Erectile dysfunction and Premature Ejaculation

Erectile Dysfunction and Premature ejaculation from psychiatric point of view

1. PRESENTER: AMITKUMAR CHOUGULE ERECTILE DYSFUNCTION AND PRE MATURE EJACULATION

2. ERECTILE DYSFUNCTION

3. OVERVIEW Definition Epidemiology Causes Assessment Approach T reatment Conclusion

4. INTRODUCTION The terms impotence and erectile dysfunction had been used interchangeably Social scientists objected to the impotence label because of its pejorative implications and lack of precision The NIH Consensus Development Conference advocated the label ‘erectile dysfunction' instead of impotence ( National Institutes of Health (1992). Consensus development conference statement on impotence . NIH,Bethesda,MD )

5. DEFINITION Erectile dysfunction ( ED) is: “ T he consistent or recurrent inability of a man to attain and/or maintain a penile erection sufficient for sexual performance” “Recurrent inability” as being 3 months or greater in duration ( First International Consultation on Erectile Dysfunction, convened by the WHO in 1999)

6. Psychogenic Erectile Dysfunction Psychogenic ED was defined by the International Society of Sex and Impotence Research as: “ T he persistent inability to achieve or maintain an erection satisfactory for sexual performance, owing predominantly or exclusively to psychological or interpersonal factors”

7. ICD 10 F52.2 Failure of genital response If erection occurs normally in certain situations, e.g. during masturbation or sleep or with a different partner , the causation is likely to be psychogenic Otherwise , the correct diagnosis of nonorganic erectile dysfunction may depend on special investigations ( e.g. measurement of nocturnal penile tumescence) or the response to psychological treatment

8. DSM 5 CRITERIA- ERECTILE DYSFUNCTION At least one of the three following symptoms must be experienced on almost all or all ( approximately 75%-100%) occasions of sexual activity (in identified situational contexts or , if generalized, in all contexts ): 1. Marked difficulty in obtaining an erection during sexual activity 2. Marked difficulty in maintaining an erection until the completion of sexual activity 3. Marked decrease in erectile rigidity B. The symptoms in Criterion A have persisted for a minimum duration of approximately 6 months

9. C. The symptoms in Criterion A cause clinically significant distress in the individual D. The sexual dysfunction is not better explained by: N onsexual mental disorder or A s a consequence of severe relationship distress or O ther significant stressors and Is not attributable to the effects of a substance/medication or another medical condition

10. Specify whether : Lifelong : The disturbance has been present since the individual became sexually active. Acquired : The disturbance began after a period of relatively normal sexual function. Specify whether : Generalized : Not limited to certain types of stimulation, situations, or partners. Situational : Only occurs with certain types of stimulation, situations, or partners. Specify current severity: Mild : Evidence of mild distress over the symptoms in Criterion A. Moderate : Evidence of moderate distress over the symptoms in Criterion A. Severe : Evidence of severe or extreme distress over the symptoms in Criterion A.

11. EPIDEMIOLOGY Incidence and prevalence is high worldwide A ffects up to 52% of men (40-70yrs) Steep age-related increase Complete ED : 5 % in 40yr olds 15 % in 70yr olds

12. INTERNATIONAL STUDIES Study Age Group PREVALENCE OF ED Massachusetts Male Aging Study (MMAS), USA 40-70 years 52% Cologne study, Central Europe 30-80 years 19.2% The multinational Men’s Attitudes to Life Events and Sexuality (MALES) study 16%

13. INDIAN STUDIES AUTHORS SETTING YEAR PREVALENCE OF ED Bagadia et.al Teaching hospital 1972 48% Verma et.al Psychosexual clinic 1998 23.6% Gupta et.al Skin OPD 2004 34% S. Sathyanarayana Rao, M. S. Darshan, Abhinav Tandon South Indian rural population 2015 15.77%

14. Sexual dysfunction among men in secondary care in southern India: Nature , prevalence, clinical features and explanatory models ( P. Thangadurai, R. Gopalakrishnan , V .J. Abraham, J. Prasad, A. Kuruvilla , K .S. Jacob) Prevalence of ED was 47.8% S tatistically significant association between premature ejaculation and erectile dysfunction The factors associated with erectile dysfunction were: B eing currently married F inancial problems (an inability to buy food in the past month) H istory of diabetes mellitus P ast history of psychiatric treatment C urrent diagnosis of common mental disorder (anxiety and depression)

15. Continued… The men had diverse beliefs about the causes of their sexual problems : (ED + PE) Masturbation (26.7%) Nocturnal emission (20.0%) Disease (22.6%) Punishment by God (9.6%) Karma (8.5%) Black magic (0.4%) Lack of privacy (2.2%)

16. A SENTINEL FOR CARDIOVASCULAR DISEASE Most significant social implication of ED is its increasingly recognized status as an early marker of vascular disease ED is a marker of significantly increased risk of CVD , coronary artery disease (CAD), stroke and all-cause mortality Erectile dysfunction commonly occurs in the presence of silent CAD T ime window between ED onset and a CAD event is usually 2 to 5 years

17. RISK FACTORS FOR ED Sedentary lifestyle Obesity Smoking Hypercholesterolemia Metabolic syndrome Diabetes mellitus ( Shared risk factors with CVD)

18. Aetiology Organic Hormonal Anatomical Drugs Psychogenic

19. CAUSES Vascular Causes CVD Atherosclerosis Hypertension Diabetes Hyperlipidemia Smoking T rauma Central causes Parkinson’s Stroke MS Tumours spinal disease/injury Peripheral causes P eripheral neuropathy Diabetes A lcoholism Uraemia P elvic surgery

20. HORMONAL CAUSES Hypogonadism Hyperprolactinaemia Thyroid disease Cushing’s disease ANATOMICAL CAUSES Peyronie’s disease Micropenis Penile anomalies (hypospadias )

21. DRUGS Antihypertensives (Beta blockers, Diuretics ) Antidepressants (Tricyclic and SSRIs) Antipsychotics ( P henothiazines , Risperidone ) Anticonvulsants (Phenytoin , Carbamazepine ) Antihistamines H2 antagonists (Cimetidine , Ranitidine ) Recreational drugs (Tobacco and Alcohol )

22. PSYCHOGENIC ERECTILE DYSFUNCTION Immediate causes : Performance anxiety Lack of adequate stimulation Relationship conflicts Remote causes : Childhood sexual trauma Sexual identity issues Unresolved partner or parental attachments Religious or cultural taboos

23. Classification ED is commonly classified into three categories based on its aetiology: O rganic Psychogenic M ixed ED M ost cases are of mixed aetiology Suggested Classification: P rimary organic P rimary psychogenic

24. Pathogenesis Model for Acquired Psychogenic ED Precipitating events ↓ One episode of erectile failure ↓ Performance anxiety ↓ Another episode of erectile failure ↓ More performance anxiety Decreased frequency of sexual initiation ↓ Changes in the sexual equilibrium ↓ Established pattern of ED with partner

25. EVALUATION

26. PSYCHIATRIC ASSESSMENT Full psychiatric history from the patient and mental status examination The sexual history must include information about: S exual orientation P revious and current sexual relationships C urrent emotional status O nset and duration of the erectile problem P revious consultations and treatments

27. A detailed description should be made of: R igidity and duration of both sexually-stimulated and morning erections P roblems with sexual desire, arousal, ejaculation, and orgasm Interview patient's sexual partner separately as she can provide information and details from her point of view

28. Erectile reserve In men with ED presence or absence of spontaneous erections is an important clue to diagnosis Most men experience spontaneous erections during REM sleep and often wake up with an erection This indicates the integrity of neurogenic reflexes and corpora cavernosa blood flow

29. HISTORY FOR PSYCHOGENIC COMPONENT Was onset of ED instantaneous (one time, and then ever since)? C ommon in: F irst-time encounters C onflicted relationships W hen patient feels obligated to have intercourse but does not want to

30. Rapidity of onset Sexually competent men who had no sexual problems until " one night when they could not perform " and thereafter become impotent invariably have psychogenic ED Men suffering from ED of any organic cause complain that “ sexual function failed sporadically at first and then more consistently”

31. Physical examination A careful assessment of femoral and peripheral pulses as a clue to the presence of vasculogenic impotence A search for visual field defects present in hypogonadal men with pituitary tumors A breast examination to detect gynecomastia, often present in Klinefelter's syndrome

32. Physical E xamination A search for penile strictures indicative of Peyronie's disease Examination of the testicles looking for atrophy, asymmetry or masses Evaluation of the cremasteric reflex, an index of the integrity of the thoracolumbar erection center

33. Lab evaluation Testosterone level (consider peak 8 am and trough 8 pm when evaluating result, can be 30% difference) Prolactin level TSH Hematology Hepatic and kidney function Hemodynamic evaluation Nerve conduction studies

34. NOCTURNAL PENILE TUMESCENCE RECORDING ( NPT) occurs in all normal males from early infancy to old age NPT is closely linked to rapid eye movement (REM ) sleep Its measurement is widely accepted in the differential diagnosis of ED The rationale for its use is : In cases of organic ED NPT is absent or diminished In psychogenic ED sleep erections occur with normal frequency and magnitude

35. Ideally done in a sleep laboratory with simultaneous standard polygraphic sleep recording: Electroencephalogram E lectro- oculogram Electromyogram Diagnostic accuracy depends more on the expertise of the individual interpreting the recording P enile expansion of more than 15 mm indicates psychogenic ED Lesser than 15mm expansion indicates organicity

36. ASSESSMENT OF ED INTERNATIONAL INDEX OF ERECTILE FUNCTION(IIEF): Superficial assessment of psychosexual background Very limited assessment of partner relationship An adjunct to rather than a substitute for a detailed sexual history and examination (Rosen R, Riley A, Wagner G, et al. Urology , 1997, 49: 822-830)

37. International Index of Erectile Dysfunction IIEF The following guide-lines may be applied: Patients with low IIEF scores (<14 out of 30) in Domain A (Erectile Function): M ay be considered for a trial course of therapy with Sildenafil unless contraindicated Specialist referral is indicated if this is unsuccessful

38. Patients demonstrating primary orgasmic or ejaculatory dysfunction (Domain B) should be referred for specialist investigation Patients with reduced sexual desire (Domain C) require testing of blood levels of androgen and prolactin Psychosexual counselling should be considered if low scores are recorded in Domains D and E

39. VALIDATED PSYCHOMETRIC QUESTIONNAIRES SEXUAL HEALTH INVENTORY FOR MEN (SHIM) ERECTILE DYSFUNCTION QUESTIONNAIRE(EDQ)

40. MANAGEMENT The ‘‘Patient-centered approach ’’ has come forward as the premier ED management principle (Rosen et al, 2004) This approach emphasizes: T he roles of the patient and/or patient/partner in the evaluation and management of the problem D iagnostic and therapeutic decisions should rely on the goals and preferences of the patient and partner

41. PROCESS OF CARE (POC) POC guide for appropriately assessing and treating ED has been developed by a multidisciplinary panel Panel had experts in family medicine, internal medicine, endocrinology, psychiatry, psychology, and urology The POC outline six phases: Establishing the diagnosis Discussing the initial findings, discussing referral, beginning the education process Modifying reversible causes of erectile dysfunction Implementing first-line treatment: Psychotherapy , oral erectogenic agents , vacuum constriction devices Implementing second-line treatment: self-injection therapy, transurethral therapy Implementing third-line treatment: implantation of a penile prosthesis

42. PSYCHOTHERAPY FOR ED Rosen divided treatment for P sychogenic ED into four types: Anxiety reduction and desensitization C ognitive-behavioral interventions Increased sexual stimulation Interpersonal assertiveness and couples communication training

43. Anxiety reduction and desensitization Designed to reduce performance anxiety by avoiding intercourse in early treatment and using relaxation techniques Instead of having coitus, the couple follows a series of nongenital, non demand , sensate focus exercises popularized by Masters and Johnson  

44. COGNITIVE BEHAVIOURAL INTERVENTIONS A ttempts are made to overcome unrealistic sexual expectations Psychoeducation of the couple

45. INTERPERSONAL AND SYSTEMIC INTERVENTIONS Following Issues are addressed: S tatus and dominance I ntimacy and trust L oss of sexual attraction

46. Dual-Sex Therapy Originated and developed by Masters and Johnson Both individuals are involved in a relationship in which there is sexual distress Both must participate in the therapy program The marital relationship as a whole is treated Improved communication in sexual and nonsexual areas is a specific goal of treatment

47. Behavioral Exercises Treatment is short term and behaviorally oriented Specific exercises are prescribed to help the couple with their particular problem Sexual dysfunction often involves a fear of inadequate performance C ouples are specifically prohibited from any sexual play other than that prescribed by the therapist Initially , intercourse is avoided and couples learn to give and receive bodily pleasure without the pressure of performance

48. Beginning exercises usually focus on heightening sensory awareness to touch, sight, sound, and smell During these exercises called sensate focus exercises : Couple is given much reinforcement to lessen anxiety They are urged to use fantasies to distract them from obsessive concerns about performance, which is termed spectatoring The needs of both the dysfunctional partner and the nondysfunctional partner are considered Open communication between the partners is urged, and the expression of mutual needs is encouraged

49. Behaviour Therapy Behavior therapists assume that sexual dysfunction is learned, maladaptive behavior Therapist sees the patient as phobic of sexual interaction Therapist sets up a hierarchy of anxiety-provoking situations for the patient Patient masters the anxiety through systematic desensitization Assertiveness training is used to teach patients to express their sexual needs openly and without fear

50. Integrated Sex Therapy Sex therapy integrated with supportive, psychodynamic, or insight-orientated psychotherapy is very effective Insight-oriented therapy helps to deal with problems in interpersonal relationships or intrapsychic conflicts that frequently are at the root of the sexual problem Sex therapy integrated with pharmacotherapy is very effective

51. Biological Treatment Methods Pharmacotherapy is useful in treatment of erectile dysfunction of various causes Drugs explored in the treatment of ED are: Nitric oxide enhancers/ PDE 5 Inhibitors Oral prostaglandin ( Vasomax) Alprostadil ( Caverject ) Injectable phentolamine Transurethral alprostadil (MUSE )

52. NITRIC OXIDE ENHANCERS/ PDE 5 INHIBITORS Sildenafil augments the natural process involved in gaining and maintaining an erection during sexual stimulation Sildenafil has no effect in the absence of sexual stimulation Two other nitric oxide enhancers are: Vardenafil Tadalafil

53. Oral phentolamine ( Vasomax) Has proved effective as a potency enhancer Useful for men with cardiac problems as sildenafil is contraindicated for men using organic nitrates Not currently approved by the FDA Apomorphine B eing tested as an oral remedy for erectile dysfunction Alprostadil Injectable and transurethral alprostadil act locally on the penis C an produce erections in the absence of sexual stimulation

54. Self-injection Of Papaverine And Phentolamine In The Treatment Of Psychogenic ED: Self-injections four times monthly has a 94% success rate Increase in frequency of intercourse and sexual satisfaction Yohimbine In Treatment Of Psychogenic Impotence: Yohimbine is a safe treatment for psychogenic ED As effective as sex and marital therapy for restoring satisfactory sexual functioning Response to yohimbine is unrelated to the cause of impotence

55. BIBLIOTHERAPY The new male sexuality, by Bernie Zilbergeld , Ph.D Practical book debunking sex myths H as exercises for ED, losing erections, premature ejaculation Humorous and useful Good anatomy descriptions The passionate marriage: love, sex, and intimacy in emotionally committed relationships by David Schnarch , Ph.D .

56. Conclusion ED is the one of the most common and most distressing sexual dysfunction in men Psychiatrist has a crucial role to play in the evaluation and management of ED as he the only specialist who has a adequate knowledge of both organic and psychogenic causes of ED Even after recent advances in pharmacotherapy sex therapy remains gold standard for psychogenic ED Sex therapy has a vital role as an adjunct in treatment of organic causes

57. PREMATURE EJACULATION

58. EVOLUTIONARY PERSPECTIVE The control of the ejaculatory reflex represents an evolutionary and cultural advance for human sexuality In the primates the rapid deposition of semen protects the animal from extended exposure to predators M en have learned to control ejaculation to enhance their and their partner’s enjoyment PE has a profound effect on relational and psychological health

59. HISTORICAL ASPECTS The term Ejaculatio praecox was introduced by the psychoanalyst Abraham U ntil the first half of the 20th century PE was not included in the list of sexual disorders Kinsey et al. in a survey of almost 20,000 Americans found that 75% of men ejaculated within 2 min of penetration Kinsey et. al rejected the notion that PE is a sexual dysfunction

60. Shapiro argued that PE might be the combination of a hyper anxious constitution with anatomical defects In 1960 PE was recognized as sexual dysfunction due to cultural change: Feminist revolution in the mid 1960s Discovery of the female orgasm

61. PE DEFINITION Research into the treatment and epidemiology of premature ejaculation (PE) is heavily dependent on how PE is defined Each of these definitions characterizes men with PE: Intravaginal Ejaculatory latency time (IELT) P erceived ability to control ejaculation R educed sexual satisfaction Personal distress P artner distress I nterpersonal or relationship distress

62. DSM DEFINITION OF PE Previously definitions of PE given in (DSM ) were: L argely accepted by the medical community with little discussion N o evidence-based medical support In ( DSM-IV-TR), PE was defined as a “ P ersistent or recurrent ejaculation with minimal sexual stimulation before, on, or shortly after penetration and before the person wishes it”

63. PROBLEMS WITH DSM- IV DEFINITION A bsence of a specific ejaculation time cutoff point to operationalize “shortly after penetration or before the person wishes ” This lead to ambiguous application of the DSM criteria for PE in epidemiological and clinical research Subject diagnosed with PE according to DSMIV- TR criteria has a 44% chance of not having PE if a PE diagnostic threshold IELT of 2 minutes, as suggested by community-based normative IELT trial is used

64. INTERNATIONAL SOCIETY FOR SEXUAL MEDICINE ( ISSM) DEFINITION FOR PE The second ISSM Ad Hoc Committee for the Definition of Premature Ejaculation defined PE (lifelong and acquired) as a male sexual dysfunction characterized by the following: 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) The inability to delay ejaculation on all or nearly all vaginal penetrations Negative personal consequences, such as distress, bother , frustration, and/or the avoidance of sexual intimacy

65. DSM-5 DEFINITION OF PE A . A persistent or recurrent pattern of ejaculation occurring during partnered sexual activity within approximately 1 minute following vaginal penetration and before the person wishes it B. The symptom in Criterion A must have been present for at least six months and must be experienced on almost all or all ( approximately 75%–100%) occasions of sexual activity ( in identified situational contexts or if generalized, in all contexts ) C. The symptom in Criterion A causes clinically significant distress in the individual D. The sexual dysfunction is not better explained by a nonsexual mental disorder or as a consequence of severe relationship distress or other significant stressors and is not attributable to the effects of a substance/medication or another medical disorder

66. DSM 5 SPECIFIERS Specify whether ; Lifelong : The disturbance has been present since the individual became sexually active Acquired : The disturbance began after a period of relatively normal sexual function Specify whether: Generalized : Not limited to certain types of stimulation, situations, or partners. Situational : Only occurs with certain types of stimulation, situations, or partners Specify current severity: Mild : Ejaculation occurring within approximately 30 seconds to 1 minute of vaginal penetration Moderate : Ejaculation occurring within approximately 15-30 seconds of vaginal penetration Severe : Ejaculation occurring prior to sexual activity, at the start of sexual activity or within approximately 15 seconds of vaginal penetration

67. ICD-10 Definition of PE “ T he inability to control ejaculation sufficiently for both partners to enjoy sexual interaction” and “an inability to delay ejaculation sufficiently to enjoy lovemaking, and manifest as either of the following: ( i) Occurrence of ejaculation before or very soon after the beginning of intercourse (if a time limit is required : before or within 15 seconds of the beginning of intercourse ) (ii ) Ejaculation occurs in the absence of sufficient erection to make intercourse possible ”

68. Classification of PE In 1943, Schapiro proposed a classification of PE into two types Type A (“hypotonic ” type) was associated with the gradual development of ED Type B (“ sexually hypertonic” or “hypererotic” type) represented a consistent tendency to ejaculate rapidly from the first act of intercourse In 1989 Godpodinoff renamed these types as lifelong (primary) and acquired (secondary) PE Over the years, other attempts to specify subtypes have occurred ( e.g ., global vs. situational PE, PE due to the effect of a substance , etc .)

69. Waldinger and Schweitzer Classification Waldinger and Schweitzer proposed a new classification of PE 4 PE subtypes were distinguished on the basis of: D uration of IELT F requency of complaints C ourse in life

70. Lifelong PE Acquired PE Natural variable PE Premature-like ejaculatory dysfunction In the majority of cases (80%) within 30–60 s or (20%) 1 and 2 min IELT is short (less than 2 min) Ejaculation time may be short or normal IELT is in the normal range or may even be of longer duration From about the first sexual encounter Early ejaculation occurs at some point in a man’s life Early ejaculations are: Inconsistent Occur Irregularly Subjective perception of consistent or inconsistent rapid ejaculation With nearly every woman The man had normal ejaculation experiences before Ability to delay ejaculation may be diminished or lacking Ability to delay ejaculation may be diminished or lacking Ejaculation occurs too early nearly in each intercourse The onset is either sudden or gradual The impression of diminished control of ejaculation Imagined early ejaculation or lack of control of ejaculation Remains rapid throughout the lifetime of the subject The dysfunction may be the result of urological/thyroid dysfunctions or psychological problems Psychotherapy should be considered as first-line treatment The preoccupation is not better accounted for by another mental disorder

71. EPIDEMIOLOGY The major problem is lack of an accurate (validated) definition at the time the surveys were conducted The highest prevalence rate of 31% (men aged 18-59 years) was found by the National Health and Social Life Survey (NHSLS) study in USA Prevalence rates were 30 % ( 18-29 years), 32% (30-39 years), 28% (40-49 years) and 55% (50-59 years) The prevalence rates in European studies have been significantly lower

72. INDIAN STUDIES AUTHORS SETTING YEAR PREVALENCE OF PE Bagadia et.al Teaching hospital 1972 34% Verma et.al Psychosexual clinic 1998 77.6% Gupta et.al Skin OPD 2004 16.6% T.S. Sathyanarayana Rao, M. S. Darshan, Abhinav Tandon South Indian rural population 2015 8.76%

73. Sexual dysfunction among men in secondary care in southern India: Nature, prevalence, clinical features and explanatory models (P. Thangadurai, r. Gopalakrishnan , v.J . Abraham, j. Prasad, a. Kuruvilla , k.S . Jacob) Prevalence of PE was 43.0 % Risk Factors associated with PE: Older age( >42) current anxiety and depression F inancial debt

74. DIAGNOSTIC EVALUATION Diagnosis of PE is based on the patient’s medical and sexual history History should: C lassify PE as lifelong or acquired D etermine whether PE is situational or consistent Special attention should be given to: Duration of time of ejaculation D egree of sexual stimulus I mpact on sexual activity QoL D rug use or abuse

75. PME/ ED/ FEMALE SEXUAL DYSFUNCTION It is important to distinguish PE from ED Many patients with ED develop secondary PE caused by the anxiety associated with difficulty in attaining and maintaining an erection S ome patients are not aware that loss of erection after ejaculation is normal and may erroneously complain of ED, while the actual problem is PE Female sexual dysfunction is often present and might be secondary to the male PE S o assessing female sexuality is an integral part of assessing PE

76. PE ASSESSMENT QUESTIONNAIRES Premature Ejaculation Diagnostic Tool (PEDT): Five-item questionnaire based on focus groups and interviews from the USA, Germany and Spain A total score > 11 suggests a diagnosis of PE Arabic Index of Premature Ejaculation ( AIPE): Seven-item questionnaire developed in Saudi Arabia A cut-off score of 30 discriminated best PE diagnosis Chinese Index Of Sexual Function For Premature Ejaculation ( CIPE) Premature Ejaculation Profile ( PEP) Index of Premature Ejaculation ( IPE) Male Sexual Health Questionnaire Ejaculatory Dysfunction

77. MANAGEMENT Before beginning treatment it is essential to discuss the patient's expectations thoroughly I t is important to treat ED first if present In lifelong PE: B ehavioural techniques are not recommended for first-line treatment They are time-intensive R equire the support of a partner and can be difficult to perform L ong-term outcomes of behavioural techniques for PE are unknown

78. PSYCHOTHERAPY IN PE Psychological therapies may be helpful for patients with PE In men for whom PE causes few problems treatment is limited to psychosexual counselling and education Psychotherapy should be considered as first-line treatment for patients with: N atural variable PE P remature-like ejaculatory dysfunction

79. PSYCHOLOGICAL/BEHAVIOURAL STRATEGIES Behavioural strategies mainly include: The ‘stop-start’ programme developed by Semans I ts modification the ‘squeeze’ technique proposed by Masters and Johnson In the ‘stop-start’ programme, the partner stimulates the penis until the patient feels the urge to ejaculate At this point, he instructs his partner to stop, waits for the sensation to pass and then stimulation is resumed

80. The ‘squeeze’ technique is similar but the partner applies manual pressure to the glans just before ejaculation until the patient loses his urge Both these procedures are typically applied in a cycle of three pauses before proceeding to orgasm

81. ADJUNCT TREATMENT MODALITIES FOR PE S imple behaviors promoting an increase in the ejaculatory time can be prescribed such as: E jaculate more frequently R elease the anal sphincter during intercourse F avour the female-on top position U se special condoms Strengthening of the pubococcygeous muscles of the pelvic floor In these exercises, named after Arnold Kegel who devised them , the patient is trained to identify his pubococcygeous muscles during urination

82. PHARMACOLOGICAL THERAPY DAPOXETINE: Dapoxetine hydrochloride is a short-acting SSRI It is approved for on-demand treatment of PE In RCTs dapoxetine 30 mg or 60 mg 1-2 hours before intercourse was effective from the first dose on: IELT and increased ejaculatory control D ecreased distress I ncreased satisfaction

83. Dapoxetine has shown a similar efficacy profile in men with lifelong and acquired PE Treatment-related side-effects were dose dependent and included nausea, diarrhea, headache and dizziness Dapoxetine co-administered with a PDE5I inhibitor is well tolerated

84. OFF-LABEL USE OF ANTIDEPRESSANTS: SSRIS AND CLOMIPRAMINE SSRI widely used ‘off-label’ for PE SSRIs must be given for 1 to 2 weeks to be effective in PE Based on meta-analysis: Paroxetine was found to be superior to fluoxetine, clomipramine and sertraline Efficacy of clomipramine was not significantly different from fluoxetine and sertraline There was no significant relationship between dose and response among the various drugs

85. TOPICAL ANAESTHETIC AGENTS LIDOCAINE-PRILOCAINE CREAM In a randomised, double-blind, placebo-controlled trial lidocaine-prilocaine cream: S ignificantly increased the stopwatch-measured IELT from 1.49 to 8.45 minutes N o difference was recorded in the placebo group (1.67 to 1.95 minutes) Lidocaine-prilocaine cream (5%) is applied for 20-30 minutes prior to intercourse

86. TRAMADOL: Tramadol has shown a moderate beneficial effect with a similar efficacy as dapoxetine E fficacy and tolerability of tramadol would have to be confirmed in more patients and longer-term PHOSPHODIESTERASE TYPE 5 INHIBITORS: Several open-label studies showed that sildenafil combined with an SSRI is superior to SSRI monotherapy Sildenafil combined with behavioural therapy significantly improved IELT and satisfaction vs. behavioural therapy alone

87. CONCLUSION F urther studies are required in order to obtain objective data to propose evidence-based definitions of acquired PE, natural variable PE and premature-like ejaculatory dysfunction syndromes S everity scale of PE must be confirmed by more studies A ppropriate treatment algorithms must be designed Treatment of PE is complex, and guidelines for treatment are limited due to the controversial definition of the disease causing a barrier to standardized evidence-based studies I t is important to consider all possible modalities when treating PE as each patient may respond differently and side effects are variable

88. Mental health clinicians generally avoid asking patients about their sexual life because they themselves are anxious, believe sexual problems occur infrequently, fear being inappropriate, or judge themselves poorly prepared to manage potential problems Sexual disorders are readily treatable, and their resolution can be gratifying both to the interested clinician and the troubled individual and/or couple

89. …… with our knowledge and support lets bring back the light lost in the dark bedroom of couples with sexual dysfunction ….

90. REFERENCES Kaplan & Sadock's Comprehensive Textbook of Psychiatry, 9th Edition: Sadock , Benjamin J.; Sadock , Virginia A.; Ruiz, Pedro Kaplan & Sadock's Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry, 10th Edition:Sadock , Benjamin James; Sadock , Virginia Alcott Psychiatry, Third Edition. Edited by Allan Tasman, Jerald Kay, Jeffrey A. Lieberman, Michael B. First and Mario Maj © 2008 John Wiley & Sons, Ltd. ISBN 978-0470-06571-6 An Evidence-Based Unified Definition of Lifelong and Acquired Premature Ejaculation: Report of the Second International Society for Sexual Medicine Ad Hoc Committee for the Definition of Premature Ejaculation.Ege Can Serefoglu , MD et.al. Sex Med 2014;2:41–59 An epidemiological study of sexual disorders in south Indian rural population : T . S. Sathyanarayana Rao, M. S. Darshan1, Abhinav Tandon: Indian Journal of Psychiatry 57(2), Apr-Jun 2015 An Update of the International Society of Sexual Medicine’s Guidelines for the Diagnosis and Treatment of Premature Ejaculation ( PE):Stanley E. Althof , PhD , Chris G. McMahon et.al. Sex Med 2014;2:60–90

91. Guidelines on Male Sexual Dysfunction: Erectile dysfunction and premature ejaculation. K. Hatzimouratidis (Chair), I. Eardley , F. Giuliano , I . Moncada , A. Salonia © European Association of Urology 2015 New insights on premature ejaculation: a review of definition , classification, prevalence and treatment:Ege C Serefoglu and Theodore R Saitz.Asian Journal of Andrology (2012) 14, 822–829; doi:10.1038/aja.2012.108 Sexual dysfunction among men in secondary care in southern India : Nature, prevalence, clinical features and explanatory models. P. Thangadurai, r. Gopalakrishnan , v.J . Abraham, j. Prasad, a. Kuruvilla,k.S . Jacob. Natl Med J India 2014;27:198–201 Integrating psychotherapy and pharmacotherapy in the treatment of premature ejaculation. Giacomo Ciocca a, Erika Limoncin,et.al. Arab Journal of Urology (2013) 11, 305–312 Psychosocial profile of male patients presenting with sexual dysfunction in a psychiatric outpatient department in Mumbai, India Gurvinder Kalra, Ravindra Kamath1, Alka Subramanyam1, Henal Shah. Indian Journal of Psychiatry 57(1), Jan-Mar 2015

92. ….THANK YOU….