The Tribune

Premature ejaculation afflicts an estimated one in three men in the Bahamas and throughout the world. Men in this country sadly often endlessly suffer in shame and despair from this very correctable medical problem.

For men, sex is not just an act, a goal, or a biological pattern; it is at the core of their well-being.

But those suffering need not despair; there are many ways to treat the problem.

Psychotherapy

This forms an integral part in the management strategy of this condition. It can address the negative emotions and thoughts that may pose a threat to the sexual relationship. The general principles of effective therapy would include:

Empowering the patient

Providing hope and establishing realistic expectations regarding outcomes

Creating a safe and conducive environment to explore the patients behavioural, psychological and relationship issues and address these issues for a better outcome.

The above options will be the mainstay for treatment for most patients.

Medical therapy

Erectile dysfunction – For those with secondary premature ejaculation, erectile dysfunction may be the cause of premature ejaculation. Managing the erectile dysfunction may also alleviate the premature ejaculation.

Other conditions – Hyperthyroidism and low testosterone levels should be managed, and this may improve the premature ejaculation problem.

Specific therapies for premature ejaculation:

1. Selective Serotonin receptor inhibitors (SSRIs)- they are the first line in the management of premature ejaculation though in the United States this a off-label use.

Most SSRIs are taken daily for the desired effect, but this carries potential for side effects like erectile dysfunction, anorgasmia, and reduced desire to have sex. Sertraline was investigated by a group of Australian scientists in 1998, and a daily dose was found to significantly improve the mean ejaculatory interval from 1 minutes to 13.1 minutes at a dose of 50mg. Siroosbahkt et al. wrote an article in the Asian Journal of Medicine in 2021, showing that daily sertraline was as effective as sertraline taken 4 hours before sex. The on-demand dosing schedule was associated with fewer side effects and was considered more tolerable.

Dapoxetine is a newer medication available in Europe that can be taken 1-3 hours before sex but approximately 90% discontinue the medication due to the side effect profile.

1. Tramadol is an opioid pain killer and is controlled medication. It has been used as second line treatment when the SSRIs have failed and has been shown to increase the IELT, ejaculatory function and sex satisfaction if taken 1-2 hours before sex. The downside is the potential serious side effects including addiction. This mode of therapy may work but it is not advised.

2. Alpha-adrenergic blockers. These medications are prescribed in patients with benign prostatic obstruction and even though they have been shown to reduce the intravaginal ejaculation latency time IELT, they tend to relax the bladder neck leading to reverse ejaculation into the bladder and no semen ejaculated at the climax of sex. This can potentially cause great distress in the sexual relationship of the partners.

Surgical management

There are no direct interventions listed for surgical management of premature ejaculation.

• Varicocelectomy: A varicocele is enlarged veins in the scrotum typically referred to as a bag of worms. The pooling of warm blood in these veins disrupts the intricate temperature setting for the manufacture of sperm and testosterone in the testicle itself. In patients who have varicocele with premature ejaculation- the treatment of the varicocele may kill two birds with one stone- as after varicocelectomy the testosterone production will improve thereby addressing the premature ejaculation.

• Medical circumcision: A systematic review and meta-analysis conducted by a group of Chinese researchers led by Ye Tian published their findings in the Asian Journal of Andrology in 2013. A total of 9,317 circumcised and 9,423 uncircumcised men were evaluated for premature ejaculation. The team concluded that circumcision reduced the incidences of premature ejaculation.

• vPatch to the Rescue: Developed by Virility, the vPatch is a patch placed on the perineum at any time convenient to the man. It delivers an electrical stimulus to the perineal muscles thereby disrupting the rhythmic perineal movements need for propulsion. It has been FDA-approved and may prove to be a useful mode of management with few side effects when compared to the use of medications or numbing agents.

Other investigational therapies:

Dorsal penile nerve cryoablation: The method is based on local freezing of the nerves on the penis resulting in slower conduction of messages through the nerves. The sensitivity is restored in 12-18 months but during this time a conditioned reflex for normal ejaculation time is formed.

Hyaluronic acid gel glans augmentation: needs large randomised prospective studies to be validated but research on the smaller scale is promising

Botulinum toxin (Botox) injection into pelvic floor musculature

Premature ejaculation is a silent problem that afflicts so many couples in the Bahamas and throughout the world. It takes an enormous toll on the male self-esteem leading to serious marital problems, divorce, and depression. Sex health is of fundamental importance to adults and essential to the overall wellbeing of an individual. A urologist can confidentially, compassionately and comprehensively effectively treat any ejaculatory disorder and restore happiness and confidence to the male sufferer and his partner. Do not continue to suffer in silence, as sexual health problems should not be treated as a taboo subject.

• Dr Greggory Pinto is a board-certified Bahamian urologist and laparoscopic surgeon. He can be contacted at OakTree Medical Center #2 Fifth Terrace and Mount Royal Avenue, Nassau, Bahamas; Telephone – (242) 322-1145-7; email: welcome@urologycarebahamas.com