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Case Studies
Case Studies provided convincing evidence that in hypogonadal men, responsiveness to ED medications, such as PDE5 inhibitors or vasoactive injectables, is often impaired. They also showed that TRT can increase the responsiveness to either medication because PDE5 enzyme expression and activity is clearly T-dependent [2–6]. • At present, no data from prospective clinical studies investigating the combination of PDE5 inhibitors and dapoxetine are available. However, pharmacokinetic studies of either tadalafil or sildenafil in combination with dapoxetine have shown that the pharmacokinetics of either medication was not influenced [7]. References 1 Sohn M. Surgical treatment of erectile dysfunction. In: Porst H, Buvat J, eds. Standard practice of sexual medicine. Oxford: Blackwell Publishing, Ltd.; 2006:126–35. 2 Zhang XH, Morelli A, Luconi M, Vignozzi L, Filippi S, Marini M, Vannelli GB, Mancina R, Forti G, Maggi M. Testosterone regulates PDE5 expression and in vivo responsiveness to tadalafil in rat corpus cavernosum. Eur Urol 2005;47:409–16. Discussion 416. 3 Aversa A, Isidori AM, Spera G, Lenzi A, Fabbri A. Androgens improve cavernous vasodilation and response to sildenafil in patients with erectile dysfunction. Clin Endocrinol (Oxf) 2003;58:632–8. 4 Shabsigh R, Kaufman JM, Steidle C, Padma-Nathan H. Randomized study of testosterone gel as adjunctive therapy to sildenafil in hypogonadal men with erectile dysfunction who do not respond to sildenafil alone. J Urol 2004;172:658–63. 5 Kalinchenko SY, Kozlov GI, Gontcharov NP, Katsiya GV. Oral testosterone undecanoate reverses erectile dysfunction associated with diabetes mellitus in patients failing on sildenafil citrate therapy alone. Aging Male 2003;6:94–9. 6 Schulman C, Destraix R, Roumeguere T. Testosterone and PDE-5 inhibitors non responders. J Sex Med 2004;1(suppl 1):Abstr. O89. 7 Dresser MJ, Desai D, Gidwani S, Seftel AD, Modi NB. Dapoxetine, a novel treatment for premature ejaculation, does not have pharmacokinetic interactions with phosphodiesterase-5 inhibitors. Int J Impot Res 2006;18:104–10.
David Rowland and Stewart Cooper A man in his early 40s has, throughout his sex life, typically ejaculated within 1 or 2 minutes of vaginal penetration. He and his now ex-wife had accommodated this situation by using a variety of sexual techniques that enabled her, on most occasions, to be sexually satisfied, although both lamented the fact that aspects of their sexual intimacy did not last longer. Following a difficult divorce, the man has now established a new relationship with a woman 5 years his junior and is finding that he is consistently ejaculating very shortly after penetration—
365 usually within the first 20–30 seconds. This has left his partner frustrated, unsatisfied, and verging on resentfulness. He, in turn, sensing her negativity, has begun to avoid sexual intercourse, and the little bit of intimacy they had been nurturing is rapidly melting away. Both are feeling increasingly frustrated and distant. The man decides, without his partner’s knowledge, to try a variety of home remedies, none of which work very consistently or effectively. Sensing that this new relationship is beginning to deteriorate, he made an appointment with his physician. The physician discusses treatment options for him, stressing that while use of medication might be helpful, the treatment is more likely to be successful if medication is accompanied by a brief course of psychotherapy. The physician stresses the point that this would be a special form of counseling targeted at alleviating his PE symptoms and would likely involve a combination of individual and couples sessions. The patient expresses some reluctance about seeing a therapist, so the physician recommends that he goes for an assessment session only and then decide upon pursuing further counseling. The patient calls the referral: a therapist with a general adult outpatient practice but with training in treating sexual dysfunctions. Subsequent to the assessment session, the patient sees the value in addressing his problem within the larger context of his relationship and decides to pursue counseling. His partner is brought into the second session (a 2-hour session), with a focus on identifying beneficial interactional and behavioral patterns the couple could use to enhance the man’s cognitive–behavioral strategies as well as discussing ways to integrate pharmacotherapy into the treatment process. The therapist also discusses, prior to the commencement of the couple’s dialogue, that if significant relationship issues emerge apart from the PE, he will offer referral to several providers specializing in couples’ therapy. No other significant relationship issues emerge during this conjoint session, and a single follow-up conjoint session is planned for the following week. Starting with the fourth session, counseling appointments were shortened from an hour to 30 minutes. At this time, the treating physician encouraged the couple to begin weaning from the medication, yet made it clear that they are permitted to revert to the medication, whenever they feel the need. Moderate reduction in the J Sex Med 2011;8(suppl 4):360–367
366 frequency of rapid ejaculation, along with improved ejaculatory control and significant reduction in affective, cognitive, and relationship correlates, was evident by the sixth session, with only occasional use of medication. A seventh psychotherapy session is planned for 1 month later, with follow-up sessions beyond that scheduled only if and as needed, with the assumption that the couple will return to medication only if/when relapse might occur. Comments
• In the majority of PE cases, overall clinical outcomes obtained with pharmacotherapy can be enhanced by incorporating a course of psychosexual counseling. • Psychosexual counseling may be more effective in addressing broader issues of sexual satisfaction and developing ejaculatory control. • Suggesting that the patients have an initial assessment session, before making a decision to pursue further counseling, can often overcome any reluctance they may have for receiving psychotherapy. • Because PE is a couple’s problem, the man’s partner should be involved whenever possible. • Typically, the duration and frequency of counseling sessions can be adjusted to the individual needs of the couple and gradually reduced over the course of treatment.
Ignacio Moncada Alberto is a 20-year-old university student who has experienced severe PE since the beginning of his sexual encounters several years ago. Alberto typically ejaculates within a couple of seconds and often before vaginal penetration. Three months ago, he met a new partner with whom he fell in love. They have not had sex yet because Alberto is afraid that he will not meet her sexual expectations. Alberto presented at my office to ask about treatment options for his PE. Investigations did not reveal any diseases and his medical records revealed no history of any serious illness. Alberto said he became aware that his father has the same problem because he unintentionally overheard a private conversation between his parents. Therefore, Alberto feels that he inherited his PE from his father. His parents are unaware that he is now seeing a doctor because he feels too embarrassed to share this information with them. Alberto feels helpless and desperate, and reports low self-esteem J Sex Med 2011;8(suppl 4):360–367
Jannini and Porst and confidence. His present belief is that he will never be a good sexual partner because of his inability to control ejaculation. His feeling is that his “penis is just too sensitive” to allow control over ejaculation. Alberto has tried various techniques to overcome the problem, including drinking alcohol, masturbating before sex, and doing mental exercises during sex; however, none of these different options turned out to be successful. When asked about his erection quality, Alberto confirmed that he can always hold his rigidity until ejaculation occurs. Based on the findings from this initial visit, it was clear that Alberto was suffering from lifelong PE. After discussing the different treatment options available for PE, Alberto was prescribed dapoxetine (Priligy; 30 mg on-demand dosing) along with a course of sexual counseling (not behavioral therapy). The patient’s progress on treatment was assessed at a follow-up session 6 weeks later. Alberto reported that, for the first time ever, he had begun to feel a sense of control over ejaculation and was now able to hold back ejaculation for 1–2 minutes after penetration when he started sex with his new girlfriend. It became evident that the combination of sexual counseling and pharmacotherapy was successfully addressing his emotional issues and giving him back self-confidence, both related to his sexual performance and to other daily life domains. He was pleased with this initial clinical outcome and was positive to get even greater improvement in the future. This follow-up session provided an invaluable opportunity to reassure Alberto that this initial clinical outcome was very encouraging. He was reassured about the benefits of continuing the chosen treatment regimen. At this point in time, no adjustments to the current treatment regimen were considered necessary because of the timely positive response. Another follow-up session was scheduled for 8 weeks later to recheck efficacy outcomes, potential treatment-related side effects as well as discuss any additional issues that may have arisen from this treatment and his new relationship. Alberto reported that his sense of control over ejaculation and time to ejaculation had meanwhile improved considerably to a level that both he and his partner were pleased with. He was not experiencing any major side effects from treatment, and there were no additional problems to address. At a subsequent follow-up session, 6 months later, he confirmed that he and his partner continue to enjoy their sex life and relationship.
Case Studies Comments
• Regular and structured follow-up is essential to adjust clinical decisions and establish an effective long-term management strategy for PE that, in this case, involved integrating a pharmacological approach with sexual counseling. • Follow-up of men with PE is an important component of the overall management of this disorder. • Follow-up provides an opportunity to reconfirm the diagnosis, assess the patient’s progress on treatment, make informed adjustments to treatment, and reeducate the patient about using the chosen treatment correctly to yield the best possible outcome.
367 • Because of a current lack of standardized guidelines, follow-up in PE is largely at the discretion of the treating physician and should be tailored to the needs of each patient and his partner. • The extent of follow-up depends on a number of factors, such as the type, frequency, and severity of PE, the extent of negative impact from PE, response to therapy, and any partner-related issues. Corresponding Author: Emmanuele A. Jannini, MD, Course of Medical Sexology, Department of Experimental Medicine, University of L’Aquila, Coppito, Blg 2, Room A2/54, Via Vetoio, Rome 67100, Italy. Tel: 39 0 862 433530; Fax: 39 0 862 433523; E-mail: [email protected]
J Sex Med 2011;8(suppl 4):360–367
David Rowland and Stewart Cooper A man in his early 40s has, throughout his sex life, typically ejaculated within 1 or 2 minutes of vaginal penetration. He and his now ex-wife had accommodated this situation by using a variety of sexual techniques that enabled her, on most occasions, to be sexually satisfied, although both lamented the fact that aspects of their sexual intimacy did not last longer. Following a difficult divorce, the man has now established a new relationship with a woman 5 years his junior and is finding that he is consistently ejaculating very shortly after penetration—
365 usually within the first 20–30 seconds. This has left his partner frustrated, unsatisfied, and verging on resentfulness. He, in turn, sensing her negativity, has begun to avoid sexual intercourse, and the little bit of intimacy they had been nurturing is rapidly melting away. Both are feeling increasingly frustrated and distant. The man decides, without his partner’s knowledge, to try a variety of home remedies, none of which work very consistently or effectively. Sensing that this new relationship is beginning to deteriorate, he made an appointment with his physician. The physician discusses treatment options for him, stressing that while use of medication might be helpful, the treatment is more likely to be successful if medication is accompanied by a brief course of psychotherapy. The physician stresses the point that this would be a special form of counseling targeted at alleviating his PE symptoms and would likely involve a combination of individual and couples sessions. The patient expresses some reluctance about seeing a therapist, so the physician recommends that he goes for an assessment session only and then decide upon pursuing further counseling. The patient calls the referral: a therapist with a general adult outpatient practice but with training in treating sexual dysfunctions. Subsequent to the assessment session, the patient sees the value in addressing his problem within the larger context of his relationship and decides to pursue counseling. His partner is brought into the second session (a 2-hour session), with a focus on identifying beneficial interactional and behavioral patterns the couple could use to enhance the man’s cognitive–behavioral strategies as well as discussing ways to integrate pharmacotherapy into the treatment process. The therapist also discusses, prior to the commencement of the couple’s dialogue, that if significant relationship issues emerge apart from the PE, he will offer referral to several providers specializing in couples’ therapy. No other significant relationship issues emerge during this conjoint session, and a single follow-up conjoint session is planned for the following week. Starting with the fourth session, counseling appointments were shortened from an hour to 30 minutes. At this time, the treating physician encouraged the couple to begin weaning from the medication, yet made it clear that they are permitted to revert to the medication, whenever they feel the need. Moderate reduction in the J Sex Med 2011;8(suppl 4):360–367
366 frequency of rapid ejaculation, along with improved ejaculatory control and significant reduction in affective, cognitive, and relationship correlates, was evident by the sixth session, with only occasional use of medication. A seventh psychotherapy session is planned for 1 month later, with follow-up sessions beyond that scheduled only if and as needed, with the assumption that the couple will return to medication only if/when relapse might occur. Comments
• In the majority of PE cases, overall clinical outcomes obtained with pharmacotherapy can be enhanced by incorporating a course of psychosexual counseling. • Psychosexual counseling may be more effective in addressing broader issues of sexual satisfaction and developing ejaculatory control. • Suggesting that the patients have an initial assessment session, before making a decision to pursue further counseling, can often overcome any reluctance they may have for receiving psychotherapy. • Because PE is a couple’s problem, the man’s partner should be involved whenever possible. • Typically, the duration and frequency of counseling sessions can be adjusted to the individual needs of the couple and gradually reduced over the course of treatment.
Ignacio Moncada Alberto is a 20-year-old university student who has experienced severe PE since the beginning of his sexual encounters several years ago. Alberto typically ejaculates within a couple of seconds and often before vaginal penetration. Three months ago, he met a new partner with whom he fell in love. They have not had sex yet because Alberto is afraid that he will not meet her sexual expectations. Alberto presented at my office to ask about treatment options for his PE. Investigations did not reveal any diseases and his medical records revealed no history of any serious illness. Alberto said he became aware that his father has the same problem because he unintentionally overheard a private conversation between his parents. Therefore, Alberto feels that he inherited his PE from his father. His parents are unaware that he is now seeing a doctor because he feels too embarrassed to share this information with them. Alberto feels helpless and desperate, and reports low self-esteem J Sex Med 2011;8(suppl 4):360–367
Jannini and Porst and confidence. His present belief is that he will never be a good sexual partner because of his inability to control ejaculation. His feeling is that his “penis is just too sensitive” to allow control over ejaculation. Alberto has tried various techniques to overcome the problem, including drinking alcohol, masturbating before sex, and doing mental exercises during sex; however, none of these different options turned out to be successful. When asked about his erection quality, Alberto confirmed that he can always hold his rigidity until ejaculation occurs. Based on the findings from this initial visit, it was clear that Alberto was suffering from lifelong PE. After discussing the different treatment options available for PE, Alberto was prescribed dapoxetine (Priligy; 30 mg on-demand dosing) along with a course of sexual counseling (not behavioral therapy). The patient’s progress on treatment was assessed at a follow-up session 6 weeks later. Alberto reported that, for the first time ever, he had begun to feel a sense of control over ejaculation and was now able to hold back ejaculation for 1–2 minutes after penetration when he started sex with his new girlfriend. It became evident that the combination of sexual counseling and pharmacotherapy was successfully addressing his emotional issues and giving him back self-confidence, both related to his sexual performance and to other daily life domains. He was pleased with this initial clinical outcome and was positive to get even greater improvement in the future. This follow-up session provided an invaluable opportunity to reassure Alberto that this initial clinical outcome was very encouraging. He was reassured about the benefits of continuing the chosen treatment regimen. At this point in time, no adjustments to the current treatment regimen were considered necessary because of the timely positive response. Another follow-up session was scheduled for 8 weeks later to recheck efficacy outcomes, potential treatment-related side effects as well as discuss any additional issues that may have arisen from this treatment and his new relationship. Alberto reported that his sense of control over ejaculation and time to ejaculation had meanwhile improved considerably to a level that both he and his partner were pleased with. He was not experiencing any major side effects from treatment, and there were no additional problems to address. At a subsequent follow-up session, 6 months later, he confirmed that he and his partner continue to enjoy their sex life and relationship.
Case Studies Comments
• Regular and structured follow-up is essential to adjust clinical decisions and establish an effective long-term management strategy for PE that, in this case, involved integrating a pharmacological approach with sexual counseling. • Follow-up of men with PE is an important component of the overall management of this disorder. • Follow-up provides an opportunity to reconfirm the diagnosis, assess the patient’s progress on treatment, make informed adjustments to treatment, and reeducate the patient about using the chosen treatment correctly to yield the best possible outcome.
367 • Because of a current lack of standardized guidelines, follow-up in PE is largely at the discretion of the treating physician and should be tailored to the needs of each patient and his partner. • The extent of follow-up depends on a number of factors, such as the type, frequency, and severity of PE, the extent of negative impact from PE, response to therapy, and any partner-related issues. Corresponding Author: Emmanuele A. Jannini, MD, Course of Medical Sexology, Department of Experimental Medicine, University of L’Aquila, Coppito, Blg 2, Room A2/54, Via Vetoio, Rome 67100, Italy. Tel: 39 0 862 433530; Fax: 39 0 862 433523; E-mail: [email protected]
J Sex Med 2011;8(suppl 4):360–367