions of premature ejaculation however are difficult to deploy clinically; 'marked inter-personal distress' is a subjective measure and not all men are able (or willing) to time their sexual activity with a stopwatch. The addition of a defined measure of intravaginal ejaculatory latency time (IELT) is, perhaps, useful for research, but less so for the individual men with premature ejaculation. Psychiatric literature considers the diagnosis and management of premature ejaculation from a behavioural perspective, where the man learnt 'hurriedly' and therefore got into a pattern of hurried sexual activity, although there is no compelling data (or evidence) that adoption of behavioural therapies are successful in providing a 'cure' for the problem. Both medical and psychological perspectives appear based on certain assumptions, i.e. that of the construction of 'normal' sexual activity and function. Neither medical rationalities nor psychological perspectives consider the person who is the premature ejaculator, and both generally fail to consider his social contexts and cultural meanings or the anxieties of managing gender-determined role perfor-mances. Similarly, the 'irrationalities' of erotic desire, intimacy and embodiment remain largely marginal or invisible elements in the pursuit of 'evidence'. Whilst there is little sociological literature on the topic, premature ejaculation provides an example, par excellence, of an aspect of human experience that demonstrates the paradigmatic tensions between medical positivism and the cultural constructions of experience. This paper seeks to discuss premature ejaculation from another perspective, problematising the complexities of sometimes contradictory, social, sexual and gendered identities, and reflecting on a number of key areas that seem absent from the clinical literature on premature ejaculation. ß 2005 WPMH GmbH.
Article
Introduction. Premature ejaculation (PE) is the most common male sexual dysfunction affecting men and their partners. Lack of community-based data describing this condition limits understanding of PE and its outcomes. Aim. To characterize PE in a large population of men with and without PE using patient-reported outcome (PRO) measures elicited from men and their partners. Methods. 4-week, multicenter, observational study of males (≥18 years) and their female partners in monogamous relationships (≥6 months). Screening, baseline, and follow-up visits scheduled at 2-week intervals. Clinicians diagnosed PE utilizing DSM-IV-TR criteria. Intravaginal ejaculatory latency time (IELT), measured by a stopwatch held by the partner, was recorded for each sexual intercourse experience. Subject and partner independently assessed PROs: control over ejaculation and satisfaction with sexual intercourse (0 = very poor to 4 = very good), personal distress and interpersonal difficulty (0 = not at all to 4 = extremely), and severity of PE (0 = none to 3 = severe). Results. Of the total study population (N = 1,587), 207 subjects were diagnosed with PE and 1,380 were assigned to the non-PE group. Median IELT (min) was 1.8 (range, 0–41) for PE and 7.3 (range, 0–53) for non-PE subjects (P < 0.0001). More PE vs. non-PE subjects gave ratings of “very poor” or “poor” for control over ejaculation (72% vs. 5%; P < 0.0001) and satisfaction with sexual intercourse (31% vs. 1%; P < 0.0001). More subjects in the PE vs. non-PE group gave ratings of “quite a bit” or “extremely” for personal distress (64% vs. 4%; P < 0.0001) and interpersonal difficulty (31% vs. 1%; P < 0.0001). Subject and partner assessments showed similar patterns and correlated moderately (0.36–0.57). Conclusions. PE subjects reported significantly shorter IELT. Overlap in IELT distributions was observed between the PE and non-PE groups, indicating the need for additional PRO measures to characterize PE. Shorter IELT was significantly associated with reduced ejaculatory control and sexual satisfaction and increased distress and interpersonal difficulty.
Article
Premature ejaculation (PE) is the most common male sexual disorder. We compared pelvic floor muscle rehabilitation to on-demand treatment with the selective serotonin reuptake inhibitor dapoxetine in 40 men with lifelong PE (baseline intra-vaginal ejaculatory latency time (IELT) ≤1 min). Subjects were randomized into the following two treatment groups: (1) PFM rehabilitation or (2) 30 or 60 mg of on-demand dapoxetine. Total treatment time for both groups was 12 weeks, at the end of which, IELT mean values were calculated to compare the effectiveness of the two different therapeutic approaches. At the end of treatment, 11 of the 19 patients (57%) treated with rehabilitation were able to control the ejaculation reflex, with a mean IELT of 126.6 sec (range: 123.6-152.4 sec). In the dapoxetine group, after 12 weeks of therapy, 5 of 8 (62.5%) patients in the 30 mg subgroup and five of seven (72%) in the 60 mg subgroup had an IELT >180 sec (mean: 178.2 and 202.8 sec, respectively). The results obtained in the group treated with pelvic floor rehabilitation are promising, and this treatment represents an important cost reduction if compared to dapoxetine on-demand treatment. The present study confirms the data that are previously available in the literature on the efficacy and safety of the new inhibitor of serotonin reuptake, dapoxetine, as well as proposes and evaluates a new type of physical treatment that may be a viable therapeutic option for treatment of PE.