Predicting responsiveness to the treatment of rapid ejaculation with 25 mg clomipramine as needed.

Clomipramine (25 mg) taken as needed increases ejaculatory latency in men with rapid ejaculation (RE), although only about half the men treated respond to this regimen. It would therefore be clinically advantageous to know the patient's potential responsiveness to an 'as needed' regimen prior to treatment. The present study attempted to identify a priori factors that might enable prediction of patients' response or nonresponse to 'as needed' clomipramine. Variables relevant to rapid ejaculation were examined in 23 men with RE, 12 of whom had responded to clomipramine. Logistic regression indicated that three factors assessed prior to treatment--initial ejaculation latency, overall sexual satisfaction, and ejaculation frequency each week--significantly improved the prediction of responsiveness to this treatment regimen. Specifically, RE men with initial ejaculatory latencies over 60 s, self-reported sexual satisfaction of 5 or higher (on a seven-point scale), and ejaculation frequency of twice or more weekly were more likely to benefit from 25 mg 'as needed' clomipramine. As such, men meeting these criteria might be considered for this treatment regimen. Those not matching these characteristics might better be considered for 20 or 30 mg clomipramine given on a daily basis.

Sexual response in men with inhibited or retarded ejaculation.

Inhibited ejaculation (IE) is a poorly understood male sexual dysfunction having both somatic and psychological etiologies. This study investigated sexual response in 25 IE men with no probable somatic cause. Using a standard psychophysiological assessment procedure, these men were compared with sexually functional and other dysfunctional groups on two measures of sexual response: erectile response and self-reported sexual arousal. Within the sample of IE men, sexual response was investigated as a function of both diagnostic classification and relationship factors. Differences occurred between IE men and the other groups on erectile response and self-reported sexual arousal during psychosexual stimulation in the lab, with IE men reporting lowest levels of sexual arousal. Within the IE group, diagnostic classifications and relationship variables were also related to self-reported sexual arousal. These findings suggest that inhibited arousal may be fairly common among IE men having no apparent somatic etiology, and further that several specific relationship factors may provide potential strategies for enhancing arousal in these men.

[Favorable effect of sildenafil on erectile dysfunction in patients after radiotherapy for prostate cancer; randomised, double-blind, placebo-controlled crossover study]. / Gunstig effect van sildenafil op erectiele disfunctie bij patiënten na radiotherapie voor prostaatkanker; gerandomiseerd, dubbelblind, placebogecontroleerd en gekruist onderzoek.

OBJECTIVE: To determine the efficacy of sildenafil in patients with erectile dysfunction after external beam radiotherapy for prostate cancer. DESIGN: Randomised, double-blind, placebo-controlled, crossover study. METHOD: A total of 406 patients with erectile dysfunction reported in their medical records who had completed external beam radiotherapy at least 6 months prior to the study, were approached by letter. Sixty patients were included in a study which lasted 12 weeks. They received 50 mg of sildenafil citrate or placebo for two weeks; during week 2 the dose could be increased to 100 mg in the case of unsatisfactory erectile response. At week 6 patients crossed over to the alternative treatment. Data were collected using the validated 'International index of erectile function' (IIEF) questionnaire, and side-effects were recorded. Patients were given the possibility of continuing to a 6-week open-label phase. RESULTS: The mean age of those participating was 68 years. All patients completed the double-blind phase. For the majority f questions in the IIEF questionnaire, there was a significant increase in mean scores from baseline with sildenafil, but of the patients with sildenafil, versus 18% with placebo. Ninety percent of the patients required a dose adjustment to 100 mg sildenafil, and 100% of the patients in the placebo group increased the dose. Side-effects were mild or moderate. Patients who proceeded to the open-label phase reported the same results as in the double-blind phase. CONCLUSION: Sildenafil improved erectile function in about half of the patients with erectile dysfunction after external beam radiotherapy for prostate cancer, and it was well tolerated.

The plication procedure for penile curvature: surgical outcome and postoperative sexual functioning.

OBJECTIVE: This study evaluates the patients' judgement of the surgical outcome of the plication procedure, as described by Schröder and Essed, and the postoperative sexual functioning of patients with congenital curvatures and Peyronie's disease. PATIENTS AND METHODS: Of 98 patients treated for penile curvatures between 1985 and 1996, 85 patients received postoperatively a 'Questionnaire Assessing the Outcome of Surgery' and a short version of the 'Questionnaire for Screening Sexual Dysfunctions'. RESULTS: 28 patients with congenital curvatures and 31 with Peyronie's disease were evaluated. 75% of the patients with congenital curvatures and 58% of the patients with Peyronie's disease were satisfied with the result. Patients treated for Peyronie's disease reported diminished penile length and inability to have sexual intercourse more often than patients with congenital curvatures (90 vs. 64%, and 29 vs. 0%). After correction for age, patients with Peyronie's disease were less satisfied with their present sex life, had more frequent erectile problems and more trouble with considerable sexual desire than a group of 42 controls. For patients with Peyronie's disease satisfaction with the result was positively correlated with satisfaction with their present sex life and negatively correlated with the frequency of erectile problems. For patients with congenital curvatures satisfaction with the result was negatively correlated with both a postoperative curvature and a repeat operation. CONCLUSIONS: Some patients with Peyronie's disease may not benefit from surgical correction (alone). Because of the occurrence of sexual problems, future evaluation of the role of pre- and postoperative sexological counselling in achieving better results is recommended.

The limited practical value of color Doppler sonography in the differential diagnosis of men with erectile dysfunction.

From the files of the outpatient urology department 44 men with ED had undergone both psychophysiological diagnostic screening (PDS, VSS, VSS+VIB, ICI+VSS+VIB) and color Doppler sonography testing (CDS, including VSS). PDS was carried out by one medical physiologist, CDS by one urologist. The diagnoses reached could be compared. This study revealed that CDS in ED-patients often resulted in an incorrect diagnosis, that is a presumed vascular abnormality while many such patients demonstrated firm erections under PDS-laboratory test conditions. Thus, it was concluded that CDS as a (first) screening test in ED-patients is of limited value. It was further emphasized that PDS, although giving quite relevant information about possible etiology and therapeutic treatment, is not a necessary first screen. Good history taking, preferably of the man and his partner, is still the basic first screen and quite often offers enough information to make a treatment plan with reasonable likelihood of success.

Intracavernosal injection therapy with and without sexological counselling in men with erectile dysfunction.

OBJECTIVE: To compare the acceptance of and satisfaction with intracavernosal injection (ICI) therapy with and without sexological counselling in men with erectile dysfunction (ED). PATIENTS AND METHODS: In a prospective randomized study, men were alternately assigned to ICI without sexological counselling (-SC) or with sexological counselling (+SC). In all, 70 patients were included, i.e. 35 in each group; 57 (28 -SC, 29 +SC) were interviewed by telephone after a mean follow-up of 11.3 months to determine their use of ICI and reasons for discontinuing. RESULTS: There were no differences between the groups in discontinuation of ICI (overall 30%), in reasons for discontinuing ICI (24% did so because of the return of spontaneous erections) or in sexual functioning. CONCLUSION: There was no positive contribution from additional sexological counselling but extensive information and support by the urologist seems to be sufficient, resulting in a high acceptance rate of ICI. The discontinuation rate (30%) is one of the lowest reported.

Intracavernous injection during diagnostic screening for erectile dysfunction; five-year experience with over 600 patients.

Psychophysiological diagnostic screening (PDS) was carried out on just over 1000 consecutive patients with erectile dysfunction (ED) during 1995 through 1999. Roughly one-third did not require an intracavernous injection (ICI) because of optimal penile response during visual and tactile penile sexual stimulation. The present article deals with those other patients (n = 609) who required an ICI and completed a 24-hour-postinvestigation questionnaire (PIQ). The two ICI preparations used, prostaglandin and papaverine + fentolamine, were virtually equally effective in the doses applied, with very low and similar percentages of unwanted side effects, for example, prolonged erection. Somatic ED patients displayed the lowest penile responses to ICI, whereas psychogenic ED patients had the highest penile responses. ED patients who also suffered from premature ejaculation (PE) ejaculated significantly more readily during PDS that those without PE. An ICI following an ejaculation/orgasm could lead to an erection presumably sufficient for intromission, which indicates ICI as a therapeutic option for rapid ejaculators. Our elaborate and lengthy PDS procedure, particularly the use of penile vibration as an addition to the visual sexual stimulation, obviates the diagnostic use of the PIQ.

Sildenafil citrate (Viagra) and erectile dysfunction following external beam radiotherapy for prostate cancer: a randomized, double-blind, placebo-controlled, cross-over study.

PURPOSE: To determine the efficacy of sildenafil citrate (Viagra) in patients with erectile dysfunction after three-dimensional conformal external beam radiotherapy (3D-CRT) for prostate cancer. METHODS AND MATERIALS: 406 patients with complaints of erectile dysfunction and who completed radiation at least 6 months before the study were approached by mail. 3D-CRT had been delivered (mean dose 68 Gy). Sixty patients were included and entered a double-blind, placebo-controlled, cross-over study lasting 12 weeks. They received during 2 weeks 50 mg of sildenafil or placebo; at Week 2 the dose was increased to 100 mg in case of unsatisfactory erectile response. At Week 6, patients crossed over to the alternative treatment. Data were collected using the International Index of Erectile Function (IIEF) questionnaire, and side effects were recorded. RESULTS: Mean age was 68 years. All patients completed the study. For most questions of the IIEF questionnaire there was a significant increase in mean scores from baseline with sildenafil, but not with placebo. Ninety percent of the patients needed a dose adjustment to 100 mg sildenafil. Side effects were mild or moderate. CONCLUSION: Sildenafil is well tolerated and effective in improving erectile function of patients with ED after 3D-CRT for prostate cancer.

['Leiden Impotence Screening Test'(LIST) in men with erectile dysfunction as a pre-selective method prior to psychophysiological diagnostic tests]. / De 'Leidse impotentiescreeningtest' (LIST) bij mannen met een erectiestoornis als voorselectie voor psychofysiologisch diagnostisch onderzoek.

OBJECTIVE: To compare, in men with erectile dysfunction, the diagnosis obtained with the 'Leiden impotence questionnaire' (LIQ)--which differentiates between psychogenic and organic erectile dysfunction--with the clinical diagnosis based on psychophysiological diagnostic screening (PDS). DESIGN: Exploratory, comparative, and prospective. METHOD: The LIQ-questionnaire was administered to 320 consecutive patients with erectile dysfunction who underwent PDS (i.e. visual sexual stimulation and penile vibration) in the Department of Endocrinology and Reproduction, Erasmus University Medical Centre, Rotterdam, the Netherlands. The clinical diagnosis was based on PDS and later, retrospectively, compared to the LIQ-based diagnosis (only the first six of the 11 LIQ-questions were answered by all patients). RESULTS: The clinical diagnosis, psychogenic or somatic, corresponded well with the LIQ-diagnosis. Following PDS an organic aetiology was assumed in 30% of the patients; compared to 33% according to the LIQ. For a psychogenic aetiology the figures were 70% and 67% respectively. Overall there was a 74% correspondence between PDS-diagnosis and the LIQ-diagnosis. Age was a significant factor: younger men (< 40 years) had the highest LIQ-score (compared to men aged 40-60 and > 60 years) and the strongest penile responses. This is indicative of a more frequent psychogenic aetiology of the erectile dysfunction in younger men. CONCLUSION: Elaborate psychophysiological diagnostic screening is not necessarily the first diagnostic choice in men with erectile dysfunction; one may start by applying the LIQ. A high LIQ-score (5-7) virtually excludes a somatic aetiology. A low LIQ-score (0-2) necessitates further psychosomatic diagnostic screening, preferably with PDS.

Age, libido, and male sexual function.

In the last decade of the 20th century, there was a distinct reappraisal of male sexual dysfunction and its pharmaco-medical treatment. Although representative studies of sexual (dys)function in the aging male (i.e., between 60-90 years of age) are still lacking, one might assume with certainty that many men and their partners could benefit from sexological counseling and treatment. At the same time, it is obvious that many older men with erectile dysfunction do not seek or want treatment for various reasons. Nevertheless, it is obligatory that modern physicians include sexual matters in dealing with their aging patients, as an essential part of their quality of life. The doctor of today should approach the old(er) male patient with sexual dysfunction (regardless of comorbidity) in an identical manner as young(er) patients, i.e., with proper sexological history-taking, proper physical examination, and/or sexological diagnostic screening, and discussing the various available treatments. Needless to say, that they should not "create" sexual problems when patients are satisfied with their current way of life. However, with the increasing number of efficacious treatments, doctors will satisfy many of their older patients with sexual difficulties who seek treatment.

Low-dose radiotherapy in 179 patients with Peyronie's disease: treatment outcome and current sexual functioning.

PURPOSE: To analyse retrospectively treatment outcome in patients irradiated for Peyronie's disease. METHODS AND MATERIALS: The records of 179 patients, median age 52 years, that received radiotherapy (RT) between 1982 and 1997 were reviewed. 78% presented with painful erections and 89% with penile deformity. The symptoms were present for a median duration of 6 months (range, 1-72 months). The RT schedule consisted of 13.5 Gy (9 x 1.5 Gy, 3 fractions per week) using orthovoltage X-rays in 123 patients or 12 Gy (6 x 2 Gy, daily fractions) using electrons in 56 patients. A questionnaire regarding current sexual functioning was mailed to 130 patients whose addresses could be traced; 106 (82%) responded. RESULTS: At mean follow-up period of 3 months, 83% reported that pain was diminished or had disappeared after RT. Twenty-three percent of patients reported a decrease in penile deformity. Following RT, surgical correction of penile curvature was performed in 29% of patients. No RT-related complications occurred except transient dysuria in 1 patient. Questionnaire data: 72% of patients were currently sexually active, 48% had erectile dysfunction, and 49% expressed dissatisfaction with their current sexual functioning. CONCLUSION: Low-dose external RT (12-13.5 Gy) results in relief of pain in the majority of patients with Peyronie's disease. Improvement in penile deformity was observed, avoiding surgery in a number of patients. No significant RT-associated morbidity was encountered. It is disappointing that almost 50% of patients complain of sexual functioning, but this is presumably not related to radiotherapy.

Ejaculatory latency and control in men with premature ejaculation: an analysis across sexual activities using multiple sources of information.

OBJECTIVE: Men with premature ejaculation (PE) exhibit diminished control over and short latency to ejaculation. The present study attempted to delineate further characteristics of men with PE and to address a number of presumed hypotheses regarding the etiology of this disorder. METHODS: Twenty-six men with PE were compared with an age-matched group of 13 sexually functional men on multiple indices of erectile and ejaculatory response during coital and masturbatory activities. These data were collected through retrospective, prospective, and laboratory methods. RESULTS: Psychophysiological testing indicated greater ejaculatory vulnerability to penile stimulation, although not visual erotic stimulation, in PE men than functional controls. PE men also showed subtle anomalies in the way they perceived their somatic response. The correlation between measures of ejaculatory latency and control was positive and high for intercourse, but low or even negative for masturbation. Whereas functional men showed consistency in ejaculatory latency over coital and masturbatory activities, PE men exhibited much shorter latencies during coitus than masturbation. Data collected under various methodologies (retrospective, prospective, and laboratory) showed greater consistency among sexually functional subjects; and preliminary analysis of laboratory data suggests psychophysiological methodology is as effective in differentiating dysfunctional from functional men as prospective and retrospective methodologies. CONCLUSION: Although ejaculatory latency and control tend to be related, these measures are not always stable over different kinds of sexual activity or using different methods of data collection. Psychophysiological methodology is effective in differentiating group membership (PE vs. control), but does not predict individual ejaculatory responses measured prospectively.

Current sexual functioning in 106 patients with Peyronie's disease treated with radiotherapy 9 years earlier.

OBJECTIVES: To analyze retrospectively the sexual functioning and treatment outcome in patients after radiotherapy (RT) for Peyronie's disease. METHODS: During 1982 to 1997, 179 patients with Peyronie's disease were treated at our radiation oncology department. One hundred thirty patients whose address could be traced were sent a questionnaire about their symptoms before RT, treatment outcome, and current sexual functioning (the past 4 weeks). One hundred six patients, mean age 59 years, responded. RESULTS: Before RT, 44% reported painful erections, 97% penile curvature, and 18% erectile dysfunction. Sixty-nine percent reported that after RT, penile pain was diminished and 29% that penile curvature was decreased; 13% reported improved erections. With respect to their current sex life, 51% reported sometimes or always having problems getting an erection and 61% in maintaining an erection; 36% never experienced spontaneous erections. Fifty-four percent reported not having erections rigid enough for sexual activity. Since RT (mean 9 years), there had been a moderate or severe decrease in sexual interest (17%), sexual activity (41%), and sexual pleasure (32%). Overall, 49% of patients were dissatisfied with their current sexual functioning. CONCLUSIONS: Low-dose external RT resulted in relief of pain in two thirds of patients with Peyronie's disease. An improvement in penile curvature was reported in one third of patients. One half of men reported problems in getting an erection. The rigidity of erections was satisfactory in only 54%. There was a moderate to severe decrease in sexual interest, activity, and pleasure after RT; however, this was associated with age, although comorbidity or medications cannot be excluded.

Testicular prostheses: body image and sexual functioning.

OBJECTIVES: To evaluate retrospectively the body image and sexual functioning in patients who have a testicular prosthesis (TP). PATIENTS AND METHODS: The medical charts were evaluated for 30 adult patients who received 32 TPs between 1985 and 1997. A questionnaire was mailed to each patient, asking about body image, satisfaction with the implant and with sexual functioning. RESULTS: Of the 30 patients, 22 (73%) replied; their mean (range) age was 30 (18-47) years. Most of the patients had a silicone gel-filled TP. No complications were reported in 25 (83%) patients and 80% reported no sexual problems; 20% felt uncomfortable in intimate contacts, 68% found their body image improved after having a TP, 58% were satisfied with their current sexual life, 90% had no erectile dysfunction and 45% reported premature ejaculation. CONCLUSIONS: Patients who have lost a testis for any reason should be informed about the availability of a TP. Prostheses were well accepted and no systemic disease was reported. Almost all patients reported an improvement in their body image. Sexual life and performance were apparently not compromised by having a TP. New surgical procedures are recommended to improve the cosmetic appearance of a TP in the scrotum.

Intracavernosal self-injection therapy in men with erectile dysfunction: satisfaction and attrition in 119 patients.

This study describes a 12-24 month follow-up on 119 ED patients in an attempt to understand satisfaction with and dropout from ICI use. Results indicate 40% attrition, attributed primarily to a lack of efficacy of ICI, but also to spontaneous return of erectile function and to negative reactions surrounding the injection procedure. Multivariate analyses indicated that ICI dropouts were more likely to have co-existing premature ejaculation, low responses during psychophysiological screening, a lack of spontaneous erections prior to ICI, and an etiology that included an organogenic component. These same factors, along with low satisfaction with their sex life, were related to attrition due specifically to a lack of drug efficacy. In contrast, attrition due to recovery of spontaneous erections was associated with high sexual satisfaction. Among ongoing users, dissatisfaction was associated with higher age, shorter erections during ICI use, and low satisfaction with sex life. These findings identify a number of factors related to attrition and satisfaction, emphasizing the importance of specifying the cause for ICI attrition and, demonstrating that a substantial portion of patients who dropout do so for positive reasons.

Clomipramine in the treatment of rapid (premature) ejaculation.

Twenty-three premature ejaculators (PEs) and 11 control subjects were administered 25 mg of clomipramine in a double-blind, placebo-controlled, crossover design study. During 2-week trials, subjects took either the drug or the placebo 4 to 6 hours prior to sexual activity. Daily diary data revealed that, for both groups, orgasmic latency was significantly increased when taking the clomipramine. For the PEs, the average increase in orgasmic latency during intercourse was from less than 1 minute to more than 3.5 minutes. Subjects also participated in two laboratory sessions while on the drug and placebo. During these lab sessions they were exposed to erotic videos with and without the addition of vibrotactile stimulation to the penis. Results from the laboratory data support those from the diaries. Specifically, PEs were significantly less likely to reach orgasm during the lab sessions while on the clomipramine than while on the placebo. Further, they reported a significantly greater sense of control over their orgasm while on the drug. The results of this study, along with previous research, strongly support the value of low doses of clomipramine in the treatment of premature ejaculation, specifically when taken on an as-needed basis as little as 4 hours prior to sexual activity. It is important to note, however, that the beneficial effects of the drug were not uniform across clinical subjects. In this study, those PEs with the shortest orgasmic latencies while on the placebo were the least likely to substantially improve while on the drug. Additional research is necessary to determine whether changes in the timing and dosage of the clomipramine administration can extend the benefits of the drug to those with the shortest latencies.

Routine psychophysiological screening of 384 men with erectile dysfunction.

Psychophysiological screening was carried out on 384 consecutive patients with erectile dysfunction of psychogenic or psychogenic-organic origin. Visual sexual stimulation with penile vibration caused a satisfactory erection in roughly 50% of patients. Nonresponders subsequently produced a good penile response with intracavernous injection of vasoactive substance. Orgasm-ejaculation can occur in the absence of a full erection. In such cases subsequent intracavernous injection brought about a (near) full erection. A first intracavernous injection was most effective when combined with visual and vibrotactile stimulation. The magnitude of the response to such stimulation is useful to enable the doctor to prescribe the lowest dose of a vasoactive substance, thus minimizing the risk of priapism. Preferably, drug treatment of men with erectile dysfunction should be combined with sexual counseling or therapy.

Fluoxetine and premature ejaculation: a double-blind, crossover, placebo-controlled study.

The purpose of this study was to investigate the effect of fluoxetine on sexual function in men with premature ejaculation and/or erectile dysfunction and control subjects in a prospective, double-blind, placebo-controlled, crossover study. There were four groups: (1) premature ejaculation (PE, N = 9); (2) premature ejaculation and erectile dysfunction (PE/ED, N = 9); (3) erectile dysfunction (ED, N = 7); and (4) healthy, sexually functional control subjects (N = 15). The study consisted of three 4-week periods: fluoxetine, washout, and placebo (or vice versa). Fluoxetine began at 5 mg/day for 2 weeks, followed by 10 mg/day for 2 weeks. At weeks 0, 4, 8, and 12, subjects visited the laboratory for evaluation of sexual function and assessment of erectile response, ejaculation, and sexual arousal to visual erotic stimulation without and with concomitant vibrotactile stimulation to the penis. At home, daily logs for sexual activities and feelings of well-being were maintained, and nocturnal penile tumescence was measured. The latency to ejaculation increased significantly in the PE/ED group (p = 0.03) and in the PE and the PE/ED group taken together (p = 0.007) but not in the PE group alone. Fluoxetine stimulated objectively but not subjectively measured erectile response during laboratory assessment in all groups. No major side effects were reported. In conclusion, fluoxetine (5-10 mg/day) was effective in increasing latency to ejaculation in patients with PE (PE and PE/ED groups combined).

The treatment of premature ejaculation: psychological and biological strategies.

This review provides criteria for defining premature ejaculation (PE) and identifying men with this dysfunction. Included are discussions of possible PE subtypes and causes of PE. Furthermore, two empirically supported cognitive-behavioral approaches for treating PE are described and salient issues surrounding these types of treatment are considered. Biologically based treatments available to PE men are presented, with attention to the relative effectiveness and limitations of the various alternatives. Finally, a model illustrating factors relevant to determining the best therapeutic strategy is described, concluding with a brief discussion of the value of combining biological and psychological modes of treatment.