LIFE 2015 Lebanese International Fertility Summit 2 – 3 October 2015 Hilton Beirut Habtoor Grand

LIFE 2015 Ejaculatory Dysfunction

Stéphane Droupy MD, PhD Professor of Urology, CHU de Nimes-Université Montpellier 1 Physiology of Male sexual response

Ejaculation et Stimulation Orgasme orgasme

Tumescence Détumescence Penetration

Excitation/ Erection Résolution Plateau

Excitation Phase réfractaire

LIFE 2015 The two phases of ejaculation

• 1st phase: Emission ¡ Peristaltic contractions of and vas deferens ¡ Secretion of spermatic liquid by and ¡ Contraction of seminal vesicles, prostate and bladder neck ¡ Propulsion of spermatozoa and seminal/prostatic fluid into posterior urethra

LIFE 2015 The two phases of ejaculation

• 2nd phase: Expulsion ¡ Rhythmic contractions of striated pelvic floor muscles (bulbospongiosus muscle) ¡ Bladder neck closure and relaxation of external urinary sphincter ¡ Propulsion of out of urethral meatus

LIFE 2015 Spinal generator of ejaculation: LSt

Sympathic IMG LumbarSpinothalamic T12-L1 TL centers neurons (L3-L4) (galanin- NK1) are connected with BS, prostate and SV. L3-L4 LSt cells N Hypog. LSt neurons coordinate N Pelv. both emission and DM Parasympathic expulsion phases of L5-S1 (VH) Sacral nucleus MPG ejaculation.

Ves Sem Prostate Emission is not a prerequist for expulsion. N Pud. BS Muscle LIFE 2015 BRAIN CONTROL of SEXUAL RESPONSE

INHIBITION / ACTIVATION OF SPINAL CONTROL Des influx nerveux activateurs avec comme neuromédiateur la DOPAMINE et Inhibiteurs comme la SEROTONINE vont converger vers le centre spinal de l’éjaculation. 1- Influx activateurs via l’hypothalamus (aire préoptique médiane (MPOA) et noyau paraventriculaire (PVN)) 2- Influx inhibiteurs via le noyau paragigantocelluaire (NPGi) du tronc cérébral.

LIFE 2015 Department of Urology University of Copenhagen Physiology of Ejaculation

Serotonergic  Dopaminergic (Inhibitory) (Excitatory)

Spinal innervation of ejaculation

LIFE 2015 Ejaculatory dysfunctions

¡ « Dry ejaculation » ¡ Anejaculation ¡ ¡ ¡ Anorgasmia ¡ Partial : hypospermia, asthenic ejaculation ¡ Emission or expulsion dysfunction ¡ Delayed ejaculations (> 25 min) ¡ Premature ejaculation (<3 min) (ante portas) ¡ Painfull ejaculation ¡ Orgasmuria

LIFE 2015 Anejaculation

• Complete absence of antegrade or retrograde ejaculation = Aspermia

• Failure of semen emission from the seminal vesicles, prostate and ejaculatory ducts into the urethra

• Anejaculation associated with a normal orgasmic sensation. ¡ Central or peripheral nervous system dysfunction ¡ Drugs ¡ Iatrogenic / surgery

LIFE 2015 Retrograde ejaculation

• Total, or partial, absence of antegrade ejaculation as a result of semen passing backwards through the bladder neck into the bladder. Aspermia or hypospermia

• Patients experience a normal or decreased orgasmic sensation. • The causes : ¡ neurogenic, ¡ pharmacological, ¡ urethral ¡ bladder neck incompetence

LIFE 2015 Delayed ejaculation

• Prolonged stimulation of the erect penis is needed to achieve orgasm with ejaculation

• Mild form of anorgasmia.

• The causes ¡ Psychological, ¡ Organic: SCI ¡ Iatrogenic penile nerve damage, ¡ Pharmacological: selective serotonin re-uptake inhibitors (SSRIs), antihypertensives, or antipsychotics

LIFE 2015 3L DISORDERS OF EJACULATION

Disorders of ejaculation are uncommon, but important causes of male .

3L.1 Classification and aetiology

3L.1.1 Anejaculation Anejaculation involves complete absence of antegrade or retrograde ejaculation. It is caused by failure of semen emission from the seminal vesicles, prostate and ejaculatory ducts into the urethra [232]. True anejaculation is usually associated with a normal orgasmic sensation. True anejaculation is always associated with central or peripheral nervous system dysfunction or with drugs [233] (Table 6).

3L.1.2 Anorgasmia Anorgasmia is the inability to reach orgasm and can give rise to anejaculation. Anorgasmia is often a primary condition and its cause is usually psychological.

3L.1.3 Delayed ejaculation In delayed ejaculation, abnormal stimulation of the erect penis is needed to achieve orgasm with ejaculation [232]. Delayed ejaculation can be considered a mild form of anorgasmia. The causes of delayed ejaculation can be psychological, organic (e.g. incomplete spinal cord lesion [234] or iatrogenic penile nerve damage [235]), or pharmacological (e.g. selective serotonin re-uptake inhibitors (SSRIs), antihypertensives, or antipsychotics) [236].

3L.1.4 Retrograde ejaculation Retrograde ejaculation is the total, or sometimes partial, absence of antegrade ejaculation as a result of semen passing backwards through the bladder neck into the bladder. Patients experience a normal or decreased orgasmic sensation. The causes of retrograde ejaculation can be divided into neurogenic, pharmacological, urethral, or bladder neck incompetence (Table 6).

Table 6: Aetiology of anejaculation and retrograde ejaculation

Neurogenic Pharmacological Spinal cord injury Antihypertensives Cauda equina lesions α1-adrenoceptor antagonists Multiple sclerosis Antipsychotics and antidepressants Autonomic neuropathy (diabetes mellitus) Alcohol Retroperitoneal lymphadenectomy Sympathectomy or aortoiliac surgery Colorectal and anal surgery Parkinson´s disease Urethral Bladder neck incompetence Ectopic ureterocele Congenital defects/dysfunction of hemitrigone Urethral stricture Bladder extrophy Urethral valves or verumontaneum hyperplasia Bladder neck resection (transurethral resection of the Etiologies prostate) Congenital dopamine b-hydroxylase deficiency Prostatectomy

3L.1.5 Asthenic ejaculation Asthenic ejaculation is characterised by an altered propulsive phase, with a normal emission phase [236]. The orgasmic sensation is reduced and the typically rhythmical contractions associated with ejaculation are missing. Asthenic ejaculation does not usually affect semen quality.

3L.1.6 Premature ejaculation The International Society for Sexual Medicine (ISSM) has adopted the first evidence-based definition of lifelong premature ejaculation (PE): “Premature ejaculation is a male characterised by ejaculation which always or nearly always occurs prior to or within about one minute of vaginal penetration; and inability to delay ejaculation on all or nearly all vaginal penetrations; and negative personal consequences, such as distress, bother, frustration and/or the avoidance of sexual intimacy”. Premature ejaculation may be strictly organic (e.g., -related) or psychogenic, partner-related or non-selective, and can be associated with

MALE INFERTILITY - UPDATE MARCH 2014 29

EAU guidelines LIFE 2015 Ejaculatory dysfunction after surgery Iatrogenic after surgery • Cystoprostatectomy ¡ Bladder cancer • Radical prostatectomy ¡ • Endoscopic and simple prostatectomy ¡ BPH • Retroperitoneal ¡ Lymphadenectomies ¡ Aortic surgery ¡ Sigmoid and rectal surgery

• EBR, Brachytherapy (Prostate cancer) ¡ Anejaculation 90% at 5 y ¡ IIEF-O: 7,4 to 2,8/10 at 3 y

Sulivan JF et al J Sex Med 2013 LIFE 2015

Retroperitoneal lymphadenectomy

Ao

VRG L1 L2 L3

VCI

Uretère Rein Dt Psoas

LIFE 2015 Sexual dysfunctions after rectal surgery 100 90 80 70 60 50 Tous 40 AAP 30 20 Résection Antérieure 10 Excison trans-anale 0

Hendren et al Ann Surg 2005 LIFE 2015 Sexual dysfunctions after rectal surgery 100 90 80 70 60 50 Tous 40 AAP 30 20 Résection Antérieure 10 Excison trans-anale 0

Hendren et al Ann Surg 2005 LIFE 2015 Drug side effects on ejaculation Drug induced ejaculatory dysfunction • Delayed or suprressed ejaculation

¡ Alphablokers ¡ Antiandrogens ¡ Antidepressants ¡ Analgesic, Baclofen ¡ Antipsychotics, lithium ¡ Antihypertensive (alpha or betablockers and central) ¡ Cytotoxics (methotrexate, vincristine) ¡ Antiparkinsonians (bromocryptine) ¡ Recreational rugs except amphetamin and heroïne ¡ Alcoolism

LIFE 2015 Alpha-blockers

• Anejaculation ¡ Silodosin> Tamsulosin> Alfusosin ¡ Anejaculation: ¡ 100% of healthy volunteers with silodosin (Kobayashi et al. J Sex Med 2008) ¡ 20-30% of treated pts in pivotal studies(Marks et al J Urol 2009)

Pression de la vésicule séminale

120 *p <0.001

80 *

* 40

0

Vehicle 3 10 3 10

Tamsulosine Alfuzosine (µg/kg) (µg/kg) LIFE 2015 Sexual side effects of drugs

Classe& Priapisme/ES Tr.&Libido& DE& Tr.& Les&médicaments&conseillés& Thérapeutique& P/HS& Orgasme/Ej&

Neuroleptiques& +" +" ±" +" Clozapine*(Leponex®),*Olanzapine* (Zyprexa®),*Quiétapine* (Seroquel®),*Arispiprazole* (Abilify®)"

Antidépresseurs& +" +" +" +" Mirtazapine*(Norset®),*Tianeptine* (Stablon®),*Moclobémide* (Moclamine®),*Agomelatine* (Valdoxan®),*Duloxetine* (Cymbalta®)"

Antiépileptiques& " +" " +" "

Antalgiques& " +" +" ±" "

Anxiolytiques& +" " +" +" Bupropion*et*Buspirone"

*Classes thérapeutiques impliquées dans la survenue de dysfonctions sexuelles iatrogènes et médicaments conseillés afin d’éviter ou de limiter la survenue de ces effets indésirables. (ESP : Excitation sexuelle persistante, HS : hypersexualité, Tr. EJ : troubles de l’éjaculation,)

S Droupy EMC 2005. Épidémiologie et physiopathologie de la dysfonction érectile 18-720-A-10 LIFE 2015 ¶ 1259 ORIGINAL RESEARCH—EPIDEMIOLOGY

1259 Selective Serotonin Reuptake Inhibitor-Induced Sexual DysfunctionORIGINAL RESEARCH—EPIDEMIOLOGY

Giovanni Corona, MD,*§ Valdo Ricca, MD,† Elisa Bandini, MD,* Edoardo Mannucci, MD,‡ Francesco Lotti, MD,* Valentina Boddi, MD,* Giulia Rastrelli, MD,* Alessandra Sforza, MD,§ Carlo Faravelli, MD,Selective† Gianni Forti, MD,* Serotonin and Mario Maggi, MD* Reuptake1264 Inhibitor-Induced Corona et al. *University of Florence—Andrology Unit, Department of Clinical Physiopathology, Florence, Italy; †University of Florence- Psychiatry Unit, Department of Neurological and Psychiatric Sciences, Florence, Italy; ‡University of Florence—Diabetes Section Geriatric Unit,Sexual Department of DysfunctionCritical Care, Florence, Italy; §Maggiore-Bellaria Hospital—Endocrinology Unit, Bologna, Italy

DOI: 10.1111/j.1743-6109.2009.01248.x Figure 1 Adjusted testosterone and prolactin (PRL; log transformed) levels Giovanni Corona, MD,*§ Valdo Ricca, MD,† Elisa Bandini, MD,* Edoardo Mannucci,in patients reporting MD, or‡ not the use of ABSTRACT Francesco Lotti, MD,* Valentina Boddi, MD,* Giulia Rastrelli, MD,* Alessandraserotonergic Sforza, reuptake MD, inhibitor§ (SSRI) † antidepressants. The following factors Introduction. SexualCarlo dysfunctions Faravelli, are often MD, presentGianni in subjects Forti, with mood MD,* disturbances; and Mario however. Maggi, antidepressants MD* have been considered as possible can induce per se sexual dysfunctions. confounders† in the multivariate analy- Aim. To explore the*University relationship of between Florence—Andrology the use of selective serotoninUnit, Department reuptake inhibitors of Clinical (SSRIs), Physiopathology, non-SSRIs Florence, Italy; University of Florence- ‡ antidepressants andPsychiatry benzodiazepines Unit, (BDZ), Department hormonal parameters, of Neurological and reported and sexual Psychiatric dysfunction Sciences, (as assessed Florence, by Italy; Universitysis: age, use of of Florence—Diabetes benzodiazepines or § the Structured InterviewSection on GeriatricErectile Dysfunction Unit, Department [SIEDY]) in ofmale Critical subjects Care, with comparable Florence, psychopathological Italy; Maggiore-Bellaria Hospital—Endocrinologynon-SSRI-antidepressants, patient’s Unit, symptoms (as assessedBologna, by the Middlesex Italy Hospital Questionnaire [MHQ] a self-reported test for the screening of hypoactive sexual desire, testosterone mental disorders in a non-psychiatric setting). or PRL levels, respectively. NS = not Methods. A consecutiveDOI: series 10.1111/j.1743-6109.2009.01248.x of 2,040 (mean age 51 Ϯ 13 years) male patients with sexual dysfunction was studied. significant. Main Outcome Measures. Several hormonal and biochemical parameters were investigated, along with SIEDY and the MHQ. Results. Higher prolactin was observed only in patients using SSRIs,was whereas considered. no other Patients hormonal reporting difference the use was of [1.48–7.59]; P < 0.005). However, logistic multi- found after adjustmentABSTRACT for confounders. Use of SSRIs was associated with a twofold risk for patient hypoactive sexual desire and with a higher impairment of reported erectile function. However,SSRIs showed no difference lower frequency in penile of blood intercourse flow was and variate analysis demonstrated that no further observed. A very highIntroduction. risk (sevenfold)Sexual for delayed dysfunctions ejaculation (DE) are washigher often observed sense present of in guilt SSRI with in users. masturbation. subjects Interestingly, with In addi- the moodincrease disturbances; of risk was derived however. from the concomitant antidepressants association with the mild, but not severe, form of DE was observed also in subjects using non-SSRI antidepressants can induce per se sexual dysfunctions.tion, the use of SSRIs was associated with a sig- use of the two kinds of drugs (data not shown). (3.35 [1.48–7.59]; P < 0.005). Different life stressors and relational parametersnificant impairment were also of associated erectile function with SSRI (higher use. Different life stressors and relational param- SSRI users reportedAim. less enjoymentTo explore with masturbation the relationship and decreased between partner desire the use and climax. of selective Conversely, serotonin a lack reuptake inhibitors (SSRIs), non-SSRIs risk for severe ED and reduced nocturnal erec- eters were also associated with the use of SSRIs. In of significant associationantidepressants was observed among and benzodiazepines BDZ or non-SSRI antidepressant (BDZ), hormonal users and all parameters, the aforementioned and reported sexual dysfunction (as assessed by life-stressors and relational parameters. tion). However, no difference in flaccid and particular, SSRI-users reported higher stress at Conclusions. SSRIsthe can Structured negatively affect Interview all the steps onof the Erectile male sexualdynamic Dysfunction response peak cycle systolic (desire–arousal–excitement– [SIEDY]) velocity (PSV) in male at penile subjectswork and with a higher comparable risk of conflicts psychopathological within the orgasm). SSRI-associatedsymptoms sexual dysfunction (as assessed has a by deleterious the Middlesex effect oncolor both Doppler Hospital auto- and ultrasound couple-erotic Questionnaire (PCDU) performances. was observed [MHQ]couple a self-reported and within the family. test Furthermore, for the screening sub- of Conversely, other antidepressantsmental disorders and BDZ in are a non-psychiatricless often associated with setting). sexual impairment. Corona G, Ricca V, Bandini E, Mannucci E, Lotti F, Boddi V, Rastrelli G, Sforza A, Faravelliwhen comparing C, Forti subjects G, and using Maggi SSRIs M. withSelective those jects using SSRIs reported a higher impairment serotonin reuptakeMethods. inhibitor-inducedA consecutive sexual dysfunction. series of J 2,040 Sex Mednot (mean using 2009;6:1259–1269. (16.0 ageϮ 4.6 51 vs.Ϯ 15.913 years)Ϯ 5.9 cm/second male patientsof partner with climax sexual and reduceddysfunction partner waslibido. studied. Key Words. ErectileMain Dysfunction; Outcome Hypoactive Measures. SexualSeveral Desire; Delayed hormonaland 48.1 Ejaculation;Ϯ and17.6 vs. biochemical SSRI; 49.2 Ϯ Hyperprolactinemia;20.3 cm/second, parameters for Accordingly, were investigated, higher SIEDY along scale with 2 (relational SIEDY and NCEP-ATPIII = Nationalthe MHQ. Cholesterol Education Program-Third Adultflaccid Treatment and dynamic Panel PSV, respectively; both component of ED) and scale 3 (intrapsychic com- Results. Higher prolactin was observedP = not only significant). in patients Accordingly, using no difference SSRIs, was whereasponent of no ED) other were observed hormonal in subjects difference using was found after adjustment for confounders.observed Use in of SIEDY SSRIs scale was 1 score associated after adjustment with aSSRIs twofold even after risk adjustment for patient for confounders hypoactive such sexual desire and with a higher impairment offor confoundersreported (Figure erectile 3). function. However,as age, no use difference of BDZ, or other in non–SSRI penile antidepres- blood flow was observed. A very high risk (sevenfold)As for expected, delayed a higher ejaculation risk for MMDE (DE) and was observedsants, patient’s in HSD, SSRI testosterone users. and Interestingly, PRL levels, the ASDE was observed in subjects reporting the and MHQ (Figure 3). No significant association association with the mild, but not severe, form of DE was observed also in subjectsS using non-SSRI antidepressants Corona and Ricca equally contributed to the article. use of SSRIs. Interestingly, the association with between the use of BDZ, or non-SSRI antidepres- (3.35 [1.48–7.59]; P < 0.005). Different life stressors and relational parameters were also associated with SSRI use. © 2009 International Society for Sexual MedicineMMDE, but not with J Sex ASDE, Med was2009;6:1259–1269 observed also in sants, and all the aforementioned life stressors and SSRI users reported less enjoyment withsubjects masturbation using non-SSRI and antidepressants decreased (3.35 partnerrelational desire parameters, and was climax. observed Conversely, (not shown). a lack of significant association was observed among BDZ or non-SSRI antidepressant users and all the aforementioned life-stressors and relational parameters. Conclusions. SSRIs can negatively affect all the steps of the male sexual response cycle (desire–arousal–excitement– orgasm). SSRI-associated sexual dysfunction has a deleterious effect on both auto- and couple-erotic performances. Conversely, other antidepressants and BDZ are less often associated with sexual impairment. Corona G, Ricca V, Bandini E, Mannucci E, Lotti F, Boddi V, Rastrelli G, Sforza A, Faravelli C, FortiFigure G, and2 Adjusted Maggi risk of M. sexual Selective • Delayed ejaculationserotonin reuptake x7 inhibitor-induced sexual dysfunction. J Sex Med 2009;6:1259–1269.symptoms, and related psychopatho- logical disturbances reported by the • SSRI: youngerKey Words.and ErectilePRL Dysfunction; Hypoactive Sexual Desire; Delayed Ejaculation;patients, SSRI; associated Hyperprolactinemia; with the use of NCEP-ATPIII = National Cholesterol Education Program-Third Adult Treatment Panelselective serotonergic reuptake inhibi- • HSD: risk x2 tor (SSRI) antidepressants. Adjusted risk (abscissa) expresses the likeli- hood (log scale) for each factors of • Less sexual intercourse being associated with the reported use of SSRI. The following factors have • ED: idem non-SSRI been considered as possible con- founders in the multivariate analysis: • Deleterious effect age, use of benzodiazepines or non-SSRI antidepressants, patient’s – AutoerotismeCorona and Ricca equally contributed to the article. hypoactive sexual desire (HSD), test- osterone, and prolactin levels. – Partner © 2009 International Society for Sexual Medicine J Sex Med 2009;6:1259–1269 J Sex Med 2009;6:1259–1269

LIFE 2015 Management of sexual dysfunctions / SSRI

• Inform and anticipate to prevent drug stop • Remplacement • Mirtazapine (Norset), Tianeptine (Stablon), Moclobémide (Moclamine), Zyban

• ED : PDE5i

• Ejaculation: • Periactine (cyproheptamine): 2 to 16 mg/d or on demand • Amantadine: 100mg 5h before SI Strategies for managing sexual dysfunction induced by antidepressant medication. Lisa R, Matthew JT, Keith H. Cochrane Database Syst Rev. 2004 Labbate et al. J Clin Psychiatry. 2003 Nurnberg et al.JAMA. 2003 and J Clin Psychiatry. 2003 LIFE 2015 ED and spinal cord injury Sexuality in SCI patients Why consider genitalWhy consider and genital and • 1 à 2 news case/sexual day rehabilitation sexual ? rehabilitation ?

f • Young men f

• Quality of reinsertion is27% dependant of 27% management of sexual dyfunctions

13% 13%

Anderson J. Neurotrauma 2004 Anderson J. Neurotrauma 2004

Phelps Arch Sex Behav 2001 LIFE 2015 Anderson et al. J Neurotrauma 2004 Spinal cord injury

• Thoracolumbar Sympathic : ¡ Emission,

• Sacral somatic and parasympathic ¡ Reflexogenic Erections, sensitivity ¡ Expulsion (perineal muscles contractions)

• Level of the spinal lesion

• Infralesional syndrom

• Complete vs incomplete Ejaculation Erection Sensibilité LIFE 2015 ED in SCI

• Ejaculation depends on the intergrity the spinal cord between T12 et L2,

• In SCI > T12, ejaculatory reflex remains intact and automatic ejaculation can be optain. • In SCI between T12 and L2 et complete, no ejaculation. • In SCI < L2, and integrity of sacral roots, psychogenic ejaculation is sometimes possible.

LIFE 2015 Management of ED in SCI

• Urinary function

• Anorectal function

• Spasticity

• Pain

• Skin

• Associated treatments

• Reeducation of erection and recreative sexual life

LIFE 2015 Department of Urology University of Copenhagen Consequence of Amplitude Study Penile Vibratory stimulation

• 22 studies since1954 University of  Development of the • 2257 patients Copenhagen first medical vibrator for • 15% (0 et 52%) of patients are able to ejaculate home use. without medical& assistance Department of Urology University of Copenhagen Principle of PVSFDA 510K registration. • VibratoryMulticept stimulation A/S of the penis: Ferticare Vibratory amplitude (N=66)  CurrentlyAbove T10 in use in 2.5 mm: 80% success rate Intact BC reflex Denmark 1.0 mm: 25% success rate more than 30 countries including US.

T12-L1 Seminal emission

Projectile ejaculation Pudendal S2-S4 nerve  PVS Spinal Sønksen et al 1994 Cord Sønksen et al 2001 

LIFE 2015 Sonkesen et al 1994 et 2001 ® Department of Urology University of Copenhagen Ferticare Clinical use of PVS

• Brackett, SØnksen. J. Urol, 1988. (653 essais chez 211 patients) ¡ C3-C7 66% ¡ D1-D5 54% ¡ D6-D10 41% Department of Urology University of Copenhagen ¡ D11-L3 36% Clinical use of PVS • Efficacy 50 to 80% if Sci > T10 • First line treatment for ED in SCI

• Home use for intravaginal inseminations

• Association with:  ¡ Midodrine :Gutron® (alpha +) ¡ iPDE5 to improve erection and sensitivity

Courtois et al 2008, Soler et al 2008 LIFE 2015

 Department of Urology University of Copenhagen

PVS and Home Insemination Home insemination

TMS (millions): 31 (1-426) 74/170couples: 100 pregnancies Outcome: 91 healthy babies Results (1 set of twins) Time to pregnancy: 1.2 years (0.1-8.2) Spontaneous abortion: 10 in 9 couples (10%)



LIFE 2015 ElectroejaculationDepartment of Urology : 100% University of Copenhagen Electroejaculation

Procedure

LIFE 2015 Partial ejaculation Obstruction of seminal tract

• CBAVD, at least one mutation of the CF gene in 82%. Dysgenesis of seminal vesicles.

• Unilateral agenesis or a partial defect ¡ Contralateral seminal duct anomalies 80% ¡ Renal agenesis in 26% • Ejaculatory duct obstruction: 1-3% of OA ¡ Cystic obstruction: Mullerian cyst (central) ¡ urogenital sinus/ejaculatory duct cysts ¡ Post-inflammatory obstruction ¡ Lithiasis ¡ Painful ejaculation

LIFE 2015 Ejaculatory duct obstruction

Phosphates amorphes de Calcium Carbonatés LIFE 2015 + Protéines MRI

LIFE 2015 Curran S et al. AJR 2007;188:1373-1379 Treatment of Mullerian cyst

• Mullerian cyst: ¡ US guided transrectal aspiration. ¡ TUR of cyst., laser resection ¡ Cryopreservation

• Risks: ¡ Rectal perforation ¡ Retrograde ejaculation ¡ Urine reflux seminal tract ¡ Recurrence

Goldstein - Surgery of – 1995, LIFE 2015 Fish World J Urol 2006, XU BJUInt 2011 The surgical treatment of obstructive HT Jiang et al

913

passed through the orifce of verumontanum and entered the prostatic utricle under direct vision. Because the orifces of the ejaculatory duct were occluded or too small to be found, the best method of entering the seminal vesicle is through a dilated ejaculatory duct. Under direct vision, a 4F ureteral catheter tentatively penetrated the two sides of the bottom of the prostatic utricle where the ejaculatory duct is located (Figure 1). If the ureteral catheter went into the ejaculatory duct, the rigid ureteroscope followed the catheter to enter the ejaculatory duct. In a few cases, it was too difcult to fnd the ejaculatory duct. Attempts to enter the ejaculatory duct should depend on the experience and skill of the operator, or be guided by transrectal ultrasonography; we could use ultrasonogram as a guide to indicate the dilated ejaculatory duct intraoperatively. Afer the ureteroscope enters the ejaculatory duct Figure 1: Transurethral incision of the ejaculatory duct. The ureteroscope and seminal vesicle, liquid (for the semen examination) was extracted enters the ejaculatory duct through the prostatic utricle. through an F4 ureteral catheter, and then calculi, jelly-like substances, or infectious liquid were removed or washed away. To increase the likelihood of keeping the ejaculatory duct open postoperatively, a holmium laser was used to incise and to enlarge the orifce penetrated by the ureteroscope. A urethral catheter was lef for 24 h and then removed. Patients started to ejaculate 4 days post-surgery. Initial hemospermia spontaneously disappeared within 7–10 days. Laparoscopy assisted microscopic vasovasostomy Patients with iatrogenic injuries to the bilateral vas (inguinal portions were resected) from childhood surgeries (Figure 2) were placed in a Figure 2: Inguinal vas was resected from childhood surgery and the pelvic vas end retreat into the pelvic cavity while the body grows and develops. supine position. With the patient under general anesthesia, 3–4 cm incision was made on the previous inguinal surgery scar, and the scar was resected. Te proximal (testicular) end of the vas was easily identifed near the external ring. Te proximal vas was dissected free, and the scarred portion was removed, a drop of vasal fuid was examined for the presence of sperm. All patients were found to have sperm in the proximal vas bilaterally. Assisted laparoscopy was needed if the distal vas end was retreated into the pelvis and inaccessible at the inguinal area or if the distal (pelvic) vas end was found and dissected near the internal ring, but the defective vas was too long to anastomose with the proximal end of the vas. Tis procedure is similar to Shaeer 4 Figure 3: A laparoscopic-assisted vasovasostomy (VV). A tension-free VV with pelviscrotal VV. A three-port transperitoneal approach is placed afer a shortcut. artifcial pneumoperitoneum. Te initial 10 mm port was placed at the inferior umbilical crease and housed the laparoscope. Ports number 2 (5 mm) and number 3 (5 mm) were placed one fngerbreadth outside lumen, a 0.032-inch Zebra guidewire was inserted into the lumen until Ejaculatory duct obstruction it reached the blockage. Te length of guidewire that was inserted the lateral border of the rectus muscle and two fngerbreadths below the umbilicus. Afer an incision of the peritoneum on the internal ring, indicated the obstruction site. the distal end of the vas was easily identifed and dissected distally, and If the obstruction site was in the pelvis or inguina, reconstructive 7–8 cm length of distal vas was dissected free. Another 5 mm trocar surgery was impossible because of uncertainty regarding the length was placed on the external ring and created a new canal by penetrating of obstructed segment and the procedure was ended immediately. If the abdominal wall into the peritoneal cavity adjacent to the outside the obstruction was in the scrotum and sperm were found in the fuid ¡ Stenosis /calculi of ejaculatory ducts of the obliterated umbilical artery fold. Tis canal was a shortcut for of the proximal vas intraoperatively, the obstructed segment was cut a tension-free VV (Figure 3). Te distal vas were delivered intact and and discarded until a healthy lumen was found, and then microscopic then trimmed under direct vision of the microscope. Te scarred end VE was considered. ¡ Endoscopic incision (laser), of the vas was cut-of until the vasal lumen appeared healthy. Te distal If the patency of the vas lumen was confrmed and no sperm was vas was near the proximal vas, and VV was performed (the procedure found in the fuid of the proximal vas intraoperatively, the epididymal ¡ Colliculus seminalis resection used was similar to the previously reported technique5). Te patients tubule was dissected free, and the fuid of the epididymis was checked started to ejaculate 3 weeks afer surgery. under high-power magnifcation for the presence of sperm. If sperm ¡ Per operative sperm retrieval were found, transverse two suture intussusception VE was performed. Microscopic vasoepididymostomy Te procedure used is similar to the previously reported technique6 Patients who were presumptively diagnosed with vasal or epididymal but with modifcations. First, instead of a transversely linear incision ¡ Peroperative US obstruction underwent scrotum exploration under spinal anesthesia. in the loop of the epididymal tubule, a round tubulotomy between Te vas was transected at the site near the epididymis. Te patency two transverse sutures was cut using a microsurgical curved scissors. ¡ Antibiotics, antiinflammtory a, repeated of the distal vas lumen was checked by injecting 10 ml of saline into Te diameter of the round tubulotomy was matched to the diameter ejaculations the cannulated vas deferens. If saline could not pass through the vas of the vasal lumen. Second, sutures place of the inner layer in the vas

Asian Journal of Andrology ¡ Dilation 9 french vesiculoscopy

Hong‐Tao Jiang et al. Asian Journal of Andrology (2014) 16, 912–916 LIFE 2015 Ballistic problems

• Normal ejaculatory sensation : no intravaginal semen emission • Hypospadias • Urethral stenosis • Congenitale or acquired penile curvature • Ejaculation prématurée ante-portas • Vaginism

LIFE 2015 Premature ejaculation Premature ejaculation

Rapid ejaculation Normal and associated response orgasm

Short plateau phase

Steep excitement phase

PE

Etiology of PE remains largely unknown LIFE 2015 Pathophysiology of PE

Biological Psychological Factors Factors

Penile Hypersensitivity Early sexual experience Hyperexcitability Sexual conditioning Genetic predisposition Anxiety Central 5-HT sensitivity Psychodynamic

Variable expression

Adapted from Perelman, Atlas of Male Sexual Dysfunction, 2004 LIFE 2015 Definitions

Primary PE(1) Acquired PE Naturally variable Pseudo-PE (2) PE(2) Délai pour éjaculer Diminution Éjaculations précoces Perception subjective après la pénétration significative du délai occasionnelles. d’une éjaculation vaginale: 1minute ou pour éjaculer après la précoce lors des moins toujours ou pénétration vaginale: Incapacité totale ou rapports sexuels. presque. 3 minutes ou moins partielle à retarder une Ejaculation précoce toujours ou presque. éjaculation imminente. imaginaire Incapacité de retarder Incapacité de retarder Le temps de latence l’éjaculation lors de l’éjaculation lors de Ejaculation parfois pour éjaculer est dans toutes ou presque les toutes ou presque les dans des délais la fourchette normale pénétrations pénétrations normaux (3 à 25 min). vaginales. vaginales. La capacité à retarder l'éjaculation Conséquences Conséquences imminente est personnelles personnelles diminuée ou absente. négatives: souffrances, négatives: souffrances, gêne, frustration, gêne, frustration, évitement de l’intimité évitement de l’intimité sexuelle sexuelle

1- McMahon CG, Althof SE, Waldinger MD, et al. An 2- Waldinger MD. Recent advances in the classification, evidence-based definition of lifelong premature neuro- biology and treatment of premature ejaculation. ejaculation: report of the Interna- tional Society for Sexual Adv Psycho- som Med 2008;29:50–69. Medicine (ISSM) ad hoc committee for the definition of LIFE 2015 premature ejaculation. J Sex Med 2008;5:1590–606. Management of PE

Ejaculation Prématurée

OUI

EP secondaire à une DE ou autre Prise en charge de OUI dysfonction sexuelle la cause primaire

NON

EP acquise EP primaire

Traitement Traitement Comportemental/Psychothérapie Préférence Pharmacothérapie Pharmacothérapie du patient Comportemental/Psychothérapie Traitement combiné Traitement combiné

Tentative d’arrêt progressif du traitement pharmacologique selon les patients

LIFE 2015 1. Althof SE, et al. International Society for Sexual Medicine’s Guidelines for the Diagnosis and Treatment of Premature Ejaculation. J Sex Med 2010;7:2947-2969. Psycho-sexological approach

§ Sexothérapies comportementales 2, 3 Ø Technique Stop and Go Ø Squeeze Ø Sensate Focus Ø Thérapies cognitivo-comportementales Ø Jeux de rôle

§ Hypnose, relaxation, sophrologie 3

§ Sexothérapies corporelles

§ Thérapie de couple 4 Ø Développer la communication

Ø Gérer les émotions (négatives)

§ Thérapie psychodynamique 3 Ø Problèmes psychologiques et relationnels en amont du symptôme sexuel

2. Mohee A, et al. Medical therapy for premature ejaculation. Ther Adv Urol 2011;3(5):211︎-222. 3. Porto R, et al. L’éjaculation prématurée. Prog Urol 2013;23:647-656. 4. AIHUS. Recommandations aux médecins généralistes pour la prise en charge de première intention de la dysfonction érectile. 2010. LIFE 2015

Pharmacological approach

Traitements per os

Andépresseurs fluoxéne, paroxéne, Placebo Priligy 30 mg Priligy 60 mg 5 hors AMM traitement citalopram, clomipramine 4 quodien 3 3 2.5

2 1.6

n=1,455( n=1,486( n=1,437( Dapoxéne à la demande PriligyR increase Fold 1

n=1,455( n=1,486( n=1,437( 0 Tramadol seul ou associé (antalgique) hors AMM à la demande

Anesthésie locale Anesthésique local lidocaïne-prilocaïne crème (EmlaR) hors AMM

Pryor et al. Lancet 2006; 368: 929-937. McMahon et al. (2008) Presented at ESSM/ISSM LIFE 2015 Delayed ejaculation male orgasmic dysfunction Median time: 5.4 min (0,55- 44) + 2DS = 25 min

Delayed ejaculation

• Persitant or recurrent difficulty or delay to reach an orgasm and obtain an ejaculation after suficient sexual stimulation.

• > 25 minutes

• Primairy (1,5/1000) or secondary (3-4%)

• Permanent or situationnal

• Seems interesing for the female partner

• In fact: penible pour both

LIFE 2015 Causes

• Inadequate stimulation ¡ Psychogenic ¡ Disparity fantasma /reality ¡ Affinity /partner ¡ Physical ¡ Masturbatory idiosyncrasism: ¡ Every day 35% ¡ auto-erotism > partner

LIFE 2015 Causes

• Psychic conflicts: fear of semen, vagina, to hurt the partner or to have a child • Relational conflicts • Hyspoactive sexual desire / dysorgasmia • Organic: ¡ SSRi ¡ Hypogonadism : Testosterone ¡ Diabetes, hypothyroidism

LIFE 2015 Treatment of delayed ejaculation: Off-label

• Alpha adrénergics sympathomimétics • Midodrine 5 to 30 mg 30 à 60 minutes before ejaculation.

• Imipramine: 25mg x2-3 /jour.

• Dopaminergiques agonists • Cabergoline (dostinex) • Apomorphine (Ixense, Uprima) • Periactine (cyproheptamine): 2 à 16 mg/jour ou à la demande (patients sous SSRI) • Amantadine: 100mg 5h avant le RS

• Ocytocine (nasal)

• Buspirone (buspar)

• Bupropion (Zyban) • SSRI: efficacy 66% • Improve orgasm men and women LIFE 2015 Painful orgasms / radical prostatectomy

¡ Pain: 14% Pathophysiology ¡ Penis: 63% ¡ Rectum:24% • Vas deferens obstruction ¡ Abdomen:9%

¡ elsewhere: 4% ¡ always: 33% ¡ Frequent: 13% ¡ sometimes: 35% ¡ Rare 19% ¡ Duration : <1min:55% , 1-5min: 33%, > 5min: 12%, >1H: 2,5%

Treatment: Alphablockers Silodosin Barnas et al BJU Int 2004, 2005 Climacturia, orgasmuria

• Following radical prostatectomy • Urinary incontinence during sexual IC: ¡ 20 to 93% ¡ Techniques ou modalité d’évaluation ? ¡ Associated to painful orgasms and penile shortening ¡ A bothered problem for 50% patients • Prevention: preservation of bladder neck and nerve sparing technique . • Information, condoms

Barnas et al BJU Int 2004, Lee et al J Urol 2006, Choi et al J Urol 2007 LIFE 2015 Conclusion

• Ejaculatory dysfunctions are frequent in infertile men ¡ Cause of infertility ¡ Consequence of Infertility or ART

• Aspermia or hypospermia need further investigations ¡ Clinical and Imaging (TRUS, MRI)

• Surgical treatment of reversible cause of infertility

• Psychological management of infertile men

LIFE 2015