Erectile Dysfunction and Premature ejaculation from psychiatric point of view

1. PRESENTER: AMITKUMAR CHOUGULE
ERECTILE DYSFUNCTION AND
PRE MATURE EJACULATION

2. ERECTILE
DYSFUNCTION

3. OVERVIEW
 Definition
 Epidemiology
 Causes
 Assessment
 Approach
 Treatment
 Conclusion

4. INTRODUCTION
 The terms impotence and erectile dysfunction had been
used interchangeably
 Social scientists objected to the impotence label because of
its pejorative implications and lack of precision
 The NIH Consensus Development Conference advocated
the label ‘erectile dysfunction' instead of impotence
(National Institutes of Health (1992). Consensus development conference statement on impotence.
NIH,Bethesda,MD)

5. DEFINITION
Erectile dysfunction (ED) is:
 “The consistent or recurrent inability of a man to attain
and/or maintain a penile erection sufficient for sexual
performance”
 “Recurrent inability” as being 3 months or greater in
duration
(First International Consultation on Erectile Dysfunction, convened by the WHO
in 1999)

6. Psychogenic Erectile Dysfunction
 Psychogenic ED was defined by the International
Society of Sex and Impotence Research as:
“The persistent inability to achieve or maintain an erection
satisfactory for sexual performance, owing predominantly
or exclusively to psychological or interpersonal factors”

7. ICD 10
F52.2 Failure of genital response
 If erection occurs normally in certain situations, e.g.
during masturbation or sleep or with a different partner,
the causation is likely to be psychogenic
 Otherwise, the correct diagnosis of nonorganic erectile
dysfunction may depend on special investigations (e.g.
measurement of nocturnal penile tumescence) or the
response to psychological treatment

8. DSM 5 CRITERIA- ERECTILE
DYSFUNCTION
A. At least one of the three following symptoms 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):
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. The symptoms in Criterion A have persisted for a
minimum duration of approximately 6 months

9. C. The symptoms in Criterion A cause clinically significant distress in the
individual
D. The sexual dysfunction is not better explained by:
 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

10.  Specify whether:
1. Lifelong: The disturbance has been present since the individual became sexually
active.
2. Acquired: The disturbance began after a period of relatively normal sexual
function.
 Specify whether:
1. Generalized: Not limited to certain types of stimulation, situations, or partners.
2. Situational: Only occurs with certain types of stimulation, situations, or partners.
 Specify current severity:
1. Mild: Evidence of mild distress over the symptoms in Criterion A.
2. Moderate: Evidence of moderate distress over the symptoms in Criterion A.
3. Severe: Evidence of severe or extreme distress over the symptoms in Criterion A.

11. EPIDEMIOLOGY
• Incidence and prevalence is high worldwide
• Affects up to 52% of men (40-70yrs)
• Steep age-related increase
• Complete ED:
1. 5% in 40yr olds
2. 15% in 70yr olds

12. INTERNATIONAL STUDIES
Study Age Group PREVALENC
E OF ED
Massachusetts Male Aging Study
(MMAS), USA
40-70
years
52%
Cologne study, Central Europe 30-80
years
19.2%
The multinational Men’s Attitudes to Life
Events and Sexuality (MALES) study
16%

13. INDIAN STUDIES
AUTHORS SETTING YEAR PREVALEN
CE OF ED
Bagadia et.al Teaching
hospital
1972 48%
Verma et.al Psychosexual
clinic
1998 23.6%
Gupta et.al Skin OPD 2004 34%
S. Sathyanarayana Rao, M.
S. Darshan, Abhinav Tandon
South Indian
rural
population
2015 15.77%

14.  Sexual dysfunction among men in secondary care in southern
India: Nature, prevalence, clinical features and explanatory models
(P. Thangadurai, R. Gopalakrishnan, V.J. Abraham, J. Prasad, A. Kuruvilla, K.S.
Jacob)
 Prevalence of ED was 47.8%
 Statistically significant association between premature ejaculation
and erectile dysfunction
 The factors associated with erectile dysfunction were:
1. Being currently married
2. Financial problems (an inability to buy food in the past month)
3. History of diabetes mellitus
4. Past history of psychiatric treatment
5. Current diagnosis of common mental disorder (anxiety and
depression)

15. Continued…
 The men had diverse beliefs about the causes of their sexual
problems: (ED + PE)
1. Masturbation (26.7%)
2. Nocturnal emission (20.0%)
3. Disease (22.6%)
4. Punishment by God (9.6%)
5. Karma (8.5%)
6. Black magic (0.4%)
7. Lack of privacy (2.2%)

16. A SENTINEL FOR CARDIOVASCULAR
DISEASE
 Most significant social implication of ED is its increasingly
recognized status as an early marker of vascular disease
 ED is a marker of significantly increased risk of CVD,
coronary artery disease (CAD), stroke and all-cause mortality
 Erectile dysfunction commonly occurs in the presence of
silent CAD
 Time window between ED onset and a CAD event is usually 2
to 5 years

17. RISK FACTORS FOR ED
1. Sedentary lifestyle
2. Obesity
3. Smoking
4. Hypercholesterolemia
5. Metabolic syndrome
6. Diabetes mellitus
(Shared risk factors with CVD)

18. Aetiology
1. Organic
2. Hormonal
3. Anatomical
4. Drugs
5. Psychogenic

19. CAUSES
Vascular Causes
1. CVD
2. Atherosclerosis
3. Hypertension
4. Diabetes
5. Hyperlipidemia
6. Smoking
7. Trauma
Central causes
1. Parkinson’s
2. Stroke
3. MS
4. Tumours spinal
disease/injury
Peripheral causes
1. Peripheral
neuropathy
2. Diabetes
3. Alcoholism
4. Uraemia
5. Pelvic surgery

20. HORMONAL CAUSES
1. Hypogonadism
2. Hyperprolactinaemia
3. Thyroid disease
4. Cushing’s disease
ANATOMICAL CAUSES
1. Peyronie’s disease
2. Micropenis
3. Penile anomalies
(hypospadias )

21. DRUGS
1. Antihypertensives (Beta blockers, Diuretics)
2. Antidepressants (Tricyclic and SSRIs)
3. Antipsychotics (Phenothiazines, Risperidone)
4. Anticonvulsants (Phenytoin, Carbamazepine)
5. Antihistamines
6. H2 antagonists (Cimetidine, Ranitidine)
7. Recreational drugs (Tobacco and Alcohol)

22. PSYCHOGENIC ERECTILE
DYSFUNCTION
 Immediate causes :
1. Performance anxiety
2. Lack of adequate stimulation
3. Relationship conflicts
 Remote causes :
1. Childhood sexual trauma
2. Sexual identity issues
3. Unresolved partner or parental attachments
4. Religious or cultural taboos

23. Classification
 ED is commonly classified into three categories based on its
aetiology:
1. Organic
2. Psychogenic
3. Mixed ED
 Most cases are of mixed aetiology
 Suggested Classification:
1. Primary organic
2. Primary psychogenic

24. Pathogenesis Model for Acquired
Psychogenic ED
 Precipitating events
↓
 One episode
of erectile failure
↓
 Performance anxiety
↓
 Another episode
of erectile failure
↓
 More performance anxiety
 Decreased frequency of
sexual initiation
↓
 Changes in the sexual
equilibrium
↓
 Established pattern of ED
with partner

25. EVALUATION

26. PSYCHIATRIC
ASSESSMENT
 Full psychiatric history from the patient and mental status
examination
 The sexual history must include information about:
1. Sexual orientation
2. Previous and current sexual relationships
3. Current emotional status
4. Onset and duration of the erectile problem
5. Previous consultations and treatments

27.  A detailed description should be made of:
1. Rigidity and duration of both sexually-stimulated
and morning erections
2. Problems with sexual desire, arousal, ejaculation,
and orgasm
 Interview patient's sexual partner separately as she
can provide information and details from her point of
view

28. Erectile reserve
 In men with ED presence or absence of spontaneous
erections is an important clue to diagnosis
 Most men experience spontaneous erections during REM
sleep and often wake up with an erection
 This indicates the integrity of neurogenic reflexes and
corpora cavernosa blood flow

29. HISTORY FOR PSYCHOGENIC
COMPONENT
 Was onset of ED instantaneous (one time, and then
ever since)?
 Common in:
1. First-time encounters
2. Conflicted relationships
3. When patient feels obligated to have intercourse
but does not want to

30. Rapidity of onset
 Sexually competent men who had no sexual problems
until "one night when they could not perform" and
thereafter become impotent invariably have psychogenic
ED
 Men suffering from ED of any organic cause complain that
“sexual function failed sporadically at first and then more
consistently”

31. Physical examination
1. A careful assessment of femoral and peripheral pulses
as a clue to the presence of vasculogenic impotence
2. A search for visual field defects present in
hypogonadal men with pituitary tumors
3. A breast examination to detect gynecomastia, often
present in Klinefelter's syndrome

32. Physical Examination
4. A search for penile strictures indicative of Peyronie's
disease
5. Examination of the testicles looking for atrophy,
asymmetry or masses
6. Evaluation of the cremasteric reflex, an index of the
integrity of the thoracolumbar erection center

33. Lab evaluation
1. Testosterone level (consider peak 8 am and trough
8 pm when evaluating result, can be 30%
difference)
2. Prolactin level
3. TSH
4. Hematology
5. Hepatic and kidney function
6. Hemodynamic evaluation
7. Nerve conduction studies

34. NOCTURNAL PENILE TUMESCENCE RECORDING
 (NPT) occurs in all normal males from early infancy to old
age
 NPT is closely linked to rapid eye movement (REM) sleep
 Its measurement is widely accepted in the differential
diagnosis of ED
The rationale for its use is :
 In cases of organic ED NPT is absent or diminished
 In psychogenic ED sleep erections occur with normal
frequency and magnitude

35.  Ideally done in a sleep laboratory with simultaneous
standard polygraphic sleep recording:
1. Electroencephalogram
2. Electro-oculogram
3. Electromyogram
 Diagnostic accuracy depends more on the expertise of
the individual interpreting the recording
 Penile expansion of more than 15 mm indicates
psychogenic ED
 Lesser than 15mm expansion indicates organicity

36. ASSESSMENT OF ED
INTERNATIONAL INDEX OF ERECTILE FUNCTION(IIEF):
 Superficial assessment of psychosexual background
 Very limited assessment of partner relationship
 An adjunct to rather than a substitute for a detailed
sexual history and examination
 (Rosen R, Riley A, Wagner G, et al. Urology, 1997, 49: 822-830)

37. International Index of Erectile Dysfunction
IIEF
 The following guide-lines may be applied:
 Patients with low IIEF scores (<14 out of 30) in
Domain A (Erectile Function):
1. May be considered for a trial course of therapy with
Sildenafil unless contraindicated
2. Specialist referral is indicated if this is unsuccessful

38.  Patients demonstrating primary orgasmic or ejaculatory
dysfunction (Domain B) should be referred for specialist
investigation
 Patients with reduced sexual desire (Domain C) require
testing of blood levels of androgen and prolactin
 Psychosexual counselling should be considered if low
scores are recorded in Domains D and E

39. VALIDATED PSYCHOMETRIC
QUESTIONNAIRES
1. SEXUAL HEALTH INVENTORY FOR MEN (SHIM)
2. ERECTILE DYSFUNCTION QUESTIONNAIRE(EDQ)

40. MANAGEMENT
 The ‘‘Patient-centered approach’’ has come forward as
the premier ED management principle (Rosen et al,
2004)
 This approach emphasizes:
1. The roles of the patient and/or patient/partner in the
evaluation and management of the problem
2. Diagnostic and therapeutic decisions should rely on the
goals and preferences of the patient and partner

41. PROCESS OF CARE (POC)
 POC guide for appropriately assessing and treating ED has been
developed by a multidisciplinary panel
 Panel had experts in family medicine, internal medicine,
endocrinology, psychiatry, psychology, and urology
 The POC outline six phases:
1. Establishing the diagnosis
2. Discussing the initial findings, discussing referral, beginning the
education process
3. Modifying reversible causes of erectile dysfunction
4. Implementing first-line treatment: Psychotherapy, oral
erectogenic agents, vacuum constriction devices
5. Implementing second-line treatment: self-injection therapy,
transurethral therapy
6. Implementing third-line treatment: implantation of a penile
prosthesis

42. PSYCHOTHERAPY FOR ED
 Rosendivided treatment for Psychogenic ED into four types:
1. Anxiety reduction and desensitization
2. Cognitive-behavioral interventions
3. Increased sexual stimulation
4. Interpersonal assertiveness and couples communication
training

43. Anxiety reduction and desensitization
 Designed to reduce performance anxiety by avoiding
intercourse in early treatment and using relaxation
techniques
 Instead of having coitus, the couple follows a series of
nongenital, non demand, sensate focus exercises
popularized by Masters and Johnson

44. COGNITIVE BEHAVIOURAL
INTERVENTIONS
 Attempts are made to overcome unrealistic sexual
expectations
 Psychoeducation of the couple

45. INTERPERSONAL AND SYSTEMIC
INTERVENTIONS
 Following Issues are addressed:
1. Status and dominance
2. Intimacy and trust
3. Loss of sexual attraction

46. Dual-Sex Therapy
 Originated and developed by Masters and Johnson
 Both individuals are involved in a relationship in which
there is sexual distress
 Both must participate in the therapy program
 The marital relationship as a whole is treated
 Improved communication in sexual and nonsexual areas
is a specific goal of treatment

47. Behavioral Exercises
 Treatment is short term and behaviorally oriented
 Specific exercises are prescribed to help the couple with their
particular problem
 Sexual dysfunction often involves a fear of inadequate
performance
 Couples are specifically prohibited from any sexual play other
than that prescribed by the therapist
 Initially, intercourse is avoided and couples learn to give and
receive bodily pleasure without the pressure of performance

48.  Beginning exercises usually focus on heightening sensory
awareness to touch, sight, sound, and smell
 During these exercises called sensate focus exercises:
 Couple is given much reinforcement to lessen anxiety
 They are urged to use fantasies to distract them from obsessive
concerns about performance, which is termed spectatoring
 The needs of both the dysfunctional partner and the
nondysfunctional partner are considered
 Open communication between the partners is urged, and the
expression of mutual needs is encouraged

49. Behaviour Therapy
 Behavior therapists assume that sexual dysfunction is
learned, maladaptive behavior
 Therapist sees the patient as phobic of sexual interaction
 Therapist sets up a hierarchy of anxiety-provoking
situations for the patient
 Patient masters the anxiety through systematic
desensitization
 Assertiveness training is used to teach patients to
express their sexual needs openly and without fear

50. Integrated Sex Therapy
 Sex therapy integrated with supportive, psychodynamic,
or insight-orientated psychotherapy is very effective
 Insight-oriented therapy helps to deal with problems in
interpersonal relationships or intrapsychic conflicts that
frequently are at the root of the sexual problem
 Sex therapy integrated with pharmacotherapy is very
effective

51. Biological Treatment Methods
 Pharmacotherapy is useful in treatment of erectile
dysfunction of various causes
 Drugs explored in the treatment of ED are:
1. Nitric oxide enhancers/ PDE 5 Inhibitors
2. Oral prostaglandin (Vasomax)
3. Alprostadil (Caverject)
4. Injectable phentolamine
5. Transurethral alprostadil (MUSE)

52. NITRIC OXIDE ENHANCERS/ PDE 5
INHIBITORS
 Sildenafil augments the natural process involved
in gaining and maintaining an erection during
sexual stimulation
 Sildenafil has no effect in the absence of sexual
stimulation
 Two other nitric oxide enhancers are:
1. Vardenafil
2. Tadalafil

54. Oral phentolamine (Vasomax)
1. Has proved effective as a potency enhancer
2. Useful for men with cardiac problems as sildenafil is
contraindicated for men using organic nitrates
3. Not currently approved by the FDA
Apomorphine
 Being tested as an oral remedy for erectile dysfunction
Alprostadil
 Injectable and transurethral alprostadil act locally on the penis
 Can produce erections in the absence of sexual stimulation

55. Self-injection Of Papaverine And Phentolamine In The
Treatment Of Psychogenic ED:
1. Self-injections four times monthly has a 94% success rate
2. Increase in frequency of intercourse and sexual
satisfaction
Yohimbine In Treatment Of Psychogenic Impotence:
1. Yohimbine is a safe treatment for psychogenic ED
2. As effective as sex and marital therapy for restoring satisfactory
sexual functioning
3. Response to yohimbine is unrelated to the cause of impotence

56. BIBLIOTHERAPY
 The new male sexuality, by Bernie Zilbergeld, Ph.D
1. Practical book debunking sex myths
2. Has exercises for ED, losing erections, premature
ejaculation
3. Humorous and useful
4. Good anatomy descriptions
 The passionate marriage: love, sex, and intimacy in
emotionally committed relationships by David
Schnarch, Ph.D.

57. Conclusion
 ED is the one of the most common and most distressing sexual
dysfunction in men
 Psychiatrist has a crucial role to play in the evaluation and
management of ED as he the only specialist who has a adequate
knowledge of both organic and psychogenic causes of ED
 Even after recent advances in pharmacotherapy sex therapy remains
gold standard for psychogenic ED
 Sex therapy has a vital role as an adjunct in treatment of organic
causes

58. PREMATURE
EJACULATION

59. EVOLUTIONARY PERSPECTIVE
 The control of the ejaculatory reflex represents an
evolutionary and cultural advance for human sexuality
 In the primates the rapid deposition of semen protects
the animal from extended exposure to predators
 Men have learned to control ejaculation to enhance their
and their partner’s enjoyment
 PE has a profound effect on relational and psychological
health

60. HISTORICAL ASPECTS
 The term Ejaculatio praecox was introduced by the
psychoanalyst Abraham
 Until the first half of the 20th century PE was not included in
the list of sexual disorders
 Kinsey et al. in a survey of almost 20,000 Americans found
that 75% of men ejaculated within 2 min of penetration
 Kinsey et. al rejected the notion that PE is a sexual
dysfunction

61.  Shapiro argued that PE might be the combination of a
hyper anxious constitution with anatomical defects
 In 1960 PE was recognized as sexual dysfunction due
to cultural change:
 Feminist revolution in the mid 1960s
 Discovery of the female orgasm

62. PE DEFINITION
 Research into the treatment and epidemiology of premature
ejaculation (PE) is heavily dependent on how PE is defined
 Each of these definitions characterizes men with PE:
1. Intravaginal Ejaculatory latency time (IELT)
2. Perceived ability to control ejaculation
3. Reduced sexual satisfaction
4. Personal distress
5. Partner distress
6. Interpersonal or relationship distress

63. DSM DEFINITION OF PE
 Previously definitions of PE given in (DSM) were:
 Largely accepted by the medical community with little
discussion
 No evidence-based medical support
 In (DSM-IV-TR), PE was defined as a
“Persistent or recurrent ejaculation with minimal sexual
stimulation before, on, or shortly after penetration and
before the person wishes it”

64. PROBLEMS WITH DSM- IV DEFINITION
 Absence of a specific ejaculation time cutoff point to
operationalize “shortly after penetration or before the person
wishes”
 This lead to ambiguous application of the DSM criteria for PE
in epidemiological and clinical research
 Subject diagnosed with PE according to DSMIV- TR criteria
has a 44% chance of not having PE if a PE diagnostic
threshold IELT of 2 minutes, as suggested by community-
based normative IELT trial is used

65. INTERNATIONAL SOCIETY FOR SEXUAL MEDICINE
(ISSM) DEFINITION FOR PE
 The second ISSM Ad Hoc Committee for the Definition of
Premature Ejaculation defined PE (lifelong and acquired) as
a male sexual dysfunction characterized by the following:
1. Ejaculation that always or nearly always occurs prior to or
within about 1 minute of vaginal penetration (lifelong PE)
or a clinically significant and bothersome reduction in latency
time, often to about 3 minutes or less (acquired PE)
2. The inability to delay ejaculation on all or nearly all vaginal
penetrations
3. Negative personal consequences, such as distress, bother,
frustration, and/or the avoidance of sexual intimacy

66. DSM-5 DEFINITION OF PE
 A. A persistent or recurrent pattern of ejaculation occurring
during partnered sexual activity within approximately 1
minute following vaginal penetration and before the person
wishes it
 B. The symptom in Criterion A must have been present for at
least six 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 Criterion A causes 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 disorder

67. DSM 5 SPECIFIERS
 Specify whether;
1. Lifelong: The disturbance has been present since the individual
became sexually active
2. Acquired: The disturbance began after a period of relatively
normal sexual function
 Specify whether:
1. Generalized: Not limited to certain types of stimulation, situations,
or partners.
2. Situational: Only occurs with certain types of stimulation,
situations, or partners
 Specify current severity:
1. Mild: Ejaculation occurring within approximately 30 seconds to 1
minute of vaginal penetration
2. Moderate: Ejaculation occurring within approximately 15-30
seconds of vaginal penetration
3. Severe: Ejaculation occurring prior to sexual activity, at the start of
sexual activity or within approximately 15 seconds of vaginal
penetration

68. ICD-10 Definition of PE
 “The inability to control ejaculation sufficiently for
both partners to enjoy sexual interaction” and
 “an inability to delay ejaculation sufficiently to enjoy
lovemaking, and manifest as either of the following:
(i) Occurrence of ejaculation before or very soon after the
beginning of intercourse (if a time limit is required: before
or within 15 seconds of the beginning of intercourse)
(ii) Ejaculation occurs in the absence of sufficient erection
to make intercourse possible”

69. Classification of PE
 In 1943, Schapiro proposed a classification of PE into two types
1. Type A (“hypotonic” type) was associated with the gradual
development of ED
2. Type B (“sexually hypertonic” or “hypererotic” type)
represented a consistent tendency to ejaculate rapidly from the
first act of intercourse
 In 1989 Godpodinoff renamed these types as lifelong (primary)
and acquired (secondary) PE
 Over the years, other attempts to specify subtypes have occurred
(e.g., global vs. situational PE, PE due to the effect of a substance, etc.)

70. Waldinger and Schweitzer Classification
 Waldinger and Schweitzer proposed a new
classification of PE
 4 PE subtypes were distinguished on the basis of:
1. Duration of IELT
2. Frequency of complaints
3. Course in life

71. Lifelong PE Acquired PE Natural variable PE
Premature-like ejaculatory
dysfunction
In the majority of
cases (80%) within
30–60 s or
(20%) 1 and 2 min
IELT is short
(less than 2 min)
Ejaculation time may be
short or normal
IELT is in the normal range
or may even be of longer
duration
From about the first
sexual encounter
Early ejaculation occurs
at some point in a man’s
life
Early ejaculations are:
• Inconsistent
• Occur Irregularly
Subjective perception of
consistent or inconsistent
rapid ejaculation
With nearly every
woman
The man had normal
ejaculation experiences
before
Ability to delay ejaculation
may be diminished or
lacking
Ability to delay ejaculation
may be diminished or
lacking
Ejaculation occurs
too early nearly in
each intercourse
The onset is either
sudden or gradual
The impression of
diminished control of
ejaculation
Imagined early ejaculation
or
lack of control of ejaculation
Remains rapid
throughout the
lifetime of the
subject
The dysfunction may be
the result of
urological/thyroid
dysfunctions or
psychological problems
Psychotherapy should be
considered as first-line
treatment
The preoccupation is not
better accounted for by
another mental disorder

72. EPIDEMIOLOGY
 The major problem is lack of an accurate (validated) definition
at the time the surveys were conducted
 The highest prevalence rate of 31% (men aged 18-59 years)
was found by the National Health and Social Life Survey
(NHSLS) study in USA
 Prevalence rates were 30% (18-29 years), 32% (30-39
years), 28% (40-49 years) and 55% (50-59 years)
 The prevalence rates in European studies have been
significantly lower

73. INDIAN STUDIES
AUTHORS SETTING YEAR PREVALENCE
OF PE
Bagadia et.al Teaching
hospital
1972 34%
Verma et.al Psychosexual
clinic
1998 77.6%
Gupta et.al Skin OPD 2004 16.6%
T.S. Sathyanarayana Rao,
M. S. Darshan, Abhinav
Tandon
South Indian
rural population
2015 8.76%

74. Sexual dysfunction among men in secondary care in southern
India: Nature, prevalence, clinical features and explanatory models
(P. Thangadurai, r. Gopalakrishnan, v.J. Abraham, j. Prasad, a. Kuruvilla, k.S.
Jacob)
 Prevalence of PE was 43.0%
 Risk Factors associated with PE:
1. Older age( >42)
2. current anxiety and depression
3. Financial debt

75. DIAGNOSTIC EVALUATION
 Diagnosis of PE is based on the patient’s medical and sexual history
 History should:
 Classify PE as lifelong or acquired
 Determine whether PE is situational or consistent
 Special attention should be given to:
 Duration of time of ejaculation
 Degree of sexual stimulus
 Impact on sexual activity
 QoL
 Drug use or abuse

76. PME/ ED/ FEMALE SEXUAL
DYSFUNCTION
 It is important to distinguish PE from ED
 Many patients with ED develop secondary PE caused by the
anxiety associated with difficulty in attaining and maintaining an
erection
 Some patients are not aware that loss of erection after ejaculation
is normal and may erroneously complain of ED, while the actual
problem is PE
 Female sexual dysfunction is often present and might be secondary
to the male PE
 So assessing female sexuality is an integral part of assessing PE

77. PE ASSESSMENT
QUESTIONNAIRES
 Premature Ejaculation Diagnostic Tool (PEDT):
1. Five-item questionnaire based on focus groups and
interviews from the USA, Germany and Spain
2. A total score > 11 suggests a diagnosis of PE
 Arabic Index of Premature Ejaculation (AIPE):
1. Seven-item questionnaire developed in Saudi Arabia
2. A cut-off score of 30 discriminated best PE diagnosis
 Chinese Index Of Sexual Function For Premature
Ejaculation (CIPE)
 Premature Ejaculation Profile (PEP)
 Index of Premature Ejaculation (IPE)
 Male Sexual Health Questionnaire Ejaculatory Dysfunction

78. MANAGEMENT
 Before beginning treatment it is essential to discuss the
patient's expectations thoroughly
 It is important to treat ED first if present
 In lifelong PE:
1. Behavioural techniques are not recommended for first-
line treatment
2. They are time-intensive
3. Require the support of a partner and can be difficult to
perform
4. Long-term outcomes of behavioural techniques for PE
are unknown

79. PSYCHOTHERAPY IN PE
 Psychological therapies may be helpful for patients with
PE
 In men for whom PE causes few problems treatment is
limited to psychosexual counselling and education
 Psychotherapy should be considered as first-line
treatment for patients with:
1. Natural variable PE
2. Premature-like ejaculatory dysfunction

80. PSYCHOLOGICAL/BEHAVIOURAL
STRATEGIES
 Behavioural strategies mainly include:
1. The ‘stop-start’ programme developed by Semans
2. Its modification the ‘squeeze’ technique proposed by
Masters and Johnson
 In the ‘stop-start’ programme, the partner stimulates the
penis until the patient feels the urge to ejaculate
 At this point, he instructs his partner to stop, waits for the
sensation to pass and then stimulation is resumed

81.  The ‘squeeze’ technique is similar but the partner
applies manual pressure to the glans just before
ejaculation until the patient loses his urge
 Both these procedures are typically applied in a cycle
of three pauses before proceeding to orgasm

82. ADJUNCT TREATMENT MODALITIES
FOR PE
 Simple behaviors promoting an increase in the ejaculatory
time can be prescribed such as:
1. Ejaculate more frequently
2. Release the anal sphincter during intercourse
3. Favour the female-on top position
4. Use special condoms
5. Strengthening of the pubococcygeous muscles of the pelvic
floor
6. In these exercises, named after Arnold Kegel who devised them,
the patient is trained to identify his pubococcygeous muscles
during urination

83. PHARMACOLOGICAL THERAPY
DAPOXETINE:
 Dapoxetine hydrochloride is a short-acting SSRI
 It is approved for on-demand treatment of PE
 In RCTs dapoxetine 30 mg or 60 mg 1-2 hours before
intercourse was effective from the first dose on:
1. IELT and increased ejaculatory control
2. Decreased distress
3. Increased satisfaction

84.  Dapoxetine has shown a similar efficacy profile in
men with lifelong and acquired PE
 Treatment-related side-effects were dose dependent
and included nausea, diarrhea, headache and
dizziness
 Dapoxetine co-administered with a PDE5I inhibitor is
well tolerated

85. OFF-LABEL USE OF ANTIDEPRESSANTS: SSRIS AND
CLOMIPRAMINE
 SSRI widely used ‘off-label’ for PE
 SSRIs must be given for 1 to 2 weeks to be effective in PE
 Based on meta-analysis:
1. Paroxetine was found to be superior to fluoxetine, clomipramine
and sertraline
2. Efficacy of clomipramine was not significantly different from
fluoxetine and sertraline
3. There was no significant relationship between dose and
response among the various drugs

86. TOPICAL ANAESTHETIC AGENTS
LIDOCAINE-PRILOCAINE CREAM
 In a randomised, double-blind, placebo-controlled trial
lidocaine-prilocaine cream:
1. Significantly increased the stopwatch-measured IELT
from 1.49 to 8.45 minutes
2. No difference was recorded in the placebo group
(1.67 to 1.95 minutes)
 Lidocaine-prilocaine cream (5%) is applied for 20-30
minutes prior to intercourse

87. TRAMADOL:
 Tramadol has shown a moderate beneficial effect with a
similar efficacy as dapoxetine
 Efficacy and tolerability of tramadol would have to be
confirmed in more patients and longer-term
PHOSPHODIESTERASE TYPE 5 INHIBITORS:
 Several open-label studies showed that sildenafil
combined with an SSRI is superior to SSRI monotherapy
 Sildenafil combined with behavioural therapy significantly
improved IELT and satisfaction vs. behavioural therapy
alone

88. CONCLUSION
 Further studies are required in order to obtain objective data to
propose evidence-based definitions of acquired PE, natural variable
PE and premature-like ejaculatory dysfunction syndromes
 Severity scale of PE must be confirmed by more studies
 Appropriate treatment algorithms must be designed
 Treatment of PE is complex, and guidelines for treatment are limited
due to the controversial definition of the disease causing a barrier to
standardized evidence-based studies
 It is important to consider all possible modalities when treating PE
as each patient may respond differently and side effects are variable

89.  Mental health clinicians generally avoid asking patients
about their sexual life because they themselves are
anxious, believe sexual problems occur infrequently, fear
being inappropriate, or judge themselves poorly prepared
to manage potential problems
 Sexual disorders are readily treatable, and their resolution
can be gratifying both to the interested clinician and the
troubled individual and/or couple

90. ……with our knowledge and
support lets bring back the light
lost in the dark bedroom of
couples with sexual
dysfunction….

91. REFERENCES
1. Kaplan & Sadock's Comprehensive Textbook of Psychiatry, 9th
Edition:Sadock, Benjamin J.; Sadock, Virginia A.; Ruiz, Pedro
2. Kaplan & Sadock's Synopsis of Psychiatry: Behavioral Sciences/Clinical
Psychiatry, 10th Edition:Sadock, Benjamin James; Sadock, Virginia Alcott
3. Psychiatry, Third Edition. Edited by Allan Tasman, Jerald Kay, Jeffrey A.
Lieberman, Michael B. First and Mario Maj © 2008 John Wiley & Sons, Ltd.
ISBN 978-0470-06571-6
4. An Evidence-Based Unified Definition of Lifelong and Acquired Premature
Ejaculation: Report of the Second International Society for Sexual Medicine
Ad Hoc Committee for the Definition of Premature Ejaculation.Ege Can
Serefoglu, MD et.al. Sex Med 2014;2:41–59
5. An epidemiological study of sexual disorders in south Indian rural
population:T. S. Sathyanarayana Rao, M. S. Darshan1, Abhinav
Tandon:Indian Journal of Psychiatry 57(2), Apr-Jun 2015
6. An Update of the International Society of Sexual Medicine’s Guidelines for
the Diagnosis and Treatment of Premature Ejaculation (PE):Stanley E.
Althof, PhD, Chris G. McMahon et.al. Sex Med 2014;2:60–90

92. 7. Guidelines on Male Sexual Dysfunction: Erectile dysfunction and
premature ejaculation. K. Hatzimouratidis (Chair), I. Eardley, F.
Giuliano, I. Moncada, A. Salonia© European Association of Urology
2015
8. New insights on premature ejaculation: a review of definition,
classification, prevalence and treatment:Ege C Serefoglu and Theodore
R Saitz.Asian Journal of Andrology (2012) 14, 822–829;
doi:10.1038/aja.2012.108
9. Sexual dysfunction among men in secondary care in southern India:
Nature, prevalence, clinical features and explanatory models. P.
Thangadurai, r. Gopalakrishnan, v.J. Abraham, j. Prasad, a.
Kuruvilla,k.S. Jacob. Natl Med J India 2014;27:198–201
10. Integrating psychotherapy and pharmacotherapy in the treatment of
premature ejaculation. Giacomo Ciocca a, Erika Limoncin,et.al. Arab
Journal of Urology (2013) 11, 305–312
11. Psychosocial profile of male patients presenting with sexual dysfunction
in a psychiatric outpatient department in Mumbai, India Gurvinder
Kalra, Ravindra Kamath1, Alka Subramanyam1, Henal Shah. Indian
Journal of Psychiatry 57(1), Jan-Mar 2015

93. ….THANK YOU….