Treatment of premature ejaculation by glans penis augmentation using hyaluronic acid gel: a pilot study

Surgical treatment of premature ejaculation: a narrative review

Recurrence after drug cessation is the biggest drawback of medical premature ejaculation (PE) treatments. Although these treatments are demonstrated to be safe and effective, most of the PE patients are interested in a more permanent solution. Despite the fact that currently available guidelines do not recommend surgical treatment for PE, some surgical interventions have been commonly performed for many years, especially in the Asian countries. The main purpose of these surgical treatments is to decrease the sensitivity of the glans penis. However, they are associated with irreversible complications such as penile deformity, sensory loss and erectile dysfunction. The aim of this narrative review is to summarize the advantages and disadvantages of various surgical interventions introduced for the treatment of PE. PubMed, Scopus and Web of Science have been utilized to search articles about glans penis augmentation and penile dorsal nerve interventions. A total of 11 articles were included, three articles excluded because they were in non-English languages. Glans penis augmentation offered a less invasive treatment that avoids severe side effects but requires retreatment in time. Selective dorsal neurectomy provided a more invasive but curative treatment alternative. However, more clinical data are necessary before surgical treatment options can be recommended to patients with PE.

Traditional, Complementary and Alternative Medicines in the Treatment of Ejaculatory Disorders: A Systematic Review

Background and Objectives: Ejaculatory dysfunction (EjD) is a common male sexual disorder that includes premature ejaculation, delayed ejaculation, retrograde ejaculation, and anejaculation. Although psychological and pharmacological treatments are available, traditional, complementary, and alternative medicine (TCAM) is reportedly used. However, the clinical evidence for TCAM in EjD remains unclear. Therefore, this study aims to systematically review human clinical trials investigating the use of TCAM to treat EjD. Materials and Methods: A systematic review of the literature following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines was conducted by searching Scopus and PubMed databases. Controlled clinical trials investigating a cohort of male patients diagnosed primarily with EjD and undergoing any TCAM intervention compared to any comparison group were included. Quality of the studies was assessed using the Cochrane Risk of Bias tool for randomized controlled trials. Results: Following article screening, 22 articles were included. Of these, 21 investigated TCAM in premature ejaculation, and only 1 investigated TCAM in retrograde ejaculation. Different TCAM categories included studies that investigated lifestyle, exercise and/or physical activities (n = 7); herbal medicine supplements (n = 5); topical herbal applications (n = 4); acupuncture or electroacupuncture (n = 3); vitamin, mineral and/or nutraceutical supplements (n = 1); hyaluronic acid penile injection (n = 1); and music therapy (n = 1). Only 31.8% (n = 7) of the included studies were found to have a low risk of bias. The available studies were widely heterogenous in the TCAM intervention investigated and comparison groups used. However, the included studies generally showed improved outcomes intra-group and when compared to placebo. Conclusions: Different TCAM interventions may have an important role particularly in the management of PE. However, more studies using standardized interventions are needed.

Hyaluronic acid injection to coronal sulcus of the penis for the treatment of premature ejaculation: a retrospective observational study

BACKGROUND

Hyaluronic acid (HA) injection has become a burgeoning method to treat premature ejaculation (PE) due to its high biocompatibility and structural properties.

PURPOSE

In this study, we proposed a modified technique: injecting hyaluronic acid around coronal sulcus to treat PE, aiming to decrease the complications of hyaluronic acid injection in penis while achieving similar effects.

METHOD

A total of 85 patients who had HA injection from January 2018 to December 2019 were analyzed retrospectively in our study. 31 patients received injection at glans penis and 54 patients received injection around coronal sulcus. Intravaginal ejaculation latency time (IELT) was mainly measured to estimate the efficacy and the severity of complications was assessed between two groups.

RESULTS

The mean IELT was 123.0 ± 37.28 s of all patients, 124.7 ± 39.01 s of patients injecting at glans penis and 121.9 ± 36.58 s of patients injecting around coronal sulcus. IELT of all patients increased to 482.1 ± 121.7 s at 1 month, 331.2 ± 81.2 s at 3 month and 280 ± 80.4 s at 6 month. In the group of injecting at glans penis, the incidence of complications is 25.8% and it is 1.9% in the group of injecting around coronal sulcus. No severe complication was reported in both groups.

CONCLUSION

The modified technique of injecting around coronal sulcus decreases complications and it has the potential to become a new injectable technique for treating premature ejaculation.

Outcome of hyaluronic acid gel injection in glans penis for treatment of lifelong premature ejaculation: A pilot study

Objective

To assess safety and efficacy of hyaluronic acid (HA) gel injection in glans penis for treatment of premature ejaculation (PE) using our new five puncture technique.

Patients and methods

This is a prospective, non-randomized clinical trial on HA gel injection in glans penis for all patients with lifelong PE; all patients were circumcised having heterosexual normal marital life and sexually active. Patients with history of ejaculatory medication use within the previous 3 months, psychiatric disorders, erectile dysfunction, lower urinary tract symptoms (LUTS) due to prostatitis and acquired PE were excluded from the study. A local anesthetic was applied to the skin of glans penis for 30 minutes before the injection of 2 ml HA in glans penis via 30-gauge needle using our new Five-puncture technique. Intra-vaginal ejaculatory latency time (IELT) was measured at 1, 3, 6 and 12 months after injection.

Results

Thirty patients completed our study follow up schedule. Mean age of the patients was 41.72 ± 8.50, while mean age of female partner was 37.23 ± 8.54 years. IELT was highly significantly increased (P-value < 0.001) after HA gel injection from baseline, which was in maximum 37.83 ± 11.01 sec at baseline to 323.03 ± 42.06, 281.07 ± 41.05, 241.03 ± 43.09 and 235.6 ± 41.87 sec after 1, 3, 6 and 12 months, respectively, after injection. Three patients complained from discomfort at the site of injection, two from bullae formation at the site of injection and one from ecchymosis, and all resolved spontaneously after 1 week to 10 days after injection.

Conclusion

HA gel injection in glans penis using our new five-puncture technique is a safe and effective method that ensures a modest long-term significant increase in IELT and improves ejaculatory control.

The Application of Hyaluronic Acid Injections in Functional and Aesthetic Andrology: A Narrative Review

Hyaluronic acid (HA) is a glycosaminoglycan widely utilised in different fields of medicine. We aimed to provide a comprehensive overview of the scientific evidence on the use of HA in andrology. A review of the literature to identify pertinent studies concerning the use of HA in andrology was carried out on the Medline, EMBASE, and the Cochrane databases, with no time restriction up to December 2022. Penile girth enlargement (PGE) using HA proved to be safe and effective in enhancing the diameter of the penis, with durable and satisfactory outcomes in long-term follow-up. Injection of HA in the glans seems to represent an alternative treatment option for those patients with premature ejaculation (PE) who fail to respond to conventional medications. HA intra-plaque injections represent a valid option which may contribute to restore sexual activity in patients with Peyronie's disease (PD). The adoption of HA filler injections should always be tailored to the patient's peculiar anatomy and underlying condition. More robust evidence is required to achieve a uniformed consensus regarding the use of HA in andrology, and further efforts should continue to improve the current injection techniques and HA products.

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.

Effects of One-Shot Hyaluronic Acid Injection in Lifelong Premature Ejaculation: A Pilot Study

The therapeutic management of premature lifelong ejaculation (PE) ranges from behavioral therapy to pharmacological and surgical treatments. Hyaluronic Acid (HA) injection into the glans penis is a non-surgical procedure, intended to reduce glans hypersensitivity, improving the intravaginal ejaculation latency time (IELT). HA injection can be performed through different techniques that, although safe and effective, rarely can cause local complications. In this pilot uncontrolled study, we tested the effectiveness of a new technique based on a single HA injection into the frenulum of the glans, to improve IELT in a sample of patients affected by PE. We observed a significant increase of the IELT after one (median 73.3, IQR 66.2–79.9 s) and two months (66.2, 63.1–73.9) that gradually decreased at three months, remaining still significantly higher than at baseline (34.8, 30.9–37.4). PEDT and IIEF questionnaires significantly improved compared to baseline in the first two months of follow-up (p < 0.001). In conclusion, the preliminary results emerging from this pilot uncontrolled study, highlight the effectiveness of this one-shot HA injection approach, although a larger sample and longer follow-up time are needed to standardize the procedure.

Efficacy and safety assessment of glandular augmentation with hyaluronic acid for premature ejaculation

Glandular augmentation (GA) with hyaluronic acid (HA) is a newly developed, minimally invasive therapy for patients with premature ejaculation (PE); however, evidence supporting its efficacy is scarce. To provide a comprehensive profile of GA with HA gel in managing PE, 184 patients with PE who received GA with HA gel therapy from October 2017 to November 2019 were included and followed up for 1 year. The Fan technique was applied. Intravaginal Ejaculation Latency Time (IELT), Chinese Index of Premature Ejaculation-5(CIPE-5) and Visualised Satisfaction Index (VSI) of sexual experience were assessed at initial and 1-, 3-, 6- and 12-month post injection. A total of 71 patients with primary PE (pPE, 38.6%) and 113 patients with acquired PE (aPE, 61.4%) were enrolled. The mean IELT increased to 100.7 ± 43.2 s(p < .05) for pPE patients and 359.2 ± 87.1 s (p < .05) for aPE patients 1-month post injection and remained significantly higher at the end point with acceptable attenuation. The mean CIPE-5 score increased to 17.6 ± 6.4 (p < .05) in the 1st month and remained steady. The VSI scores increased to 6.6 ± 1.0 (p < .05) for patients with pPE and 7.7 ± 1.2 (p < .01) for patients with aPE. Increments in VSI in patients with aPE were significantly higher than those in patients with pPE (p < .01). No severe complications were noted. GA with HA may be an effective and safe method to treat PE. Patients with acquired PE were also more satisfied post treatment.

Glans penis augmentation: when, how, and why?

The growing demand for glans penis augmentation (GPA) makes it a hot topic in the field of andrological surgery, albeit still widely debated. The lack of high supporting evidence and its technically challenging aspects are the main concerns. The aim of this study was to review the current literature about GPA in order to provide an easy and comprehensive overview of the topic. GPA is suitable for managing both cosmetic and functional issues. Counseling should be the cornerstone of the decision-making process. A thorough understanding of the glans anatomy and treatment strategies remain essential to safely and effectively address the patient's needs. GPA can be performed using injectable fillers or surgical grafting. Glans-shaft penis asymmetries, small glans size, and loss of glans tumescence can be managed by both injectable fillers and surgery. On the other hand, patients with lifelong premature ejaculation can mainly benefit from using injectable fillers. Currently, available studies show promising results but are limited by small sample's size and non-randomized design. Furthermore, treatment-related complications are poorly reported. The long-term efficacy and safety profiles of GPA techniques should be further investigated.

Clinical use of hyaluronic acid in andrology: A review

Background

Hyaluronic acid is a glycosaminoglycan widely used in the fields of orthopedics, ophthalmology, and aesthetic medicine due to its significant ability to reduce the synthesis of pro‐inflammatory proteins and its activity against oxidative stress, a feature of many degenerative illnesses.

Objectives

The objective of the present review is to provide a comprehensive narrative review of the most recent literature on the use of hyaluronic acid in andrology in order to facilitate the use of this therapeutic device in the common clinical practice of many physicians. Specific conditions covered in the review are Peyronie's disease, premature ejaculation, and penile enlargement.

Materials and methods

A broad and comprehensive literature search included Medline, EMBASE, and the Cochrane Libraries, with no time restriction up to December 2020 and restricted to English language publications. Unpublished studies were not included. The study was registered as “The role of hyaluronic acid in andrology: A systematic review and meta‐analysis” in PROSPERO with the ID CRD42021223416.

Discussion and conclusion

Hyaluronic acid is a valid choice for the treatment of Peyronie's disease in terms of the resolution of the acute phase of the disease and of contributing to stabilizing the disease as a bridge to potential surgery. Data, furthermore, suggest that hyaluronic acid is frequently associated with an overall clinical improvement, allowing the patient to resume normal sexual activity.

With regard to premature ejaculation, data suggests hyaluronic acid‐based treatments were effective in prolonging intra‐vaginal ejaculation time. Furthermore, hyaluronic acid was found to be safe and well‐tolerated, with main adverse events limited to local discomfort, ecchymosis, papule formation, and glans numbness, all of which were reported to resolve spontaneously.

Last, with regard to penile enlargement, the overall perception of experts is that hyaluronic acid may be an extremely well‐tolerated compound with potential for application in specific areas of male sexual health that are often neglected as compared to more common, and relatively simpler to treat, conditions.

Hyaluronic acid injection in the glans penis for the treatment of refractory premature ejaculation: A prospective, controlled study

We aimed to demonstrate the safety and efficacy of hyaluronic acid (HA) injection in the glans penis for the treatment of persistent premature ejaculation (PE). Eighty patients with persistent PE were divided equally into two groups. In group A, patients underwent HA injection by four-inlet injection technique, while in group B, patients were subjected to saline injection in glans penis by the same method as a control group. Patients were followed up for six months. At the end of follow-up, the IELT significantly improved in the HA injection group, as compared to the baseline values and control group. The maximal glandular circumference significantly increased at the 1st, 3rd and 6th month of follow-up. The rate of patient satisfaction with sexual intercourse was 64.9%, 70.3% and 78.4% at the 1st, 3rd and 6th month of follow-up, respectively. Besides, the partner satisfaction with sexual intercourse was 54.1%, 48.6% and 59.5% at the 1st, 3rd and 6th month of follow-up, respectively. In conclusion, HA injection may represent a promising treatment modality for persistent PE.

Penile girth augmentation by injectable fillers: a comprehensive review of imaging features and inflammatory complications

Despite the extensive controversy and debate of penile girth augmentation, high demands for such procedures are increasing. Penile inflammation is not common sequel after penile filler augmentation, but when it occurs, it has serious complications that sometimes necessitate emergency surgical intervention. Imaging with a variety of modalities, including ultrasonography, magnetic resonance imaging, and ascending urethrogrphy plays a paramount role in the detection and assessment of these conditions. Inflammatory conditions after penile girth augmentation using injectable fillers are ranging from local granuloma to penile abscess formation or diffuse cellulitis that may extend to the scrotum, perineum or deep pelvic organs. Rapid diagnosis and evaluation of extensions are important to avoid associated morbidity and permanent deformity. Our purpose is to provide a practical review of relevant penile anatomy, imaging appearance and injection technique of different types of subcutaneous fillers used in penile girth augmentation, and inflammatory complications that may occur after these procedures. Brief descriptions of patient clinical information and imaging features of inflammatory complications will be included and correlated in actual cases.

Application of micronised acellular dermal matrix for primary premature ejaculation: A preliminary study

This study aimed to explore the efficacy of injection of micronised acellular dermal matrix (MADM) particles for treating primary premature ejaculation. This study was a prospective single-arm clinical trial. Thirty patients who met the surgical indications were enrolled. MADM particles, mixed in platelet-rich plasma, were injected into Buck's fascia to spread over the dorsal penile nerve, suppress the influx of nerve impulses and, thus, reduce penis sensitivity. We evaluated the changes according to intravaginal ejaculation latency time using a stopwatch and a premature ejaculation diagnostic tool. Meanwhile, we also recorded sexual partner satisfaction and adverse events. All patients recovered well after surgery with no complications such as infections or allergies. The mean intravaginal ejaculation latency time before surgery was 0.72 ± 0.28 min, compared with 2.41 ± 0.54 min, 2.64 ± 0.41 min, 2.79 ± 0.25 min and 2.89 ± 0.35 min at, respectively, 4, 8, 16 and 20 weeks after surgery. The premature ejaculation diagnostic values and sexual partner satisfaction had significantly improved after treatment. Injection of MADM particles is an effective, safe and simple method for treating premature ejaculation.

Premature ejaculation - current concepts in the management: A narrative review

Premature ejaculation (PE; early ejaculation or rapid ejaculation) is a common sexual problem affecting about 20-30% of men in the sexually active age group. PE can be of four types: Primary, secondary, natural variable, and subjective PE. Various non-pharmacological and pharmacological treatment options are available to treat PE including Dapoxetine, which is specifically developed for the treatment of PE. In this review, we discuss the pathophysiology and management aspects of PE.

Complications and management of penile augmentation with hyaluronic acid injection

Hyaluronic acid injection is becoming a popular way for penile augmentation. However, only few studies and follow-ups have investigated the various complications of hyaluronic acid injection and their corresponding management. In this study, a total of 230 patients who had penile augmentation with hyaluronic acid injection from January 2018 to December 2019 were examined on follow-up for penile girth, complications, and their corresponding management. At 1-month, 3-month, and 6-month postoperative follow-ups, the penile circumference had increased by 2.66 ± 1.24 cm, 2.28 ± 1.02 cm, and 1.80 ± 0.83 cm, respectively. During the entire 6-month follow-up, 4.3% had complications such as subcutaneous bleeding, subcutaneous nodules, and infection. There were no systemic or local allergic reactions among all the patients. All complications were treated accordingly, and no further deterioration or severe sequelae were observed. Although complications of hyaluronic acid injections are mild and rare, these may affect the patient's satisfaction postoperatively. Preoperative redundant prepuce may increase the incidence of penile edema or postoperative gel migration. Standardization of the surgery protocol and elucidation of the effects of other injection parameters are still lacking. Nevertheless, it still highlights the importance of preoperative preparation and surgical technique.

Glans penis augmentation using hyaluronic acid for the treatment of premature ejaculation: a narrative review

Premature ejaculation (PE) is the most common self-reported male sexual disorder estimated to occur in approximately 5% of men in the general community. Penile hypersensitivity is thought to be an etiologic factor of lifelong PE. The role of glans penis augmentation using injectable hyaluronic acid (HA) for the treatment of PE is debatable and remains to be confirmed. The creation of a barrier at the level of the glans, by the bulking agent blocking accessibility and inhibiting the tactile stimuli to reach the dorsal nerve of the penis (branch of the pudendal nerve) receptors, is the theory behind the effectiveness of HA in the field of PE. We reviewed the literature using PubMed and searched for the following keywords: premature ejaculation, glans penis and HA, over the last 20 years. Five studies were found. These studies showed that HA injection could significantly increase IELT (2.43- to 4.46-fold), and this increase could persist for long term (up to 5 years). No serious adverse reactions were reported besides transient discoloration and swelling of the glans that recovered to normal within 2 weeks. Many techniques were discussed, their effectiveness remains to be proved. However, proper patient selection and mastering the esthetics of the technique, by adequate surgical training, is necessary in order to achieve the optimal results.

Progresses in pharmaceutical and surgical management of premature ejaculation

OBJECTIVE

Premature ejaculation (PE) is regarded as one of the most common male sexual dysfunctions. This review introduced several pharmaceutical and surgical methods for the management of PE. The definition, etiology, behavioral, and psychological therapy of PE were also discussed.

DATA SOURCES

"Premature," "ejaculation," or "sexual dysfuction" were used as the medical subject headings (MeSH) to obtain relevant articles before June 2019 on Pubmed, Google Scholar and CNKI. Most articles used were written in English and several Chinese articles were also cited.

STUDY SELECTION

Full-text articles of retrospective/prospective/randomized controlled trials were analyzed. Animal experiments and letters were excluded.

RESULTS

There are four PE sub-types: lifelong PE, acquired PE, natural variable PE, and subjective PE. Behavioral therapy, psychotherapy, medication, topical anesthetics, and surgery are currently used for the treatment of PE. However, all the above treatments have limitations. Therefore, novel ways should be investigated to more efficiently control PE.

CONCLUSIONS

The pharmaceutical therapy that is currently being used in clinical practice for the management of PE is still the main choice globally due to its good efficacy. Surgery may be a choice for patients who are resistant to medication. However, it should be performed cautiously.

Efficacy and safety of newly developed cross-linked dextran gel injection for glans penis augmentation with a novel technique

There is no safe and effective standard method for glans penis augmentation. Furthermore, there has been scant research on glans penis augmentation due to a poor understanding of glans anatomy, technical difficulty, and a lack of suitable substances for augmentation. Cross-linked dextran gel is a newly developed filler for soft-tissue augmentation. We evaluated the efficacy and safety of using a novel technique to inject cross-linked dextran gel for glans penis augmentation during a 24-week follow-up study. This prospective, single-arm, multicenter study enrolled twenty healthy adult men who underwent glans penis augmentation between June and August 2013. Cross-linked dextran gel was injected into the glans penis using a simple and easy technique. The sizes of the glans penis and individual satisfaction were assessed. Any adverse event was also reported. A total of 18 individuals were analyzed; two of them were lost to follow-up. The mean procedure time and injected volume were about 30 min and 6.6 ± 0.9 ml, respectively. The mean surface areas of the glans at baseline and 24 weeks were 20.0 ± 3.5 cm² and 33.6 ± 5.4 cm², respectively, representing a mean increase of 68.7% ± 14.0% (P < 0.001). Sixteen individuals (88.9%) were satisfied with the outcomes, and none were dissatisfied. There were no serious adverse events during the study. Cross-linked dextran gel injection for glans penis augmentation was easy and showed a significant augmentative effect on the glans penis, good durability, and was well tolerated without serious adverse events. Therefore, cross-linked dextran gel injection may be an effective, new technique for glans penis augmentation.

Hyaluronic acid injection in glans penis for treatment of premature ejaculation: a randomized controlled cross-over study

This randomized controlled cross-over study aimed to assess the efficacy and safety of glans penis injection with hyaluronic acid (HA) in treating premature ejaculation (PE). A total of 30 patients with PE were randomly allocated into two groups: group 1 (n = 15) which was subjected to glans penis HA injection and group 2 (n = 15) which was injected with saline as a control then both groups were subjected to follow-up at 1 week and 1 month after injection. These subjects were evaluated by intra-vaginal ejaculation latency time (IELT) and the Arabic validated index of premature ejaculation (AIPE). After a wash-out period, cross-over and re-evaluation of both groups were carried. Additionally, patients with reported improvement after 1 month of HA injection (n = 20) were subjected to extended evaluation by IELT at 3, 6, and 9 months intervals. Two-way repeated measures ANOVA indicated significant improvement after HA in comparison with saline across the follow-up periods (F(1.66: 91.37) = 24.85, p = 0.001). Post-hoc Bonferroni test indicated no significant difference after 1 week period in comparison with baseline IELT, but a significant difference after 1 month of injection in comparison with baseline IELT (p < 0.001) and after 1 week (p < 0.001). After 1 month of HA, IELT increased by a median of 2.6 folds while 1.1 folds increase was observed after 1 month of saline injection. Total AIPE scores improved significantly after HA injection compared with baseline (p = 0.003) and saline scores (p = 0.002). Reported adverse effects were minimal and self-limited. It could be concluded that glans penis injection with HA for treatment of PE is a safe method that ensures a modest but significant increase in IELT and improves couple sexual satisfaction.

Complications of glans penis augmentation

Despite the controversy regarding penile augmentation (PA), glans penis augmentation (GPA) is used in penile reconstructive surgery in selected patients with small glans penis. Since 2003, injectable hyaluronic acid (HA) gel has been used for GPA. The attractiveness of HA gel fillers and interest in this technique have led to the use of other fillers for GPA, particularly irreversible fillers that improve the longevity of HA gels. Conversely, indirect glans augmentation via implantation of dermofat grafts or scaffolds between the corpus spongiosum and the distal tip of the corpus cavernosum is used to overcome poor longevity of the gel and glans surface undulation, which are the primary limitations of GPA using HA gel. Unfortunately, these implants form hard painful lumps over time in most patients and are difficult to remove. Blunt dissection is an invasive procedure that may cause vascular compromise and consequent glans necrosis in a few patients. We present our review regarding the current status of GPA for a more comprehensive understanding of this subject. Additionally, we have discussed a few complicated cases that were referred to us.

Practice Patterns Among Korean Urologists for Glans Penis Augmentation Using Hyaluronic Acid Filler in the Management of Premature Ejaculation

Introduction

Glans penis augmentation (GPA) using hyaluronic acid (HA) gel has been developed for treating premature ejaculation (PE) with penile hypersensitivity. The injected HA filler creates a barrier that reduces the tactile stimuli to the hypersensitive dorsal nerve. Although the HA filler is biodegradable and is believed to not cause permanent loss of sexual function, the current International Society for Sexual Medicine guideline for PE does not recommend this procedure owing to concerns regarding sexual dysfunction.

Aim

To investigate the practice patterns for GPA using HA filler among Korean urologists, and to identify whether urologist experienced patient reports of sexual dysfunction post-treatment.

Methods

Between March 2016 and July 2016, a specially designed questionnaire was mailed to 86 selected Korean urologists who had used injectable materials to treat PE.

Main Outcome Measures

The prevalence and awareness of sexual dysfunction after GPA using HA filler were evaluated.

Results

Overall, 56 urologists completed the survey (response rate: 69.2%), of which 36 (64.3%) had performed GPA using HA filler. They reported having performed a combined total of 4,344 such GPA procedures. Most urologists (72.7%) performed GPA using HA filler in patients who benefit from topical anesthetics. Patients with a history of failed pharmacotherapy (59.1%) and selective dorsal nerve neurotomy (45.5%) were selected for GPA using HA filler. The respondents (44.4%) encountered overall 206 (4.7%) cases of patients reports of recurrence of PE. Interestingly, only 36 (0.8%) cases of glans pain or paresthesia and no cases of erectile dysfunction post-treatment were reported.

Conclusion

Korean urologists performed GPA using HA filler when pharmacotherapy failed or if there was a response to topical treatment. Paresthesia and hypoesthesia after GPA using HA filler are rare, and no cases of erectile dysfunction were encountered by Korean urologists.

Jeong HG, Ahn ST, Kim JW, et al. Practice Patterns Among Korean Urologists for Glans Penis Augmentation Using Hyaluronic Acid Filler in the Management of Premature Ejaculation. Sex Med 2018;6:297–301.

Surgery is not indicated for the treatment of premature ejaculation

Premature ejaculation (PE) is considered the most common male sexual disorder, affecting up to 75% of men at some point in their lives. While medical management is the mainstay of therapy, surgical options such as dorsal nerve neurectomy (DNN), hyaluronic acid (HA) gel glans penis augmentation, and circumcision have been studied as alternative forms of treatment. Preliminary studies have suggested that DNN and HA gel glans penis augmentation are relatively safe and effective, but due to a lack of large, multicenter, randomized-control trials with long-term follow-up, the International Society of Sexual Medicine (ISSM) has been unable to endorse DNN or HA gel glans penis augmentation as options in the treatment of PE. Conflicting data regarding the efficacy and safety of circumcision has similarly led to its exclusion from ISSM recommendations for the treatment of PE. Ethical concerns, particularly the fundamental concept of non-maleficence, are also barriers to the implementation of surgery for PE.

Glans Penis Augmentation Using Hyaluronic Acid Gel as an Injectable Filler

Glans penis augmentation (GPA) has received little attention from experts despite the existence of a subset of patients who may be dissatisfied with a small glans or poor tumescence of the glans during erection. Recently, GPA using an injectable filler or implantation of a graft or filler has been developed. Despite a demanding injection technique and inevitable uneven undulation of the glandular surface, GPA using injectable hyaluronic acid (HA) gel is a novel and useful therapy and an effective and safe procedure for soft tissue enhancement. For long-term presence of implants, timed supplementation can be used similar to that for fascial plasty. In complications such as mucosal necrosis of the glans penis, most cases occur from the use of non-HA gel or an unpurified form and misunderstanding of the management protocol for immediate side effects. Currently, GPA using injectable HA gel is not recommended in the International Society for Sexual Medicine guideline due to possible sensory loss. In a 5-year long-term follow-up of GPA by subcutaneous injection of HA gel, the residual volume of implants decreased by 15% of the maximal glandular circumference, but was still effective for alleviating the hypersensitivity of the glans penis in premature ejaculation patients. For efficacy in premature ejaculation, selection of appropriate candidates is the most important factor for success. GPA does not harm erectile function and is less invasive and irreversible compared to dorsal neurectomy. To refine the procedure, more interest and well-designed studies are required for the establishment of the procedure.

A clinical study to assess the effectiveness of a hyaluronic acid-based procedure for treatment of premature ejaculation

Premature ejaculation is a sexual debilitating condition affecting a large number of men worldwide and leading to important dysfunctions influencing the patients' affective and emotional life. Hyaluronic acid is a natural and safe compound that has been widely used not only in the aesthetic medicine clinic, but also for treatment of osteoarthritis. The present study shows the effectiveness of a hyaluronic acid-based procedure for treatment of premature ejaculation. A hundred and ten male patients were treated with hyaluronic acid injections in the deep dermis of their glans penis to increase the volume and the circumference of their penis to prevent male premature ejaculation and improve the patients' and their partners' sexual satisfaction. The intravaginal ejaculation latency time increased significantly from a baseline value of 88.34±3.14 s to 293.14±8.16 s after 6 months from the procedure. Maximal glandular circumference increased from 98.51±0.71 mm to 114.35±0.66 mm after 6 months from the procedure. At 6-month follow-up, patients' self-rated satisfaction was 5.3±0.07 (range: 4–6). At the follow-up, partners' self-rated satisfaction was 5.1±0.09 (range: 3–6). The present clinical study showed that hyaluronic acid injection is a promising treatment for premature ejaculation. The effect of the procedure in the long-term follow-up needs to be clarified.

Premature ejaculation: do we have effective therapy?

INTRODUCTION

Premature ejaculation (PE) is the most common sexual dysfunction, with the majority of PE patients remaining undiagnosed and undertreated. Despite its prevalence, there is a current paucity of data regarding available treatment options and mechanisms. The objective of the current investigation is to review and summarize pertinent literature on therapeutic options for the treatment of PE, including behavioral/psychologic, oral pharmacotherapy, and surgery.

METHODS

A pubmed search was conducted on articles reporting data on available treatment options for PE. Articles describing potential mechanisms of action were additionally included for review. Preference was given towards randomized, controlled trials, when available.

RESULTS

PE remains an underdiagnosed and undertreated disease process, with limited data available regarding potential underlying mechanisms and long-term outcomes of treatment options. Psychological/behavioral therapies, including the stop-start, squeeze, and pelvic floor rehabilitation techniques have demonstrated improvements in short-term series, with decreased efficacy with additional follow-up. Topical therapies, which are commonly utilized result in prolonged intravaginal ejaculatory latency time (IELT) at the expense of potential penile/vaginal Hypothesia. Oral therapies similarly demonstrate improved IELTs with variable side effect profiles and include selective serotonin reuptake inhibitors (daily or on demand), phosphodiesterase-5 inhibitors, alpha-1 adrenergic antagonists, and tramadol. Alternative therapies such as acupuncture have shown benefits in limited studies. Surgery is not commonly performed and is not recommended by available guidelines.

CONCLUSIONS

PE is a common condition, with limited data available regarding its underlying pathophysiology and treatment. Available therapies include topical, oral, behavioral/psychologic modification, or a combination thereof. Additional research is required to assess the optimal treatment strategies and algorithms as well as to better define the mechanisms for PE and its management.

New insights on premature ejaculation: a review of definition, classification, prevalence and treatment

There are ongoing debates about the definition, classification and prevalence of premature ejaculation (PE). The first evidence-based definition of PE was limited to heterosexual men with lifelong PE who engage in vaginal intercourse. Unfortunately, many patients with the complaint of PE do not meet these criteria. However, these men can be diagnosed as one of the PE subtypes, namely acquired PE, natural variable PE or premature-like ejaculatory dysfunction. Nevertheless, the validity of these subtypes has not yet been supported by evidence. The absence of a universally accepted PE definition and lack of standards for data acquisition have resulted in prevalence studies that have reported conflicting rates. The very high prevalence of 20%-30% is probably due to the vague terminology used in the definitions at the time when such surveys were conducted. Although many men may complain of PE when questioned for a population-based prevalence study, only a few of them will actively seek treatment for their complaint, even though most of these patients would define symptoms congruent with PE. The complaints of acquired PE patients may be more severe, whereas complaints of patients experiencing premature-like ejaculatory dysfunction seem to be least severe among men with various forms of PE. Although numerous treatment modalities have been proposed for management of PE, only antidepressants and topical anaesthetic creams have currently been proven to be effective. However, as none of the treatment modalities have been approved by the regulatory agencies, further studies must be carried to develop a beneficial treatment strategy for PE.