The Premature Ejaculation Profile: validation of self-reported outcome measures for research and practice

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.

A Psychometric Study of a Trait and State Assessment of Sexual Pleasure - The Amsterdam Sexual Pleasure Inventory

We studied the Amsterdam Sexual Pleasure Inventory's (1.0) psychometric properties. The ASPI, a revised self-report battery designed to measure domains of state and trait sexual pleasure in diverse gender, sex, and relationship populations, is based on a recently proposed conceptual framework of sexual pleasure. We collected quantitative (n = 1371) and qualitative data (n = 637) using a cross-sectional multi-method design targeting the general (German-speaking) population. After pre-processing, we conducted analyses on a sample of n = 706 participants. The theory-based 5-factor exploratory structural equation model and the principal component analyses of the two general exploratory index-scales showed good and acceptable structural validity evidence respectively. Measurement invariance was confirmed separately for male and female participants and for those with sexually functional-scoring and dysfunctional-scoring levels. Coefficient omega indicated that all scales, except those of one facet, showed acceptable to very good internal consistency. The ASPI's convergent and discriminant associations with sexological and psychological constructs demonstrated good overall construct validity. Participants understood the items as intended and felt that the ASPI covered relevant facets of sexual pleasure. The ASPI might help understand how individuals differ in experiencing sexual pleasure and how different contexts enable some people to experience pleasure while disadvantaging others.

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.

Efficacy and Safety of Extracorporeal Shock Wave Therapy in the Treatment of Chronic Prostatitis/Chronic Pelvic Pain Syndrome and Acquired Premature Ejaculation Patients

INTRODUCTION

The aim of this study was to evaluate the efficacy and safety of extracorporeal shock wave therapy (ESWT) in patients with acquired premature ejaculation (APE) due to chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS).

METHOD

Patients with APE due to CP/CPPS between January 2020 and June 2022 were included in the study. Demographic data of the patients were recorded, and the degree of their symptoms was evaluated with the National Institutes of Health-Chronic Prostatitis Symptom Index (NIH-CPSI), premature ejaculation diagnostic tool (PEDT), and Premature Ejaculation Profile (PEP). The international prostate symptom index (IPSS) was also used for lower urinary tract symptoms (LUTS), and the international erectile function index-erectile function (IIEF-EF) was used to evaluate erectile functions. All patients received treatment with the Medispec Bold Li-ESWT device without using any anesthesia method (12 sessions). The changes in the symptom scores of the patients were evaluated before the treatment and at the 3rd month after the treatment.

RESULTS

A total of 42 patients were included in the study. The mean age of the patients was 43.75 ± 12.03 (20-55), and the mean BMI was 23.58 ± 7.61 (18.03-35.98) kg/m2. The patients' estimated mean intravaginal ejaculation latency time (IELT) before ESWT was 37.98 ± 21.87 s. After a total of 12 sessions of ESWT, the IIEF-EF, IPSS, NIH-CPSI, and PEP index scores of the patients showed significant improvements (p < 0.001 for each). The IELT mean increased to 74.81 ± 46.79 s (p < 0.001). Posttreatment IELT fold increase was determined as 3.25 ± 1.72 fold. A highly significant positive correlation (p = 0.032; r = 0.839) was found between the CPSI score difference and the posttreatment PEP index score.

CONCLUSION

Li-ESWT treatment is an effective and safe treatment with positive effects on both LUTS and premature ejaculation in patients with APE symptoms due to CP/CPPS. Patients who benefit from CP treatment also have longer IELT times.

Patient-reported outcomes validated in phase 3 clinical trials: a targeted literature review

BACKGROUND

Regulatory guidance advises validation of patient-reported outcome (PRO) instruments prior to use in pivotal clinical studies, which may then be used to generate critical patient-centered evidence and support labelling claims. This targeted literature review aimed to determine if PRO instruments psychometrically validated in a phase 3 trial setting could support label claims from the same phase 3 study (i.e. PRO data were generated as an endpoint).

METHODS

A targeted search of published studies (1 January 2006-3 June 2021) using the MEDLINE database identified PRO instruments validated during phase 3 trials. The search included instrument terms (e.g. patient-reported outcome measures, questionnaire, survey) and validation terms (e.g. reproducibility, minimal important difference), without filtering for therapeutic indications. Results were limited to phase 3 clinical trials or validation studies. The PROLABELS database was used to identify PROs validated in phase 3 trials and accepted in labelling claims.

RESULTS

Of 355 references identified, 68 studies with PRO psychometric validation in phase 3 studies were selected, covering 78 instruments. Of these, 20 were novel PRO instruments and 58 were existing instruments being validated for a new therapeutic indication/population. The psychometric properties most frequently validated were internal consistency reliability, known-group validity, responsiveness, minimal important difference, and concurrent validity. Five novel instruments obtained ten labelling claims for seven drugs/products.

CONCLUSIONS

These results suggest that quantitative validation of novel PRO instruments, and existing PROs for new indications, can occur within the context of phase 3 trials, and these PROs can also support label claims.

Atlas of 35 patient reported outcome measures (PROMs) in andrology: a comprehensive overview of literature

INTRODUCTION

Disorders of male sexual health and functioning are complex and can have significant deleterious effects on patients psychological wellbeing and interpersonal relationships. It is well recognised that clinicians have an overall poor understanding of the true effect that disease has on their patients and self-reported patient-reported outcome measures (PROMs) aim to better communicate these issues. PROMs are generally welcomed by patients and their use in this highly sensitive area of clinical practice is well recognised. An atlas of available PROMs for key conditions in andrology is presented in this article.

METHODS

A comprehensive search of world literature was conducted from the inception of databases to June 2022, to identify male-specific PROMs relevant to four key andrological disorders: hypogonadism, erectile dysfunction, penile curvature and disorders of ejaculation. Each tool was evaluated in narrative format.

RESULTS

35 PROMs were identified. 6 were designed for the assessment of hypogonadism, 18 for erectile dysfunction, one for penile curvature and 10 for ejaculatory disorders. In general, PROMs were brief, self-administered and user-friendly. There was sufficient scope and variety in all categories (apart from penile curvature) to give the clinician flexibility in tool selection and find an appropriate tool for different scenarios.

CONCLUSION

A number of PROMs exist within andrology that can be utilised in both research and clinical settings. PROMs enable subjective evaluation of difficult-to-assess aspects of the patient experience.

A novel on-demand therapy for lifelong premature ejaculation using a miniature transperineal electrical stimulator-the vPatch: an as-treated analysis

BACKGROUND

While premature ejaculation (PE) is a common and disturbing sexual dysfunction in men, current available treatment modalities have limited efficacy and low treatment adherence.

AIM

To assess the feasibility, safety, and efficacy of the vPatch, a miniaturized on-demand perineal transcutaneous electrical stimulation device for treating PE.

METHODS

This prospective bicenter international first-in-human clinical study consisted of 2 arms, was sham controlled, and had a randomized double-blind design. In terms of statistical power calculation, 59 patients aged 21 to 56 years (mean ± SD, 39.8 ± 9.28) with lifelong PE were included. During the initial visit, intravaginal ejaculatory latency time (IELT) was measured over a 2-week run-in period. Eligibility was confirmed in visit 2, based on IELT values, medical and sexual history, and patients' individualized sensory and motor activation thresholds during perineal stimulation with the vPatch. Patients were randomized to the active (vPatch) and sham device groups in a 2:1 ratio, respectively. The vPatch device's safety profile was determined by comparing the incidence of treatment-emergent adverse events. During visit 3, IELTs, Clinical Global Impression of Change scores, and Premature Ejaculation Profile questionnaire outcomes were recorded. Primary end points assessed vPatch device efficacy as mean change in geometric mean IELT; each person was compared with himself, with and without the device, and the sham group was compared with the active group.

OUTCOMES

Outcomes included changes in IELT and Premature Ejaculation Profile before and after treatment, last visit Clinical Global Impression of Change scores, and vPatch safety profile.

RESULTS

Of 59 patients, 51 completed the study: 34 in the active group and 17 in the sham group. The baseline geometric mean IELT significantly increased from 67 to 123 seconds (P < .01) in the active group, as compared with an insignificant increase from 63 to 81 seconds (P = .17) in the sham group. The increase in mean IELT in the active group was significantly higher than in the sham group (56 vs 18 seconds, P = .01). IELT significantly increased by 3.1 times in the active vs sham group. The mean ratio of fold change (active:sham) was 1.4, significantly different from 1.0 (P = .02). No serious adverse events were reported.

CLINICAL IMPLICATIONS

Therapeutic use of the vPatch during coitus may become an on-demand, noninvasive, and drug-free treatment for PE.

STRENGTHS AND LIMITATIONS

To our knowledge, this is the first rigorous study investigating whether transcutaneous electrical stimulation during coitus could improve the symptoms of men with lifelong PE. The study is limited by the small number of patients, the exclusion of patients with acquired PE, the short-term follow up, and the use of a device based on a theoretic mechanism of action.

CONCLUSION

We demonstrated the possibility to treat lifelong PE by prolonging coitus on demand, using electric stimulation of ejaculation muscles with the vPatch.Clinical trial registration: NCT03942367 (ClinicalTrials.gov).

Does Bother/Distress Contribute to the Diagnosis of Premature Ejaculation?

Introduction

The role of bother/distress in the diagnosis of premature ejaculation (PE) has received minimal investigation compared with the 2 other diagnostic criteria, ejaculatory control and ejaculatory latency (EL).

Aim

This study assessed (i) the added variance explained by bother/distress to the diagnostic accuracy of PE and (ii) determined its overall contribution to a PE diagnosis.

Methods

The 3 diagnostic criteria for PE were assessed in 2,589 men (mean age = 38.2 years, SD = 13.5) in order to determine the contribution of each factor to a dysfunctional diagnosis. A series of regression and discriminant analyses were used to assess the value of bother/distress in explaining ejaculatory control and in predicting accuracy of PE group status. Commonality analysis was used to determine the relative contribution of each of these factors to the diagnosis of PE.

Main Outcome Measure

The major outcome was the quantified contribution of “bother/distress” to a PE diagnosis.

Results

Bother/distress accounted for about 3–4% of the variation in ejaculatory control and added only minimally to the prediction accuracy of PE group status (no, probable, definite PE). Commonality analysis indicated that bother/distress comprised about 3.6% of the unique explained variation in the PE diagnosis, compared with ejaculatory control and EL which contributed 54.5% and 26.7%, respectively. Common variance among factors contributed the remaining 15.5% to the PE diagnosis.

Clinical Translation

Bother/distress contributes least to the determination of a PE diagnosis. Its contribution is largely redundant with the unique and combined contributions of ejaculatory control and EL.

Strengths and Limitations

Using a well-powered and multivariate analysis, this study parsed out the relative contributions of the 3 diagnostic criteria to a PE diagnosis. The study is limited by its use of estimated EL, a single item assessment of bother/distress, and the lack of differentiation of PE subtypes, lifelong and acquired.

Conclusion

Bother/distress contributes minimally to the PE diagnosis, yet its assessment may be key to understanding the experiences of the patient/couple and to developing an effective treatment strategy.

Rowland DL, McNabney SM, Hevesi K. Does Bother/Distress Contribute to the Diagnosis of Premature Ejaculation?. Sex Med 2022;10:100548.

The Tenuous Role of Distress in the Diagnosis of Premature Ejaculation: A Narrative Review

BACKGROUND

Unlike the other 2 criteria for diagnosing premature ejaculation (PE), namely lack of ejaculatory control and short ejaculation latency (EL), the role of bother/distress has received only minimal consideration and investigation.

AIM

The specific aim was to determine both why distress is included in the PE diagnosis and whether such inclusion is advantageous to achieving better diagnostic outcomes. To this end, the review explored the historical and theoretical underpinnings of the inclusion of "bother/ distress" in the diagnosis of PE, with reference to the larger role that distress has played in the diagnosis of mental disorders, in an attempt to understand the utility (or lack thereof) of this construct in making a PE diagnosis.

METHODS

We reviewed the role of bother/distress across current professional definitions for PE and then expanded this discussion to include the role of distress in other sexual dysfunctions. We then included a brief historical perspective regarding the role that distress has played in the diagnosis of PE. This discussion is followed by a deeper look at 2 nosological systems, namely DSM and ICD, to allow perspective on the inclusion of the bother/distress construct in the diagnosis of mental and behavioral disorders, including the assumptions/arguments put forward to include or exclude bother/distress as an important criterion underlying various professional assumptions.

OUTCOME

Determination of the value and/or need of including bother/distress as a necessary criterion for the diagnosis of PE.

RESULTS

Based on the research literature, bother/distress does not appear to be as critical for a PE diagnosis as either the lack of ejaculatory control or short EL. It is the weakest of the differences among men with and without PE, and recent evidence suggests that its inclusion is generally redundant with the severity of the 2 other criteria for PE, ejaculatory control and EL.

CLINICAL TRANSLATION

Bother/distress appears to serve little purpose in the diagnosis of PE yet its assessment may be important for the treatment strategy and for assessing treatment effectiveness.

STRENGTHS AND LIMITATIONS

This review did not provide a critical analysis of the literature regarding the role of bother/distress in PE, but rather focused on its potential value in understanding and diagnosing PE.

CONCLUSION

Although bother/distress appears to add little to the improvement of accuracy for a PE diagnosis, understanding and assessing the man's or couple's experience of distress has important implications for the treatment strategy and focus, as well as for assessing treatment success. Rowland DL, Cooper SE. The Tenuous Role of Distress in the Diagnosis of Premature Ejaculation: A Narrative Review. Sex Med 2022;XX:XXXXXX.

Are the Criteria for the Diagnosis of Premature Ejaculation Applicable to Gay Men or Sexual Activities Other than Penile-Vaginal Intercourse?

Introduction

The criteria for premature ejaculation (PE) have generally been limited to the diagnosis of heterosexual men engaging in penile-vaginal intercourse and therefore the applicability of PE diagnostic criteria to gay men and to activities beyond penile-vaginal intercourse has yet to be explored in depth.

Aim

To compare the prevalence of PE in gay and straight men and to assess whether PE-related diagnostic measures (ejaculatory control, ejaculation latency [EL], and bother/distress) can be applied with confidence to gay men or to men engaging in sexual activities other than penile-vaginal intercourse.

Methods

Gay and straight participants (n = 3878) were recruited to take an online survey assessing sexual orientation, sexual function/dysfunction (including specific PE-related measures), sexual relationship satisfaction, and various other sexual behaviors during partnered sex or masturbation.

Outcomes

Comparison of ejaculatory control, EL, and bother/distress across gay and straight men, as well as across different types of sexual activities.

Results

A slightly lower PE prevalence among gay men became undetectable when other predictors of prevalence were included in a multivariate analysis (aOR = 0.87 [95% CI: 0.60–1.22]). Gay men with PE reported longer typical ELs (z_U = -3.35, P < .001) and lower distress (z_U = 3.68, P < .001) relative to straight men, but longer ELs and lower distress were also associated with anal sex.

Clinical Translation

Clinicians can feel confident about using existing criteria for the diagnosis of PE in gay men but should be aware of potentially longer ELs and lower PE-related bother/distress—probably related to the practice of anal sex—compared with straight men.

Strengths and Limitations

Although well-powered and international in scope, this study was limited by biases inherent to online surveys, the lack of a sizable sample of bisexual men, and a lack of differentiation between men with acquired vs lifelong PE.

Conclusions

Irrespective of sexual orientation, gay and straight men with PE reported shorter ELs, lower satisfaction, and greater bother/distress than functional counterparts. While PE-related diagnostic criteria (ejaculatory control, EL, and bother/distress) are applicable to gay men, accommodation for longer ELs and lower bother/distress in gay men should be considered.

McNabney SM, Weseman CE, Hevesi K, et al. Are the Criteria for the Diagnosis of Premature Ejaculation Applicable to Gay Men or Sexual Activities Other than Penile-Vaginal Intercourse?. Sex Med 2022;10:100516.

Influence of modafinil on early ejaculation - Results from a double-blind randomized clinical trial

BACKGROUND

For men, early ejaculation is a serious health concern. Here, we tested the influence of modafinil (Profinil®) on early ejaculation. To this end, we performed a double-blind randomized clinical trial among men with early ejaculation.

METHODS

A total of 46 men with early ejaculation (mean age: 37.35 years) and in stable marital relationships with regular weekly penile-vaginal intercourse were randomly assigned either to the modafinil (100 mg) or to the placebo condition. Compounds were taken about 4-6h before intended penile-vaginal intercourse. At baseline and four weeks later at the end of the study, participants completed a series of self-rating questionnaires covering early ejaculation. Female partners also rated their male partners' early ejaculation profile.

RESULTS

Dimensions of early ejaculation improved over time, but only so in the modafinil condition, while no improvements were observed in the placebo condition.

CONCLUSIONS

Among male adults in stable marital relationships with regular weekly penile-vaginal intercourse modafinil improved dimensions of early ejaculation, always compared to placebo. Given the strong effect of modafinil on cognitive-executive processes, it is conceivable, that modafinil acted both via physiological and cognitive-executive pathways.

International Continence Society (ICS) report on the terminology for sexual health in men with lower urinary tract (LUT) and pelvic floor (PF) dysfunction

INTRODUCTION

The terminology for sexual health in men with lower urinary tract (LUT) and pelvic floor (PF) dysfunction has not been defined and organized into a clinically based consensus terminology report. The aim of this terminology report is to provide a definitional document within this context that will assist clinical practice and research.

METHODS

This report combines the input of the members of sexual health in men with LUT and PF Dysfunction working group of the International Continence Society (ICS), assisted at intervals by external referees. Appropriate core clinical categories and a sub-classification were developed to give coding to definitions. An extensive process of 18 rounds of internal and external review was involved to exhaustively examine each definition, with decision-making by collective opinion (consensus). The Committee retained evidence-based definitions, identified gaps, and updated or discarded outdated definitions. Expert opinions were used when evidence was insufficient or absent.

RESULTS

A terminology report for sexual health in men with LUT and PF dysfunction, encompassing 198 (178 NEW) separate definitions, has been developed. It is clinically based with the most common diagnoses defined. Clarity and user-friendliness have been key aims to make it interpretable by practitioners and trainees in all the different speciality groups involved. Conservative and surgical managements are major additions and appropriate figures have been included to supplement and clarify the text. Emerging concepts and measurements, in use in the literature and offering further research potential, but requiring further validation, have been included as an appendix. Interval (5-10 years) review is anticipated to keep the document updated.

CONCLUSION

A consensus-based terminology report for sexual health in men with LUT and PF dysfunction has been produced to aid clinical practice and research. The definitions that have been adopted are those that are most strongly supported by the literature at this time or are considered clinical principles or consensus of experts' opinions.

The Unfinished Business of Defining Premature Ejaculation: The Need for Targeted Research

INTRODUCTION

Fifteen years have passed since the International Society of Sexual Medicine first established the 3-pronged criteria for premature ejaculation (PE): a short ejaculation latency, lack of ejaculatory control, and bother/distress. Although the process of establishing valid criteria for any condition or disorder is an ongoing one, a dearth of targeted research on these criteria has hindered professional societies from updating and revising them.

OBJECTIVES

To review and critique existing criteria used in the diagnosis of PE, to identify specific problems with them, and to recommend studies that will address shortcomings.

METHODS

Each of the PE criteria was evaluated and compared against standard procedures for establishing validated measures. Following each analysis, targeted research to address the gaps has been recommended.

RESULTS

Each PE criterion has shortcomings and each can be improved by using standard validation procedures, as noted by the targeted research outcomes. Professional societies can play an important role by encouraging broad participation in research that generates new and relevant data supporting, validating, or challenging the existing criteria.

CONCLUSION

The concepts underlying the diagnostic criteria for PE have both broad consensus and functional utility. Nevertheless, much of the research investigating PE has uncritically adopted these criteria without concomitantly recognizing their limitations. These limitations prevent determining accurate prevalence rates, interpreting research findings with confidence, and establishing efficacious treatment outcomes. Rowland DL, Althof SE, McMahon CG. The Unfinished Business of Defining Premature Ejaculation: The Need for Targeted Research. Sex Med Rev 2021;XX:XXX-XXX.

Advances and Missteps in Diagnosing Premature Ejaculation: Analysis and Future Directions

BACKGROUND

There are several problems with diagnostic criteria for premature ejaculation (PE) that lack objectivity, clarity and precision. They hamper accurate determination of PE prevalence estimates, investigations into the etiology of the dysfunction, impact on partners, development of validated Patient Reported Outcomes, regulatory authority oversight, and which men might benefit from specific treatment interventions.

AIM

We sought to review, analyze and comment on the evolution of the definitions of PE and offer suggestions for future directions for PE definitions. Our goal is to propose strategies whereby the criterion sets are useful to researchers, clinicians and governmental oversight agencies alike and bring harmony and scientific rigor among the conflicting and confusing definitions.

METHODS

There are several premature ejaculation definitions published in the peer reviewed medical literature. The PUBMED electronic database from 1970 to 2021 was searched for published definitions. Search terms included the medical subject headings of premature ejaculation, definition and diagnosis. In chronological order, Table 1 lists the various diagnosis and criteria sets for PE. We discuss the process by which constructs, which make up diagnostic criteria sets, are operationalized and validated.

RESULTS

We review definitions of PE beginning with Masters and Johnson's focus on partner orgasmic attainment and move through the nebulous and subjective criterion sets found in the early Diagnostic and Statistical Manuals and International Classification of Disease series, to the more evidenced-based definitions found in International Society of Sexual Medicine, Diagnostic and Statistical Manuals-5 and the American Urological Association (AUA) definitions. Additionally, we discuss how constructs and criteria sets have been adopted to minimize errors of inclusion and exclusion in defining disease/dysfunction.

STRENGTHS AND LIMITATIONS

This manuscript offers a careful chronological analysis of the published definitions of PE. This historical lens allows the reader to perceive the shifting science underlying the development of PE definitions. The manuscript is limited regarding our comments on acquired PE as evidenced-based research is incomplete.

CONCLUSION

Over the past 50 years there has been considerable forward momentum in defining PE based on well conducted scientific studies. We support the American Urological Association's modification in Intravaginal ejaculatory latency time to 2-minutes for lifelong PE, concur with the 11th revision of the International Classification of Diseases recommendation for changing the terminology from premature ejaculation to early ejaculation. We also recommend ongoing validation of definitions, moving away from the current heterosexist definition of PE based on penile-vaginal sex and urge further population based research into acquired PE to develop stronger evidenced-based criterion sets for this subtype.

Efficacy of Dapoxetine in the Treatment of Patients With Lifelong Premature Ejaculation as an Alternative to Sertraline Therapy

Introduction

Before dapoxetine was approved for the treatment of lifelong premature ejaculation (LPE) in China, daily dosing with off-label sertraline was common.

Aim

To investigate the efficacy of dapoxetine in the treatment of patients with LPE as an alternative to sertraline therapy.

Methods

This prospective study included LPE patients who previously attempted treatment with sertraline and who agree to receive dapoxetine therapy in our hospital from January 2020 to March 2021. Patients who received any PE therapy in the two months prior to the dapoxetine therapy were excluded. All patients received dapoxetine 30 mg (taken 1–3 hours before sexual intercourse) for 12 weeks, and they were not taking sertraline during the trial.

Main Outcome Measure

Data on their intravaginal ejaculatory latency time and premature ejaculation profile were recorded before and after the dapoxetine treatment. Clinical Global Impression of Change scores and data on Treatment-Emergent adverse events were collected after treatment.

Results

A total of 144 patients with LPE completed this study; including 64 patients who reported that previous sertraline treatment was satisfactory (group A) and 80 patients for whom previous sertraline therapy was unsatisfactory in treating PE (group B). Both groups experienced significantly increased intravaginal ejaculatory latency time. Dapoxetine therapy was reported satisfactory by 67.5% of patients with LPE in whom sertraline therapy unsatisfactory according to their Clinical Global Impression of Change score, which was not different from those who reported this result in group A (62.5%). Similar outcomes were also reported for premature ejaculation profile and treatment-emergent adverse events.

Conclusion

: Although both dapoxetine and sertraline are selective serotonin re-uptake inhibitors, dapoxetine therapy is satisfactory in 67.5% of patients with LPE in whom sertraline treatment unsatisfactory, and the effect of dapoxetine was independent of the effect of sertraline.

Liu G, Yin Y, Zhang L. et al., Efficacy of Dapoxetine in the Treatment of Patients With Lifelong Premature Ejaculation as an Alternative to Sertraline Therapy. Sex Med 2021;10:100473.

Do the diagnostic criteria for premature ejaculation apply to non-straight men and to sexual activities other than penile-vaginal intercourse?

Professional standards committees have generally applied the diagnostic criteria for premature ejaculation only to situations involving (presumed) heterosexual men having penile-vaginal intercourse. This paper reviews the existing evidence supporting expansion of the criteria for use among non-straight men engaging in sexual activities that do not include vaginal intercourse. In brief, estimated ejaculation latencies appear similar across men identifying with different sexual orientations, and various partnered sexual activities (oral, vaginal, and manual) tend to be well correlated. In contrast, masturbation latency patterns are different between men with and without premature ejaculation, and ejaculatory control and bother/distress may be less critical to gay men than straight men during partnered sex. Finally, it should be noted that existing patient report outcomes (PROs) require modification for use with non-straight men.

Influence of Lisdexamfetamine Dimesylate on Early Ejaculation-Results from a Double-Blind Randomized Clinical Trial

BACKGROUND

Among male sexual dysfunctions, erectile dysfunction and early ejaculation have the highest prevalence rates. Here, we tested the influence of lisdexamfetamine dimesylate (Vyas®) on early ejaculation. To this end, we performed a double-blind randomized clinical trial among males with early ejaculation.

METHODS

A total of 46 males with early ejaculation (mean age: 35.23 years) and in stable marital relationships with regular weekly penile-vaginal intercourse were randomly assigned either to the lisdexamfetamine dimesylate condition (30 mg) or to the placebo condition. Compounds were taken about six hours before intended penile-vaginal intercourse. At baseline and four weeks later at the end of the study, participants completed a series of self-rating questionnaires covering early ejaculation. Female partners also rated participants' early ejaculation profile.

RESULTS

Compared to the placebo condition, dimensions of early ejaculation improved over time in the lisdexamfetamine condition, though improvements were also observed in the placebo condition.

CONCLUSIONS

Among male adults in stable marital relationships with regular weekly penile-vaginal intercourse, lisdexamfetamine dimesylate improved dimensions of early ejaculation. Given that improvements were also observed in the placebo condition, psychological factors such as increased attention to early ejaculation and favorable expectations of the compound should be considered.

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.

Selective serotonin re-uptake inhibitors for premature ejaculation in adult men

BACKGROUND

Premature ejaculation (PE) is a common problem among men that occurs when ejaculation happens sooner than a man or his partner would like during sex; it may cause unhappiness and relationship problems. Selective serotonin re-uptake inhibitors (SSRIs), which are most commonly used as antidepressants are being used to treat this condition.

OBJECTIVES

To assess the effects of SSRIs in the treatment of PE in adult men.

SEARCH METHODS

We performed a comprehensive search using multiple databases (the Cochrane Library, MEDLINE, Embase, Scopus, CINAHL), clinical trial registries, conference proceedings, and other sources of grey literature, up to 1 May 2020. We applied no restrictions on publication language or status.

SELECTION CRITERIA

We included only randomized controlled clinical trials (parallel group and cross-over trials) in which men with PE  were administered SSRIs or placebo. We also considered 'no treatment' to be an eligible comparator but did not find any relevant studies.

DATA COLLECTION AND ANALYSIS

Two review authors independently classified and abstracted data from the included studies. Primary outcomes were participant-perceived change with treatment, satisfaction with intercourse and study withdrawal due to adverse events. Secondary outcomes included self-perceived control over ejaculation, participant distress about PE, adverse events and intravaginal ejaculatory latency time (IELT). We performed statistical analyses using a random-effects model. We rated the certainty of evidence according to GRADE.

MAIN RESULTS

We identified 31 studies in which 8254 participants were randomized to receiving either SSRIs or placebo. Primary outcomes: SSRI treatment probably improves self-perceived PE symptoms (defined as a rating of 'better' or 'much better') compared to placebo (risk ratio (RR) 1.92, 95% confidence interval (CI) 1.66 to 2.23; moderate-certainty evidence). Based on 220 participants per 1000 reporting improvement with placebo, this corresponds to 202 more men per 1000 (95% CI 145 more to 270 more) with improved symptoms with SSRIs.  SSRI treatment probably improves satisfaction with intercourse compared to placebo (defined as a rating of 'good' or 'very good'; RR 1.63, 95% CI 1.42 to 1.87; moderate-certainty evidence). Based on 278 participants per 1000 reporting improved satisfaction with placebo, this corresponds to 175 more (117 more to 242 more) per 1000 men with greater satisfaction with intercourse with SSRIs. SSRI treatment may increase treatment cessations due to adverse events compared to placebo (RR 3.80, 95% CI 2.61 to 5.51; low-certainty evidence). Based 11 study withdrawals per 1000 participants with placebo, this corresponds to 30 more men per 1000 (95% CI 17 more to 49 more) ceasing treatment due to adverse events with SSRIs.  Secondary outcomes: SSRI treatment likely improve participants' self-perceived control over ejaculation (defined as rating of 'good' or 'very good') compared to placebo (RR 2.29, 95% CI 1.72 to 3.05; moderate-certainty evidence). Assuming 132 per 1000 participants perceived at least good control, this corresponds to 170 more (95 more to 270 more) reporting at least good control with SSRIs.  SSRI probably lessens distress (defined as rating of 'a little bit' or 'not at all') about PE (RR 1.54, 95% CI 1.26 to 1.88; moderate-certainty evidence). Based on 353 per 1000 participants reporting low levels of distress, this corresponds to 191 more men (92 more to 311 more) per 1000 reporting low levels of distress with SSRIs.  SSRI treatment probably increases adverse events compared to placebo (RR 1.71, 95% CI 1.48 to 1.99; moderate-certainty evidence). Based on 243 adverse events per 1000 among men receiving placebo, this corresponds to 173 more (117 more to 241 more) men having an adverse event with SSRIs.  SSRI treatment may increase IELT compared to placebo (mean difference (MD) 3.09 minutes longer, 95% CI 1.94 longer to 4.25 longer; low-certainty evidence).

AUTHORS' CONCLUSIONS

SSRI treatment for PE appears to substantially improve a number of outcomes of direct patient importance such as symptom improvement, satisfaction with intercourse and perceived control over ejaculation when compared to placebo. Undesirable effects are a small increase in treatment withdrawals due to adverse events as well as substantially increased adverse event rates. Issues affecting the certainty of evidence of outcomes were study limitations and imprecision.

A Preliminary Report on Quality of Life and Sexual Function in Brain Tumor Patients

BACKGROUND

As tumor treatment has advanced, patients are surviving and returning to productive lives. Quality of life (QoL) has become a significant consideration in the care of survivors. The 2005 Institute of Medicine Cancer Survivorship Care Planning requires the inclusion of information on the possible effects of cancer on marital/partner relationship and sexual functioning, among other factors related to QoL.

AIM

The purpose of this study is to explore the quality of life and the rates and types of sexual dysfunction among brain tumor patients.

METHODS

Patients were recruited from a neuro-oncology practice and given a QoL questionnaire (FACT-Br). Women were given the Female Sexual Function Index (FSFI). Men were given scales to assess premature ejaculation (PE), erectile dysfunction (ED), and Peyronie's disease. In addition, information about the site and type of tumor and treatment (surgery, radiation, chemotherapy) was collected. Descriptive statistics, as well as T-tests and ANOVAs, were used to analyze the data.

OUTCOMES

Study outcomes were obtained utilizing clinical cutoff scores for the sexual function questionnaires.

RESULTS

Data were collected on 50 patients. The most common form of brain tumor in this sample was glioblastoma. The frontal lobe was the most common location of tumors. There was significantly more sexual dysfunction than previously reported, with 66% of the sexually active women meeting the criteria for total FSFI. Of the men who were sexually active, 60% reported some ED, and 80% reported PE.

CLINICAL TRANSLATION

The current findings contribute to supporting the assertion that it is important for physicians to discuss with their cancer patients the issues related to sexual function.

STRENGTHS & LIMITATIONS

A primary strength of this study is the utilization of validated assessments of sexual function. The primary limitation is the sample size, particularly for men.

CONCLUSION

Our capacity to address the sexual function concerns of patients is dependent on our understanding of the types of difficulties encountered. This study contributes information about sexual function, a major contributor to QoL, in patients with brain tumor diagnosis and treatment. Boccia ML, Anyanda EI, Fonkem E. A Preliminary Report on Quality of Life and Sexual Function in Brain Tumor Patients. J Sex Med 2021;18:737-742.

Bipolar prostate thermotherapy for the improvement of chronic prostatitis symptoms and ejaculation problems

This study aims to evaluate the efficacy of the new bipolar radiofrequency thermotherapy device (TEMPRO) on urinary and sexual functions in patients with chronic prostatitis. Between April 2017 and September 2018, 42 male patients with chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) were included. The patients had received at least 6 months of treatment via conventional medical treatments. NIH-Chronic Prostatitis Symptom Index (CPSI), International Index of Erectile Function-Erectile Function part (IEEF-EF), and Premature Ejaculation Profile (PEP). The intravaginal ejaculation latency times (IELT) of the patients were recorded before and 6th months after the procedure. Bipolar radiofrequency thermotherapy was applied with TEMPRO system containing a16Fr applicator. The mean age of the patients was 42.62 ± 8.25 years. All patients were treated with local anesthesia, and three patients were unable to complete the procedure. After 6 months, significant improvements were observed in the NIH-CPSI total (20.25 vs. 12.18; p < .001) and subgroup scores, PEP scores (0.98 ± 1.12 vs. 2.06 ± 1.03; p < .001) and IELT (68.24 ± 56.78 vs. 103.02 ± 188.56; p < .001). There was no significant difference between IIEF-EF scores. Symptomatic improvement was observed in 78.57% (33/42) of the patients. Bipolar radiofrequency thermotherapy, which is a transurethral method in patients with CP/CPPS, decreases the severity of the disease and improvement of the symptom scores on urinary and sexual function. Additional studies are required to further evaluate treatment effectiveness.

Safety and efficacy of traditional Chinese medicine, Qiaoshao formula, combined with dapoxetine in the treatment of premature ejaculation: An open-label, real-life, retrospective multicentre study in Chinese men

To evaluate the safety and efficacy of Chinese medicine, Qiaoshao formula combined with dapoxetine was used for the treatment of premature ejaculation in a real-life setting. Nine hundred and five males diagnosed with premature ejaculation were reviewed in this retrospective cohort study. We divided the patients into two groups: dapoxetine alone and Qiaoshao formula combined with dapoxetine according to actual interventions provided to patients in clinics. The perceived intravaginal ejaculation latency time and the premature ejaculation profile measures markedly improved in both groups. However, in men with severe premature ejaculation (baseline perceived intravaginal ejaculation latency time <1 min) and those with baseline age ≤30 years, the perceived intravaginal ejaculation latency time was slightly but significantly longer with combined therapy than with dapoxetine alone (p < .05). Therefore, combined therapy involving the Qiaoshao formula and dapoxetine proved to safe as well as effective for treating premature ejaculation while prolonging the perceived intravaginal ejaculation latency time, which significantly improved the overall satisfaction of the patient and likely that of the couple.

Global perspectives on the three criteria for premature ejaculation: An observational study of ejaculatory latency, ejaculatory control and bother/distress

Criteria for premature ejaculation (PE) were established using Western-based samples, yet these criteria are applied worldwide for its diagnosis. This study (a) determined whether men from various world regions differ/agree on their views of ejaculation latency (ELT) and their perceptions of ejaculatory control and bother/distress, the three criteria for PE, and (b) compared PE and non-PE men across worldwide regions on these measures. 1,065 participants were recruited via social media to respond to a survey about men's typical, ideal and PE ELTs, about their own ELT, and about perceptions of ejaculatory control and bother/distress related to PE. Responses from men from four worldwide regions were compared to a reference group of North American/European men, and PE men were compared with non-PE men across three world regions. Results showed that most world region groups showed similarity in ELT estimations. The Sub-Saharan group focused more heavily on the importance of ejaculatory control. Both ELT and ejaculatory control differed between PE and non-PE groups in all regions assessed. In conclusion, perceived ELTs and ejaculatory control show substantial consistency across world regions despite geo-cultural variations and traditions. Such findings argue for the universality of the concepts of ELT, control and bother/distress related to PE.

Smartphone-Based Therapeutic Exercises for Men Affected by Premature Ejaculation: A Pilot Study

INTRODUCTION

Smartphone-delivered healthcare interventions allow patients to access services on demand when needed, improving motivation and compliance. However, the use of mobile health apps has been scarcely explored in sexual medicine.

AIM

To evaluate the effects of integrating psychological treatment for premature ejaculation (PE) with a mobile coaching app that offers therapeutic exercises on the patient's smartphone.

METHODS

This study comprised 35 heterosexual men with primary psychogenic PE (mean age 34 years, standard deviation = 9.15). All patients entered a cycle of 15 sessions of psychodynamic psychotherapy integrating behavioral therapy, each lasting about 45 minutes. The patients were randomly assigned to 2 groups, each of which performed daily homework exercises (physiotherapy exercises for reinforcing the pelvic floor muscles and cognitive exercises for distancing from sexual failure.) The first group (15 patients) received verbal and printed instructions only (treatment as usual-TAU), whereas the second group (17 patients) experienced the exercises with guidance from the mobile app (app). In both groups, the exercises started after the seventh session. Patients were advised to perform the exercises 3 times a day for 3 months.

MAIN OUTCOME MEASURES

The primary outcome measures were the Premature Ejaculation Diagnostic Tool and the Premature Ejaculation Profile.

RESULTS

Analysis of the data revealed significant pre-post improvements in Premature Ejaculation Diagnostic Tool and Premature Ejaculation Profile scores for the app group compared with those of the TAU group (P < .01). The frequency of patients with no-PE condition for the app group after treatment was significantly higher than the frequency of patients with no-PE condition for the TAU group (P < .001).

CONCLUSION

Results suggest that a mobile coaching app performs better than TAU in improving both the behavioral skills of ejaculatory delay and sexual self-confidence within a psychological treatment for PE. Future studies should collect follow-up data and explore the potential of mobile coaching apps in combined pharmacotherapy and psychotherapy interventions. Optale G, Burigat S, Chittaro L. et al. Smartphone-Based Therapeutic Exercises for Men Affected by Premature Ejaculation: A Pilot Study. J Sex Med 2020;8:461-471.

Premature ejaculation in couples using contraceptive withdrawal and associations with characteristics of its use: A cross-sectional study

This study aimed to investigate the Premature Ejaculation Profile (PEP) and its related factors in couples using contraceptive withdrawal (WD). The study sample was composed of 108 participants including 54 males and 54 females (their partners) who used WD. The data were collected via a questionnaire and the male and female forms of the PEP. The mean total PEP index score of the couples (female (F); 1.69 ± 0.55 and male (M); 1.65 ± 0.36) was below the average possible score. Although both males and their partners generally rated control over ejaculation (F; 57.4%, M; 61.1%) and satisfaction with sexual intercourse (F; 63%, M; 79.7%) as good/very good, they rate personal distress related to ejaculation (F; 64.8%, M; 83.4%) and interpersonal difficulty related to ejaculation (F; 81.5%, M; 92.6%) as 'extremely/quite a lot'. As the time of using WD increased, male control over ejaculation increased (p = .019); as the marriage duration (p = .045) and ages (F; p = .012, M; p = .045) of the couples increased, their problems related to ejaculation increased. According to the results, couples who use WD experience PE-related problems, and the problems they experience vary depending on the period of WD use, marriage duration and age.

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.

Assessment Scales for Sexual Disorders—A Review

Over the last 3 to 4 decades then has been an upsurge in designing rating instruments for assessing various aspects of sexuality, sexual dysfunction, and sexual disorders. In this article, we review the instruments used for assessing/rating various sexual disorders stemming from problems in the areas of sexual knowledge to erection/ejaculation to marital functioning, etc. Some of the available scales focus on all the phases of the sexual cycle, whereas other scales focus on the specific phases of the sexual cycle. Some of the commonly used scales, which assess multiple domains of sexual dysfunction include the Arizona Sexual Experience Scale or the International Index of Erectile Dysfunction. Some of the scales focus on other disorders such as Dhat syndrome. Though a lot of scales are available, there is a paucity of culturally sensitive, translated-validated scales. Although rating instruments provide us with valuable information about the sexual functioning of an individual, these should always be used as an add-on, ie, secondary to detailed taking and clinical examination for making any diagnosis or formulation of a management plan.

Impact of Childhood Sexual Assault on Sexual Function in the Czech Male Population

Introduction

This study explores the impact of childhood sexual assault (CSA) on men's sexual function. There is limited understanding on the impact of CSA perpetrated against boys on later adult male sexual function, as there is a dearth of research on this topic. It was hypothesized that men reporting a history of CSA were more likely to report sexual function issues than men with no history of CSA.

Material and methods

A cross-sectional survey study of 1,004 Czech men aged between 15 and 85 years (M = 42.8 years; Standard deviation = 17.6 years) have been conducted. The participants anonymously answered a questionnaire on multiple aspects of their life and sexuality. This questionnaire included sought data on history of CSA and self-reported intravaginal ejaculation latency time and the 5-item International Index of Erectile Function.

Results

25 men (2.5%) indicated a history of CSA. 71% of the perpetrators where known by the victims, with a minority declaring the crime to authorities (37.5%). Half of those reporting assault also reported sexual function issues in the present or at some time in their life. Significant correlations were recorded between a history of CSA and erectile dysfunction but not significantly with premature ejaculation.

Conclusions

Men who reported a history of CSA are more likely to report sexual function issues than those who do not. The identified association between CSA and sexual function issues in adult life contributes to the small body of literature on the topic. When taking a sexual history, it is recommended to practitioner to include questions about CSA, considering its correlation with erectile dysfunction. An understanding of the relationship between CSA and adult sexual function helps practitioner to improve his patient's well--being and life satisfaction.

Kamnerdsiri WA, Fox C, Weiss P, et al. Impact of Childhood Sexual Assault on Sexual Function in the Czech Male Population. J Sex Med 2020;8:446–453.

The Oxytocin Antagonist Cligosiban Prolongs Intravaginal Ejaculatory Latency and Improves Patient-Reported Outcomes in Men with Lifelong Premature Ejaculation: Results of a Randomized, Double-Blind, Placebo-Controlled Proof-of-Concept Trial (PEPIX)

INTRODUCTION

Cligosiban is an orally administered oxytocin receptor antagonist being developed to treat premature ejaculation (PE).

AIM

To determine the safety and efficacy of cligosiban capsules (dose range 400-800 mg) to improve intravaginal ejaculation latency time (IELT) and patient-reported outcomes in men with severe lifelong PE.

METHODS

Patients recorded details of at least 4 sexual intercourse events during a 4-week run-in period, after which they underwent baseline assessments. Patients were eligible for the study if they rated their control of ejaculation as poor/very poor and their stopwatch-assessed IELT was ≤1 minute in ≥75% of intercourse attempts. Eligible patients were randomized to an 8-week treatment period with double-blind cligosiban or placebo (to be taken 1 to 6 hours prior to sexual activity). The starting dose was 400 mg (not more than 1 dose per day) which could be increased to 800 mg after 2 and/or 4 weeks of treatment. Assessments were conducted at 2, 4, and 8 weeks.

MAIN OUTCOME MEASURE

Efficacy measures were comprised of IELT, self-rating of ejaculation control and ejaculation-related distress (recorded in an electronic diary after each intercourse attempt), premature ejaculation profile, and the Clinical Global Impression of Change.

RESULTS

The mean ratio of fold change from baseline in IELT to the last 4 weeks of treatment (cligosiban/placebo) was 1.9 compared to a baseline of 1.0 (P = .0079). The mean increase in IELT from baseline to the last 4 weeks of treatment was 61.0 seconds for cligosiban, which was significantly different from (and 3.6-fold greater than) the mean increase of 16.4 seconds for placebo (P = .0086). Statistically significant improvements in ejaculation control and ejaculation-related personal distress scores were also observed for cligosiban compared to little or no change with placebo. Cligosiban was generally well tolerated, with no serious or severe adverse events or other safety parameters.

CLINICAL IMPLICATIONS

This proof-of-concept study demonstrated the potential for cligosiban, an oxytocin antagonist, to successfully treat symptoms of severe lifelong PE.

STRENGTHS AND LIMITATIONS

This was a Phase II, randomized, double-blind, placebo-controlled study that was adequately powered to detect a clinically meaningful difference in change in IELT between cligosiban and placebo. Larger studies will be needed to confirm these findings, determine the optimal dose of cligosiban and assess efficacy in men with acquired PE.

CONCLUSIONS

Cligosiban was well tolerated, and resulted in significant benefits in both objective and subjective measures of ejaculatory control in men with lifelong PE and therefore offers significant potential as an on-demand, orally administered agent for the treatment of PE. McMahon C, Althof S, Rosen R, et al. The Oxytocin Antagonist Cligosiban Prolongs Intravaginal Ejaculatory Latency and Improves Patient-Reported Outcomes in Men with Lifelong Premature Ejaculation: Results of a Randomized, Double-Blind, Placebo-Controlled Proof-of-Concept Trial (PEPIX). J Sex Med 2019; 16:1178-1187.

The Oxytocin Antagonist Cligosiban Fails to Prolong Intravaginal Ejaculatory Latency in Men with Lifelong Premature Ejaculation: Results of a Randomized, Double-Blind, Placebo-Controlled Phase IIb trial (PEDRIX)

INTRODUCTION

Cligosiban is an orally administered, centrally penetrant oxytocin receptor antagonist being developed to treat premature ejaculation (PE).

AIM

To determine the efficacy of 3 dose levels of cligosiban caplets to prolong intravaginal ejaculation latency time (IELT) and improve patient-reported outcomes in men with lifelong PE.

METHODS

Patients recorded details of at least 4 sexual intercourse events during a 4-week run-in period, after which they underwent baseline assessments. Patients were eligible for the study if their stopwatch-assessed IELT was ≤1 minute in ≥75% of intercourse attempts and if they met other diagnostic criteria for lifelong PE. Eligible patients (target 220 evaluable) were randomized to double-blind cligosiban 400, 800, or 1200 mg or matching placebo caplets (to be taken 1 to 6 hours prior to sexual activity). Assessments were conducted at 2, 4, and 8 weeks.

MAIN OUTCOME MEASURE

Efficacy measures were comprised of IELT, self-rating of ejaculation control and ejaculation-related distress (recorded in an electronic diary after each intercourse attempt), premature ejaculation profile, Patient's Global Impression of Severity, and the Clinical Global Impression of Change.

RESULTS

There were no clinically or statistically significant differences between cligosiban (at any dose level) and placebo for the primary endpoint (change in geometric IELT) or any of the secondary endpoints. Cligosiban was well tolerated with a side-effect profile similar to placebo.

CLINICAL IMPLICATIONS

This Phase IIb study failed to demonstrate the potential for cligosiban, an oxytocin antagonist, to successfully treat symptoms of severe lifelong PE at doses up to 1200 mg.

STRENGTHS AND LIMITATIONS

This was a Phase IIb, randomized, double-blind, placebo-controlled study that was adequately powered but failed to detect a clinically meaningful or statistical difference in change in IELT between cligosiban at 3 dose levels and placebo. This is in contrast to a similarly designed proof-of-concept study where cligosiban was flexibly dosed at doses up to 800 mg and did demonstrate clinically meaningful and statistically significant changes in efficacy parameters. The reasons for this disparity are not known.

CONCLUSIONS

Cligosiban was well tolerated but failed to demonstrate efficacy for the treatment of men with lifelong PE at doses up to 1200 mg. Althof S, Osterloh IH, Muirhead GJ, et al. The Oxytocin Antagonist Cligosiban Fails to Prolong Intravaginal Ejaculatory Latency in Men with Lifelong Premature Ejaculation: Results of a Randomized, Double-Blind, Placebo-Controlled Phase IIb trial (PEDRIX). J Sex Med 2019; 16:1188-1198.

Advantages and limitations of current premature ejaculation assessment and diagnostic methods: a review

Premature ejaculation (PE) is the most common male sexual dysfunction worldwide. Characteristic symptoms of PE are unexpected, rapid, complete ejaculation, which negatively impacts the sexual act for both sexual partners. Despite the existence of a definitive PE classification system and various diagnostic tools, diagnosing PE is still challenging due to the limitations associated with the assessment of this condition. Hence, it is necessary to review the diagnostic methods and processes of the physical examination that are currently performed in the medical setting. It is also important to analyze any controversial results of each main PE assessment method and propose novel diagnostic and assessment methods. To date, it is important to verify the accuracy of the PE evaluation method due to the ambiguity of previous definitions and proven invalidity of current examining techniques. Clinical diagnosis is based mainly on the patient history, patient-reported outcome scores, and diagnostic tools. Introduction of intravaginal ejaculatory latency time, penile biothesiometry, and the electrophysiological test provided objective means of evaluating PE. Due to the controversial and inconclusive findings in PE psychogenic and neurogenic etiology, utilizing a single parameter to describe and qualify PE using the aforementioned diagnostic methods provides valuable, but insufficient information for PE diagnosis. There is still a lack of a feasible and plausible means of objective measurement to evaluate the ejaculatory latency and control over ejaculation. Consequently, a comprehensive penile stimulation that simulates sexual intercourse could be useful to record intensity and duration parameters before the ejaculatory threshold, providing a more accurate method of describing and diagnosing PE versus a single chronological observation.

Objective and Subjective Measures of Premature Ejaculation: How Closely Do They Correspond and How Well Are the Subjective Measures Recalled?

BACKGROUND

Clinical trials evaluating new treatments for premature ejaculation (PE) should ideally include both objective end points and patient reported outcomes (PROs), but there is no consensus currently over the optimal measures or combination of outcomes. In addition, many PROs use a 1-month recall period, despite concerns about potential recall bias.

AIMS

Data from a clinical trial of men with lifelong PE were used to examine the consistency of 2 core items of the Premature Ejaculation Profile (PEP), a widely used PRO for assessing subjective aspects of PE. The specific aim was to assess the level of agreement between the original 1-month recall version compared with a new event-based version of the scale in men meeting current definitions of lifelong PE. A further aim was to investigate the convergent validity between an objective end point of intravaginal ejaculatory latency time (IELT), subjective PEP responses, and a patient's Clinical Global Impression of Change (CGIC) measure.

METHODS

For assessment of consistency of PEP responses (short-term [ie, sexual event driven] vs 1-month recall), descriptive statistics, correlation coefficients (Pearson and Spearman), and Bland-Altman plots are presented for each time interval. For assessment of convergent validity, descriptive statistics and correlation coefficients (Pearson and Spearman) are presented for each assessment with geometric mean IELT values. Results are also depicted graphically. Geometric mean IELT over the last 4 weeks of treatment and change from baseline (absolute and fold change) were estimated via a general linear model for each category of change in PEP and CGIC, adjusting for baseline IELT.

OUTCOMES

PEP items administered via 1-month recall and short-term event-driven responses gave virtually identical results. There was a strong correlation (very good convergent validity) between IELT and responses to PEP and the CGIC.

CLINICAL TRANSLATION

Men with lifelong PE can accurately recall their level of sexual functioning over the previous month. The PEP and CGIC are appropriate instruments to measure the subjective response of men with PE to new treatments.

STRENGTHS AND LIMITATIONS

Our analyses address gaps in previously published research on PE assessment methodology. Men with acquired PE, men without partners, and men in homosexual relationships were not studied.

CONCLUSIONS

In a clinical trial setting, PEP and CGIC are appropriate end points and are likely the optimal combination of PROs for use with IELT to enable a global assessment of patient response to new PE treatments. Althof S, Rosen R, Harty B, et al. Objective and Subjective Measures of Premature Ejaculation: How Closely Do They Correspond and How Well Are the Subjective Measures Recalled? J Sex Med 2020;17:634-644.

Efficacy of dapoxetine treatment in Chinese patients with premature ejaculation and possible factors affecting efficacy in the real-world practice

BACKGROUND

The treatment effect of dapoxetine in real-world practice is not well established. This study was to investigate the factors influencing efficacy of dapoxetine for the treatment of Premature ejaculation (PE) in the real-world setting.

METHODS

Altogether 154 patients were followed up between Jan 2015 and Dec 2015. The clinical global impression of change (CGIC), premature ejaculation profile (PEP), the estimated intravaginal ejaculation latency time (eIELT) and estimated number of intravaginal thrusts before ejaculation (NITBE) were collected. The clinical characteristics of patients with CGIC = 0 and CGIC≥1 were compared.

RESULTS

After 4 weeks treatment, an obvious improvement compared with the baseline was found regarding mean eIELT (2.4 ± 1.6 min vs 1.0 ± 0.7 min, P < 0.001) and mean NITBE (85.9 ± 61.9 times vs 37.4 ± 28.6 times, P < 0.001). The proportion of patients with a self-evaluation of at least "slightly better" and were categorized into "CGIC≥1" group was 70.1%. There were significant differences between patients in the "CGIC = 0" and "CGIC≥1" groups regarding mean NITBE (P = 0.010) and PEDT (P = 0.009) score at baseline. The adverse effects were acceptable.

CONCLUSION

Dapoxetine was well-tolerated and improved the sexual satisfaction of patients with PE. The severity of PE based on PEDT and NITBE suggest that there could be an effectiveness change with dapoxetine use in real-world practice.

Sexual dysfunction in people with epilepsy

Sexual dysfunction is a common comorbidity in people with epilepsy (PWE) that adversely affects their quality of life. Nearly one-half of men and women with epilepsy have sexual dysfunction, but in the majority, this often goes unnoticed. The wide variation in the reported prevalence of sexual dysfunction in PWE is due to the significant heterogeneity among the studies with regard to patient population, type and severity of epilepsy, number and type of antiseizure drugs (ASDs) used, and the tools used for assessing sexual dysfunction. Generally, patients with uncontrolled epilepsy, longer duration of epilepsy, focal epilepsy, higher seizure frequency, and those receiving enzyme-inducing and multiple ASDs are more likely to have sexual dysfunction. Women generally have dysfunction in the domains of desire, while males usually have arousal disorders such as erectile dysfunction and premature ejaculation. There is limited evidence to indicate that sexual function improves in patients rendered seizure-free following epilepsy surgery. Multiple mechanisms including direct effects of epilepsy, effects of ASDs, and psychosocial factors contribute to sexual dysfunction in epilepsy. Circumstantial evidence indicates that seizures and interictal epileptiform discharges can directly affect the hypothalamic-pituitary axis as well as production of gonadal steroids. Enzyme-inducing ASDs cause sexual dysfunction by affecting the metabolism of gonadal steroids. Limited data suggest that newer ASDs including oxcarbazepine, lamotrigine, and levetiracetam cause no or minimal sexual dysfunction. Depression and anxiety significantly contribute to sexual dysfunction in PWE. A multipronged and multidisciplinary approach is essential for optimizing the sexual functions. Every effort should be made to identify and treat reversible causes including changing to nonenzyme-inducing ASDs and to provide symptomatic relief. Large, prospective studies are required to improve our understanding on prevalence and mechanisms of sexual dysfunction in PWE.

Comparison of the treatment efficacies of paroxetine, fluoxetine and dapoxetine in low socioeconomic status patients with lifelong premature ejaculation

Introduction

To assess the treatment efficacies of paroxetine, fluoxetine and dapoxetine in patients with lifelong premature ejaculation (PE).

Material and methods

One hundred and seventy male patients with lifelong PE were included in our study. Premature ejaculation profile (PEP) and Intravaginal ejaculation latency times (IELT) were recorded. Paroxetine 20 mg/d was given in Group 1 (n = 64), fluoxetine 20 mg/d was given in Group 2 (n = 47) and dapoxetine 30 mg on demand (at least two times/week) was given in Group 3 (n = 59) patients. After 1 month of treatment, the patients' IELT, PEP and patient reported clinical global impression of change (CGIC) were completed.

Results

The mean age was 36 ±9.2 years. There was no difference between the groups' age, PEP and IELT before treatment (p >0.05). PEP and IELT improved in all three groups (p <0.001). The changes in the 1^st and 3^rd questions of PEP was significantly higher in group 1 than in the other groups (pPEP-1 = 0.042, pPEP-3 = 0.001). The changes in the 2^nd and 4^th questions of PEP were similar between groups (pPEP-2 = 0.444, pPEP-4 = 0.442). In group 1 and 3 IELT changes were better than group 2 (pIIEL1-3 = 0.297, pIIEL1-2 = 0.017, pIIEL2-3 = 0.100). There was no difference between CGIC scores (p = 0.087). The treatment was terminated by 8 patients in Group 1 and 9 patients in Group 2 because of side effects.

Conclusions

While paroxetine treatment seemed to be better than the other medications, dapoxetine 30 mg treatment has less side effects than the two others and its' on demand usage makes it more prominent than the others.

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.

Beneficial effect of tamsulosin combined with dapoxetine in management of type III prostatitis with premature ejaculation

To evaluate the efficacy and safety of tamsulosin combined with dapoxetine in the treatment of type IIIB chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) that is complicated by premature ejaculation (PE), a total of 251 CP/CPPS patients with PE were recruited from nine hospitals across China and were randomly divided into two groups: one received tamsulosin as a control, and the other received a combination therapy of tamsulosin and dapoxetine. Follow-up was conducted at four time points, and indicators describing CP/CPPS and PE were compared between the two groups. In all, 223 patients were followed up at least once, and 114 patients completed all of the treatment process. The combination group showed more improvement in the symptoms of both PE and CP/CPPS, including thrust number (50.5 vs. 45), premature ejaculation profile score (11.39 vs. 6.96), intravaginal ejaculation latency time (5.95 min vs. 2.63 min) and the National Institutes of Health Chronic Prostatitis Symptom Index (7.44 vs. 11.81) in comparison with the tamsulosin group. In conclusion, for CP/CPPS patients with PE, tamsulosin combined with dapoxetine provided better therapeutic efficacy in the treatment of not only PE symptoms but also CP/CPPS indicators in comparison with tamsulosin monotherapy.

Content Validity of the Premature Ejaculation Profile, Original and Per-Event Formats, in Men with Lifelong Premature Ejaculation

BACKGROUND

The Premature Ejaculation Profile (PEP) is a patient-reported outcome (PRO) measure that is widely used in clinical research in men with premature ejaculation (PE) but has not been fully validated for men meeting the current International Society for Sexual Medicine (ISSM) definition of lifelong PE.

AIM

To explore the content validity of the PEP (original 1-month recall version and new event-driven version) in men meeting current definitions of lifelong PE and to understand the relevance of the concept of ejaculation control.

METHODS

In-depth individual interviews were conducted with 24 men in a stable heterosexual relationship, including 15 with lifelong PE, 4 with acquired PE (with intravaginal ejaculation latency time values confirmed during a 4-week period of no treatment), and 5 with no sexual dysfunction. Initial concept elicitation explored individual experiences of having PE (in those with PE), experiences of control, and impact on sexual life. This was followed by a cognitive debriefing of the PEP versions.

MAIN OUTCOME MEASURE

Thematic analysis was used to identify key concepts of PE, understand the experience of control in men with and without PE, and confirm understanding and relevance of questions from original and event-driven versions of the PEP.

RESULTS

The interviews confirmed substantial negative consequences for men with lifelong PE. Men with and without PE could describe ejaculation control (or lack of it). The PEP was shown to cover the key concepts in PE, and the questions were easily understood in both the original or event-driven versions. The items were comprehensive, and the concept of ejaculation control was confirmed. A 1- or 2-category change in each item of the PEP was considered clinically meaningful.

CLINICAL IMPLICATIONS

The PEP (original and per-event) has strong content validity for use in clinical research studies of men meeting the ISSM definition of lifelong PE.

STRENGTHS & LIMITATIONS

This study addressed gaps in previously published research on the development and validation of the PEP and also confirmed that a new event-driven version is also suitable for use in research. However, the study was limited mainly to men meeting a strict definition of lifelong PE; in addition, homosexual men and those not in stable long-term relationships were not studied.

CONCLUSION

Both the original and per-event PEP versions were shown to have strong content validity and be acceptable for use in men with lifelong PE. Burbridge C, Symonds T, Osterloh IH, et al. Content Validity of the Premature Ejaculation Profile, Original and Per-Event Formats, in Men with Lifelong Premature Ejaculation. J Sex Med 2019;16:569-576.

[Ejaculation disorders in multiple sclerosis: Prospective study of 44 patients]

INTRODUCTION

To analyze in a descriptive way the ejaculation disorders during MS and to study the correlations between dysejaculations, other sexual, urinary and anorectal disorders.

MATERIAL

Prospective, monocentric, non-interventional study. Ejaculation disorders were assessed by Premature Ejaculation Profile (PEP) scores, intravaginal latency, and the Male Sexual Health Questionnaire - Ejaculation (MSHQ-Ej). The sexual disorders were evaluated by the International Index of Erectile Function (IIEF15) and the Sclerosis Intimacy and Sexuality Questionnaire-19 (MSISQ).

RESULTS

Forty-four men of mean age 46.8 (±10.3) years, with an average EDSS of 5.0 (±1.5) were included. According to the MSHQ-Ej score, ejaculation disorders were present in 28 out of 44 patients included (64%); 26/44 (59%) had an orgasm disorder, 23/44 (52%) a delay in ejaculation, 26/44 (59%) a decrease in ejaculation flow, 24/44 (55%) decreased ejaculated volume, 18/44 (41%) decreased ejaculation frequency, 15/44 (33%) ejaculatory pain and 11 34 (25%) showed systematic non ejaculation. The PEP score showed premature ejaculation in 14 patients (32%). The intra-vaginal latency time was less than 1minute in 6 patients (13.6%). There was a statistically significant correlation between ejaculation disorders and erectile dysfunction (P<0.05, correlation coefficient at 0.53) but no statistically significant correlation between ejaculation disorders and urinary or ano-rectal disorders.

CONCLUSIONS

Dysejaculation was present in 64% of MS. These disorders were mainly characterized by a decrease in the volume of the ejaculation, the strength of ejaculation and the delay in ejaculation.

LEVEL OF EVIDENCE

4.

Efficacy of Sphincter Control Training (SCT) in the treatment of premature ejaculation, a new cognitive behavioral approach: A parallel-group randomized, controlled trial

Introduction

Current evidence suggests that Cognitive Behavioral therapy (CBT) has a limited role in the contemporary management of premature ejaculation (PE).

Aim

The aim of this study was to determine the efficacy of a new CBT for the PE called Sphincter Control Training (SCT) in combination with a masturbation aid device.

Methods

The present study included 35 patients’ that met diagnostic criteria for PE including intravaginal ejaculatory latency time (IELT) of ≤2 minutes and had a Premature Ejaculation Diagnostic Tool (PEDT) score ≥11. Participants completed all phases of a randomized controlled clinical study with a parallel group design, which was approved by the Ethical Committee of the Hospital Morales Meseguer of Murcia (Spain).The two treatment groups completed SCT over 7 weeks. The SCT consists of four different exercises and an educational session. Its objective is to provide patients with greater knowledge, awareness, and control of the external urethral sphincter. The only difference between groups was the use of a masturbation aid device called Flip Zero (TFZ-001) from the Japanese company Tenga Co., Ltd.

Outcomes

The main measure was the "fold increase" (FI) of the IELT, which was calculated using the geometric mean pre-treatment and post-treatment. In addition, Premature Ejaculation Profile PE was used as a secondary measure.

Results

The geometric mean of the measurements corresponding to the 7 weeks of treatment was calculated, and both groups were compared by means of an ANCOVA test, finding a statistically significant difference (F: 10.51, 1; p = .003) in the increase experienced by subjects in the group with the device (GWD) mean = 166.63, SD = 106.54) compared with that experienced by subjects in the group without device (GWtD) (mean = 86.99, SD = 59.98).Using Student's t-test, the Fold increase (FI) corresponding to both groups were compared. The results showed statistically significant differences (p = .008) between the measurements corresponding to the GWtD (1.38 (0.50)) and those relative to the GWD (2.69 (1.81))

Clinical implications

The FI in the GWD at the end of the trial allow us to consider this new CBT as a potential and viable PE treatment alternative. No side effects were observed in either treatment group and it required little therapeutic input and no partner involvement.

Strengths & limitations

The main limitation of this study is the lack of a 3- to 6-month follow-up of the treatment and placebo control.

Conclusions

This SCT exercise program combined with the use of a masturbation device shows promise because has numerous advantages in relation to current recommended treatments in patients with PE.

Efficacy and safety of dapoxetine/sildenafil combination tablets in the treatment of men with premature ejaculation and concomitant erectile dysfunction-DAP-SPEED Study

Premature ejaculation (PE) and erectile dysfunction (ED) are the most prevalent sexual disorders in men. ED is commonly reported among patients with PE. Although recent guidelines recommend to treat ED first in men with both PE and ED, this recommendation is not based on evidence and there are limited data about the efficacy and safety of dapoxetine/sildenafil combination therapy for these patients. The aim of this study is to evaluate the clinical efficacy and safety of the dapoxetine/sildenafil combination (Dapoxil^® 30/50 mg film-coated tablet) in the treatment of patients with PE and concomitant ED. In a single-center, single-arm, open-label clinical study conducted between October 2016 and September 2017, 74 patients with lifelong or acquired PE and ED were included. All patients were instructed to record their intravaginal ejaculatory latency time (IELT) with a stopwatch for 4 weeks. After the screening, they were requested to complete Premature Ejaculation Diagnostic Tool (PEDT), Premature Ejaculation Profile (PEP), and International Index of Erectile Function-Erectile Function (IIEF-EF) questionnaires before the treatment. The patients received on demand Dapoxil^® 1-3 h before sexual intercourse for the next 4 weeks (2 days a week and no more than once a day). The patients were also assessed with global impression of change (GIC) question for the treatment satisfaction and the side effects were recorded. The study was completed with 53 patients (53/74, 71.62%). Mean age of the patients was 45.32 ± 10.05 years. At the end of the 4-week treatment period, the geometric mean IELT of the patients significantly increased (from 22.72 ± 15.16 to 68.25 ± 82.33 s; p < 0.001). Similarly, significant improvements were observed in the mean PEP index score (0.86 ± 0.72 vs. 2.36 ± 1.13; p < 0.001) and mean IIEF-EF domain score (13.17 ± 3.33 vs. 24.60 ± 3.96; p < 0.001). According to the GIC results, 81.13% of the patients were satisfied with the treatment. Non-serious adverse events occurred in 10 patients (18.87%) and 4 (7.55%) of these patients dropped out of the treatment. The most common adverse events were headache, palpitation, and flushing. The dapoxetine/sildenafil combination therapy significantly improves the IELT values and patient reported outcome measures of PE patients who also suffer from ED. Although several side effects were reported, these were mild and transient.

Contemporary management of ejaculatory dysfunction

Although erectile dysfunction is the most common disorder of male sexual health, ejaculatory dysfunction is the most common form of sexual dysfunction experienced by men. Ejaculatory dysfunction covers a broad range of disorders that we have divided into four main categories: premature ejaculation, delayed ejaculation (DE)/anorgasmia, unsatisfactory sensation of ejaculation (including painful ejaculation and ejaculatory anhedonia), and absent ejaculate (including retrograde ejaculation and aspermia). We also cover several special scenarios including hematospermia, spinal cord injury and fertility with anejaculation. In this paper, we will review the anatomy and pathophysiology of normal ejaculation to establish the baseline knowledge of how this pathway can go awry. We will then briefly review the critical diagnostic criteria, pertinent steps in evaluation, risk factors, and causes (if known) for each of the ejaculatory disorders. Finally, the bulk of the paper will discuss current management strategies of each disorder.

Premature ejaculation: challenging new and the old concepts

Premature ejaculation remains a difficult condition to manage for patients, their partners, and the clinician. Whilst prevalence rates are estimated to be 20-40%, determining a diagnosis of premature ejaculation is difficult, as the definition remains both subjective and ill-defined in the clinical context. As our understanding of the ejaculatory pathway has improved, new opportunities to treat the condition have evolved with mixed results. In this review, we explore some of these controversies surrounding the aetiology, diagnosis, and treatment of this condition and discuss potential novel therapeutic options.

Fortacin™ Spray for the Treatment of Premature Ejaculation

Premature ejaculation (PE) is a common complaint of male sexual dysfunction affecting men and their partners and consequently causing significant personal and interpersonal distress. Increased sensitivity of the glans penis and abnormalities of the afferent-efferent reflex pathway within the ejaculatory process are involved in the occurrence of PE. Drugs that either selectively reduce penile sensitization or modify the afferent-efferent reflex are well established therapeutic options for PE. Fortacin™ is the first topical treatment to be officially approved for the treatment of primary PE in adult men, and is mentioned as an experimental aerosol (as TEMPE) in the current European Association of Urology guidelines. It was approved for use in the European Union and launched in the United Kingdom in November 2016. Fortacin™ is a eutectic-like mixture of lidocaine 150 mg/mL and prilocaine 50 mg/mL that meets the requirements of an ideal treatment for PE because it is fast acting (within 5 minutes), has durable effects, can be easily used "on-demand", and shows minimal side-effects. The metered-dose spray delivery system allows the desensitizing agents to be deposited in a dose-controlled, concentrated film onto the glans penis consequently reducing its sensitivity. This is translated into a delaying of the ejaculatory latency time without adversely affecting the sensation of ejaculation and orgasmic pleasure. The efficacy and safety of Fortacin™ have been proven by means of increased ejaculatory latency, control, and sexual satisfaction in large scale studies demonstrating the significant benefits for both patients and their partners.

Standards for Clinical Trials in Male and Female Sexual Dysfunction: III. Unique Aspects of Clinical Trials in Male Sexual Dysfunction

This series of articles, Standards for Clinical Trials in Male and Female Sexual Dysfunction, began with the discussion of a common expected standard for clinical trial design in male and female sexual dysfunction, a common rationale for the design of phase I to IV clinical trials, and common considerations for the selection of study population and study duration in male and female sexual dysfunction. The second article in this series discussed fundamental principles in development, validation, and selection of patient- (and partner-) reported outcome assessment. The third and present article in this series discusses selected aspects of sexual dysfunction that are that are unique to male sexual dysfunctions and relevant to the conduct of clinical trials of candidate treatments for men.

Standards for Clinical Trials in Male and Female Sexual Dysfunction: II. Patient-Reported Outcome Measures

The second article in this series, Standards for Clinical Trials in Male and Female Sexual Dysfunction, focuses on measurement of patient-reported outcomes (PROs). Together with the design of appropriate phase I to phase IV clinical trials, the development, validation, choice, and implementation of valid PRO measurements-the focus of the present article-form the foundation of research on treatments for male and female sexual dysfunctions. PRO measurements are assessments of any aspect of a patient's health status that come directly from the patient (ie, without the interpretation of the patient's responses by a physician or anyone else). PROs are essential for assessing male and female sexual dysfunction and treatment response, including symptom frequency and severity, personal distress, satisfaction, and other measurements of sexual and general health-related quality of life. Although there are some relatively objective measurements of sexual dysfunction (ie, intravaginal ejaculatory latency time, frequency of sexual activity, etc), these measurements do not comprehensively assess the occurrence and extent of sexual dysfunction or treatment on the patient's symptoms, functioning, and well-being. Data generated by a PRO instrument can provide evidence of a treatment benefit from the patient's perspective.

Silodosin versus naftopidil in the treatment of premature ejaculation: A prospective multicenter trial

OBJECTIVES

To determine the efficacy of two α1-adrenoceptor antagonists with different affinities for α1-adrenoceptor subtypes, silodosin and naftopidil, in the treatment of premature ejaculation.

METHODS

This was a prospective, open-label, multicenter trial. A total of 26 patients with untreated acquired premature ejaculation were enrolled. Premature ejaculation was defined based on the International Society for Sexual Medicine recommendation. Patients self-administered on demand silodosin 4 mg or naftopidil 25 mg 1 h before intercourse, alternating drugs at least three times each. Clinical global impression change for premature ejaculation, premature ejaculation profile, and intravaginal ejaculation latency time were evaluated at baseline and during treatment.

RESULTS

Due to clinical global impression change, 24 patients (92%) and 12 patients (46%) reported improvement in their own premature ejaculation problems under silodosin and nafitopidil administration, respectively. Silodosin treatment produced a significantly higher improvement rate compared with naftopidil (P = 0.0002). Objectively, silodosin significantly prolonged intravaginal ejaculation latency time compared with baseline and naftopidil (P < 0.01). Mean intravaginal ejaculation latency times were 1.9, 4.1, and 7.6 min at baseline, control and with silodosin, respectively. The rate of reduced semen volume during silodosin treatment was higher than during naftopidil treatment. There were no adverse systemic effects in either group.

CONCLUSIONS

Silodosin, a highly selective α1A-adrenoceptor antagonist, produces greater improvements in premature ejaculation profiles and related symptoms along with intravaginal ejaculation latency time in acquired premature ejaculation patients with or without erectile dysfunction. This result supports the clinical use of silodosin as an alternative treatment for premature ejaculation.