Handbook of sexual dysfunction - part 8 pps

of ejaculation is usually irreversible and the patient should be counseled to optimize his and his partner’s enjoyment from the residual sexual functioning. Androgen deficiency requires appropriate testosterone replacement therapy. In the case of inadequate stimulation, pelvic floor exercises may be helpful. Most patients require general advice on reducing precipitating factors, reduction in alcohol use, finding more time for sexual activity when not fatigued. Research and Methodology Research on lifelong delayed ejaculation is scarce. Most of the literature consists of hypotheses that have not been investigated according to methodological well- designed studies. Several factors may have contributed to this state of affairs. Delayed ejaculation is a relatively rare condition. Both in the general population and in the clinical practice, the prevalence of delayed ejaculation is rather low (84). Furthermore, delayed ejaculation is known as a disorder that is relatively difficult to treat (92). Although controlled studies do not exist, clinical experience suggests that the outcome is rather poor (92). A major problem in the research of lifelong delayed ejaculation is the absence of an empirically derived operational definition of delayed ejaculation. The DSM-IV criteria are arbitrary and not based on quantified research. For example, consider the sentence “orgasm in a male following a normal sexual excitement phase during sexual activity that the clinician, taking into account the person’s age, judges to be adequate in focus, intensity, and duration,” what one wonders is meant by “normal” and how may a clinician judge that the excitement phase has been adequate in focus, intensity, and duration. There are no well-controlled studies regarding average or “normal” time of stimulation and therefore it is difficult to determine what is a delayed time of stimulation. In the absence of objective standards on orgasmic latency, the clinician must rely on the subjective judgment of the patient. Generally, if the patient feels that it takes too long to reach orgasm, the diagnosis of delayed orgasm will be considered. RETROGRADE EJACULATION Definition Retrograde ejaculation (ejaculation sicca, dry orgasm) is the propulsion of semen from the posterior urethra into the bladder instead of being ejected externally from the urethra (96). Symptoms Men with retrograde ejaculation do experience emission and expulsion and do feel the subjective feeling of orgasm, but semen is not propelled from the penis. Some men may be able to urinate during erection. 238 Waldinger A definite diagnosis is made when examination of the urine following orgasm shows the presence of fructose and spermatozoa. The sperm, however, may be absent in cases of genital duct obstruction. Etiology Owing to a congenital or acquired anatomical and/or functional failure of closure of the internal sphincter of the bladder (“bladderneck”) during the ejaculatory process, sperm passes into the bladder. Most frequently the cause is a transure- thral prostatectomy, a surgical treatment of benign prostatic hypertrophy. But any traumatic, neurogenic or drug-induced interference with the thoracolumbar sympathetic nervous system may lead to retrograde ejaculation. Spinal cord injury through trauma, birth defect, neoplasm, or surgery and abdominopelvic surgery, retroperitoneal lymph node dissection or total lymphadenectomy, and diabetes may also result in retrograde flow of semen. The medications that may give rise to retrograde ejaculation include alpha- adrenergic blockers (e.g., prazosin, tamsulosin), peripheral sympatholytics (e.g., guanethidine), and antipsychotics (e.g., thioridazine). Treatment Treatments for retrograde ejaculation focus on closing the bladder neck using surgical bladder reconstruction or pharmacotherapy with sympathicomimetic agents (e.g., ephedrine) or anticholinergics (e.g., imipramine). If sperm is needed for procreation and retrograde ejaculation cannot be corrected pharmaco- logically, vibratory stimulation of the penile shaft and glans penis (93) can be used. For those men who fail vibrator therapy, transrectal stimulation (94) may be used to obtain sperm. ANESTHETIC EJACULATION (EJACULATORY ANHEDONIA) Definition Men with anesthetic ejaculation have a normal propulsive ejaculation, but the accompanying sensation of orgasm is absent. The mechanism of the emission and expulsion phase of ejaculation are intact (97). Symptoms Both at masturbation and at intercourse, ejaculation occurs without sense of plea- sure or orgasmic sensation. The lack of enjoyable ejaculation may lead to a rather indifferent attitude of some of these men to have intercourse. Male Ejaculation and Orgasmic Disorders 239 Etiology Anesthetic ejaculation is probably a rare syndrome. Only 4 publications, describ- ing a total of 13 cases, have been published. In 1923, Stekel (98) described one case. In 1975, Dormont (99), using the term ejaculatory anhedonia, described four cases and suggested that the problem was distinctly psychological in nature but concluded that the condition is very difficult to treat. Williams (97) described seven case vignettes. He could not find any organic causative factors or common psychological dynamics. Treatment of these patients with various sex therapy procedures was ineffective. In contrast, Garippa (100) published a successful sextherapy of a man with anesthetic ejaculation. In my opinion, it may well be possible that anesthetic ejaculation is due to a disturbance in the neural circuitry that mediates the sensation of orgasm, leaving the circuitry of ejaculation intact. One of the ways to elucidate the neurobiologi- cal cause of this syndrome is to perform a PET-scan study in these men during orgasm. Treatment There are no controlled studies supporting a psychological cause and success of psychotherapy for this disorder. The most ethical way is to inform the patient that the syndrome is rare, the cause is unknown, that psychotherapy has no guarantee for success and that drug treatment is as yet not available. PARTIAL EJACULATORY INCOMPETENCE Definition Men with partial ejaculatory incompetence lack a forceful propulsive ejaculation, by which semen seeps out of the penis. The associated orgasmic experience may be weak or absent (85). Symptoms Semen seeps out of the penis instead of being propelled. The associated orgasmic experience is weak or absent. Etiology In partial ejaculatory incompetence, there is a normal emission of ejaculate, but the expulsion phase of ejaculate is impaired. The patient experiences the sensations of ejaculatory inevitability but fails to experience true orgasmic ejaculatory sensation. 240 Waldinger Treatment Although hardly any study has been published, case reports suggest that psycho- therapy and drug treatment may be beneficial. According to Kaplan (85), partial ejaculatory incompetence is frequently psychogenic and responds favor- ably to psychotherapeutic intervention. Riley and Riley (101) mentioned 11 cases of partial ejaculatory incompetence; 2 men responded to behavioral therapy, 3 men were lost to follow up. The remaining 6 men did not respond to psychotherapy, antidepressant therapy or ephedrine taken before intercourse. A placebo-controlled study with the selective alpha-adrenoceptor agonist midodrine in 6 patients was effective. PAINFUL EJACULATION Definition In painful ejaculation, there is a sharp painful sensation in the penis during or shortly after ejaculation. Symptoms During or immediately following ejaculation, there is a sharp or burning pain in the urethra. Etiology Pain during ejaculation can be due to strictures of the urethra and if there is infec- tion in the bladder, seminal vesicles, prostate or urethra, intense burning immedi- ately following ejaculation may occur. With gonococcal infection, this pain can be severe. In rare cases, painful ejaculation may also be a side-effect of tricyclic antidepressant drugs (102). Treatment Following bacteriological investigation, appropriate antibiotical treatment needs to be prescribed. Painful ejaculation induced by tricyclic antidepressants seems to be dose-dependent. Treatment should therefore consist of discontinuing or reducing the dosage of the antidepressant. POSTORGASMIC ILLNESS SYNDROME Definition In postorgasmic illness syndrome (103), the patient feels extremely fatigue and develops a flu-like state immediately or 20 –30 min after the occurrence of ejacu- lation and/or orgasm. There are no disturbances in the sexual performance itself. Male Ejaculation and Orgasmic Disorders 241 This peculiar syndrome has been discovered and described for the first time by Waldinger and Schweitzer in 2002. Symptoms Immediately or 20–30 min after the occurrence of ejaculation and/or orgasm, the patient feels extremely tired, and may develop symptoms of a flu-like rhinitis, sneezing, painful muscles, iching eyes. It is often associated with irritability and a depressed mood and may last 3–7 days after which the symptoms gradually dis- appear. These patients very characteristically plan their intercourses in order not the get in trouble with their work in the days after. Etiology The etiology is unknown. The syndrome is probably very rare. Treatment No treatment is available yet. CONCLUSIONS In this chapter, I omitted all sorts of methodologically weak publications in the field of psychotherapy that have been published during the last 30 years. Unfortunately, in last decade hardly any or even no progress has been made in the development of evidence-based research into the psychology and psychotherapy of ejaculatory dis- turbances. Instead, I have tried to provide you with up-to-date knowledge about the neurobiology and pharmacological treatment of ejaculatory disorders. Most of it, however, pertains to premature ejaculation. I hope and am also convinced that in the near future, with the development of new animal models of ejaculatory disturb- ances, the use of brain-imaging techniques in humans, and interest of pharma- ceutical companies, also the other ejaculatory and orgasm disturbances, will become amenable for effective drug treatment. 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J Am Med Womens Assoc 2003; 58: 82– 88 2 68 Pukall et al ´ 10 Meana M, Binik YM, Khalife S, Cohen D Biopsychosocial profile of women with dyspareunia Obstet Gynecol 1997; 90: 583 – 589 11 Reed BD, Advincula AP, Fonde KR, Gorenflo DW, Haefner HK Sexual. .. there were significant improvements in overall sexual functioning and self-reported frequency of intercourse at the 6-month follow-up, with no treatment differences However, means for intercourse frequency for all three groups remained below the mean frequency of intercourse for healthy women of similar age In a 2.5-year follow-up of this study ( 98) , members of all three treatment groups continued to improve... or painful performance of the sexual function” (p 68) Although the usefulness of the term dyspepsia is a matter of some controversy (2), the diagnosis of dyspareunia has not been seriously challenged and is still used by all major classificatory systems, such as the DSM-IV-TR (3) and the ICD-10 (4) The lack of specificity of the word dyspareunia is evidenced by the growing number of overlapping terms (e.g.,... 82 McKay M Subsets of vulvodynia J Reprod Med 1 988 ; 33:695– 6 98 83 Oldenhave A Some aspects of sexuality during the normal climacteric In: Berg G, Hammer M, eds The Modern Management of the Menopause Carnforth: Parthenon Publishing, 1994:605– 615 84 Hurd WW, Amesse LS, Randolph JF Jr Menopause In: Berek JS, ed Novack’s Gynecology 13th ed Philadelphia: Lippincott Williams & Wilkins, 2002:1109–1142 85 ... (83 ) These conditions are manifestations of tissue aging, cytological changes, and chemical transformations within the vagina, urethra, and bladder, which result from declining levels of endogenously produced estrogens at menopause (84 ,85 ) Both the DSM-IV-TR (3) and the ICD-10 (4) specifically mention this problem but do not classify it as dyspareunia In the DSM-IV-TR, it would be termed a sexual dysfunction. .. in the treatment of dyspareunia resulting from vulvar vestibulitis Pain 2001; 91:297– 306 ´ 98 Bergeron S, Meana M, Binik Y, Khalife S Painful genital sexual activity In: Levine SB, Risen CB, Althof SE, eds Handbook of Clinical Sexuality for Mental Health Professionals New York: Brunner-Routledge, 2003:131 –152 ¨ ¨ 99 Danielsson I, Sjoberg I, Ostman C Acupuncture for the treatment of vulvar vestibulitis:... syndrome J Sex Marital Ther 2004; 30:69 – 78 21 Eva LJ, Reid WM, MacLean AB, Morrison GD Assessment of response to treatment in vulvar vestibulitis syndrome by means of the vulvar algesiometer Am J Obstet Gynecol 1999; 181 :99 – 102 22 McKay M Vulvodynia versus pruritus vulvae Clin Obstet Gynecol 1 985 ; 28: 123– 133 23 Baram DA Sexuality, sexual dysfunction, and sexual assault In: Berek JS, ed Novack’s... profiles of and sexual function in women with vulvar vestibulitis and their partners Obstet Gynecol 1996; 88 :65– 70 69 Gates EA, Galask RP Psychological and sexual functioning in women with vulvar vestibulitis J Psychosom Obstet Gynaecol 2001; 22:221 – 2 28 70 Janssen SA Negative affect and sensitization to pain Scand J Psychol 2002; 43:131–137 71 Asmundson GJG, Taylor S Role of anxiety sensitivity in pain-related... acquisition of voluntary control After $4 months of training, subjective pain reports decreased an average of 83 %, with 52% of the women reporting painfree intercourse, and 79% of women who were abstaining from intercourse resuming activity posttreatment However, this study contained a mixed group of women with vulvar pain and likely contained a high proportion of vaginismic women, considering that many participants . Pharmacol Biochem Behav 1 981 ; 15: 785 –792. 4. Foreman MM, Hall JL, Love RL. The role of the 5-HT2 receptor in the regulation of sexual performance of male rats. Life Sci 1 989 ; 45:1263 –1270. 5. Waldinger. agonist 8- OH-DPAT. Physiol Behav 1997; 62 :88 1 89 1. 12. Coolen LM, Peters HJ, Veening JG. Anatomical interrelationships of the medial preoptic area and other brain regions activated following male sexual. follow-up of couples treated for sexual dysfunction. Arch Sex Behav 1 985 ; 14:467–490. 35. Hawton K, Catalan J, Martin P, Fagg J. Prognostic factors in sex therapy. Behav Res Ther 1 988 ; 24:377– 385 . 36.