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ASSESSMENT OF

PREMATURE EJACULATION

AND ERECTILE

DYSFUNCTION

Dr Michael Gillman

St Andrews Hospital Wickham Terrace Spring Hill

Mater Private Clinic, South Brisbane

Shore St West Medical Centre, Cleveland

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Disclosure Slide

Advisor Lilly Australia Cialis

Advisor Pfizer Australia Viagra / Caverject

Advisor Bayer Levitra

Advisor Andrology Australia Erectile Dysfunction Board

Advisor Janssen Cilag Priligy

Advisor Sanofi Adventis Xatral

Advisor CSL / Astellis Flomaxtra

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Premature Ejaculation

• A common sexual disorder

• Usually affects younger couples

• May accommodate problem with second attempt while still young enough to have a short refractory period

• Higher levels of intercourse related anxiety

• Greater patient and partner impairment in intercourse satisfaction

• Greater impairment in relationship satisfaction

Premature Ejaculation (PE)

• ISSM definition of PE:

– intravaginal ejaculatory latency time (IELT) <1 min

– inability to delay ejaculation- lack of control

– negative impact on man and partner- distress

• either lifelong or acquired (often associated with erectile

dysfunction)

• psychological and physiological components

Diagnof Premature Ejaculation

McMahon et al, 2008

Time to

ejaculation

Inability to

delay

ejaculation

Negative

personal

consequences + +

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• 20–30% of men report PE at some point in their lives

• IELT range 0 to 44 mins1

1Waldinger et al, 2005; McMahon et al, 2008.

Median IELT=5.4 mins

IELT in unselected population of 500 heterosexual males

IELT

1 min

0 3 5 7 10 20 30 40 45

Mean intravaginal ejaculatory latency time (mins)

Num

ber

of m

en

Prevalence of PE

Premature Ejaculation Management

YES Manage primary cause first

Patient preference

Adapted from McMahon et al, 2004.

Patient presents with suspected PE • establish PE diagnosis (ISSM definition) • sexual, medical and psychological history • physical examination

LIFELONG PE Pharmacotherapy behavioural therapy and relationship counselling

NO

ACQUIRED PE Behavioural therapy and relationship counselling pharmacotherapy

Is PE secondary to ED or other condition?

PE pharmacotherapy:

• serotonin and 5-HT receptors are involved in ejaculation1,2

1. Donatucci, 2006. 2. Giuliano & Clement, 2006. 3. Dapoxetine Product Information. Janssen-Cilag: 2009.

Effect of SSRIs on Ejaculation

1. Waldinger MD, Hengeveld MW, Zwinderman, AH: J.Clin.Pssychopharmacol.1998;18:274-81.

0

20

40

60

80

100

120

140

0 1 2 3 4 5 6

Weeks

Me

an

ELT

(se

co

nd

s)

Placebo Fluvoxamine 100mg Fluoxetine 20mg Paroxetine 20mg Sertraline 50mg

• Effective

• Daily paroxetine - 8.8 fold increase in IELT

• “On demand” clomipramine – 4.6 fold increase

• Safe

• Usually well tolerated

• Minor, self limiting adverse effects of SSRIs ...

• Fatigue, yawning, mild nausea, loose stools or perspiration

Effective, Safe, Well Tolerated …

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PE management plan and follow-up

Management plan

Involve patient and partner

• partner may influence choice of management

Consider SSRI treatment in combination with behavioural

therapy

Follow up

4 weeks or 6 doses after starting therapy; check…

• efficacy

• dose titration

• side effects

1. Dapoxetine Product Information. Janssen-Cilag: 2009.

Summary Premature Ejaculation (PE)

• PE is common and distressing

• Behavioural therapies are effective in some cases

• If lifelong PE requires pharmacological treatment

• Combined medical and psychological treatment is most

effective strategy for PE

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ASSESSMENT OF ERECTILE

DYSFUNCTION

Dr Michael Gillman

St Andrews Hospital Wickham Terrace Spring Hill

Mater Private Clinic, South Brisbane

Shore St West Medical Centre, Cleveland

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IMPOTENCE

Impotence is the inability to

achieve or sustain an erection

sufficient for the sexual needs

of the man or his partner

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ERECTILE DIFFICULTIES

40% at age 40

50% at age 50

60% at age 60

70% at age 70

Do Men Really Care???

How many of your male patients book

appointments to discuss erection problems

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Erectile Dysfunction

History – Main Points

Duration of onset of problem.

Quality of all erections ( Spontaneous and

sexual )

Relationship issues

Previous Treatments including Newspaper

Commercial Clinics

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Erectile Dysfunction

History – Main Points

>70% have an organic component

Assume that most men have both

Organic and Psychogenic

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Psychogenic

Mainly Performance anxiety

Relationship Difficulties

Financial Difficulties

etc

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Diabetes Hypertension

The Deadly Quartet

Obesity Dyslipidemia

Why does ED occur earlier than cardiovascular disease?

Artery Diameter (mm) Critical events

Penile 1–2 Erectile

dysfunction

Coronary 3–4 Angina / MI

Carotid 5–7 TIA / Stroke

Adapted from Montorsi et al. Am J Cardiol 2005; 96: 19M–23M

The arterial size hypothesis

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Examination

Examination

BP

Height Weight and waist circumference

Penile shaft for fibrosis

Testicles

Vascular system AAA, peripheral

pulses

? Prostate with informed consent

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Investigations

E/LFTs

HDL/LDL

Testosterone ( LH and PRL if low )

TSH

Urine WTU

?PSA

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Testosterone and ED ??

– Low testosterone is an uncommon cause of ED

– However PDE 5 inhibitors do not work as well in the presence of low testosterone

– Free Androgen Index, Bioavailable Index and Free Testosterone are unreliable and generally not used

– “best of a bad bunch” is two morning sample serum testosterone levels

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TREATMENT

Counselling

Viagra Cialis, Levitra, Uprima ( Not Yet Available )

Intracavernosal Injections ( Caverject and Combinations)

Trans-urethral Agents (MUSE) ( Not currently available)

Topiglans ( Not yet available )

Vacuum Devices

Penile implants

Testosterone

Vascular Surgery ( Selected Cases Only )

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VACUUM DEVICES

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INTRACAVERNOSAL

INJECTIONS

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SELF INJECTION THERAPY (cont)

Side effects

scarring

priapism

bruising

pain

Follow up

at one month, then every six months

as appropriate

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PRIAPISM

Prolonged erection not associated with

sexual stimulation

After 24 hours may have irreversible

cavernosal damage resulting in

permanent erectile dysfunction

Must have action plan

Not usual with PDE5 inhibitors alone

INTRACAVERNOSAL

IMPLANTS

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Three – Piece Inflatable

Penile Implant

Simple to use

Totally concealed within body

Acts and feels like a natural

erection

Provides fullness and girth

expansion

Softer and more flaccid when

deflated

Disadvantages

Requires some manual

dexterity

Possibility of malfunction

Possibility of leakage

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PDE5’s ARE

DISCOVERED!!!!!!

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Oral Agents

Needs sexual stimulation to work

Allow time

On demand or daily dosing

Tailor management to individual

couple Cost

Convenience

Efficacy

Side effects

The Role of PDE5 Inhibitors in Achieving and Maintaining Erection

cGMP-specific

protein kinase

Endothelial

cell

Guanylate

cyclase

GT

P

cGMP

K+

Ca2+

Decreased

Ca2+

Smooth

muscle

relaxation

& erection

Nitric

oxide

Smooth muscle cell

5'GMP PDE5

Cavernous

nerve

Sexual Stimulation

PDE5 Inhibitors

CHANCE OF A

“CURE”????

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CAVERNOSAL HYPOXIA

Aging effects on the corporal

vasculature supply (hyperlipidaemia,

hyperglycaemia etc.) cause hypoxic

changes

Transforming Growth Factor TGF-B(1)

is inhibited by prostaglandin

PGE(1&2) suppress collagen

synthesis in human fibroblast

cultures

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CAVERNOSAL HYPOXIA

(cont)

An imbalance between PGE and

TGF-B(1) in the corpora due to

hypoxia, may cause increased

extracellular matrix deposition,

inhibition of smooth muscle growth,

and eventually fibrosis

PGE may have a role in the

management of cavernosal fibrosis

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Main Points

Take a good history

Ask at risk patients about sexual

function

Offer patients a range of options

Discuss pros and cons of each

Ensure they use product effectively

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They do grow on trees!

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