Disorders of Ejaculation: An AUA/SMSNA Guideline (2020) Flashcards

Question

What is the role of galaninergic neurons in ejaculation? a. They have no role in ejaculation. b. They play a minor role in ejaculation. c. They play a critical role in ejaculation. d. It depends on the individual.

Answer 1

c. They play a critical role in ejaculation. Explanation: Galaninergic neurons are responsible for integrating stimuli from peripheral and cerebral sources and triggering the ejaculatory reflex. Lesion of these structures is strongly associated with ejaculatory failure.

Answer 2

Galaninergic neurons are a type of nerve cell that produce galanin, a neuropeptide that plays a critical role in the regulation of various physiological processes, including ejaculation. In the context of ejaculation, galaninergic neurons are responsible for integrating stimuli from peripheral and cerebral sources and triggering the ejaculatory reflex. Lesion of these structures is strongly associated with ejaculatory failure. These neurons are arranged in columns within the central spinal cord, and some experts have described this structure as the "spinal ejaculation generator" (SEG).

Answer 3

The sexual response cycle consists of four phases: excitement, plateau, orgasm, and resolution. During the excitement phase, there is an increase in heart rate, blood pressure, and respiration. This phase is characterized by the onset of sexual arousal. During the plateau phase, sexual arousal continues to increase, but at a slower rate. This phase is characterized by increased muscle tension and vasocongestion. During the orgasm phase, there is a release of sexual tension and a feeling of intense pleasure. This phase is characterized by rhythmic contractions of the genital organs. During the resolution phase, there is a return to the pre-aroused state.

Answer 4

Ejaculation is triggered by the integration of tactile and non-tactile stimuli in the brain. At some set point of arousal, a centrally-mediated action potential is triggered leading to ejaculatory and/or orgasmic inevitability. The presence of galaninergic neurons arranged in columns within the central spinal cord is critical in this process. These neurons are responsible for integrating stimuli from peripheral and cerebral sources and triggering the ejaculatory reflex. Lesion of these structures is strongly associated with ejaculatory failure.

Answer 5

. Emission and Ejection Explanation: Ejaculation consists of two distinct phases, emission and ejection. The first phase is emission, characterized by closure of the bladder neck and contraction of smooth muscles throughout the seminal tract, mediated by the sympathetic nervous system. The second phase is ejection, a reflex driven by the somatic nervous system, specifically the pudendal nerve.

Answer 6

C. Sympathetic Nervous System Explanation: The emission phase of ejaculation is mediated by the sympathetic nervous system. It is characterized by closure of the bladder neck and contraction of smooth muscles throughout the seminal tract, as well as secretion of seminal fluid into the proximal urethra.

Answer 7

Onuf's nucleus is a cluster of motor neurons in spinal segments S2-4 that appears to be of particular import for control of the striated muscles of the pelvis during ejaculation. This includes the bulbospongiosus and ischiocavernous muscles that contract during the ejection phase of ejaculation, leading to forceful expulsion of seminal fluid from the urethral meatus. The somatic nervous system, specifically the pudendal nerve, is responsible for driving this reflex during the ejection phase.

Answer 8

c. Alpha blockers Explanation: Alpha blockers are commonly used to manage benign prostatic hyperplasia (BPH), but they can cause decreased ejaculate volume and force due to their effect on prostate function.

Answer 9

a. Transurethral resection of the prostate (TURP) Explanation: TURP is a conventional surgical treatment for BPH that can cause pronounced and difficult to resolve alterations in ejaculatory function. This has led to the development of novel procedural approaches to BPH.

Answer 10

b. Seminal vesicles and prostate Explanation: The seminal vesicles and prostate are responsible for the vast majority of seminal volume. Surgical removal of these organs for prostate cancer typically results in marked reduction or complete absence of ejaculation.

Answer 11

Disruption of ejaculation is associated with changes in subjective experience of orgasm for some men. Ejaculation is a key part of the male sexual response cycle, and its disruption can lead to decreased or altered sensation of orgasm. For example, men who have undergone surgical removal of the prostate and seminal vesicles for prostate cancer often report a decrease or absence of orgasmic sensation. The psychological and emotional impact of these changes can also be significant, and may require counseling or therapy.

Answer 12

C. Orgasm is typically experienced at peak sexual arousal. Orgasm is a transient neurological state characterized by intense feelings of pleasure, relaxation, and intimacy. It is typically experienced at peak sexual arousal, which can vary between individuals and within a given person at different times.

Answer 13

B. The time period following orgasm during which arousal and sexual climax are not possible. Explanation: In men, orgasm is typically followed by a refractory period during which arousal and sexual climax are not possible. The duration of the refractory period tends to become longer with increasing age.

Answer 14

d. All of the above Explanation: The stria terminalis, the posterodorsal area of the medial amygdala, and the parvicellular part of the supraparafascicular thalamus are all thought to be intimately involved in central integration of stimuli germane to ejaculatory response.

Answer 15

The putative SEG (spinal ejaculation generator) is a group of neurons located in the lumbosacral spinal cord that are responsible for the ejaculatory reflex. Explanation: Understanding the role of the SEG is important in understanding disorders of ejaculation, as these disorders may involve dysfunction of the SEG.

Answer 16

B) Dopaminergic and oxytocinergic activation Explanation: In general, dopaminergic and oxytocinergic activation stimulates ejaculation and orgasm.

Answer 17

C) Mu Explanation: Agonists of opioid receptors, principally mu subtypes, are associated with impairment of ejaculatory and orgasmic response.

Answer 18

Serotonergic and GABA-ergic activation generally oppose ejaculation and orgasm. Serotonin is involved in mood regulation and is associated with feelings of calm and contentment, while GABA is the main inhibitory neurotransmitter in the brain. Activation of these neurotransmitters can decrease sexual arousal and inhibit ejaculation and orgasm.

Answer 19

c. Androgens Explanation: Experimental and observational data in animals and humans indicate that androgens are necessary for at least the initial maturation of sexual, including ejaculatory, reflexes.

Answer 20

b. They suggest a sexually dimorphic developmental pathway. Explanation: Male cadavers had a greater density of galaninergic neurons in the L3 and L4 spinal segments as compared to female cadavers, suggesting a sexually dimorphic developmental pathway likely mediated by differential exposure to androgens.

Answer 21

Galaninergic neurons in the L3 and L4 spinal segments are thought to be essential to the ejaculatory process as evidenced by frequency of failure to ejaculate in response to penile vibratory stimulation in men with L3-5 spinal cord injury. These neurons are part of the putative SEG (spinal ejaculatory generator), which is responsible for the coordination of the motor activity necessary for ejaculation. The density of these neurons is greater in male cadavers as compared to female cadavers, suggesting a sexually dimorphic developmental pathway likely mediated by differential exposure to androgens.

Answer 22

Serum testosterone levels do not represent peripheral action of T in the tissues, where T acts. Variations in androgen receptor function (e.g., number of CAG repeats), intracellular trafficking of T bound to the androgen receptor, and the balance among modulators of T receptors determine the final action of T within target tissues.

Answer 23

: T action in the CNS is carried out by nuclear receptors and possibly by non-nuclear G-protein coupled receptors.

Answer 24

Variations in androgen receptor function, such as the number of CAG repeats, can affect T action within target tissues by altering the receptor's sensitivity to T. This can result in different levels of T activity in different tissues, even when serum T levels are the same. Additionally, variations in intracellular trafficking of T bound to the androgen receptor and the balance among modulators of T receptors can also affect the final action of T within target tissues.

Answer 25

c. Lack of sexual desire and/or erectile dysfunction Explanation: According to the guideline statements, one of the common causes of disruption in ejaculation or orgasm is failure of the earlier elements of sexual response such as lack of sexual desire and/or erectile dysfunction leading to inadequate genital and subjective excitement.

Answer 26

: c. Cerebral lesions Explanation: According to the guideline statements, it is possible for ejaculatory reflexes to be preserved in the context of psychological, cerebral, or other neurologic lesions that may impair the subjective experience of orgasm.

Answer 27

C. Ejaculatio Praecox

Answer 28

B. Ejaculation that occurs before the female partner has experienced sexual climax during at least 50% of sexual encounters

Answer 29

A. Chronicity and time of onset

Answer 30

According to DSM-V, premature ejaculation is diagnosed as a persistent or recurrent pattern of ejaculation occurring during partnered sexual activity within approximately 1 minute following vaginal penetration and before the individual wishes it. The disorder must be present in 75% or more of sexual encounters and persistent over at least the last 6 months. To qualify as a dysfunction, the man must experience personal distress related to the dysfunction and the condition cannot be better explained by a comorbid or concomitant diagnosis.

Answer 31

he definition of premature ejaculation by the International Society of Sexual Medicine (ISSM) is the strongest in terms of evidence basis. The robust evidence basis is also a limitation in that the data used in its development were derived from studies of vaginal intercourse and hence it is explicitly specific to coitus.

Answer 32

D. All of the above Explanation: The DSM-V recognizes four sub-types of premature ejaculation - lifelong, acquired, generalized, and situational. Additionally, ejaculation that occurs before penetration or within 15 seconds, between 15-30 seconds after penetration, and from 30-60 seconds after penetration are categorized as severe, moderate, or mild PE, respectively.

Answer 33

D) Ejaculation that always or nearly always occurs prior to or within about 1 minute of vaginal penetration (lifelong PE) or a clinically significant and bothersome reduction in latency time, often to about 3 minutes or less (acquired PE). This definition is to date the strongest in terms of evidence basis.

Answer 34

r: B) The inability to attain orgasm after sufficient sexual stimulation.

Answer 35

A) Primary is a lifelong experience while secondary is a distressing lengthening of ejaculatory latency that occurs after a period of normal ejaculatory function.

Answer 36

B) The disorder must be present in 75% or more of partnered sexual encounters and persistent over at least the last 6 months.

Answer 37

DE stands for delayed ejaculation, which is the phenomenon of delay in ejaculation and/or orgasm. According to the 3rd International Consultation on Sexual Dysfunction in 2010, DE is defined as the persistent or recurrent difficulty, delay in, or absence of attaining orgasm after sufficient sexual stimulation, which causes personal distress. The DSM-V defines DE as the condition in which a man experiences “a marked delay in ejaculation” or “marked infrequency or absence of ejaculation.” The ICD-11 defines “male delayed ejaculation” as “inability to achieve ejaculation or an excessive or increased latency of ejaculation, despite adequate sexual stimulation and the desire to ejaculate. The 4th International Consultation on Sexual Medicine in 2015 developed new terminology for lifelong and acquired DE. Lifelong, alternatively classified as primary, delayed ejaculation was defined as a lifelong experience or inability to ejaculate in all of almost all (75%-100%) occasions of coital activity, associated with distress. Acquired, alternatively classified as secondary, DE was defined as a distressing lengthening of ejaculatory latency that occurs in most (>50%) coital experiences after a period of normal ejaculatory function or a clinically meaningful change that results in distress.

Answer 38

The DSM-V criteria for a DE diagnosis are as follows: The disorder must be present in 75% or more of partnered sexual encounters and persistent over at least the last 6 months. To qualify as a dysfunction, the patient must not desire delay of ejaculation and he must experience personal distress. Furthermore, the DE condition cannot be better explained by a comorbid or concomitant diagnosis or situation. The DSM-V definition permit categorization of DE into generalized versus situational sub-types and also includes an ordinal severity scale based on the degree of subjective distress (i.e., mild, moderate, and severe) rather than any quantitative measure.

Answer 39

c. The presence of blood in ejaculated semen Explanation: Hematospermia is defined as the presence of blood in ejaculated semen. It may present as bright red blood, clots, or disintegrating blood products.

Answer 40

a. The absence or marked infrequency of the orgasm experience Explanation: Anorgasmia may be conceptualized as an extreme variant of DE in which orgasm cannot be achieved.

Answer 41

c. The absence of seminal ejaculation with sexual climax Explanation: Anejaculation refers specifically to the absence of seminal ejaculation with sexual climax.

Answer 42

Retrograde ejaculation is the condition in which semen is not ejected antegrade but rather flows into the bladder during climax. This is typically due to failure of the bladder neck to close during the emission phase and may be idiopathic or secondary to bladder neck surgery, pharmacological agents, or neurologic lesion. In most cases of retrograde ejaculation, orgasm occurs and feels pleasurable. Some men with retrograde ejaculation may report that their experience of orgasm is qualitatively different.

Answer 43

Anhedonic orgasm is the condition in which ejaculation occurs but is not associated with subjective feelings of pleasure, intimacy, or relaxation. This condition is poorly understood but may relate to medications (particularly antidepressants), neurologic lesions, or psychogenic causes.

Answer 44

Painful ejaculation, also known as dysejaculation, odynorgasmia, post orgasmic pain, dysorgasmia, or orgasmalgia, is a poorly understood condition that may have both psychogenic and organic elements. Pelvic lesion, traumas, or surgery may be contributing factors and painful ejaculation is often comorbid with other types of chronic pelvic pain syndromes. Men with painful ejaculation should be evaluated for lower urinary tract dysfunction and other causes of chronic pelvic pain.

Answer 45

Post Orgasmic Illness Syndrome (POIS) is a provisional diagnosis which has been applied to cases of somatic symptoms that occur in close association with sexual climax. POIS is distinguished from painful ejaculation by the presence of symptoms outside the pelvis, such as malaise, confusion, myalgias, fatigue, or other somatic concerns. The etiology of POIS is unclear but may be an autoimmune, cytokine-mediated, or allergic reaction to seminal components has been proposed. The condition may be empirically managed with antihistamines, selective serotonin reuptake inhibitors (SSRIs), and benzodiazepines although data to support these modalities is scant.35

Answer 46

b) 10% Explanation: Similar data on the prevalence of DE are more limited; a substantial proportion of men in epidemiological studies report difficulty achieving orgasm, but the degree of associated distress is not reported.

Answer 47

c. Poor ejaculatory control, ejaculation within about 2 minutes of initiation of penetrative sex, and associated bother Explanation: Lifelong premature ejaculation is defined as poor ejaculatory control, associated bother, and ejaculation within about 2 minutes of initiation of penetrative sex that has been present since sexual debut.

Answer 48

D. Over 70% Explanation: Men with premature ejaculation frequently report poor ejaculatory control. Very poor to poor ejaculatory control is characteristic of over 70% of men who have premature ejaculation.

Answer 49

Treatment options for lifelong premature ejaculation may include behavioral therapy, such as the stop-start and squeeze techniques, as well as the use of topical anesthetics and oral medications, such as selective serotonin reuptake inhibitors (SSRIs) and phosphodiesterase-5 (PDE-5) inhibitors. Counseling may also be beneficial for addressing underlying psychological factors. It is important for individuals to discuss treatment options with their healthcare provider to determine the most appropriate course of action.

Answer 50

Self-efficacy is a psychological construct that refers to the perceived ability to be effective at a given task based on previous experiences. Lack of self-efficacy regarding ejaculatory control is a sine qua non for diagnosing PE. Men with PE often report poor ejaculatory control and lack of self-efficacy regarding ejaculation control. This lack of self-efficacy is central to both the diagnosis of PE and perceived treatment benefits. Men who have self-efficacy regarding ejaculation control or voluntarily ejaculate with short latency do not by definition have a sexual problem regardless of ELT.

Answer 51

Sine qua non is a Latin term that means "without which, there is nothing". It refers to an essential or necessary condition or requirement without which something is not possible or cannot exist. In the context of disorders of ejaculation, lack of self-efficacy regarding ejaculatory control is a sine qua non for diagnosing premature ejaculation.

Answer 52

The ISSM definition for lifelong PE states that the criterion of 1 minute affords the clinician sufficient flexibility to also diagnose PE in the 10–20% of PE-treatment-seeking men who ejaculate within 1–2 minutes of penetration without unnecessarily stigmatizing the remaining 80–90% of men who ejaculate within 1–2 minutes of penetration but have no complaints of PE. Although the majority of men seeking treatment for lifelong PE are characterized by latencies of less than 60 seconds, about 20% of men seeking treatment for PE ejaculate after more than 60 seconds. An extended latency time of 120 seconds would capture most of the remaining 20%. This higher limit increases true positives (decreasing false negatives and Type 2 error), but also increases false positives (Type 1 error). Reliance on control and bother are essential elements for diagnosis.

Answer 53

B. Acquired premature ejaculation is defined as consistently poor ejaculatory control, associated bother, and ejaculation latency that is markedly reduced from prior sexual experience during penetrative sex.

Answer 54

D. Personal and psychological health issues, new environmental pressures, evolving relationship issues and dynamics, and partner-specific issues may be possible causes of acquired premature ejaculation.

Answer 55

Lifelong premature ejaculation refers to a man's persistent and consistent inability to delay ejaculation, leading to distress and negative personal or interpersonal consequences. On the other hand, acquired premature ejaculation refers to a later onset of poor ejaculatory control, associated bother, and ejaculation latency that is markedly reduced from prior sexual experience during penetrative sex. Men with acquired PE experience a period of sufficient ejaculatory control and lack of distress prior to developing the distressing shortened latency. Possible causes of acquired premature ejaculation may include medical comorbidities, health conditions, pain, surgery or trauma, erectile dysfunction, or medication. The latter condition may include personal and psychological health issues, new environmental pressures, evolving relationship issues and dynamics, and partner-specific issues. In some instances, no clear etiology is delineated (i.e., idiopathic acquired PE). Diagnosis of acquired premature ejaculation requires that the man meets the criteria of poor ejaculatory control, diminished sexual satisfaction with intercourse, and negative personal or interpersonal consequences. The average estimated ejaculation latency time during partnered sex should fall under about 2-3 minutes, or ELT should be reduced by about 50% or more from prior estimations. However, these criteria are limited by lack of evidence and should be interpreted cautiously, and clinicians should exercise their own best judgement when making the diagnosis of acquired PE.

Answer 56

The questions that should be asked in the medical and sexual history to make the diagnosis of premature ejaculation include: concerns about ability to control ejaculation, ejaculating before wanting to, whether it is lifelong or not, feeling poor or no control of ejaculation, inability to postpone or delay ejaculation, negative interpersonal consequences, anxiety, depression, avoidance of sexual activity, self-estimated ejaculatory latency time, duration of premature ejaculation, occurrence with almost every sexual encounter, variations in ELT related to different sexual partners or circumstances, and history of prostatitis or other prostate conditions. These questions are important as they help in identifying the characteristics of premature ejaculation and its impact on the patient's life, psychological health, and relationship with the partner.

Answer 57

Assessing the patient's psychological health is important as it helps in identifying any underlying mood disorders or significant psychiatric problems that may contribute to the development of premature ejaculation or affect the patient's response to treatment. Depression occurs in about 20% of men with premature ejaculation compared to 12% in men without, while anxiety occurs in 24% of men with premature ejaculation compared to 13% in men without. Studies have reported even higher prevalence rates for anxiety of up to one-third of men with premature ejaculation. A systematic review of 18,035 men in 8 studies determined that the odds ratio for depression was 1.63 in men with premature ejaculation versus without. Assessment by a mental health professional may be of benefit, or even a necessity, depending on the severity of the mood disorder. Mood disorders may or may not improve with initiation of effective premature ejaculation therapy.

Answer 58

Physical examination is an essential standard in medical practice; however, it seldom contributes to the evaluation of premature ejaculation. Although it rarely changes management, a focused physical examination is reassuring to patients and may identify issues meriting consideration. A brief genital exam should be considered when feasible. Particular areas of note include penile morphology, testicular size and consistency, and prostate size and consistency. The relevance of any of these factors to management of premature ejaculation is ambiguous, but evaluation may be informative in other ways and suggest other issues for discussion and management.

Answer 59

B) To facilitate a conversation about ejaculatory issues

Answer 60

B) Possible spectrum bias

Answer 61

Five studies evaluated the accuracy of validated questionnaires for diagnosing premature ejaculation, including the Premature Ejaculation Diagnostic Tool (PEDT), the Premature Ejaculation Profile (PEP), Index of Premature Ejaculation, the Multiple Indicators of Premature Ejaculation, the Checklist for Early Ejaculation Symptoms, and the Arabic Index for Premature Ejaculation. Despite limitations such as possible spectrum bias, these questionnaires have very good sensitivity and specificity scores and high discrimination.

Answer 62

While the clinical value of using validated questionnaires for diagnosing premature ejaculation is uncertain, they may be useful as an adjunct to diagnosis or as an “ice breaker” to facilitate a conversation about ejaculatory issues. They can also be useful for research purposes. However, their value in longitudinal measurement to assess change over time or in response to treatment has not been studied, and interpreting changes in scores is a challenge as minimal clinically important differences are unknown.

Answer 63

c. Clinicians should not use additional testing.

Answer 64

b. High serum T has been inconsistently associated with increased likelihood of premature ejaculation.

Answer 65

Biothesiometry is a technique used to measure the sensitivity of the penis to vibration. Lower penile vibratory sensation thresholds, indicative of greater sensitivity, have been noted in men with premature ejaculation compared to controls. However, a more recent study did not detect any significant difference in penile sensitivity between men with or without premature ejaculation. These findings suggest a possible etiology for some cases of lifelong premature ejaculation, but it is not clear if any particular intervention is preferred over another.

Answer 66

e. Erectile dysfunction. Men with acquired premature ejaculation often have comorbidities, including hypertension, sexual desire disorder, diabetes mellitus, chronic prostatitis, and erectile dysfunction.

Answer 67

a. Men with premature ejaculation have higher testosterone levels compared to men without premature ejaculation. However, it is unclear whether these high-normal testosterone levels were congenital or acquired.

Answer 68

B) Premature ejaculation

Answer 69

C) Thyroid function tests Explanation: Laboratory tests related to the hypothalamic-pituitary-testicular axis, thyroid function, glucose metabolism, and prostatitis or chronic pelvic pain syndrome should be employed when there is clinical suspicion of these conditions in men with acquired premature ejaculation.

Answer 70

Laboratory tests, particularly tests related to the hypothalamic-pituitary-testicular axis, thyroid function, glucose metabolism, and prostatitis or chronic pelvic pain syndrome should be employed when there is clinical suspicion of these conditions in men with acquired premature ejaculation. Clinicians may utilize additional laboratory testing as clinically indicated and may treat such abnormalities accordingly. However, such tests are not a required element of evaluation for acquired premature ejaculation. The evidence regarding additional testing in men with acquired premature ejaculation is limited and inconsistent.

Answer 71

C. It has no significant impact on ejaculatory latency. Explanation: According to the guideline statement 7, clinicians should advise patients that ejaculatory latency is not affected by circumcision status.

Answer 72

C. Circumcision has no significant impact on the risk of premature ejaculation. Explanation: The systematic review of 12 studies on circumcision and premature ejaculation found no association between circumcision and increased risk of premature ejaculation (OR: O.90; 95% CI: 0.72-1.13).

Answer 73

A. Decreased emotional intimacy Explanation: Psychological and interpersonal factors associated with premature ejaculation include depression, anxiety, history of sexual abuse, decreased emotional intimacy, and conflict within the relationship.

Answer 74

C. Behavioral therapy Explanation: Behavioral therapy interventions include the stop-start technique, the squeeze technique, and sensate focus exercises. These interventions are designed to help men delay ejaculation while broadening their sexual scripts, increasing sexual self-confidence, and diminishing performance anxiety.

Answer 75

Psychological and behavioral interventions can be useful in treating premature ejaculation, even when no clear psychological or physiological etiology is apparent. These interventions have two overlapping goals: helping men develop sexual skills to delay ejaculation while broadening their sexual scripts, and resolving psychological and interpersonal issues that may have precipitated or resulted from premature ejaculation. Behavioral therapy interventions such as the stop-start technique, the squeeze technique, and sensate focus exercises can be helpful in achieving these goals. The potential advantages of these interventions include the ability to offer benefit without the need for pharmacological intervention, and the ability to be integrated into sexual encounters as part of the experience. The potential disadvantages of these interventions include the difficulty in studying their efficacy in a double-blind, controlled, randomized fashion, and the investment in time required, typically at least 5-10 sessions, which may not be covered by insurance carriers.

Answer 76

B. Depression, anxiety, history of sexual abuse, decreased emotional intimacy, and conflict within the relationship. Explanation: Clinical experience suggests that psychological and interpersonal factors may precipitate premature ejaculation. These factors may also exacerbate premature ejaculation and generate additional psychological and interpersonal symptoms for the man, partner, and couple. Psychological and interpersonal factors associated with premature ejaculation include depression, anxiety, history of sexual abuse, decreased emotional intimacy, and conflict within the relationship.

Answer 77

B. Women in relationships with men who have premature ejaculation have lower scores for all domains of the Female Sexual Function Index except desire and pain. Explanation: Women in relationships with men who have premature ejaculation have lower scores for all domains of the Female Sexual Function Index except desire and pain compared to women whose partners do not have premature ejaculation. One of the most troubling aspects of premature ejaculation for female partners may be the man’s focus on his ejaculatory performance; this may distract him from other salient aspects of a sexual encounter.

Answer 78

c. A way to train men to focus on excitatory sensations rather than avoiding them for fear of ejaculating quickly Explanation: Sensate focus trains men to focus on excitatory sensations rather than avoiding them for fear of ejaculating quickly. By mastering these skills, men may learn to increase and control their ejaculatory latency.

Answer 79

D Explanation: The use of topical local anaesthetics, such as lidocaine, prilocaine or benzocaine, alone or in association, to diminish the sensitivity of the glans penis is the oldest known pharmacological treatment for PE.

Answer 80

D Explanation: The utilization of specific SSRIs (i.e., paroxetine, sertraline, fluoxetine, and citalopram) and the TCA clomipramine has revolutionized the treatment of PE. These drugs block axonal re-uptake of serotonin from the synaptic cleft of central serotonergic neurons by 5-HT transporters, resulting in enhanced 5-HT neurotransmission and stimulation of post-synaptic membrane 5-HT receptors.

Answer 81

The utilization of specific SSRIs (i.e., paroxetine, sertraline, fluoxetine, and citalopram) and the TCA clomipramine has revolutionized the treatment of PE. These drugs block axonal re-uptake of serotonin from the synaptic cleft of central serotonergic neurons by 5-HT transporters, resulting in enhanced 5-HT neurotransmission and stimulation of post-synaptic membrane 5-HT receptors. This results in a clinically meaningful patient-reported response from treatment that exceeds placebo response rates by about 40-60%.

Answer 82

c. Daily SSRIs and on-demand clomipramine or dapoxetine (where available) Explanation: The AUA/SMSNA guideline recommends daily SSRIs, on-demand clomipramine or dapoxetine (where available), and topical penile anesthetics as first-line agents of choice in the treatment of premature ejaculation.

Answer 83

b. Headache Explanation: Adverse effects from SSRI treatment of premature ejaculation have been reported in up to 54% of men using these medications, with headache being the most common. Other adverse effects include fatigue, yawning, mild nausea, diarrhea, perspiration, or decreased libido.

Answer 84

c. Clinicians may consider on-demand dosing of tramadol for treatment of premature ejaculation in men who have failed first-line therapy pharmacotherapy. Explanation: According to Guideline Statement 10, clinicians may consider on-demand dosing of tramadol for treatment of premature ejaculation in men who have failed first-line therapy pharmacotherapy. This recommendation is a conditional recommendation with evidence level Grade C.

Answer 85

c. Low potential Explanation: According to the guideline, the potential of tramadol for addiction or abuse appears low in most patient populations, but has not been assessed in men with premature ejaculation. The study by Adams et al. reported abuse rates of 0.7% for tramadol, which is lower than the rates for non-steroidal anti-inflammatory drugs and hydrocodone. However, caution should be exercised in prescribing an analgesic medication with opioid-like properties for management of premature ejaculation, especially in light of the ongoing opioid crisis in many nations.

Answer 86

Tramadol is a centrally acting synthetic opioid analgesic and weak inhibitor of re-uptake of GABA, norepinephrine, and serotonin. It has been reported to be effective in the treatment of premature ejaculation by several authors. However, most studies of tramadol for premature ejaculation are poorly designed open label trials with a wide range of efficacy. The only well-designed double-blind trial demonstrates superiority to placebo but a modest increase in IELT of 2.49-fold, consistent with the weak serotonin re-uptake inhibitor activity of tramadol. A large, international, prospective, randomized, placebo-controlled, double-blind trial of tramadol for the treatment of PE (NCT00983151) was recently stopped prematurely with no reason provided. There have been four meta-analyses of tramadol published clinical trial data, all of which conclude that tramadol appears effective in the treatment of premature ejaculation, but caution should be exercised given the observed levels of between-trial heterogeneity and the reporting quality of the available evidence.

Answer 87

Approximately 20% of patients receiving tramadol experience non-serious adverse effects including nausea, vomiting, dizziness, somnolence, tiredness, and headache. Serotonin Syndrome has been reported as an adverse effect of tramadol alone or in combination with SSRI drugs. The potential of tramadol for addiction or abuse appears low in most patient populations, but has not been assessed in men with premature ejaculation. Adams et al. reported abuse rates of 0.7% for tramadol, which is lower than the rates for non-steroidal anti-inflammatory drugs and hydrocodone, but caution should be exercised in prescribing an analgesic medication with opioid-like properties for management of premature ejaculation, especially in light of the ongoing opioid crisis in many nations.

Answer 88

C. α1-Adrenoceptor antagonists Explanation: According to Guideline Statement 11, clinicians may consider treating men with premature ejaculation who have failed first-line therapy with α1-adrenoreceptor antagonists.

Answer 89

D. All of the above Explanation: According to Guideline Statement 11, existing studies of α1-adrenoceptor antagonists are limited by flaws in sample size, inclusion criteria, premature ejaculation definitions, and outcome measures.

Answer 90

α1-adrenoceptor antagonists may induce ejaculatory dysfunction such as retrograde ejaculation and/or failure of emission. This is because these drugs also block the α1-adrenoceptors in the smooth muscle of the vas deferens, seminal vesicles, and prostate gland, which are essential for the process of ejaculation. The possible side effects of α1-adrenoceptor antagonists include dizziness, headache, orthostatic hypotension, nasal congestion, and abnormal ejaculation.

Answer 91

b. Determine which condition is more sexually disabling and/or primary and manage accordingly Explanation: The guideline recommends determining which condition is more troublesome and managing accordingly. While management of ED should be primary in cases where acquired PE may be an adaptation to ED, a more nuanced approach is recommended.

Answer 92

c. PDE5is Explanation: Several authors have reported experience using PDE5is alone or in combination with SSRIs as a treatment for PE. ED pharmacotherapy alone or in combination with PE pharmacotherapy may be considered for the treatment of lifelong and acquired PE in men with co-morbid ED.

Answer 93

ED pharmacotherapy alone or in combination with PE pharmacotherapy may be considered for the treatment of lifelong and acquired PE in men with co-morbid ED. Several authors have reported experience using PDE5is alone or in combination with SSRIs as a treatment for PE. PDE5i modulate activity of the NO/cGMP pathway, which is in turn a central and genital mediator of nitrergic neurotransmission that may influence ejaculatory responses. It is also conceivable that use of PDE5i improves sexual confidence and erection durability, enabling men with PE to focus on behavioural changes that help prolong ELT. In a study of 42 men with lifelong PE and no ED who were randomized to vardenafil vs placebo, Aversa et al. reported a 7.5-fold increase in geometric mean IELT following treatment with vardenafil (4.5±1.1 versus 0.6±0.3 minutes with placebo; P<0.01). Significant improvements were also noted in the IPE domains of ejaculatory control, confidence, overall sexual satisfaction, and distress. A recent meta-analysis of RCTs of PDE5i for management of PE indicated that PDE5i are effective compared with placebo and that a PDE5i combined with a SSRI is more effective in PE management than an SSRI alone. However, the efficacy of dapoxetine for PE was less robust in men with mild ED compared to men with no ED. Thus, clinicians should evaluate each patient individually and consider the potential benefits and risks of each pharmacotherapeutic option.

Answer 94

d. All of the above Explanation: Behavioral strategies, including stop-start, squeeze, and sensate focus, have been studied in combination with pharmacological approaches to increase ejaculatory latencies and sexual satisfaction beyond that resulting from pharmacological treatment alone. Cognitive-behavioral therapy may also improve sexual satisfaction by expanding the couple's sexual behavioral repertoire, improving communication, and addressing relationship dynamics.

Answer 95

c. Combination of behavioral and pharmacological approaches Explanation: Clinicians should advise men with premature ejaculation that combining behavioral and pharmacological approaches may be more effective than either modality alone, according to the AUA/SMSNA guideline.

Answer 96

The behavioral strategies that can be used in combination with pharmacological approaches are start-stop, squeeze, and sensate focus techniques. Start-stop technique involves stopping sexual stimulation for a brief period when nearing ejaculation and then starting again. Squeeze technique involves squeezing the penis at the base when nearing ejaculation to reduce the sensation of orgasm. Sensate focus technique involves engaging in non-sexual touch to increase awareness of physical sensations and decrease performance anxiety.

Answer 97

Combination therapy, which includes both behavioral and pharmacological approaches, has been shown to increase ejaculatory latencies by about 1 minute over pharmacological therapy alone. In addition, combination therapy is associated with greater improvement in scores on validated instruments for assessment of premature ejaculation, such as the Premature Ejaculation Diagnostic Tool (PEDT). Patient-reported outcomes, such as sexual satisfaction, anxiety, and partner satisfaction, also improve with combination therapy.

Answer 98

Cognitive-behavioral therapy may also improve sexual satisfaction in men with premature ejaculation by expanding the couple's sexual behavioral repertoire, improving communication, and addressing relationship dynamics. Incorporation of cognitive-behavioral therapy may result in an additional 1-3 minutes increase in ejaculatory latencies compared to pharmacotherapy alone. However, cognitive-behavioral therapy typically requires a specialist in psychosexual therapy and may not be covered by insurance.

Answer 99

b. Surgical management should only be considered in the context of an ethical board-approved clinical trial. Explanation: According to the AUA/SMSNA guideline, surgical management (including injection of bulking agents) of premature ejaculation should be considered experimental and only be used in the context of an ethical board-approved clinical trial.

Answer 100

c. Selective dorsal penile neurectomy plus circumcision Explanation: A recent study of 96 Chinese men with lifelong PE found that selective dorsal penile neurectomy plus circumcision was associated with longer post-surgical IELT than circumcision alone (4.29 versus 0.82 minutes; p=0.02).

Answer 101

Delayed ejaculation (DE) is a male sexual dysfunction that is characterized by a delay or absence of ejaculation and concomitant impairment of orgasm. It is of particular concern when procreation is desired, but the impact of failure to achieve orgasm is significant in that it typically results in a lack of sexual fulfillment for both the man and his partner. According to Guideline Statement 16, lifelong delayed ejaculation is defined as lifelong, consistent, bothersome inability to achieve ejaculation, or excessive latency of ejaculation, despite adequate sexual stimulation and the desire to ejaculate. On the other hand, acquired delayed ejaculation is defined as an acquired, consistent, bothersome inability to achieve ejaculation, or an increased latency of ejaculation, despite adequate sexual stimulation and the desire to ejaculate.

Answer 102

d) All of the above

Answer 103

The essential elements that should be assessed during the evaluation of a patient with delayed ejaculation include determining whether the patient's delayed ejaculation is lifelong or acquired, global or situational, and the assessment of time of onset, chronicity, frequency, and associated factors. It is also important to establish whether a man can ejaculate during intercourse and the time elapsed between penetration and ejaculation. If ejaculation fails to occur, the duration of thrusting before suspension of intercourse, the reasons for suspension of intercourse, and whether ejaculation can occur during post-penetrative self- or partner-assisted masturbation must be determined. Variables that improve or worsen performance, the man's ability to relax, sustain, and heighten arousal, and the degree to which he can concentrate on sensations should also be noted and documented.

Answer 104

A general medical history is important when evaluating a patient with delayed ejaculation as it can help to identify underlying medical conditions associated with neuropathy, metabolic derangements, or traumas to the nervous system or pelvis that may be contributing to the patient's delayed ejaculation. Additionally, assessment for signs of metabolic disorders or decreased serum T can help to identify possible hormonal imbalances that may be causing delayed ejaculation.

Answer 105

b. Increases Explanation: The prevalence of symptoms consistent with delayed ejaculation increases at progressively lower serum T levels.

Answer 106

a. Basic serum studies including electrolytes, lipids, and glycosylated hemoglobin Explanation: Basic serum studies including electrolytes, lipids, glycosylated hemoglobin, and possibly others may be informative of medical conditions that could predispose to neuropathy or vascular disease, which may contribute to sexual dysfunction, including delayed ejaculation. Genetic tests have not been approved for use in the clinical context of delayed ejaculation.

Answer 107

B. Psycho-behavioral strategies Explanation: While biomedical options for increasing the ejaculatory threshold are available (e.g., SSRIs), no clear options are available for lowering the threshold and thus decreasing ejaculation time. Psycho-behavioral strategies are unlikely to directly alter the ejaculatory threshold but may enhance psychosexual arousal and/or remove barriers and inhibitions that interfere with psychosexual excitement.

Answer 108

D. Age Explanation: One of the most significant factors in DE is age, which likely combines psychological and physiological processes. Age-related increases in latency may be managed with psychological and behavioral approaches (e.g., increasing the repertoire of behaviors) aimed at increasing physical and psychological arousal.

Answer 109

The four major psychological approaches to managing delayed ejaculation are as follows: a) The first approach is applicable to men in whom there is insufficient penile or psychological stimulation. These men may report having an insensate penis or diminished ability to experience penile sensations. A psychogenic etiology is strongly suggested when men report having normal penile sensation while masturbating, yet have diminished sensation when being stimulated by a partner. Psychological intervention aims to increase penile and psychological stimulation by using a vibrator, enhancing psychological arousal, or recommending vigorous pelvic thrusting while addressing the psychological factors that may inhibit ejaculation. b) The second approach is applicable to men in whom there is a discrepancy between masturbatory patterns and fantasy life and the experience of partnered sex. Specifically, some men with DE report high-frequency masturbation, an idiosyncratic (i.e., referring to speed, pressure, and intensity that do not mimic sensations during intercourse) masturbation style, or a discrepancy between the reality of sex with a partner and sexual fantasy. In this context, the therapist recommends adaptation of the man’s masturbatory style to be more reflective of what is experienced during partnered sex and assists the man with reconciling fantasy and reality. c) The third approach is applicable in the context of DE as a response to a preference for masturbation over partnered sex. Some men may prefer self-stimulation to stimulation by a partner. Psychological intervention aims to diminish the man’s focus on himself and enhance his ability to accept pleasure from his partner. d) The last approach is applicable when there is psychological conflict regarding ejaculation and orgasm. This conflict may reduce arousal and inhibit orgasm. Possible sources of conflict include fear that semen loss will lead to health problems; fear of harm from female genitals; fear that ejaculation may hurt the partner; fear of impregnating a female partner; fear of defiling the partner with semen; hostility toward partner; unwillingness to give oneself; and guilt about sexuality in general, in many cases due to conservative religious upbringing. Psychological intervention focuses on resolving the psychological conflict, which may help normalize ejaculatory patterns.

Answer 110

b. Behavioral interventions Explanation: Behavioral interventions, such as modifying sexual positions or practices to increase arousal, may help some men with DE enhance arousal and trigger orgasmic response.

Answer 111

b. Penile vibratory stimulation Explanation: A limited evidence basis exists for the application of penile vibratory stimulation for management of acquired DE.

Answer 112

Behavioral interventions that can be recommended for men with delayed ejaculation include modifying sexual positions or practices to increase arousal, incorporating alternative sexual practices and scripts (such as oral or manual stimulation of the penis, use of alternative sexual positions, stimulation of other erogenous zones, and incorporation of fantasy or roleplay), and incorporating sexual enhancement devices (such as vibrators). Explanation: Behavioral interventions are a low-risk option that may help some men with DE enhance arousal and trigger orgasmic response. This may include incorporation of alternative sexual practices and scripts (e.g., oral or manual stimulation of the penis, use of alternative sexual positions, stimulation of other erogenous zones, incorporation of fantasy or roleplay), and incorporation of sexual enhancement devices (e.g., vibrators). The specific nature of changes to sexual practice are dictated by what the couple is currently doing sexually, what each partner considers arousing, and what is physically and psychologically acceptable to both partners in terms of novel sexual practices. At a minimum, recommending a discussion about sexual needs and desires may help open lines of communication between partners and help facilitate treatment.

Answer 113

: b) Dose adjustment or substitution of the offending psychiatric drug Explanation: Substitution of the offending psychiatric drug with an alternative agent may be the most medically feasible way to adjust therapy in patients with drug-induced delayed ejaculation.

Answer 114

c. Insufficient evidence to assess risk-benefit ratio Explanation: The Guideline Statement 23 emphasizes that there is a scarcity of published studies on the pharmacotherapy for delayed ejaculation, and thus, there is a lack of evidence to evaluate the risk-benefit ratio of these medications.

Answer 115

Currently, there are no FDA-approved pharmacotherapies for delayed ejaculation, and the bulk of published studies consist of case reports and non-randomized, non-placebo-controlled case series. Some of the drugs that have been evaluated for the management of delayed ejaculation include bupropion, oxytocin, cabergoline, buspirone, sympathomimetics, imipramine, yohimbine, amantadine, and cyproheptadine. However, the Panel does not believe that existing evidence is robust enough to render an opinion on the actual risk/benefit ratio of these pharmacotherapies. The Guideline Statement 23 emphasizes that well-designed, appropriately powered studies are needed to better define efficacy and safety of pharmacotherapies for delayed ejaculation. Therefore, there is a lack of evidence-based recommendation for the use of these pharmacotherapies, and patients should be counseled on the weak evidence base and the potential for both known and unknown side effects.

Answer 116

The Panel recognizes the current needs of patients with delayed ejaculation and their partners for therapeutic options, which may include pharmacotherapy. Therefore, clinicians can offer appropriately selected and counseled patients pharmacotherapies that have a physiologic rationale for benefit in delayed ejaculation treatment. However, the Guideline Statement 23 emphasizes that patients should be counseled on the weak evidence base and the potential for both known and unknown side effects. The benefit of enhanced orgasmic function must be weighed by the patient against the potential risks, and an individualized decision can then be made based on the patient's own personal values. The majority of these drugs are not commonly utilized in urological practice, and therefore, the urologist who is not comfortable prescribing these medications should consider referral of the patient for discussion of these management options.

Answer 117

C. Testosterone replacement therapy Explanation: According to Guideline Statement 24, clinicians may offer treatment to normalize serum testosterone levels in patients with delayed ejaculation and testosterone deficiency.

Answer 118

B. Above 550 ng/dl Explanation: Most experts recommend a target T level at or above the 50th percentile (>500-550 ng/dl) during treatment unless positive response is achieved with lower levels.

Answer 119

Testosterone is a hormone that plays a role in male sexual function, including ejaculation and orgasm. Although not all men with biochemically low testosterone levels suffer from delayed ejaculation, it is logical to hypothesize that the androgenic milieu has an influence on ejaculation and orgasm. In men with delayed orgasm and ejaculation and testosterone deficiency, clinicians may consider testosterone replacement therapy as per the 2018 AUA Guideline on the Management of Testosterone Deficiency. The target testosterone level during treatment should be at or above the 50th percentile (>500-550 ng/dl) unless positive response is achieved with lower levels. However, testosterone therapy is not indicated in men with delayed ejaculation and normal testosterone levels. Benefit from testosterone treatment should be evident within 90 days of the patient becoming eugonadal, and periodic follow-up is needed to gauge the need for continuing treatment. The choice of testosterone therapy should be patient-specific as available testosterone preparations in the USA differ in pharmacokinetics, costs, and side-effects profile.

Answer 120

D. Medications (e.g. SSRI, SNRI) are a common risk factor for both erectile dysfunction and delayed ejaculation.

Answer 121

B. When DE precedes the onset of ED, the focus should be on defining the etiologies of DE and trying to determine if they have played a role in the development of ED and address any etiological factors appropriately.

Answer 122

Common risk factors for delayed ejaculation include medications (e.g. SSRI, SNRI), endocrine conditions (e.g., T deficiency, hyperprolactinemia), penile sensation loss, and psychological factors (e.g., anxiety, depression, relationship stress). To address these risk factors in treatment, clinicians should first identify the underlying cause of delayed ejaculation and address it appropriately. For example, if the patient is taking medications that are known to cause delayed ejaculation, the clinician may consider adjusting the dosage or switching to an alternative medication. Similarly, if the patient has an endocrine condition that is contributing to their delayed ejaculation, such as low serum T, the clinician may recommend hormone therapy. Addressing psychological factors may involve counseling or therapy to help the patient manage anxiety or relationship stress that may be contributing to their delayed ejaculation.

Answer 123

d. None of the above. No published, peer-reviewed data exists supporting any of these approaches.

Answer 124

b. Penile sensation loss. Penile vibratory stimulation has been suggested as a potential management strategy in men with DE, particularly in men with a penile sensory deficit.

Disorders of Ejaculation: An AUA/SMSNA Guideline (2020) Flashcards

(154 cards)