Erectile Dysfunction Overview
Erectile Dysfunction (ED) is a major concern for millions of men, but ED is a bit of a catch all term and represents a spectrum of factors for different patients. You're probably familiar with the concept that "no two fingerprints are exactly the same"...well, this applies to erectile dysfunction patients. Many men suffer from ED due to contributing disease states like cardiovascular disease, hypertension, diabetes, obesity, and substance use disorders to name a few. For others, age, stress, depression, surgeries, or injuries may be a factor.
Some men deal with "unsatisfactory" erectile function as a lifelong or recently developing issue. I used quotation marks with unsatisfactory because there are objective and subjective conditions that, while equally significant to the individual, present and are frequently addressed in different ways. Per the University of Wisconsin: Symptoms of mild to moderate ED increased by 10% per decade of life (i.e. 60% of men in their 60's), but increasing incidence of lifestyle diseases (obesity/smoking, drugs/alcohol) has triggered the appearance of a much younger patient population. (1) This explains why the patients commonly treated for ED range from their 20's to centenarians and variance in disease presentation is equally diverse.
What is Premature Ejaculation?
Of all varieties of male sexual dysfunction, Premature Ejaculation (PE) is the most common. Some studies show 30-50% of men are affected, but others indicate an occurrence rate of up to 75%. Actual diagnosis of PE is generally based on Intravaginal Ejaculatory Latency Time (IELT), which is the time from vaginal intromission (penetration) until ejaculation, and can be etiologically divided into psychogenic and biogenic factors. (2)
Psychogenic PE (also known as Acquired PE) is a psychoseual disorder stemming from immediate factors like performance anxiety or recent life experiences, and childhood/adolescent developmental vulnerabilities. Examples: Psychological/personality disorders, anxiety, lack of experience and/or sexual technique, infrequent sexual activity, and high arousability.
Biogenic PE (also referred to as Lifelong PE) has a hereditary root which has been demonstrated by twin studies of Dutch men with lifelong PE who were first-degree relatives of men with lifelong PE. Genetic factors leading to hypersensitivity were discovered as well as endocrinal issues, prostatitis, MS, low B12 and low seminal magnesium levels.
PE is further broken down into Objective PE which is determined by measurable IELT, and Subjective (Relational) PE which is defined by a loss of ejaculatory control that is emotionally distressing for one or both sexual partners. In other words, if it bothers you that you don't last long enough, it's an issue. To further aid in definition, Objective PE is categorized as severe (IELT < 15 seconds), moderate (IELT < 1 minute) and mild (IELT < or = 2 minutes). (3)
Considering the prevelance of PE, you would think there would be a variety of FDA approved therapies for these patients...and... you would be wrong. There are no approved therapies for PE and the most recent application by Lilly for the SSRI Dapoxetine specifically for PE was rejected due to safety and efficacy concerns. Couple those concerns with the study participant drop out rate (only 9.9% of participants continued treatment for 2 years) and the message to hopeful patients is not very optimistic. (4) That being said, there are a number of therapies that have shown promise as options for PE. These options include behavioral modifications, targeted exercises, climax control aids, and pharmacological options. Surgical options have been suggested, but uncommon and can create more issues for the patient.
Approaches to PE
Behavioral approaches often incorporate the practice of edging which is a term used to describe the technique of repeatedly stimulating and approaching climax but interrupting sensation prior to reaching the "point of no return". Some of these exercises include "Penis root masturbation", and the "Stop/Start" and "Squeeze" techniques which interupt sensations as a man approaches climax. Kegel exercises are a valuable tool used to strengthen pelvic floor muscles and allow for improved climax control. Pre-sex masturbation is another behavioral tool that may be beneficial in some cases. (5)
Certain correctable behaviors that have been linked to PE are overindulgance in pornography which causes dopamine spikes that contribute to faster ejaculation, and masturbation while watching porn with intent to climax quickly may cause a physiological conditioning and predisposes men to PE. (6)
There are also devices available to assist men in improving their ejaculatory control. Vibrator assisted masturbation devices simulate sensations of penetrative sex and allow men to improve control similar to edging exercises and Ejaculation Control Stimulators use electrostimulation either in the rectum or to the perineal region to similarly generate arousal response that improves ejaculatory control. (7)
Desensitizing products have been used for years with some success to address PE. There are a wide variety of sprays, creams, gels, and wipes that incorporate topical numbing agents like benzocaine to reduce sensation and prolong control. Most of these products need to be used with condoms to prevent transfer of the numbing agent to their partner, but a few absorb or dry sufficiently to allow for unprotected sex. For simplicity, some men use desensitizing condoms that are lined with benzocaine to acheive up to a 3 fold increase in IELT. (8)
As I mentioned previously, there are no approved medication therapies for PE, but several off-label applications are commonly used. There are a number of medications that are known to cause issues with sexual function and it makes sense that many of those medications are the go to remedies for PE. Among these, Selective Serotonin Reuptake Inhibitors (SSRIs) like sertraline, citalopram, paroxetine and the aforementioned dapoxetine are the most sought after pharmacologic approaches. Of the FDA approved drugs, paroxetine has been shown to be most effective..BUT..significant beneficial effects in IELT require daily dosing while PRN use offers only modest improvement. As was stated regarding the dapoxetine trials, close to 90% of patients discontinue daily SSRI therapy due to the undesirable side effects and lack of efficacy. Opioid agonists like tramadol have shown promise, but they involve the complication of daily use of a controlled substance medication which prescribers often want to avoid. One potential exception to daily therapy is Clomipramine, a non-selective serotonin reuptake inhibitor, that has demonstrated efficacy as a PRN therapy when taken 4 hours prior to expected sexual activity. Combining these agents with a PDE5 inhibitor like tadalafil has shown to improve effectiveness. (9)
Because of this, it makes sense and is convenient for patients try a compound like a clomipramine 25mg/tadalafil 20mg capsule for PRN use as an option for PE.
Conclusion
The most successful patient outcomes result from a combination of the approaches I have mentioned with counseling to assist patients to find the best therapeutic fit for their condition. Men with PE represent the highest reported rate of incidence among ED patients while being arguably the most underserved segment of this patient population. PE can have a significant impact on relationships due to the negative psychological and emotional effects these patients encounter. Along with the stigma involved with seeking help for a condition that is intimately personal, patients are all too often offered little advice or unpleasant solutions.
As practitioners, it is extremely important to understand the challenges these patients face, due in part to the lack of approved therapies, and educate ourselves on all the options available that may improve their sexual performance and confidence. For the benefit of patients and providers alike, there are reources available to help. Revelation Pharma has clinical specialists experienced in sexual medicine, a dedicated Men's Health website at penilerehabprotocol.com, individual counseling for patients and prescribers at ConsultRx, and a team of collaborative partners including sexual educators available to support your practice and your patients.
Please visit RevelationPharma.com or PenileRehabProtocol.com for more information.
Disclaimer
The FDA does not review any compounded medication for safety or efficacy. The information contained in this article is not meant to diagnose or treat a specific healthcare condition but should be used as educational-only material.
References
1.Erectile Dysfunction (ED): Symptoms, Causes, Diagnosis, and Treatment. R Bielinski MD. The Healthline Editorial Team. Nov 29, 2023
2. A Multinational Population Survey of Intravaginal Ejaculatory Latency Time. J Sex Med 2005; 2:492-7. Waldinger MD, QP Dilleen MD, M Schweitzer DH, et al
3.Premature Ejaculation: An Update on Definition and Pathophysiology. Asian J Andrology. 2019 Sep-Oct, 21(5): pgs. 425-432. M. Abu-Hamad, A. Majzoub, R. Sadeh
4. Discontinuation of Dapoxetine Treatment in Patients with Premature Ejaculation: A 2 Year Prospective Observational Study. Sex Med. 2017 Apr 5; 5(2): pgs 99-105. H. Park, N. Park, T. Kim, S Baek, K. Lee, S. Choe
5.Medical News Today. What to Know About Masturbating Before Sex. J. Johnson, J. Brito. 7/18/2019
6.IMH 2024 – Innovations in Men’s Health. How to deal with Premature Ejaculation. Dr. W. Washington MD
7. A, Shechter, I. Gruenwald. Int Journal of Impotency Research. New Technologies Developed For the Treatment of Premature Ejaculation. 27 March 2024
8. Medical News Today. Do Premature Ejaculation Wipes Work? K. Iavarone, J. Eske, M. Coward MD 9/30/22
9.A, Shechter, I. Gruenwald. Int Journal of Impotency Research. New Technologies Developed For the Treatment of Premature Ejaculation. 27 March 2024
10.M. El-Hamid, R. Saleh, A. Majzoub. An Update on the Treatment of Premature Ejaculation: A systemic Review. Arab J Urol 2021; 19(3)281-302
