The relationship between premature ejaculation and hyperthyroidism

Thyroid disorders and male sexual dysfunction

Though early research suggested that thyroid hormones were not involved with the testes, male spermatogenesis, or erectile function, investigations on this topic over the past few decades have increased and shed new light. A literature review of studies conducted between 1963 and 2022 regarding male sexual dysfunction (SD) and thyroid disorders was performed to define the diagnostic consideration, pathophysiology, and management of SD secondary to thyroid dysregulation. This article provides evidence and interpretation of prior clinical and preclinical studies and contextualizes these studies for clinical practice. Clinical manifestations of SDs included erectile and ejaculatory dysfunction, impaired spermatogenesis, and disruption of the hypothalamic-pituitary-gonadal axis. Our aim of this communication was to perform a literature review detailing the impact of thyroid disorders on male SD. We hope to provide a framework for practicing urologists, endocrinologists, or general practitioners when evaluating patients with concurrent thyroid and male SD. It is important to recognize that thyroid disorders can be an important part of the pathophysiology of male SD in patients. Future research studies are needed to further elucidate the mechanisms involved.

The impact of hyperthyroidism on sexual functions in men and women: a systematic review and meta-analysis

This study aimed to review the current knowledge on sexual dysfunction in men and women with hyperthyroidism through a systematic review and meta-analysis. Available clinical trials from the MEDLINE database were searched using a prerecorded protocol (Protocol Prospero ID: CRD42022340587), and obtained data were analyzed and reported according to the PRISMA guidelines. Pooled effect estimates were computed using a random-effects model. Twenty eligible studies were identified, of which 15 were included in this meta-analysis. The prevalence of erectile dysfunction was significantly higher in participants with hyperthyroidism than that in controls [odds ratio = 9.16 (95% confidence interval [CI], 5.0-16.5)]. Treatment of hyperthyroidism alone improved erectile functions [effect size, ES = 0.36 (95% CI, -0.01-72)] and mean intra-vaginal ejaculation latency time [ES = 0.63 (95% CI, 0.27-98)] among men with erectile dysfunction and/or premature ejaculation. The prevalence of premature ejaculation also decreased with treatment of hyperthyroidism [odds ratio = 0.11 (95% CI, 0.04-28). Women with hyperthyroidism demonstrated higher odds in female sexual dysfunction than controls [odds ratio = 4.34 (95% CI, 2.63-7.18)]. Female sexual function index scores in women with hyperthyroidism were also significantly lower than those in the controls with moderate effect sizes. An evident and reversible disruption of sexual functions under hyperthyroidism conditions was observed in both sexes.

Bilateral orchiectomy deteriorates the structure and function of seminal vesicles in a rat model

The effects of hormone levels on ejaculation are known. In addition to thyroid hormone levels, testosterone levels are also associated with ejaculation, but no consensus has been reached on this issue. Thus, we investigated the effect of decreased testosterone levels due to bilateral orchiectomy on the chemical stimulation-induced ejaculation phases in rats. Twenty-one male Wistar rats were randomized into the orchiectomy, sham, and control groups, with seven rats in each group. Bilateral orchiectomy was performed. The ejaculation parameters were evaluated 5 days after the sham and bilateral orchiectomy operations and the waiting period in the control group. The seminal vesicle (SV) phasic contraction number and increase in basal pressure amplitude were significantly lower in the orchiectomy group (6.9 ± 3.3 and 0.6 ± 0.3 mmHg) than in the sham and control groups (11.2 ± 1.7 and 1.0 ± 0.4 mmHg, and 14.5 ± 6.6 and 1.1 ± 0.2 mmHg, respectively; p = 0.016 and p = 0.03, respectively). The interval between the SV contractions was significantly longer in the orchiectomy group (166.2 ± 104.3 s) than in the sham and control groups (76.0 ± 15.5 s and 63.1 ± 31.1 s, respectively; p = 0.014 (between groups), orchiectomy vs sham p = 0.040 and orchiectomy vs control p = 0.018). The SV weights of the rats were significantly lower in the orchiectomy group (0.14 ± 0.01 g) than in the sham and control groups (0.37 ± 0.05 g and 0.48 ± 0.03 g respectively; p < 0.0001 (between groups), orchiectomy vs sham p < 0.0001 and orchiectomy vs control p < 0.0001). The groups showed no significant differences in ejaculation time, SV basal pressure, SV maximum amplitude, and bulbospongiosus muscle contraction electromyographic activity. Our results partially clarified the relationship between decreased testosterone levels and ejaculation. Decreased testosterone levels caused statistically significant changes in SV functions and affected the ejaculation emission phase.

The association of reproductive hormones, thyroid function, and vitamin levels with premature ejaculation: A prospective case-control study

PURPOSE

To investigate whether serum hormone (testosterone, prolactin, gonadotropins, and thyroid hormones) and vitamin (vitamin B12, folic acid, and vitamin D) levels are associated with premature ejaculation (PE).

MATERIALS AND METHODS

This prospective case-control study included 126 patients with PE (lifelong PE [LPE] in 94 and acquired PE [APE] in 32) who presented to the urology outpatient clinic between April 2016 and January 2023 and 92 healthy men as a control group. The diagnosis of PE was based on the criteria defined by the International Society for Sexual Medicine. Serum total testosterone (TT), free and bioavailable testosterone, follicle-stimulating hormone, luteinizing hormone, prolactin, thyroid-stimulating hormone, free triiodothyronine, thyroxine (fT4), vitamin B12, folic acid, and vitamin D levels were measured.

RESULTS

Serum TT, fT4, and vitamin D levels were significantly higher in patients with PE than in the control group (p=0.022, p=0.002, and p=0.044, respectively). However, the serum vitamin B12 level was significantly lower in the PE group (p=0.021). In the multivariate logistic regression analysis, only vitamin B12 was found to be an independent risk factor for PE, with an estimated odds ratio of 0.997 (95% confidence interval 0.994-0.999, p=0.036).

CONCLUSIONS

This study demonstrated that lower vitamin B12 levels are associated with the presence of PE. Therefore, we believe that it would be beneficial to consider vitamin B12 levels in the evaluation of patients with PE.

The rs6296 polymorphism in the 5-HT1b receptor in Dutch men with lifelong premature ejaculation: a genetic case-control association study

BACKGROUND

Lifelong premature ejaculation (LPE) is a rare sexual condition believed to be caused by genetic neurobiological disorders.

AIM

In this study we sought to evaluate the genetic association between the rs6296 polymorphism of the 5-HT1b receptor and intravaginal ejaculation latency times (IELTs) in men with LPE compared with men in a control group.

METHODS

This study was a prospective observational genetic case-control association study. The LPE definition of the International Society for Sexual Medicine (ISSM) 2013 was used. Patients were recruited in 2005-2009 while attending the department of Neurosexology, HagaZiekenhuis, the Netherlands. We obtained IELTs with the stopwatch method. Polymerase chain reaction (PCR) was used for genotyping rs6296. A randomly selected group of European Caucasian men from the 1000GENOMES project was used as a control group.

OUTCOMES

Study outcomes included results of comparisons of analysis of variance (ANOVA) tests between genotypes and IELTs in study participants, genotypes of cases and controls determined with the chi-square test, and expressions of allelotype- and genotype-specific risks for LPE determined with odds ratios.

RESULTS

In total, 67 men with LPE were included in this study. The geometric mean (SD) IELT was 32.0 (27.4) seconds and was non-normally distributed. Genotype frequencies consisted of 29 (43.3%) GG, 31 (46.3%) GC, and 7(10.4%) CC individuals in the LPE group. Log-transformed IELTs were not statistically significant (per ANOVA tests) in men with GG, GC, or CC genotypes (P = .54). Genotype frequencies consisted of 16 (6.6%) GG; 93 (38.8%) GC, and 131 (54.6%) CC individuals in the control group (n = 240). Significant differences were found when comparing allele (P = 1.02e-17) and genotype (P = 3.22e-16) frequencies in cases and controls using a chi-square test. A statistically significant increased risk for LPE was found for carriers of the G allele (OR 5.62; 95% CI 4.13-9.42). Statistically significant risks were also found for the CG genotype (OR 6.24; 95% CI 2.63-14.77) and the GG genotype (OR 33.92; 95% CI 12.79-89.93).

CLINICAL IMPLICATIONS

By investigating polymorphisms in target genes the neuro-pathophysiology of LPE could be further elaborated, potentially leading to more effective treatment.

STRENGTHS AND LIMITATIONS

This is to our knowledge the first study investigating rs6296 with regard to LPE. By using a strict definition for LPE (ISSM 2013) and using the stopwatch method for measuring IELTs, bias in selection of true LPE patients will be relatively low. This study is limited by a relatively small study population and the lack of IELT data in the control group.

CONCLUSIONS

This study shows a genetic association in rs6296 in men with LPE compared with healthy controls. This result warrants attempted replication in future studies.

Premature Ejaculation after Lithium Treatment in a Patient with Bipolar Disorder

Lithium has proven its efficacy in treating bipolar disorder. Severe side effects caused by lithium, including renal and endocrine outcomes, have already been amply documented. The impact of lithium on sexual function, however, is less well known. A 33-year-old man, with no past medical history, diagnosed with bipolar disorder, developed premature ejaculation after short-term use of lithium. The dose of lithium was reduced, leading to a rapid clinical resolution. Retrospectively, lithium-induced premature ejaculation was deemed the most likely diagnosis. Premature ejaculation is a rare side effect of lithium. Changing the time of medication administration and lowering dose could be considered as alternatives. Given lithium's pharmacological profile, it is likely that the pathophysiologic mechanism behind premature ejaculation is altered levels or altered serotonin receptor sensitivity in the ejaculatory modulating centers of the central nervous system. Given the reluctance to spontaneously report sexual adverse effects, clinicians should be aware of this possible side effect.

Current and emerging treatment options for premature ejaculation

Premature ejaculation (PE) is a prevalent male sexual dysfunction. Current standard treatment regimens include behavioural therapies, topical anaesthetics, dapoxetine and other selective serotonin reuptake inhibitors (SSRIs). Most of the pharmacotherapeutic options target neurotransmitters (such as serotonin and oxytocin) that have a role in the ejaculation mechanism. However, these treatments are mildly effective and only provide a temporary delay in the ejaculation latency time, and PE recurs when the treatment is stopped. Thus, a treatment for PE is urgently needed and research is ongoing to find the ideal PE therapy. The efficacy and safety of topical anaesthetics and SSRIs in delaying ejaculation have been confirmed in many well-designed controlled trials. Both preclinical and clinical studies on new-generation SSRIs are ongoing. Moreover, promising results came from clinical trials in which the efficacy of on-demand PE therapies targeting neurotransmitters other than serotonin, such as α1-adrenoceptor antagonists and oxytocin antagonists, was assessed. Surgical intervention and neuromodulation have been proposed as potential treatment options for PE; however, current PE guidelines do not recommend these treatments owing to safety concerns.

Neurons for Ejaculation and Factors Affecting Ejaculation

Simple Summary

Sexual dysfunctions are rarely discussed in our current society. Males experience different sexual dysfunctions, including erectile, infertility, and ejaculatory dysfunctions. In this review only the ejaculatory dysfunction will be discussed. Ejaculation is defined as the ejection of contents collectively from the vas deferens, seminal vesicle, prostate and Cowper’s glands. It is completely controlled by a population of neurons present in the lumbar spinal cord. The presence of lesion in these neurons ceases the ejaculatory behavior in males. This population of neurons was first identified in rats; however, recently it was confirmed that these neurons are present in human males as well. The issues are known as ejaculatory dysfunction. The following are the different types of ejaculatory dysfunctions: early ejaculation, ejaculation into the urinary bladder, late ejaculation and no ejaculation.

Abstract

Ejaculation is a reflex and the last stage of intercourse in male mammals. It consists of two coordinated phases, emission and expulsion. The emission phase consists of secretions from the vas deferens, seminal vesicle, prostate, and Cowper’s gland. Once these contents reach the posterior urethra, movement of the contents becomes inevitable, followed by the expulsion phase. The urogenital organs are synchronized during this complete event. The L3–L4 (lumbar) segment, the spinal cord region responsible for ejaculation, nerve cell bodies, also called lumbar spinothalamic (LSt) cells, which are denoted as spinal ejaculation generators or lumbar spinothalamic cells [Lst]. Lst cells activation causes ejaculation. These Lst cells coordinate with [autonomic] parasympathetic and sympathetic assistance in ejaculation. The presence of a spinal ejaculatory generator has recently been confirmed in humans. Different types of ejaculatory dysfunction in humans include premature ejaculation (PE), retrograde ejaculation (RE), delayed ejaculation (DE), and anejaculation (AE). The most common form of ejaculatory dysfunction studied is premature ejaculation. The least common forms of ejaculation studied are delayed ejaculation and anejaculation. Despite the confirmation of Lst in humans, there is insufficient research on animals mimicking human ejaculatory dysfunction.

Premature Ejaculation and Endocrine Disorders: A Literature Review

Premature ejaculation (PE) is the most common male sexual dysfunction, with 30% of men experiencing PE worldwide. According to the generally accepted classification, there are two types of PE: lifetime PE and acquired PE. Various biological and psychological causes are known to be involved in the etiology of PE. However, due to the incomplete definition and etiopathogenesis of PE, there is no effective treatment. Although clinical and animal studies indicate that hormones play a role in controlling the ejaculation process, the precise endocrine mechanisms are unclear. In addition, little is known about the role of endocrine disorders in PE etiology. However, there is evidence that diabetes mellitus (DM), obesity, metabolic syndrome (MetS), thyroid gland disorders, pituitary gland disorders, and vitamin D deficiency affect the prevalence of PE. Moreover, it has been reported that the prevalence of PE decreases with treatment of these endocrine disorders. In this review, the relationship between PE and DM, MetS, obesity, vitamin D deficiency, and thyroid and pituitary gland disorders is summarized.

Systematic review and meta-analysis for the value of thyroid disorder screening in men with ejaculatory dysfunction

OBJECTIVE

To demonstrate evidence from available clinical studies to clarify the scientific points that have been achieved in relation to thyroid disorders and ejaculatory dysfunction (EjD).

DATA SOURCES

Clinical trial articles published in English on Medline.

ELIGIBILITY CRITERIA

Clinical studies that investigated the association of thyroid disorders with the ejaculatory function of subjects and the trials evaluating the effect of thyroid dysfunction treatment on the ejaculatory function of the subjects were eligible.

SYNTHESIS METHODS

We searched Medline with "ejaculation" and different combinations of "thyroid," "serum TSH," "serum T3," "serum T4" keywords in PubMed.

RESULTS

Standardised mean serum thyroid-stimulating hormone (TSH) levels in premature ejaculation (PE) sufferers differed from non-PE control subjects (P = .05). Hyperthyroidism was associated with increased odds among PE subjects (OR = 2.0, P = .03). Delayed ejaculation was seen with increased odds in hypothyroid patients compared with hyperthyroidism patients (OR = 57, P = .0001). Serum TSH and mean intra-vaginal ejaculation latency time (IELT) of the subjects showed a correlation both before and after treatment for thyroid disorder. Treatment of thyroid disorders improved the mean IELT measures of the subjects. The overall estimate of the effect of hyperthyroidism treatment on mean IELT was .64 (P = .0001) in the random-effects model.

LIMITATIONS

The low quality and quantity of evidence from available studies limited the interpretation of our study findings.

CONCLUSIONS

The causal relationship between EjD and thyroid disorders remains to be clarified. Sufferers of delayed ejaculation acquired PE subjects, and PE sufferers who have accompanying erectile dysfunction and/or anxiety may benefit from thyroid disorder investigation.

Hyperthyroidism as an Underlying Cause of Premature Ejaculation

INTRODUCTION

Hormonal imbalances have been associated with various sexual dysfunction disorders. In particular, the connection of hyperthyroidism has been discovered to correlate to premature ejaculation (PE) but has yet to been thoroughly elucidated. As one of the most frequently self-reported sexual dysfunctions, it is imperative for health care professionals to evaluate possible underlying conditions in regard to treatment options for individuals with PE.

OBJECTIVES

To review the literature regarding hyperthyroidism effects on sexual dysfunction, with a focus on hyperthyroidism and PE.

METHODS

A literature review of articles and clinical studies was performed to define the classification, pathophysiology, diagnostic considerations, and management of hyperthyroidism on PE. Search terms included "hyperthyroidism" and/or "premature ejaculation," "treatment of premature ejaculation," "defining premature ejaculation," and "management of premature ejaculation."

RESULTS

To improve the accuracy of diagnosing PE, there needs to be a set definition amongst the different guidelines, as using these guidelines can help determine possible underlying etiologies of PE. The correlation of hyperthyroidism and PE has been described in a limited number of studies. It has been reported that individuals with hyperthyroidism are much more likely to have PE than individuals with euthryoidism. Management of hyperthyroidism has been shown to alleviate the symptoms of PE.

CONCLUSION

Further understanding of hyperthyroidism as an underlying cause of PE could lead to increased efficacy of treatment and management of PE. Tannenbaum J, Youssef M, Attia AS, et al. Hyperthyroidism as an Underlying Cause of Premature Ejaculation. Sex Med Rev 2021;XX:XXX-XXX.

Management of premature ejaculation: a clinical guideline from the Italian Society of Andrology and Sexual Medicine (SIAMS)

Premature ejaculation (PE) is the most prevalent male sexual dysfunction, and the most recently defined. PE is often mistakenly considered a purely psychosexological symptom by patients: the lacking awareness in regards to the pathophysiology and treatments often lead to resignation from the patients' side, making PE the most underdiagnosed sexual complaint. However, an ever-growing body of evidence supporting several organic factors has been developed in the last decades and several definitions have been suggested to encompass all defining features of PE. In the present document by the Italian Society of Andrology and Sexual Medicine (SIAMS), we propose 33 recommendations concerning the definition, pathophysiology, treatment and management of PE aimed to improve patient care. These evidence-based clinical guidelines provide the necessary up-to-date guidance in the context of PE secondary to organic and psychosexological conditions, such as prostate inflammation, endocrine disorders, and other sexual dysfunctions, and suggest how to associate pharmacotherapies and cognitive-behavioral therapy in a couple-centered approach. New therapeutic options, as well as combination and off-label treatments, are also described.

Redefining a sexual medicine paradigm: subclinical premature ejaculation as a new taxonomic entity

Premature ejaculation (PE) and poor ejaculatory control are multidimensional sexual symptoms estimated to affect almost one-third of men, severely impairing the overall quality of life of patients and their partners. However, patients who do not completely fulfil the definition criteria for PE rarely receive a diagnosis or adequate treatment, with the risk of subsequent progression from initial, subclinical symptoms to clinically overt PE, frequently with other sexual comorbidities. Thus, the current definitions of PE warrant review, in order to consider and propose a new taxonomy encompassing other unaddressed, crucial clinical aspects of PE. These newly proposed criteria include the recommendation for a primary screening for erectile dysfunction (ED), as PE and ED can be comorbid in up to 50% of patients but have never before been considered as a unified clinical entity. In order to facilitate clinical practice and improve clinical management of men with PE and comorbid conditions, we propose and define the new taxonomic clinical entities of subclinical PE (SPE) and loss of control of erection and ejaculation (LCEE). Application of these diagnoses to men who meet the criteria for SPE and/or LCEE, but not the overt conditions, could improve access to treatment for these patients and reduce progression to the more serious clinical disorder.

Premature ejaculation: an update on definition and pathophysiology

Premature ejaculation (PE) is the most common male sexual dysfunction, which represents a diagnostic as well as a therapeutic challenge for physicians. However, no universally accepted definition is currently available for PE. As a result, physicians continue to diagnose patients with PE according to major guidelines set by the professional societies. These guidelines either recommend the use of validated questionnaires or patient-reported outcomes. Recent efforts directed toward classifying PE may help provide a better understanding of the prevalence and risk factors of this disorder. While the exact etiology of PE has not been clearly elucidated, several risk factors have been strongly reported in the literature. Clearly, to understand the revised definition of PE, its etiology and pathophysiology is necessary to improve the clinical management of this medical condition and form the basis of future research in this regard. In this review, we highlight the past and current definitions of PE and present an appraisal on the classifications and theories suggested for the etiopathogenesis of PE.

Frequency of etiological factors among patients with acquired premature ejaculation: prospective, observational, single-center study

Although premature ejaculation (PE) is a common male sexual dysfunction, its pathophysiology has not been fully elucidated. Several medical problems such as erectile dysfunction, depression, anxiety, hormonal disorders and chronic prostatitis may play a role in the etiology of acquired PE. This study aims to evaluate the frequency of these etiologic factors among patients with acquired PE. Between May and July 2016, 53 men with acquired PE were included in the study. Self-estimated intravaginal ejaculation latency time (IELT) of these patients was recorded along with their medical history and physical examination findings. Moreover, 5-item version of the International Index of Erectile Function (IIEF-5), premature ejaculation profile (PEP), anxiety and depression scales (STAI-1, STAI-2, and BECK), and chronic prostatitis symptom index (NIH-CPSI) were administered. Fasting plasma glucose, follicle stimulating hormone (FSH), luteinizing hormone (LH), prolactin, total and free testosterone, total prostate specific antigen, thyroid and thyroid stimulating hormone levels were measured. Urine analysis and 2 cup tests were also studied. Mean age of the patients was 42.41 ± 11.14 (22-60). Mean duration of the PE complaint was 34.18 ± 36.76 (3-144) months. Mean IELT time of the patients was 38.28 ± 30.79 (3-180) s. Of the patients; 69.81%, 62.26%, 56.60%, 45.28%, 30.19%, 24.53%, 16.98%, 15.09%, and 7.55% had depression, chronic prostatitis, erectile dysfunction, anxiety, diabetes mellitus, abnormal FSH or LH, hypoprolactinemia, hyperthyroidism, and high testosterone levels, respectively. The results of our study revealed that anxiety disorders, depression, erectile dysfunction, and chronic prostatitis are common among patients with acquired PE and may play role in the etiology of this problem. There is a need for further researches related to the exact pathophysiology of acquired PE with larger number of patients.

Sexual function and depressive symptoms in young women with overt hyperthyroidism

OBJECTIVE

Despite high prevalence in a female population, surprisingly little is known about sexual functioning of women with thyroid hyperfunction. This study was aimed at assessing female sexual function and depressive symptoms in women with overt hyperthyroidism of autoimmune and non-autoimmune origin.

STUDY DESIGN

The study included three age-matched groups of young women inhabiting the Upper Silesia (a selenium-deficient and iodine-sufficient area): individuals with overt hyperthyroidism induced by Graves' disease (group A, n = 31), women with overt hyperthyroidism caused by toxic multinodular goiter or toxic adenoma (group B, n = 30) and women with normal thyroid function (group C, n = 34). Apart from measuring serum hormone levels, serum antibody titers and determining calculated parameters of thyroid homeostasis, all women completed questionnaires evaluating femalesexual function (FSFI) and depressive symptoms (BDI-II).

RESULTS

The mean total FSFI score and all domain scores were lower while the overall BDI-II score was higher in both groups of women with overt hyperthyroidism than in the control group, and correlated with thyrotropin and free thyroid hormone levels, as well as with the SPINA-GT index. The FSFI score as well as domain scores for desire, arousal and sexual satisfaction were lower, while the BDI-II score was higher in group A than in group B. In group A, the total FSFI score, desire, arousal, sexual satisfaction and severity of depressive symptoms correlated with TRAb and TPOAb titers.

CONCLUSION

The obtained results suggest that excessive thyroid hormone production and thyroid autoimmunity have an additive effect on sexual functioning and mood.

Effect of Thyroid Hormone Derangements on Sexual Function in Men and Women

INTRODUCTION

Sexual dysfunction affects many people, with 33‒60% of women reporting sexual dysfunction and 8‒52% of men with erectile dysfunction or premature ejaculation. In an effort to determine the constellation of factors responsible for sexual dysfunction, the effect of thyroid hormone derangements has been of recent interest.

AIM

To investigate the associations between thyroid hormones and sexual dysfunction in women and men.

METHODS

Literature was reviewed to examine the effects of hypo- and hyperthyroidism on sexual function.

MAIN OUTCOME MEASURE

We present a summary of the effects of thyroid dysfunction on domains of sexual functioning.

RESULTS

Most studies demonstrate that men with hypo- and hyperthyroidism have increased rates of sexual dysfunction, including erectile dysfunction in men with hypothyroidism. However, studies vary on the strength of correlation between hormonal derangement and level of sexual dysfunction. In both men with hyper- and hypothyroidism, treating the thyroid disorder at least partially reverses sexual dysfunction. In contrast, the current literature provides no consensus on the effect of hypothyroidism, hyperthyroidism, or Hashimoto's thyroiditis on female sexual function. In studies that observed increased rates of sexual dysfunction in women with thyroid disorders, correction of the thyroid derangement resulted in resolution of some sexual dysfunction. Studies are also conflicted on whether there is a relationship between the degree of sexual dysfunction and the degree of hormone derangement in women. However, prior work has demonstrated a relationship between thyroid autoantibodies and sexual dysfunction in women.

CONCLUSION

Thyroid dysfunction is an important factor in the pathogenesis of sexual dysfunction in men and possibly women. Evidence suggests a reversibility of sexual dysfunction with correction of thyroid dysfunction, although the exact pathophysiology of thyroid-mediated sexual dysfunction remains unknown. However, current evidence supports thyroid derangements rather than autoantibodies as the causative factor in men, whereas autoantibodies appear to play a more prominent role in women. Bates JN, Kohn TP, Pastuszak AW. Effect of Thyroid Hormone Derangements on Sexual Function in Men and Women. Sex Med Rev 2020;8:217-230.

Effects of the dopamine D3 receptor agonist 7-hydroxy-2-(di-N-propylamino) tetralin in hyperthyroidism-induced premature ejaculation rat model

Various factors are involved in the aetiology of premature ejaculation (PE). Hyperthyroidism is one of the causes of acquired PE, but the exact mechanism by which it causes the disorder is not yet understood. The aim of this study was to evaluate the role of the dopaminergic system in hyperthyroidism-induced PE by the intracerebroventricular microinjection of the preferentially active dopamine receptor agonist 7-hydroxy-2-(di-N-propylamino) tetralin (7-OH-DPAT) in a rat model of this disorder. Wistar rats were randomly divided into hyperthyroid and control groups, and ejaculation was induced by the ICV administration of 7-OH-DPAT. To evaluate the emission and expulsion phases of ejaculation, measurements of seminal vesicle pressure (SVP) and electromyographic recordings of the bulbospongiosus muscle were taken. The interval between the 7-OH-DPAT administration and the first ejaculation was significantly less in the hyperthyroid group (p < .01) than in the control group, and the maximum amplitude of the SVP values revealed a statistically significant difference between the groups (p < .01). The intervals between contractions of the seminal vesicle and bulbospongiosus muscles were also significantly less in the hyperthyroid group (p = .0187) than in the control group. No other results differed significantly between the groups. This study determined that hyperthyroidism altered only the emission phase of ejaculation.

Assessment of hormonal activity in patients with premature ejaculation

Purpose

Premature ejaculation is considered the most common type of male sexual dysfunction. Hormonal controls of ejaculation have not been exactly elucidated. The aim of our study is to investigate the role of hormonal factors in patients with premature ejaculation.

Materials and Methods

Sixty-three participants who consulted our outpatient clinics with complaints of premature ejaculation and 39 healthy men as a control group selected from volunteers were included in the study. A total of 102 sexual active men aged between 21 and 76 years were included. Premature ejaculation diagnostic tool questionnaires were used to assessment of premature ejaculation. Serum levels of follicle stimulating hormone, luteinizing hormone, prolactin, total and free testosterone, thyroid-stimulating hormone, free triiodothyronine and thyroxine were measured.

Results

Thyroid-stimulating hormone, luteinizing hormone, and prolactin levels were significantly lower in men with premature ejaculation according to premature ejaculation diagnostic tool (p=0.017, 0.007 and 0.007, respectively). Luteinizing hormone level (OR, 1.293; p=0.014) was found to be an independent risk factor for premature ejaculation.

Conclusions

Luteinizing hormone, prolactin, and thyroid-stimulating hormone levels are associated with premature ejaculation which was diagnosed by premature ejaculation diagnostic tool questionnaires. The relationship between these findings have to be determined by more extensive studies.

The relationship between acquired premature ejaculation and metabolic syndrome: a prospective, comparative study

The aim of this study was to investigate the relationship between metabolic syndrome (MetS) and acquired premature ejaculation (PE). A total of 100 patients with acquired PE and 100 control cases were enrolled in the study. After obtaining a detailed medical history, anthropometric (weight, height and waist circumference) and blood pressure measurements were performed. Ejaculation and erection functions were evaluated by Premature Ejaculation Diagnostic Tool (PEDT) and International Index of Erectile Function-5 (IIEF-5), respectively. Self-estimated intravaginal ejaculatory latency time (IELT) of the participants was recorded. Fasting blood samples were taken for biochemical and hormonal work-up. The median PEDT scores were 16 (9-22) and 4.5 (2-8) in acquired PE and control groups, respectively (P<0.001). The mean estimated IELT values in PE patients and controls were 36.1±46.5  versus 488.2±313.8 s (P<0.001). MetS was diagnosed in 51 patients (51%) in the PE group and 24 (24%) participants in the control group (P<0.001). A significant negative correlation was observed between the components of MetS and estimated IELT, except for diastolic blood pressure. Moreover, there was a significant positive correlation between the all components of MetS and total PEDT score, except for fasting blood glucose and high-density lipoprotein cholesterol (HDL) levels. Logistic regression analysis revealed that, except blood pressure and HDL levels, MetS components were significant risk factors for PE after adjusting for age and total testosterone. In conclusion, MetS is associated with acquired PE.

Epidemiology of delayed ejaculation

A large body of literature on diminished ejaculatory disorders has been generated without the use of a clear diagnostic definition. Many studies have not distinguished between the orgasm and ejaculation disorders leading to doubtful results. Delayed ejaculation (DE) is one of the diminished ejaculatory disorders, which range from varying delays in ejaculatory latency to a complete inability to ejaculate. The present review is aimed at providing a comprehensive overview of the current knowledge on the definition and epidemiology of diminished ejaculatory disorders. We focus on the acquired diseases, such as benign prostatic hyperplasia (BPH) and specific drug regimens that may cause an iatrogenic form of ejaculatory disorder. In addition, the impact of aging is discussed since the prevalence of DE appears to be moderately but positively related to age. Finally, we also focus on the importance of the hormonal milieu on male ejaculation. To date, evidence on the endocrine control of ejaculation is derived from small clinical trials, but the evidence suggests that hormones modulate the ejaculatory process by altering its overall latency.

Dapoxetine and the treatment of premature ejaculation

Background

Premature ejaculation (PE) is the most common male sexual complaint. Off-label oral selective serotonin reuptake inhibitors (SSRIs) are commonly prescribed for the treatment of PE. Dapoxetine is a short-acting SSRI specifically designed for on-demand use. The objective of this communication is to summarize the clinical and physiological evidence regarding the role of the serotonergic pathway and specifically dapoxetine in the treatment of PE.

Methods

A PubMed search was conducted on articles reporting data on dapoxetine for the treatment of PE. Articles describing the pathophysiology and treatment options for PE were additionally included for review.

Results

The etiology of PE is multi-factorial in nature. There are many treatment options for PE such as psychological/behavioral therapy, topical anesthetic agents, phosphodiesterase type 5 (PDE-5) inhibitors, and tramadol hydrochloride. SSRIs play a major role in PE treatment. Animal and clinical studies in addition to its pharmacokinetic document dapoxetine’s clinical efficacy and safety for on-demand treatment of PE.

Conclusions

Dapoxetine demonstrates clinical efficacy and a favorable side effect profile. Dapoxetine is currently the oral drug of choice for on-demand treatment of PE.

Is thyroid hormones evaluation of clinical value in the work-up of males of infertile couples?

STUDY QUESTION

Is thyroid hormones (TH) evaluation of clinical value in the work-up of males of infertile couples?

STUDY ANSWER

Our results suggest that TH evaluation is not mandatory in the work-up of male infertility.

WHAT IS KNOWN ALREADY

A few previous studies performed on a limited series of subjects reported a negative impact of hyper- and hypo-thyroidism on semen volume, sperm concentration, progressive motility and normal morphology. No previous study has systematically evaluated associations between TH variation, semen parameters and ultrasound characteristics of the male genital tract.

STUDY DESIGN, SIZE AND DURATION

Cross-sectional analysis of a consecutive series of 172 subjects seeking medical care for couple infertility from September 2010 to November 2014.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Of the entire cohort, 163 men (age 38.9 ± 8.0 years) free of genetic abnormalities were studied. All subjects underwent a complete andrological and physical examination, biochemical and hormonal assessment, scrotal and transrectal colour-Doppler ultrasound (CDUS) and semen analysis (including seminal interleukin 8 levels, sIL-8) evaluation within the same day.

MAIN RESULTS AND THE ROLE OF CHANCE

Among the patients studied, 145 (88.9%) showed euthyroidism, 6 (3.7%) subclinical hyper- and 12 (7.4%) subclinical hypo-thyroidism. No subjects showed overt hyper- or hypo-thyroidism. At univariate analysis, no associations among thyroid-stimulating hormone (TSH) or TH levels and sperm parameters were observed. Conversely, we observed positive associations among free triiodothyronine (fT3) and free thyroxine (fT4) levels, ejaculate volume and seminal fructose levels. In a multivariate model, after adjusting for confounders such as age, body mass index, smoking habit, sexual abstinence, calculated free testosterone, prolactin and sIL-8 levels, only the associations found for fT3 levels were confirmed. When CDUS features were investigated, using the same multivariate model, we found positive associations between fT3 levels and seminal vesicles (SV) volume, both before and after ejaculation (adj. r = 0.354 and adj. r = 0.318, both P < 0.0001), as well as with SV emptying (ΔSV volume; adj. r = 0.346, P < 0.0001) and echo-texture inhomogeneity. In addition, after adjusting for confounders, negative associations between fT4 levels and epididymal body and tail diameters were found. No significant associations between TSH or TH levels and CDUS features of other organs of the male genital tract, including testis and prostate, were found. Finally, when the features of subjects with euthyroidism, subclinical hypo- and hyper-thyroidism were compared, no significant differences in seminal or hormonal parameters were found. Conversely, evaluating CDUS parameters, subjects with subclinical hyperthyroidism showed a higher difference between the SV longitudinal diameters measured before and after ejaculation when compared with that of subclinical hypothyroid men, even after adjusting for confounders (P < 0.007). All the other male genital tract CDUS characteristics did not differ among groups.

LIMITATIONS, REASONS FOR CAUTION

First, the number of patients investigated is relatively small and those with (subclinical) thyroid dysfunctions are an even smaller number; hence, it is therefore difficult to draw firm conclusions. Moreover, the present results are derived from patients consulting an Italian Andrology Clinic for couple infertility, and could have different characteristics from the male general population or from those males consulting general practitioners for reasons other than couple infertility. Finally, due to the cross-sectional nature of the study, neither a causality hypothesis nor mechanistic models can be inferred.

WIDER IMPLICATIONS OF THE FINDINGS

Although no associations between TH and sperm parameters were observed, present data support a positive effect of TH on SV size and a permissive role on the ejaculatory machinery, likely through an action on SV and epididymal contractility. This is the first study reporting such evidence. However, in contrast with the view that TH assessment is important for female fertility, our results do not support a systematic evaluation of thyroid function in males of infertile couples. How TH abnormalities impact male fertility needs to be addressed by further studies.

STUDY FUNDING/COMPETING INTERESTS

No funding was received for the study. None of the authors have any conflict of interest to declare.

Normal male sexual function: emphasis on orgasm and ejaculation

Orgasm and ejaculation are two separate physiological processes that are sometimes difficult to distinguish. Orgasm is an intense transient peak sensation of intense pleasure creating an altered state of consciousness associated with reported physical changes. Antegrade ejaculation is a complex physiological process that is composed of two phases (emission and expulsion), and is influenced by intricate neurological and hormonal pathways. Despite the many published research projects dealing with the physiology of orgasm and ejaculation, much about this topic is still unknown. Ejaculatory dysfunction is a common disorder, and currently has no definitive cure. Understanding the complex physiology of orgasm and ejaculation allows the development of therapeutic targets for ejaculatory dysfunction. In this article, we summarize the current literature on the physiology of orgasm and ejaculation, starting with a brief description of the anatomy of sex organs and the physiology of erection. Then, we describe the physiology of orgasm and ejaculation detailing the neuronal, neurochemical, and hormonal control of the ejaculation process.

Hormonal correlations of premature ejaculation

Premature ejaculation is the most frequent male sexual dysfunction, significantly impairing quality of life of both the patient and the partner and affecting up to one-third of men of every age. In the last years, our knowledge about this topic has greatly increased, and studies on the causes and treatments related to ejaculatory disorders have shed a light on previously uncharted territory. Public interest on sexual dysfunctions has likewise increased in the general population: the time lapse between the first symptoms of sexual dysfunction and the seeking of medical advice has been significantly reduced, whereas demand for a treatment has markedly increased. A role of endocrine regulation has been established in all the aspects of male reproduction; however, the endocrine control of ejaculation is not fully understood. Sex steroid, pituitary, and thyroid hormones have all been advocated as potential candidates in the regulation of the ejaculatory process, but exact mechanisms are not clear yet and further studies are required in order to identify potential targets for treatment.

Associations between Salivary Testosterone Levels, Androgen-Related Genetic Polymorphisms, and Self-Estimated Ejaculation Latency Time

Introduction

Recently, testosterone (T) has been shown to be associated with premature ejaculation (PE) symptoms in the literature. Furthermore, studies suggest that the etiology of PE is partly under genetic control.

Aim

The aim of this study was to reassess findings suggesting an association between testosterone (T) and a key symptom of PE, ejaculation latency time (ELT), as well as exploratively investigating associations between six androgen-related genetic polymorphisms and ELT.

Materials and Methods

Statistical analyses were performed on a population-based sample of 1,429 Finnish men aged 18–45 years (M = 26.9, SD = 4.7). Genotype information was available for 1,345–1,429 of these (depending on the polymorphism), and salivary T samples were available from 384 men. Two androgen receptor gene-linked, two 5-alpha-reductase type 2-gene-linked, and two sex hormone-binding globuline gene-linked polymorphisms were genotyped.

Main Outcome Measures

Ejaculatory function was assessed using self-reported ELT.

Results

We found no association between salivary T levels and ELT. We found a nominally significant association between a 5-alpha-reductase type 2-gene-linked polymorphism (rs2208532) and ELT, but this association did not remain significant after correction for multiple testing. One single nucleotide polymorphism in the sex hormone-binding globulin gene (rs1799941) moderated (significantly after correction for multiple testing) the association between salivary T and ELT, so that A:A genotype carriers had significantly lower salivary T levels as a function of increasing ELT compared with other genotype groups.

Conclusions

We were unable to find support for the hypothesis suggesting an association between T levels and ELT, possibly because of the low number of phenotypically extreme cases (the sample used in the present study was population based). Our results concerning genetic associations should be interpreted with caution until replication studies have been conducted. Jern P, Westberg L, Ankarberg-Lindgren C, Johansson A, Gunst A, Sandnabba NK, and Santtila P. Associations between salivary testosterone levels, androgen-related genetic polymorphisms, and self-estimated ejaculation latency time. Sex Med 2014;2:107–114.

An Update of the International Society of Sexual Medicine's Guidelines for the Diagnosis and Treatment of Premature Ejaculation (PE)

INTRODUCTION

In 2009, the International Society for Sexual Medicine (ISSM) convened a select panel of experts to develop an evidence-based set of guidelines for patients suffering from lifelong premature ejaculation (PE). That document reviewed definitions, etiology, impact on the patient and partner, assessment, and pharmacological, psychological, and combined treatments. It concluded by recognizing the continually evolving nature of clinical research and recommended a subsequent guideline review and revision every fourth year. Consistent with that recommendation, the ISSM organized a second multidisciplinary panel of experts in April 2013, which met for 2 days in Bangalore, India. This manuscript updates the previous guidelines and reports on the recommendations of the panel of experts.

AIM

The aim of this study was to develop clearly worded, practical, evidenced-based recommendations for the diagnosis and treatment of PE for family practice clinicians as well as sexual medicine experts.

METHOD

A comprehensive literature review was performed.

RESULTS

This article contains the report of the second ISSM PE Guidelines Committee. It offers a new unified definition of PE and updates the previous treatment recommendations. Brief assessment procedures are delineated, and validated diagnostic and treatment questionnaires are reviewed. Finally, the best practices treatment recommendations are presented to guide clinicians, both familiar and unfamiliar with PE, in facilitating treatment of their patients.

CONCLUSION

Development of guidelines is an evolutionary process that continually reviews data and incorporates the best new research. We expect that ongoing research will lead to a more complete understanding of the pathophysiology as well as new efficacious and safe treatments for this sexual dysfunction. We again recommend that these guidelines be reevaluated and updated by the ISSM in 4 years. Althof SE, McMahon CG, Waldinger MD, Serefoglu EC, Shindel AW, Adaikan PG, Becher E, Dean J, Giuliano F, Hellstrom WJG, Giraldi A, Glina S, Incrocci L, Jannini E, McCabe M, Parish S, Rowland D, Segraves RT, Sharlip I, and Torres LO. An update of the International Society of Sexual Medicine's guidelines for the diagnosis and treatment of premature ejaculation (PE). Sex Med 2014;2:60-90.

An update of the International Society of Sexual Medicine's guidelines for the diagnosis and treatment of premature ejaculation (PE)

INTRODUCTION

In 2009, the International Society for Sexual Medicine (ISSM) convened a select panel of experts to develop an evidence-based set of guidelines for patients suffering from lifelong premature ejaculation (PE). That document reviewed definitions, etiology, impact on the patient and partner, assessment, and pharmacological, psychological, and combined treatments. It concluded by recognizing the continually evolving nature of clinical research and recommended a subsequent guideline review and revision every fourth year. Consistent with that recommendation, the ISSM organized a second multidisciplinary panel of experts in April 2013, which met for 2 days in Bangalore, India. This manuscript updates the previous guidelines and reports on the recommendations of the panel of experts.

AIM

The aim of this study was to develop clearly worded, practical, evidenced-based recommendations for the diagnosis and treatment of PE for family practice clinicians as well as sexual medicine experts.

METHOD

A comprehensive literature review was performed.

RESULTS

This article contains the report of the second ISSM PE Guidelines Committee. It offers a new unified definition of PE and updates the previous treatment recommendations. Brief assessment procedures are delineated, and validated diagnostic and treatment questionnaires are reviewed. Finally, the best practices treatment recommendations are presented to guide clinicians, both familiar and unfamiliar with PE, in facilitating treatment of their patients.

CONCLUSION

Development of guidelines is an evolutionary process that continually reviews data and incorporates the best new research. We expect that ongoing research will lead to a more complete understanding of the pathophysiology as well as new efficacious and safe treatments for this sexual dysfunction. We again recommend that these guidelines be reevaluated and updated by the ISSM in 4 years.

Serum testosterone and gonadotropins levels in patients with premature ejaculation: A comparison with normal men

BACKGROUND

To investigate the role of testosterone (T) in the pathogenesis of ejaculatory symptoms, particularly premature ejaculation (PE).

MATERIALS AND METHODS

A total of 41 male patients with PE as well as 41 controls with no sexual dysfunction were recruited in this cross-sectional study. We used the stopwatch measurement to monitor the intravaginal ejaculatory latency time (IELT). Patients with mean IELT values lower than 60 s were considered to have PE. Serum levels of follicle stimulating hormone (FSH), luteinizing hormone (LH), prolactin (PRL), total testosterone (TT) and free testosterone (FT) were measured in patients as well as controls. Patients with thyroid dysfunction, hypogonadism, hypertension and dyslipidemia were excluded from the study.

RESULTS

The serum levels of FT and FSH were significantly higher in cases (P = 0.036 and 0.003, respectively). There was no significant difference between TT, LH and PRL levels of the two groups.

CONCLUSION

Patients with PE have higher FT and FSH levels compared with normal men. The causative relationship between these entities and also the clinical importance of this finding has to be determined by more comprehensive studies.

Safety and efficacy of tramadol hydrochloride on treatment of premature ejaculation

Premature ejaculation (PE) is the most common sexual disorder. It affects 20%-30% of adult men; the aetiology of this condition has not yet been elucidated. The aim of this study is to evaluate the efficacy, safety, tolerability, undesirable effects and improved satisfaction with sexual intercourse with tramadol hydrochloride at different dosages for the treatment of PE. A total of 300 patients who presented with lifelong (primary) PE were included in this study. The study was performed for 28 weeks, in which placebo (starch tablet) was given for 4 weeks, and active ingredient (tramadol hydrochloride) was administered at different therapeutic dosages for 24 weeks. Patients were divided into three equal groups, each consisting of 100 patients. The first group (A) was given tramadol hydrochloride capsule 25 mg. The second group (B) was given tramadol hydrochloride capsule 50 mg. The third group (C) was given tramadol hydrochloride capsule 100 mg. All of the 300 participants included completed the study voluntarily. The age of the patients varied from 25 to 50 years. After the treatment period, the recorded data were collected for each group and analysed. The results showed a highly significant increase in the mean intravaginal ejaculatory latency time (IELT) in all groups compared to baseline data (P<0.0001). We concluded that using tramadol hydrochloride at different doses on demand for the treatment of PE is effective, safe and tolerable, with minimal undesirable effects, and approval for this indication should be sought.

The hormonal control of ejaculation

Hormones regulate all aspects of male reproduction, from sperm production to sexual drive. Although emerging evidence from animal models and small clinical studies in humans clearly point to a role for several hormones in controlling the ejaculatory process, the exact endocrine mechanisms are unclear. Evidence shows that oxytocin is actively involved in regulating orgasm and ejaculation via peripheral, central and spinal mechanisms. Associations between delayed and premature ejaculation with hypothyroidism and hyperthyroidism, respectively, have also been extensively documented. Some models suggest that glucocorticoids are involved in the regulation of the ejaculatory reflex, but corresponding data from human studies are scant. Oestrogens regulate epididymal motility, whereas testosterone can affect the central and peripheral aspects of the ejaculatory process. Overall, the data of the endocrine system in regulating the ejaculatory reflex suggest that widely available endocrine therapies might be effective in treating sexual disorders in these men. Indeed, substantial evidence has documented that treatments of thyroid diseases are able to improve some ejaculatory difficulties.

Hyperthyroidism and erectile dysfunction: a population-based case-control study

Dysthyroidism has been highlighted as a common endocrine disorder associated with erectile dysfunction (ED); however, to date, no large-scale population-based study has investigated the association between hyperthyroidism and ED. This case-control study aimed to explore the association between ED and hyperthyroidism using a population-based data set. In total, 6310 adult patients who received new diagnoses of ED were recruited as cases together with 18 930 matched enrollees with no history of ED who served as controls. Conditional logistic regressions were conducted to explore the association between ED and having been previously diagnosed with hyperthyroidism. In total, 569 (2.3%) of the 25 240 sampled subjects had been diagnosed with hyperthyroidism before the index date; hyperthyroidism was found in 207 (3.3%) cases and 362 (1.90%) controls. After adjusting for potential confounding factors, the odds ratio (OR) of prior hyperthyroidism among cases was 1.64 (95% confidence interval=1.37-1.96, P<0.001) than that of controls. No association was detected between prior hyperthyroidism and ED for the 18-30, 30-39 and >70 age groups. Subjects aged between 60 and 69 years had the highest ORs for prior hyperthyroidism among cases when compared to controls (OR=1.84; 95% confidence interval=1.20-2.84; P<0.001). Our study further confirms the existence of an association between ED and prior hyperthyroidism.

Hormonal causes of male sexual dysfunctions and their management (hyperprolactinemia, thyroid disorders, GH disorders, and DHEA)

INTRODUCTION

Besides hypogonadism, other endocrine disorders have been associated with male sexual dysfunction (MSD).

AIM

To review the role of the pituitary hormone prolactin (PRL), growth hormone (GH), thyroid hormones, and adrenal androgens in MSD.

METHODS

A systematic search of published evidence was performed using Medline (1969 to September 2011). Oxford Centre for Evidence-Based Medicine-Levels of Evidence (March 2009) was applied when possible.

MAIN OUTCOME MEASURES

The most important evidence regarding the role played by PRL, GH, thyroid, and adrenal hormone was reviewed and discussed.

RESULTS

Only severe hyperprolactinemia (>35 ng/mL or 735 mU/L), often related to a pituitary tumor, has a negative impact on sexual function, impairing sexual desire, testosterone production, and, through the latter, erectile function due to a dual effect: mass effect and PRL-induced suppression on gonadotropin secretion. The latter is PRL-level dependent. Emerging evidence indicates that hyperthyroidism is associated with an increased risk of premature ejaculation and might also be associated with erectile dysfunction (ED), whereas hypothyroidism mainly affects sexual desire and impairs the ejaculatory reflex. However, the real incidence of thyroid dysfunction in subjects with sexual problems needs to be evaluated. Prevalence of ED and decreased libido increase in acromegalic patients; however, it is still a matter of debate whether GH excess (acromegaly) may create effects due to a direct overproduction of GH/insulin-like growth factor 1 or because of the pituitary mass effects on gonadotropic cells, resulting in hypogonadism. Finally, although dehydroepiandrosterone (DHEA) and its sulfate have been implicated in a broad range of biological derangements, controlled trials have shown that DHEA administration is not useful for improving male sexual function.

CONCLUSIONS

While the association between hyperprolactinemia and hypoactive sexual desire is well defined, more studies are needed to completely understand the role of other hormones in regulating male sexual functioning.

Hormonal evaluation in premature ejaculation

INTRODUCTION

Premature ejaculation (PE) is a frequently encountered sexual dysfunction in men. It significantly impairs quality of life of the affected male and his partner. The aim of this study is to investigate the role of hormonal factors in patients with PE.

PATIENTS AND METHODS

107 male patients aged between 26 and 64 years (mean 45.1 ± 10.36) who consulted our outpatient clinics with complaints of PE and 94 healthy males (48.1 ± 11.81 years) as a control group were included in the study.

RESULTS

When mean serum hormone concentrations of both groups were compared, levels of prolactin and free T4 were found to be significantly higher in the PE group relative to the control group (p < 0.05). At least one of the hormonal parameters was abnormal in 36 cases (33.6%) with PE, compared to only 22 (23.4%) of the controls. The number of hyperprolactinemic cases was found to be significantly increased in the PE group (p < 0.05).

CONCLUSION

We feel that during the evaluation of this problem, which affects great numbers of men and their partners throughout the world, consideration of potential effects of hormonal factors might be beneficial.

Are urology residents ready to treat premature ejaculation after their training?

INTRODUCTION

The management of premature ejaculation (PE) among urology residents (URs) in the era of standard definition and new treatments is unknown.

AIM

To determine how future urologists currently address PE and to review their adherence to guidelines.

METHODS

A specifically designed survey on the preferred approaches to the treatment of PE was given to residents during the Eighth European Urology Education Programme. The results were tabled, and descriptive statistics were used to analyze differences in practice patterns.

MAIN OUTCOMES MEASURES

The responses are compared with clinical guidelines and recommendations.

RESULTS

A total of 360 URs attended the recommendation course, and 140 answered the survey (response rate: 38.8%). Seventeen (12.1%) of the respondents considered PE to be a very common sexual dysfunction, 62 (44.3%) considered PE to be frequent, 33 (23.6%) considered this condition uncommon, and 28 (20%) did not consider PE to be a dysfunction. Regarding incidents, 67 residents (47.9%) treated one patient per week. To assess PE, 132 (94.3%) used sexual history, 37 (26.4%) used physical examination, 38 (27.1%) used questionnaires, and 4 (2.9%) used laboratory testing. The preferred initial management strategy for PE was psychological/behavioral therapy for 65 (46.4%) residents. Topical anesthetic, andrological referral, and prescription of selective serotonin reuptake inhibitors (SSRIs) on demand were favored by 34 (24.3%), 19 (13.6%), and 8 (12.9%) of the respondents, respectively. Other options were psychiatric referral, which was preferred by two (1.4%) respondents, and prescription of daily SSRIs, which was preferred by two (1.4%) respondents. The preferred secondary treatment for patients who did not improve initially was prescription of SSRIs for on demand, which was 46 (32.9%) respondents. In cases where patients had concomitant erectile dysfunction (ED), 16 (11.4%) URs treated only the ED and 60 (42.9%) treated both conditions.

CONCLUSIONS

The majority of URs follow the established guidelines for diagnosis of PE, but not for treatment. The URs have an insufficient medical education in sexual medicine.

Premature and delayed ejaculation: two ends of a single continuum influenced by hormonal milieu

Although it is well established that all the aspects of male reproduction are hormonally regulated, the endocrine control of the ejaculatory reflex is still not completely clarified. Sex steroids, thyroid and pituitary hormones (oxytocin and prolactin) have been proposed to control the ejaculatory process at various levels; however, only a few reports are currently available. The aim of this study was to evaluate the contribution of testosterone, thyrotropin (TSH) and prolactin (PRL) in the pathogenesis of ejaculatory dysfunction in a large series of subjects consulting for sexual dysfunction. Among the 2652 patients studied, 674 (25.2%) and 194 (7.3%) reported premature and delayed ejaculation (PE and DE), respectively. Categorizing ejaculatory difficulties on an eight-point scale starting from severe PE and ending with anejaculation (0 = severe PE, 1 = moderate PE, 2 = mild PE, 3 = no difficulties, 4 = mild DE, 5 = moderate DE, 6 = severe DE and 7 = anejaculation), PRL as well as TSH levels progressively increased from patients with severe PE towards those with anejaculation. Conversely, the opposite was observed for testosterone levels. All of these associations were confirmed after adjustment for age (adjusted r = 0.050, 0.053 and -0.038 for PRL, TSH and testosterone, respectively; all p < 0.05). When all hormonal parameters were introduced in the same regression model, adjusting for age, ΣMHQ (an index of general psychopathology) and use of selective serotonin reuptake inhibitor antidepressants, they were independently associated with ejaculatory problems (adjusted r = 0.056, 0.047 and -0.059 for PRL, TSH and testosterone, respectively; all p < 0.05). This study indicates endocrine system is involved in the control of ejaculatory function and that PRL, TSH and testosterone play an independent role.

Update on treatments for premature ejaculation

Current and upcoming treatment options for premature ejaculation (PE) are of global clinical interest. In 2008, the International Society for Sexual Medicine published an evidence-based definition for PE. While there are no US Food and Drug Administration-approved therapies for PE, the American Urological Association 2004 guidelines state the serotonergic antidepressants paroxetine, sertraline, fluoxetine and clomipramine and the topical lidocaine-prilocaine cream are effective treatment options. However, there are limitations associated with their use, which may be overcome by PE-specific therapies currently in development. Two agents that are in advanced stages of clinical development include: (i) dapoxetine, an on-demand short-acting selective serotonin reuptake inhibitor, and (ii) PSD502, a metered-dose aerosol containing lidocaine and prilocaine, also for on-demand treatment. Another on-demand agent in development is tramadol, a weak opioid that is currently approved for treating pain. Coupled with efficient diagnosis, it is hoped that these newer agents will improve the quality of life for patients who suffer from PE.

Investigation of the neural target level of hyperthyroidism in premature ejaculation in a rat model of pharmacologically induced ejaculation

INTRODUCTION

Association between hyperthyroidism and premature ejaculation was demonstrated in clinical studies.

AIM

The aim of this study is to determine the target level of changes on ejaculatory physiology under hyperthyroid states.

METHODS

p-Chloroamphetamine (PCA)-induced pharmacologic ejaculation model with 24 male Wistar rats was used in the study. Subcutaneous injection of L-thyroxine for 14 days was performed to induce hyperthyroidism. At the end of the injection period, thyroid hormone status was evaluated by serum thyroid-stimulating hormone measurements in all rats. At the beginning of the operations, complete spinal transections (tx) at the T8-T9 level were performed to half of the L-thyroxine-injected and control group rats. Thus, experimental groups were constructed as follows: Group 1--control-spinal intact (n=6), group 2-control-spinal tx (n=6), group 3-hyperthyroid-spinal intact (n=6), and group 4-hyperthyroid-spinal tx (n=6). Ejaculatory responses were recorded before and 30 minutes after intraperitoneal administration of 5 mg/kg PCA.

MAIN OUTCOME MEASURES

During the operations, seminal vesicle (SV) catheterization and bulbospongiosus (BS) muscle dissections were performed in all rats to demonstrate SV pressure (SVP) BS electromyographic (EMG) activity changes.

RESULTS

Following PCA administration SVP tonic amplitude, SV phasic contraction (SVPC) frequency, SVPC maximal amplitude, and BS EMG area under curve values were higher in hyperthyroid intact rats than in control intact rats. The time interval between PCA administration and first ejaculation of hyperthyroid intact rats were significantly shorter than control intact rats (261 ± 7.30 seconds vs. 426 ± 49.6 seconds, P=0.008). All of the changes in the ejaculatory parameters that were induced by hyperthyroidism were completely resolved after spinal transections at the T8-T9 level in group 4.

CONCLUSION

In this study, we confirmed the recent data that hyperthyroidism affects both the emission and expulsion phases of ejaculation. The changes that were induced by hyperthyroidism on ejaculatory physiology probably take place in the supraspinal centers above T8 level.

[Update hyperthyreoidism]

Hyperthyroidism is mainly caused by Graves' disease and toxic adenoma or multinodular goiter. In Europe, treatment of both disorders is usually started with antithyroidal drugs such as methimazole. Complications include agranulocytosis and the risk is dose-dependent. The starting dose of methimazole should not exceed 15-20 mg/d. Propylthiouracil can cause severe liver failure, leading to liver transplantation or death. Propylthiouracil, therefore, should not be used as first line agent and is only recommended when an antithyroid drug is to be started during the first trimester of pregnancy or in individuals who have experienced adverse responses to methimazole. Toxic adenoma is finally treated with radioioidine. To reduce the risk of treatment failure, antithyroidal drugs should be stopped at least one week prior to radioiodine. For Graves' disease, remission is unlikely if antibodies against the TSH-receptor remain above 10 mU/l after 6 months of antithyroidal treatment and radioiodine or thyroidectomy can be recommended. Thyroidectomy should be performed as (near) total thyreoidectomy.

Self-reported halitosis and emotional state: impact on oral conditions and treatments

Background

Halitosis represents a common dental condition, although sufferers are often not conscious of it. The aim of this study was to examine behavior in a sample of Italian subjects with reference to self-reported halitosis and emotional state, and specifically the presence of dental anxiety.

Methods

The study was performed on Italian subjects (N = 1052; range 15-65 years). A self-report questionnaire was used to detect self-reported halitosis and other variables possibly linked to it (sociodemographic data, medical and dental history, oral hygiene, and others), and a dental anxiety scale (DAS) divided into two subscales that explore a patient's dental anxiety and dental anxiety concerning dentist-patient relations. Associations between self-reported halitosis and the abovementioned variables were examined using multiple logistic regression analysis. Correlations between the two groups, with self-perceived halitosis and without, were also investigated with dental anxiety and with the importance attributed to one's own mouth and that of others.

Results

The rate of self-reported halitosis was 19.39%. The factors linked with halitosis were: anxiety regarding dentist patient relations (relational dental anxiety) (OR = 1.04, CI = 1.01-1.07), alcohol consumption (OR = 0.47, CI = 0.34-0.66), gum diseases (OR = 0.39, CI = 0.27-0.55), age > 30 years (OR = 1.01, CI = 1.00-1.02), female gender (OR = 0.71, CI = 0.51-0.98), poor oral hygiene (OR = 0.65, CI = 0.43-0.98), general anxiety (OR = 0.66, CI = 0.49-0.90), and urinary system pathologies (OR = 0.46, CI = 0.30-0.70). Other findings emerged concerning average differences between subjects with or without self-perceived halitosis, dental anxiety and the importance attributed to one's own mouth and that of others.

Conclusions

Halitosis requires professional care not only by dentists, but also psychological support as it is a problem that leads to avoidance behaviors and thereby limits relationships. It is also linked to poor self care. In the study population, poor oral health related to self-reported halitosis was associated with dental anxiety factors.

Ontogenetic profile of the expression of thyroid hormone receptors in rat and human corpora cavernosa of the penis

Introduction

In the last few years, various studies have underlined a correlation between thyroid function and male sexual function, hypothesizing a direct action of thyroid hormones on the penis.

Aim

To study the spatiotemporal distribution of mRNA for the thyroid hormone nuclear receptors (TR) α1, α2 and β in the penis and smooth muscle cells (SMCs) of the corpora cavernosa of rats and humans during development.

Methods

We used several molecular biology techniques to study the TR expression in whole tissues or primary cultures from human and rodent penile tissues of different ages.

Main Outcome Measure

We measured our data by semi-quantitative reverse transcription polymerase chain reaction (RT-PCR) amplification, Northern blot and immunohistochemistry.

Results

We found that TRα1 and TRα2 are both expressed in the penis and in SMCs during ontogenesis without development-dependent changes. However, in the rodent model, TRβ shows an increase from 3 to 6 days post natum (dpn) to 20 dpn, remaining high in adulthood. The same expression profile was observed in humans. While the expression of TRβ is strictly regulated by development, TRα1 is the principal isoform present in corpora cavernosa, suggesting its importance in SMC function. These results have been confirmed by immunohistochemistry localization in SMCs and endothelial cells of the corpora cavernosa.

Conclusions

The presence of TRs in the penis provides the biological basis for the direct action of thyroid hormones on this organ. Given this evidence, physicians would be advised to investigate sexual function in men with thyroid disorders. Carosa E, Di Sante S, Rossi S, Castri A, D'Adamo F, Gravina GL, Ronchi P, Kostrouch Z, Dolci S, Lenzi A, and Jannini EA. Ontogenetic profile of the expression of thyroid hormone receptors in rat and human corpora cavernosa of the penis. J Sex Med 2010;7:1381–1390.