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Delayed ejaculation & anorgasmia EMMANUELE A. JANNINI Chair of Endocrinology & Sexual Medicine Tor Vergata University of Rome, Italy It Soc Androl & Sex Med – President-elect Taxonomy of ejaculatory disorders Epidemiology of ejaculatory disorders 25 a) timing 20 – PREMATURE EJACULATION 15 – DELAYED EJACULATION 10 Percentage 5 b) modality 0 E N IA R PE DE IO M AS ‐ RETROGRADE EJACULATION LAT G U R O JAC ‐ ANEJACULATION (impotentia ejaculationis) E AN AN Taxonomy of ejaculatory disorders • EMISSION PHASE DISORDERS: – Retrograde ejaculation • EJACULATION PHASE DISORDERS: – Premature ejaculation – Deficient ejaculation: • Delayed ejaculation • Anejaculation • ORGASM DISORDERS: – Anorgasmia – Postorgasmic illness syndrome Standard Operating Procedures (SOP) in Diagnosis and Treatment of Delayed Ejaculation/Anejaculation ISSM Standards Committee Meeting June 23-25, 2010 Hotel Agneshof Nürnberg, Germany Pierre Assalian Canada Emmanuele A. Jannini Italy Chris G McMahon (Chairman) Australia David Rowland USA Marcel Waldinger (Chairman) The Netherlands DELAYED EJACULATION Delayed ejaculation • Much less frequent than PE • A rare reason for medical help seeking • Underdiagnosed • Undertreated Is DE a disease? • girls are happy… …where is the problem? …but girls are not happy… Why so poor science? • Low prevalence • Few studies • Classically considered A new psychogenic in nature • Classically treated with behavioral therapies challenge • Definition(s) lacking • Etiologies largely unknown for • Pathogenesis obscure • Lack of awareness and Sexual acknowledgements of DE as a symptom of medical diseases • Low request of help by the medicine patients Delayed Ejaculation & Anejaculation Confusing nomenclature Synonyms: delayed (DE), retarded (RE), or inhibited ejaculation (IE), inadequate ejaculation, idiopathic anejaculation, anorgasmia, primary impotentia ejaculations, and psychogenic anejaculation No clear and evidence based definition DSM‐IV‐TR: Definition “The persistent or recurrent delay in, or absence of, orgasm after a normal sexual excitement phase during sexual activity that the clinician, taking into account the person’s age, judges to be adequate in focus, intensity, and duration” “The disturbance causes marked distress or interpersonal difficulty…” “It should not be better accounted for by another Axis I (clinical) disorder or caused exclusively by the direct physiologic effects of a substance or a general medical condition” DSM‐V: Definition A. Either of the following symptoms must be experienced on almost all or all occasions (approximately 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. B. The symptoms in Criterion A have persisted for a minimum duration of approximately 6 months. C. C. The symptoms in Criterion A cause 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. Operationalisation Criteria of time‐to‐ejaculate, inability to ejaculate, distress, satisfaction … Lack of operationalized criteria Given that most sexually functional men ejaculate within about 4‐10 minutes following intromission [1], a clinician might assume that men with latencies beyond 25‐30 minutes (21‐23 min represents about two SD above the mean) who report distress or men who simply cease sexual activity due to exhaustion or irritation qualify for this diagnosis. 1. Patrick DL, Althof SE, Pryor JL, et al. Premature Ejaculation: An Observational Study of Men and Their Partners. J Sex Med. 2005: 2:58-367 Classification ‐ 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. • Generalized: Not limited to certain types of stimulation, situations, or partners. • Situational: Only occurs with certain types of stimulation, situations, or partners. Classification ‐ Specify current severity: • Mild: Evidence of mild distress over the symptoms in Criterion A. • Moderate: Evidence of moderate distress over the symptoms in Criterion A. • Severe: Evidence of severe or extreme distress over the symptoms in Criterion A. Prevalence of DE Since the beginning of sex therapy, DE was seen as a clinical rarity Masters and Johnson [1]: 17 cases. Apfelbaum [2]: 34 cases Kaplan [3]: 50 cases However, based on clinical experiences, some urologists and sex therapists are reporting an increasing prevalence of DE 1. Masters WH, Johnson VE. Human Sexual Inadequacy, Boston: Little Brown, 1970 2. Apfelbaum B. Retarded ejaculation: A much-misunderstood syndrome. In Lieblum, SR and Rosen, RC Eds, Principles and practice of sex therapy: Update for the 1990's 2nd ed pp 168-206 New York: Guilford Press. 1989: 3. Kaplan H. The evaluation of sexual disorders: Psychological and medical aspects. New York: Brunner/Mazel. 1995: EPIDEMIOLOGY Epidemiology • 1632 patients studied at the Andrology Unit of the Univ. of Florence • 82 (5.0%) with DE – of those, 62 reported mild DE – and 20 reported severe DE or anejaculation Prevalence of Delayed Ejaculation Prevalence is unclear DE is reported at low rates in the literature, rarely Prevalence isexceeding unclear because 3% [1of ‐the3] lack of a Limitedprecise normative definition data of this for syndrome. defining Itthe is the duration of “normal”least ejaculatory common male latency, sexual complaint. particularly Only regarding75% the right “tail” of menthe reportIELT distribution always ejaculating (i.e., during beyond the mean sexual activity, and less than 1% of men will complain of problemslatency with to orgasm)reaching ejaculation Epidemiologicthat last studies more than have 6 months. not distinguished (DSM V) delayed ejaculation vs. anejaculation 1. Perelman M. Curr Sex Hlth Rep. 2004: 1:95-101 2. Laumann EO, Paik A, Rosen RC. JAMA. 1999 Feb 10: 281:537-44 3. Simons JS, Carey MP. Arch Sex Behav. 2001: 30:177-219. Characteristics • High levels of relationship distress, sexual dissatisfaction, anxiety about their sexual performance, and general health issues • Lower frequencies of coital activity [Rowland 2005] • A distinguishing characteristic: men with DE have little or no difficulty attaining or keeping their erections‐in fact they are often able to maintain erections for prolonged periods of time • Despite their good erections, they report low levels of subjective sexual arousal, at least compared with sexually functional men [Rowland 2004] CLINICAL ASPECTS Assalian Jannini McMahon Rowland Waldinger Evaluation of men presenting with DE should include a full medical/sexual history, a focused physical examination and any investigations suggested by these findings Recommendation Pathophysiology Psychogenic Inhibited EjaculationNEUROGENICInfective DE Urethritis Congenital Mullerian duct cyst Genitourinary tuberculosis interruptionWolfian duct abnormaility of the nerve supply to the Schistosomiasisgenitals • traumaticPrune surgicalbelly syndrome injury to the lumbarEndocrine sympatheticHypogonadism ganglia Neurogenic Diabetic autonomic Hypothyroidism • abdominoperitoneal surgery Causes neuropathy Medication Alpha-methyl Dopa Spinal cord injury• lumbar sympathectomy. Thiazide diuretics Radical prostatectomy Tricyclic and SSRI ProctocolectomyNeurodegenerative Diseases antidepressants Bilateral sympathectomy• multiple sclerosis Phenothiazine Abdominal aortic• diabetic neuropathy Alcohol abuse aneurysmectomy • alcoholic neuropathy Para-aortic lympthadenectomy Etiologies and risk factors of deficient ejaculation • NON‐ORGANIC • ORGANIC Repressive sexual Spinal cord injury education Retroperitoneal lymph Sexual abuse in childhood node dissection Deep psychological Diabetes mellitus conflicts Transverse myelitis Multiple sclerosis Neuroleptic drugs • higher frequency of masturbatory activity • lower night emissions • longer IELT • higher anxiety and depression states • higher mean penile shaft sensory threshold values • Longer mean latencies of dorsal nerve somatosensory evoked potential • penile shaft hyposensitivity and hypoexcitability • adaptation to a certain masturbatory technique Psychoanalytic theories on DE • “Anal” block. • Sperm retention. • Heavy misogyny. • ‘Autosexual’, rather than heterosexual, or homosexual, orientation. (Apfelbaum, 2000) Personality characteristics of delayed ejaculators • Overcontrolled, or paltry, poor, week personalities. • Obsessive‐compulsive need for control over the body. • Obstinate. A clinical continuum Premature ejaculation Delayed ejaculation Mild Moderate Severe Anejaculation Lifelong DE, like lifelong PE, is considered to be a primarily a neurobiological variant, which may or may not secondarily lead to psychological or psychosocial distress. Aging • seminal volume ? • testosterone levels ? • prostate contractility ? • vescicle contractility ? • deferentes contractility ? Variation in ability to reach orgasm and orgams‐related concern as a function of the aging process (EMAS and ED Florentine centre data) Corona et al., Best Pract Res Clin Endocrinol Metab. 2013;27:581 “Lost Penis” Syndrome • Extended vagina (multipara) Drugs affecting ejaculation • Alprazolam • Aloperidol • Iproniazide • Aminocaproico Acid
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