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Premature Ejaculation


Information about male Premature Ejaculation

Premature ejaculation (PE) can be a serious problem. This happens when a man climaxes too early (usually within 1-2 two minutes or sometimes less). Men who suffer from this feel they are unable to control their urge to ejaculate. This happens to a lot more men than you imagine. This can lead to frustrating situations placing a considerable strain on your sex life. Premature ejaculation is more common than you think. Around 25% to 60% of men suffer from this. As a matter of fact, some cases get so serious that a man cannot be touched on the penis without quickly ejaculating. This can lead to several problems related to your sex life and relationship. Nevertheless, premature ejaculation can be treated. Priligy is a very popular medicine for premature ejaculation.With Priligy you will take more time to ejaculate and a better control. Another thing that can help is Emla cream. This is a topical local anaesthetic cream that can numb the surface of the skin, reducing sensitivity and thus making you last longer. This cream is responsible for a huge improvement in the sex life of many men.

Premature ejaculation (PE) is a common disorder of sexual function. It should be noted that the patient does not always accurately describe his complaints, this was the reason for the continuous improvement of the very definition of this pathological condition. Inaccurate definitions of PE prevent the correct detection of its prevalence. According to the European Clinical Recommendations for Urology 2017, PE meets the following criteria: 

  • occurs before penetration or after about 1 min (with primary PE);
  • clinically significant reduction in the duration of sexual intercourse to 3 minutes or less (with acquired PE);
  • the inability to control ejaculation;
  • psychological discomfort due to the existing ejaculatory disorders and interpersonal conflicts in pairs. 

The diagnosis of PE is based on the time of ejaculation, the ability to control it and the emotional impact on the patient. First of all, PE has a negative impact on the quality of life of the patient, his self-esteem and relationships in the pair. It should be remembered that age is not a risk factor for the development of PE. 

In general, treatment approaches should be based on the identification of the pathogenetic mechanisms of this phenomenon.

Erection, emission, ejaculation, and orgasm have different mechanisms. With the exception of nocturnal emissions, emission and ejaculation occur only with stimulation of the genitals. Emission and ejaculation represent the culmination of male sexual intercourse. As the stimulation of sensitive fibers increases during coitus, activation of the sympathetic efferent nerves of the lower thoracic and upper lumbar segments occurs. Afferent fibers, the excitation of which leads to emission, pass as a part of the shame and pelvic nerves to the sacral parts of the spinal cord and as part of the sympathetic nerves to the thoracolumbar departments.

Activation of sympathetic neurons leads to a reduction in the epididymis, vas deferens, seminal vesicles, and prostate; as a result, seminal fluid is ejected into the posterior urethra. The reflex excitation of sympathetic fibers causes a contraction of the internal sphincter of the bladder, which prevents the throwing of seminal fluid into the bladder. 

Sperm filling of the proximal urethra leads to the excitation of afferent fibers of the genital nerve, which activates the reflex center in the sacral spinal cord, which causes rhythmic contractions of the sciatic-cavernous and bulbous-cavernous muscles located at the base of the penis. It is this process that leads to the rhythmic expulsion of sperm from the urethra.

The rhythmic contractions of the bulbous-spongy muscle push the sperm through the narrowest part of the urethra, squeezed by swollen cavernous bodies and the spongy body. Finally, ejaculate in the amount of 2-5 ml is thrown out. Ejaculation is provided by motor fibers in the genital nerve, causing contraction of the bulbous-spongy muscle. 

Ejaculation is mediated by the spinal nerve center, under a stimulating or inhibitory effect from the brain and peripheral centers. 

Thus, ejaculation is an involuntary process. For its implementation, the interaction of the somatic and autonomic nervous system is necessary.

Diagnostics

Understanding the physiology of ejaculation is at the heart of the diagnosis and treatment of PE. First of all, it should be clarified when PE appeared, from the beginning of the sexual activity or arose later. It is important to find out the conditions for the occurrence of PE in order to understand what form of PE occurs - situational or permanent. It is important to find out the features of the implementation of intimate contact. 

The consequences of premature ejaculation are an important component of the diagnosis. Decreased self-esteem, worsening relationships of the couple most often motivate the patient to seek help.

It is necessary to establish whether drugs are used and whether there is drug addiction. Often, PE develops in patients as a reaction to the difficulty in achieving an erection. In this case, it should be explained to the patient that the loss of an erection after ejaculation is natural. Common risk factors for PE are considered the time before the onset of ejaculation, a feeling of control over ejaculation, a negative emotional reaction, negative relationships in a pair.

An objective indicator - a time of intravaginal delay (VIVZ) - is not enough to establish a diagnosis, since this indicator does not significantly differ in men with complaints and lack thereof. As mentioned above, in order to establish a diagnosis, it is necessary to identify not only a decrease in subjective control but also negative consequences for both the patient himself and the couple as a whole. Although VIVZ is an objective indicator of PE assessment, satisfaction with sexual intercourse and anxiety for the patient and the couple as a whole do not reflect this indicator. VIVZ is more closely associated with a sense of control over ejaculation than with independently measured time to ejaculation.

To distinguish between PE and its absence, the Premature ejaculation diagnostic tool (PEDT) helps. It allows you to evaluate the degree of control, frequency, level of stimulation, negative consequences in the patient and the couple. Using the Arabic index of premature ejaculation questionnaire, the level of desire, the degree of erection, satisfaction, anxiety and depression are assessed. In general, the principle of constructing these questionnaires is based on key points in the diagnosis of PE. 

A low correlation was noted between the PEDT data and the condition described by the patient. An objective examination of a patient with complaints of PE, in addition to specific questions, includes clarifying the state of the cardiovascular, endocrine, and nervous systems.

The specialist should take into account the factors affecting the duration of the arousal phase: age, a new or former sexual partner in the patient, characteristics of the situation, recent frequency of sexual contacts.

Treatment

Pharmacotherapy is currently the method of choice for treating PE. Selective serotonin reuptake inhibitors (SSRIs) are used, primarily dapoxetine, a short-acting drug that can be taken on demand. 

Along with SSRIs, tramadol or drugs for local anesthesia are prescribed as an alternative. In patients with complaints of PE with concomitant erectile dysfunction, type 5 phosphodiesterase inhibitors are used. Behavioral strategies, most often used in combination with drug therapy, occupy a special place in the treatment of PE.

The goal of behavioral techniques is to develop intimate contact skills, increase the time before ejaculation, increase confidence and reduce anxiety. Behavioral strategies are divided into psychotherapeutic and directly physical methods, which include the technique of “stop-start”, “compression” and exercises for the muscles of the pelvic floor. The effectiveness of behavioral therapy is 50-60%, the effect is short-lived. Behavioral techniques are often used in combination with drug therapy.

SSRIs reduce the movement of serotonin from the synaptic cleft in the central and peripheral serotonergic neurons. As a result, the concentration of serotonin increases and there is an increase in the stimulation of postsynaptic 5-HT2C receptors. Drugs in this group can be used daily or on-demand. 

The inhibitory effect of serotonin on ejaculation is probably due to spinal or supraspinal activation of 5-HT1B and 5-HT2C receptors, while stimulation of 5-HT1A receptors causes ejaculation.

SSRIs are used to treat emotional disorders, but there is also experienced with the use of drugs to delay ejaculation, and therefore they have previously been used in PE as over-the-counter drugs. As with depression, to achieve an effect in PE, SSRIs are prescribed for 1–2 weeks. 

Long-term administration of SSRIs causes a prolonged increase in the concentration of serotonin in the synaptic cleft, thereby desensitizing 5-HT1A and 5-HT1B receptors. But it is worth remembering that with the cumulative effect of SSRIs, the risk of developing unwanted reactions, up to suicidal manifestations, increases. For a long time, doctors prescribed sustained-release SSRIs to patients with PE at their own risk.

The situation changed with the advent of the drug dapoxetine, which was developed specifically for the treatment of PE. The naphthyl component was added to the molecule, due to which a quick reabsorption and excretion time of the drug is achieved. It is these pharmacokinetic properties that distinguish dapoxetine from other SSRIs. 

Today, the only urologist with dapoxetine available to domestic urologists is Primaxetine ®, which is included in list B and is assigned to patients suffering from PE. Pharmacological properties of the drug are confirmed by bioequivalence studies. According to the accumulated clinical experience, treatment with the drug should begin with a dosage of 30 mg, however, in the absence of proper positive dynamics, the doctor has the opportunity to adjust the dosage of the drug to 60 mg. Currently, dapoxetine is the only drug that is optimal for treating PE.

A large amount of data indicates the effectiveness and safety of the drug. VIVZ ejaculation while taking dapoxetine significantly increases compared to the original. Dapoxetine showed good tolerance and the absence of serious side effects. Most side effects associated with drug treatment are dose-dependent.      

The rapid absorption of dapoxetine can lead to a sharp increase in the extracellular concentration of 5-HT after administration, sufficient to overcome the compensatory mechanisms of self-regulation.

Contraindications to dapoxetine include hypersensitivity, severe heart disease, concomitant use of monoamine oxidase and SSRI inhibitors, thioridazine, impaired liver and kidney function. It is necessary to identify these contraindications when establishing a diagnosis and clarifying the anamnesis. 

Prior to dapoxetine, daily SSRIs were considered the treatment of choice for PE. Widely used SSRIs have a similar pharmacological mechanism of action, but their effect is based on the cumulative properties of the drugs, which significantly increases the risk of side effects. A number of studies have shown the effectiveness of daily intake of SSRIs in PE.

Another treatment for PE is the use of local anesthetics. Topical desensitizing drugs reduce the sensitivity of the glans penis and increase the time to ejaculation without affecting the sensation of ejaculation. Despite a proven increase in VIVZ with local anesthetics, the effect is fleeting. Creams and ointments with an analgesic effect are inconvenient to use and allergenic. It is due to these properties that the method is not widely used.

Tramadol is a central-action analgesic that combines the activation of opioid receptors and the inhibition of serotonin and norepinephrine uptake. Tramadol has activity against opiate receptors but also exhibits antagonism to the transporters of norepinephrine and 5-HT. The efficacy and safety of two doses of tramadol 62 and 89 mg in the form of orally dispersible tablets for the treatment of PE have been demonstrated. 

Given the data on the neuropharmacology of ejaculation and the mechanism of action of tramadol, the elongation of time to ejaculation can be explained by combined stimulation of mu-opiate receptors in the central nervous system and increased the availability of 5-HT in the brain.

Thus, the construction of clinical diagnosis in a patient with complaints of PE includes the time before ejaculation, the degree of patient control over ejaculation, the presence of anxiety and depression, as well as the absence of anatomical abnormalities. These are the main components of diagnosis. The beginning and duration of complaints are taken into account. Anamnesis and physical examination allow you to choose a method of treating PE, taking into account contraindications and possible side effects.

It should be remembered that currently, the drug of choice for the treatment of PE is dapoxetine. This drug is used at the request of 1 r. / Day 1-3 hours before the alleged coition. Primaxetine® is available in a dosage of 30 mg and is included in list B. The administration of dapoxetine to patients suffering from PE fully complies with the clinical recommendations of the European Society of Urology. Methods of behavioral therapy and local medicines can improve the effectiveness of treatment for PE.

Conclusion

Thus, modern approaches to the treatment of PE are based on the idea of ​​the structure and function of serotonin receptors. The use of SSRIs allows for clinical efficacy. The distribution of serotonin receptors that realize various physiological functions explains not only the slowdown of ejaculation but also side effects. The duration of the use of selective serotonin uptake inhibitors increases the risk of side effects, which requires control of the drug and the timely withdrawal of drugs. The pharmacokinetics of dapoxetine can significantly reduce the frequency of adverse side effects, achieve an improvement in the condition of a patient with premature ejaculation, and take the drug on demand.