Premature (Early) Ejaculation, Delayed Ejaculation and Erectile

M ODE RATOR – DR S OLOM ON DA BI , P SYCHIATR IST
P R EPARED BY – DR MES KEREM A BE BE

A P R IL 1 7 , 2017
OUTLINE
 OBJECTIVES
 INTRODUCTION
 EPIDEMIOLOGY
 CLINICAL PICTURE
 DIAGNOSTIC CRITERIA
 DIFFERENTIAL DIAGNOSIS
 MANAGEMENT
APRIL 27 2017 MESKEREM ABEBE,MD 2

OBJECTIVES
 To have a better understanding of the disorders and be able to diagnose it
 To be able to treat the disorder

PREMATURE (EARLY EJACULATION)

INTRODUCTION
 When the man recurrently achieves orgasm and ejaculates before he wishes.
 within or less than 1 minute
DSM 5 refers only to vaginal penetration
 commonly reported among colleague educated men

FACTORS TO BE CONSIDERED
 Age
 Novelty of the sexual partner
 Duration and frequency of coitus

PREVALENCE
 1-3% of men are diagnosed with this disorder
 More than 20-30% of men ages 18-70 report concerns on how frequent they
ejaculate
Prevalence increases with age

DSM-5 DIAGNOSTIC CRITERIA
A. A persistent or recurrent pattern of ejaculation occurring during partnered sexual activity within
approximately 1 minute following vaginal penetration and before the individual wishes it.
Note :Although the diagnosis of premature ejaculation maybe applied to individuals engaged in non
vaginal sexual activities, specific duration criteria have not been established for these activities .
B. The symptom in criteria A must have been present for at least 6 months and must be experienced
on almost all or all( approximately 75-100%) occasions of sexual activity ( in identified situational
contexts or ,if generalized, in all contexts)
C. The symptom in criteria A causes clinically significant distress in the individual
D. The sexual dysfunction is not better explained by a non sexual mental disorder or as a consequence
of severe relationship distress or other significant stressors and is not attributable to the effects of a
substance /medication or another medical condition .

Diagnostic criteria con’d
Specify whether
Life long : the disturbance has been present since the individual became sexually
active
Acquired :the disturbance begun after a period of relatively normal sexual
function
Generalized – not limited to certain type of stimulation, situation or partners
Situational – only occurs with certain types of stimulation ,situation or partner
Specify current severity :

Diagnostic criteria con’d
Mild – ejaculation occurring within approximately 30 sec to 1 minute of vaginal
penetration
Moderate – ejaculation occurring within approximately 15 -30 seconds of
vaginal penetration
Severe –ejaculation occurring prior to sexual activity ,at the start of sexual
activity ,or within approximately 15 seconds of vaginal penetration

ASSOCIATED FACTORS SUPPORTING
DIAGNOSIS
1) Partner factors
2) Relationship factors
3) Individual vulnerability factors
4) cultural/religious factors
5) Medical factors

Difficulty in ejaculatory control might be associated with
Anxiety regarding the sex act
 unconscious fear about the vagina
 Negative cultural conditioning
 Men with early sexual contact with prostitutes
 stressful marriage

DEVELOPMENT AND COURSE
 Little is known about acquired premature ejaculation
 In about 20% of men PE, ejaculatory latency decreases further with age.

RISK AND PROGNOSTIC FACTORS
 Temperamental – common in men with anxiety ,especially social anxiety
disorder.
 Genetic and physiological – moderate genetic contribution to lifelong PE
Dopamine transporter gene polymorphism
 serotonin gene transporter polymorphism

FUNCTIONAL CONSEQUENCES
 Low self esteem
 A scene of lack of control
Personal distress in sexual partner
Decreases sexual satisfaction in sexual partner
 ejaculation prior to penetration might be associated with difficulty of conception

DIFFERENTIAL DIAGNOSIS
 SUBSTANCE /MEDICATION INDUCED SEXUAL DYSFUNCTION-
 EJACULATORY CONCERNS THAT DO NOT MEET THE CRITERIA
 ERECTILE PROBLEMS
ANXIETY PROBLEMS

COMORBIDITY
Associated with erectile problems
 Anxiety disorder
 Drug withdrawal or thyroid disease

DELAYED EJACULATION
 ‘ Retarded ejaculation’
 A man achieves ejaculation with great difficulty.
 Rarely present with masturbation
 lifelong and acquired
 orgasm and ejaculation should be differentiated

PREVALENCE
 Least common male sexual complaint
 less than 1% complain of problems of reaching ejaculation
 Masters and Johnson- 3.8% of DE in a group of 447 men with sexual

dysfunction
 A general prevalence of 5% has been reported

DSM 5 DIAGNOSTIC CRITERIA
A. Either of the following symptoms must be experienced on almost all or all
occasions (~75%-100%) of partnered sexual activity (in identified situational
contexts or, if generalized, in all contexts), and without the individual desiring
delay:
1. Marked delay in ejaculation.
2. Marked infrequency or absence of ejaculation.
B. Persisted for a minimum duration of ~6 months.

C. Clinically significant distress in the individual.

D. The sexual dysfunction is not better explained by a nonsexual mental disorder or as a
consequence of severe relationship distress or other significant stressors and is not
attributable to the effects of a substance/medication or another medical condition
Specify whether:
Lifelong: The disturbance has been present since the individual became sexually active.
Acquired: The disturbance began after a period of relatively normal sexual function.

Specify whether:
Generalized: Not limited to certain types of stimulation, situations, or partners.
Situational: Only occurs with certain types of stimulation, situations, or partners.
Specify current severity:

Mild: Evidence of mild distress over the symptoms
Moderate: Evidence of moderate distress over the symptoms
Severe: Evidence of severe or extreme distress over the symptoms

Genetic and physiological- Age-related loss of the fast-conducting peripheral
sensory nerves
 Age-related decreased sex steroid secretion - in men older than 50 years.

FUNCTIONAL CONSEQUENCES
Difficulties in conception
 Psychological distress in one or both partners

Another medical condition
A situational aspect to the complaint is suggestive of a psychological basis, e.g.,
◦ Men who can ejaculate during sexual activity with one sex but not the other
◦ men with paraphilic arousal patterns;
◦ men who require highly ritualized activity to ejaculate during partnered sexual
activity
Another medical illness or injury may produce delays in ejaculation independent

of psychological issues

Substance/medication use
Agents, such as antidepressants, antipsychotics, alpha sympathetic drugs, and
opioid drugs, can cause ejaculatory problems.

Dysfunction with orgasm
Ascertain whether the complaint concerns delayed ejaculation or the sensation

of orgasm, or both.
Ejaculation occurs in the genitals, whereas orgasm is believed to be primarily
subjective.
Ejaculation and orgasm usually occur together but not always.
For example, a man with a normal ejaculatory pattern may complain of
decreased pleasure (i.e., anhedonic ejaculation).
◦ Not coded as delayed ejaculation but could be coded as other specified sexual
dysfunction or unspecified sexual dysfunction

COMORBIDITY
 Common in severe forms of major depressive disorder.

ERECTILE DISORDER
 Historically called impotence
Inability to obtain erection sufficient for penetration
Can be organic or psychological, or a combination of both,
In young and middle-aged men the cause is usually psychological.

 35-50% of treated sexual dysfunction
 Freud
Inability to reconcile feelings of affection with desire for her
Men with such conflicting feelings can function only with women whom they
see as degraded
Other factors
A punitive superego,
An inability to trust, and
Feelings of inadequacy or a sense of being undesirable as a partner

PREVALENCE
~13%-21% of men ages 40-80 years
~2% ,<40-50years
40%-50% of men >60-70yrs may have significant problems with erections.
~20% fear ED on their first sexual experience,

 8% experienced erectile problems that hindered penetration during their first sexual
experience

Prevalence con’d
 Acquired ED reported in 10-20% of all men.
Lifelong ED; occurs in ~1% of men <35yrs.
2-8% of the young adult population.
75% at age 80.

DSM 5 DIAGNOSTIC CRITERIA
A. At least one of the three following symptoms must be experienced on almost all or all(~75%-
100%) occasions of sexual activity (in identified situational contexts or, if generalized, in all
contexts):
1. Marked difficulty in obtaining an erection during sexual activity.
2. Marked difficulty in maintaining an erection until the completion of sexual activity.
3. Marked decrease in erectile rigidity.
B. Duration of 6 months.
C. Clinically significant distress in the individual.

D. The sexual dysfunction is not better explained by a nonsexual mental disorder or as a
consequence of severe relationship distress or other significant stressors and is not at-
tributable to the effects of a substance/medication or another medical condition.
Specify whether:
Lifelong: The disturbance has been present since the individual became sexually active.
Acquired: The disturbance began after a period of relatively normal sexual function

Specify whether:
Generalized: Not limited to certain types of stimulation, situations, or partners.
Situational: Only occurs with certain types of stimulation, situations, or partners.
Specify current severity:

Mild: Evidence of mild distress over the symptoms
Moderate: Evidence of moderate distress over the symptoms
Severe: Evidence of severe or extreme distress

DIAGNOSTIC MARKERS
Nocturnal penile tumescence testing and measured erectile turgidity
during REM sleep
Organic from psychogenic erectile problems.
 Assess vascular integrity

◦ Doppler ultrasonography
◦ Intra-vascular injection of vasoactive drugs,
◦ Invasive diagnostic procedures such as dynamic infusion

cavernosography,

Serum free testosterone if they also have sexual desire,
Thyroid function may also be assessed.
FBS, to screen for DM
The assessment of serum lipids is important

ASSOCIATED FEATURES SUPPORTING
DIAGNOSIS
May have low self-esteem, and a decreased sense of masculinity,
May experience depressed affect
Fear and/or avoidance of future sexual encounters may occur
Decreased sexual satisfaction and reduced sexual desire in the

individual's partner are common

DEVELOPMENT AND COURSE
Erectile failure on first sexual attempt were related to d/t factors
Most of them spontaneously remit , but some men may continue to

have episodic problems.
Acquired ED is likely to be persistent b/c it’s usually related with

biological factors

Risk factors for acquired erectile disorder include
-Age,
-Smoking tobacco,
-Lack of physical exercise,
-Diabetes, and
-Decreased desire.

FUNCTIONAL CONSEQUENCES OF ED
ED can interfere with fertility and produce both individual and
interpersonal distress
Fear and/or avoidance of sexual encounters may interfere with the

ability to develop intimate relationships.

Nonsexual mental disorder
MDD and ED are closely associated, and ED accompanying severe MDD
may occur.
Normal erectile function

Consider in men with excessive expectations
Substance/medication use
An onset that coincides with the beginning of substance/medication use

Other sexual dysfunctions.
ED may coexist with

◦ Premature (early) ejaculation and
◦ Male hypoactive sexual desire disorder

COMORBIDITY
Premature (early)ejaculation
Male hypoactive sexual desire disorder,
Anxiety and depressive disorders
Men with lower urinary tract symptoms related to prostatic hypertrophy
Dyslipidemia, cardiovascular disease, hypogonadism, multiple sclerosis, diabetes

mellitus

TREATMENT

DUAL SEX THERAPY
The concept is
• The couple must be treated when a dysfunctional person is in a

relationship
• The entire relationship is treated, with emphasis on the sexual

functioning

Discuss the psychological and physiological aspects of sexual functioning,
• Therapists have an educative attitude.

• Suggest specific sexual activities for the couple to follow in private
The aim is to establish or reestablish communication within the partner unit.
• Sex is emphasized as a natural function that flourishes in the appropriate domestic

climate, &
• Improved communication is encouraged

Treatment is short term and is behaviorally oriented.
Reflect the situation as you see it, rather than interpret underlying dynamics.
An undistorted picture of the relationship presented by the therapists often

corrects the myopic, narrow view held by each partner.
• Can interrupt the couple’s destructive pattern of relating & encourage

improved, communication.
The couple is prohibited from any sexual play other than prescribed
Beginning exercises usually focus on
• heightening sensory awareness to touch, sight, sound, and smell.
• Initially, intercourse is interdicted, and
• The couple learn to give and receive bodily pleasure without the pressure of
performance or penetration.
• learn that sexual foreplay is an enjoyable alternative to intercourse and

orgasm.
The couple receives much reinforcement to reduce anxiety.
• Encourage to use fantasies to distract them from concerns about
performance
The needs of both are considered.
• If either partner becomes sexually excited,
• Encouraged to bring him or her to orgasm by manual or other means.

Open communication and expression of mutual needs is encouraged.
Genital stimulation is eventually added

Instructed sequentially to
• Try various positions for intercourse, without necessarily completing
the act, and
• To use varieties of stimulating techniques

Psychotherapy sessions follow each new exercise period,
• problems and satisfactions, both sexual and in other areas of the
couple’s lives, are discussed
Gradually, the couple gains confidence and learns to communicate,

verbally and sexually.

SPECIFIC TECHNNIQUES AND EXERCISES
→ In cases of premature ejaculation,
Squeeze technique
 The man or the woman stimulates the erect penis until the earliest
sensations of impending ejaculation are felt.
→ The woman forcefully squeezes the coronal ridge of the glans,

Erection is diminished, and ejaculation is inhibited.

This raises the threshold of the sensation of ejaculatory inevitability
Allows the man to focus on sensations of arousal without anxiety
Develop confidence in his sexual performance.

Stop–start technique,
The woman stops all stimulation of the penis when the man first senses
an impending ejaculation.
No squeeze is used.
Sex therapy has been most successful in the treatment of premature

ejaculation.

A man with ED is sometimes told to masturbate
Proves, full erection and ejaculation are possible
Delayed ejaculation is managed initially by extr avaginal ejaculation
Gradual vaginal entry after stimulation to a point near ejaculation
Early exercises forbid ejaculation to
Remove the pressure to climax and
Allow the man to immerse himself in sexual pleasuring

HYPNOTHERAPY
Focus specifically on the anxiety-producing situation—
Sexual interaction that results in dysfunction.
The focus of treatment is on symptom removal and attitude alteration.
The therapist assesses the patient’s capacity for the trance experience
 The patient is instructed in developing alternative means of dealing with the

anxiety provoking situation, the sexual encounter
BEHAVIOURAL THERAPY
Assumes sexual dysfunction is learned maladaptive behavior,
Makes patients fearful of sexual interaction
Therapists set up a hierarchy of anxiety provoking situations,
Start from least threatening (e.g., the thought of kissing) to most threatening
(e.g., the thought of penile penetration).
Medication, hypnosis, and special training in deep muscle relaxation
Can help with the initial mastery of anxiety

Assertiveness training
Helps in teaching patients to express sexual needs openly and without fear
Patients are encouraged to make sexual requests and to refuse requests
perceived as unreasonable
Sexual exercises may be prescribed for patients to perform at home,
Hierarchy may be established,
Start with activities that have proved most pleasurable and successful in the
past

MINDFULNES
A cognitive technique
The patient is directed to focus on the moment and maintain an
awareness of sensations—visual, tactile, auditory, and olfactory—that he
or she experiences in the moment.
The aims is
Distract the patient from spectatoring (watching himself) and
Center the person on the sensations that lead to arousal and/or orgasm.

GROUP THERAPY
Used to examine both intra psychic and interpersonal problems in patients with
sexual disorders
Provides a strong support system for a patient who feels ashamed, anxious, or
guilty about a particular sexual problem
Uses:
Counteract sexual myths,
Correct misconceptions, and
Provide accurate information about sexual anatomy, physiology, and varieties of
behavior

BIOLOGICAL TREATMENTS
Biological treatments, including pharmacotherapy, surgery, and mechanical

devices, are used to treat specific cases of sexual disorder

PHARMACOTHERAPY
 Sildenafil (Viagra) and its congeners ;
Oral phentolamine ;
Alprostadil, and
Injectable medications;
◦ Papaverine,
◦ Prostaglandin E1,
◦ Phentolamine, or some combination of these (Edex); and
◦ Transurethral alprostadil (MUSE), all used to treat erectile disorder.

SILDENAFIL
 Nitric oxide enhancer
Facilitates the inflow of blood to the penis
Effect starts in ~1hr , and can last up to 4hrs
Not effective in the absence of sexual stimulation
Adverse events: headaches, flushing, and dyspepsia

Contraindicated if, taking organic nitrates
Can result in large, sudden, and sometimes fatal drops in systemic BP

Ineffective in some cases of ED
50% of men with radical prostate surgery or

Long-standing diabetes.
Fails to produce an erection that is sufficiently rigid for penetration
Certain cases of nerve damage

A small number of patients developed non arteritic ischemic optic neuropathy
(NAION) soon after use of sildenafil.
Six patients had vision loss within 24 hours after use of the agent.
Both eyes were affected in one individual.
All affected individuals had preexisting HTN, DM, elevated cholesterol, or
hyperlipidemia.
Although very rare, sildenafil may provoke NAION in individuals with an
arteriosclerotic risk profile.
Very rare cases of hearing loss have also been reported.

 Oral phentolamine and apomorphine
Not US(FDA) approved, but have proved effective as potency enhancers in men
with minimal ED
Phentolamine
Reduces sympathetic tone and relaxes corporeal smooth muscle
Adverse events include hypotension, tachycardia, and dizziness.
Apomorphine
Results in vasodilation that facilitates the inflow of blood to the penis.
Adverse events include nausea and sweating

 Injectable and transurethral forms of alprostadil
Act locally on the penis and

Can produce erections in the absence of sexual stimulation
 Alprostadil contains a naturally occurring form of prostaglandin E, a
vasodilating agent.
May be given by direct injection into the corpora cavernosa or

By intraurethral insertion of a pellet through a canula.

Firm erection produced within 2 to 3 minutes
May last as long as 1 hour.
Infrequent and reversible adverse effects of injections include
penile bruising and
changes in liver function test results.

Possible hazardous sequelae includes,
priapism and sclerosis of the small veins of the penis.
Users of transurethral alprostadil sometimes complain of burning sensations in
the penis.

OTHER PHARMACOLOGIC AGENTS
IV methohexital, used in desensitization therapy
Antianxiety agents have some application in tense patients
The SSRIs and TCAs, have been used to prolong the sexual response in
patients with premature ejaculation

Topical anesthetic creams
Helpful in decreasing the intravaginal ejaculation latency time (IELT) in cases of
premature ejaculation.
Antidepressants; Advocated in treatment of
Patients who are phobic of sex and
In those with PTSD following rape.
Trazodone; an antidepressant
Improves nocturnal erections

Recreational drugs, including cocaine, alcohol, amphetamines, and cannabis,
are considered enhancers of sexual performance.
Initial benefit due to their tranquilizing, disinhibiting, or mood-elevating
effects,
Consistent or prolonged use of any of these substances impairs sexual

functioning

HORMONE THERAPY
Androgens increase the sex drive in men with low testosterone
concentrations
- Most effective when given parenterally; however, effective oral and

transdermal preparations are available
- Prolonged use; HTN &prostatic enlargement

SURGICAL TREATMENT
MALE PROSTHESES
Two main types
_Semi-rigid rod prosthesis
Produces a permanent erection that can be positioned close to the body for
concealment and
_Inflatable type
Implanted with its own reservoir and pump for inflation and deflation.
Designed to mimic normal physiological functioning.

VASCULAR SURGERY
When vascular insufficiency is present due to atherosclerosis or other

blockage, bypass surgery of penile arteries has been attempted in selected cases
with some success.

REFERENCES
 SYNOPSIS OF SYCHIATRY ,11TH EDITION
 KAPLAN AND SADOCK’S COMPREHENSIVE TEXT BOOK OF PSYCHIATRY,9TH EDITION
 DSM-5
 UPTO DATE


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M ODE RATOR – DR S OLOM ON DA BI , P SYCHIATR IST

P R EPARED BY – DR MES KEREM A BE BE

APRIL 27 2017 MESKEREM ABEBE,MD 2

 To be able to treat the disorder

APRIL 27 2017 MESKEREM ABEBE,MD 3

APRIL 27 2017 MESKEREM ABEBE,MD 4

 within or less than 1 minute

DSM 5 refers only to vaginal penetration

 commonly reported among colleague educated men

APRIL 27 2017 MESKEREM ABEBE,MD 5

 Novelty of the sexual partner

 Duration and frequency of coitus

APRIL 27 2017 MESKEREM ABEBE,MD 6

Prevalence increases with age

APRIL 27 2017 MESKEREM ABEBE,MD 7

APRIL 27 2017 MESKEREM ABEBE,MD 8

APRIL 27 2017 MESKEREM ABEBE,MD 9

APRIL 27 2017 MESKEREM ABEBE,MD 10

3) Individual vulnerability factors

APRIL 27 2017 MESKEREM ABEBE,MD 11

 unconscious fear about the vagina

 Negative cultural conditioning

 Men with early sexual contact with prostitutes

APRIL 27 2017 MESKEREM ABEBE,MD 12

APRIL 27 2017 MESKEREM ABEBE,MD 13

Dopamine transporter gene polymorphism

 serotonin gene transporter polymorphism

APRIL 27 2017 MESKEREM ABEBE,MD 14

 A scene of lack of control

Personal distress in sexual partner

Decreases sexual satisfaction in sexual partner

 ejaculation prior to penetration might be associated with difficulty of conception

APRIL 27 2017 MESKEREM ABEBE,MD 15

 EJACULATORY CONCERNS THAT DO NOT MEET THE CRITERIA

APRIL 27 2017 MESKEREM ABEBE,MD 16

 Drug withdrawal or thyroid disease

APRIL 27 2017 MESKEREM ABEBE,MD 17

 A man achieves ejaculation with great difficulty.

 Rarely present with masturbation

 lifelong and acquired

 orgasm and ejaculation should be differentiated

APRIL 27 2017 MESKEREM ABEBE,MD 18

 less than 1% complain of problems of reaching ejaculation

 Masters and Johnson- 3.8% of DE in a group of 447 men with sexual

 A general prevalence of 5% has been reported

APRIL 27 2017 MESKEREM ABEBE,MD 19

B. Persisted for a minimum duration of ~6 months.

APRIL 27 2017 MESKEREM ABEBE,MD 20

APRIL 27 2017 MESKEREM ABEBE,MD 21

Generalized: Not limited to certain types of stimulation, situations, or partners.

Situational: Only occurs with certain types of stimulation, situations, or partners.

Specify current severity:

Moderate: Evidence of moderate distress over the symptoms

Severe: Evidence of severe or extreme distress over the symptoms

APRIL 27 2017 MESKEREM ABEBE,MD 22

 Age-related decreased sex steroid secretion - in men older than 50 years.

APRIL 27 2017 MESKEREM ABEBE,MD 23

 Psychological distress in one or both partners

APRIL 27 2017 MESKEREM ABEBE,MD 24

◦ men with paraphilic arousal patterns;

Another medical illness or injury may produce delays in ejaculation independent

APRIL 27 2017 MESKEREM ABEBE,MD 25

APRIL 27 2017 MESKEREM ABEBE,MD 26