Handbook of sexual dysfunction - part 8 pps

Clomipramine vs placebo in thetreatment of premature ejaculation: a pilot study.. Paroxetine treatment ofpremature ejaculation: a double-blind, randomised, placebo-controlled study.. Eja

of ejaculation is usually irreversible and the patient should be counseled tooptimize his and his partner’s enjoyment from the residual sexual functioning.Androgen deficiency requires appropriate testosterone replacement therapy Inthe case of inadequate stimulation, pelvic floor exercises may be helpful Mostpatients require general advice on reducing precipitating factors, reduction inalcohol use, finding more time for sexual activity when not fatigued.

Research and Methodology

Research on lifelong delayed ejaculation is scarce Most of the literature consists

of hypotheses that have not been investigated according to methodological designed studies Several factors may have contributed to this state of affairs.Delayed ejaculation is a relatively rare condition Both in the general populationand in the clinical practice, the prevalence of delayed ejaculation is rather low(84) Furthermore, delayed ejaculation is known as a disorder that is relativelydifficult to treat (92) Although controlled studies do not exist, clinical experiencesuggests that the outcome is rather poor (92) A major problem in the research oflifelong delayed ejaculation is the absence of an empirically derived operationaldefinition of delayed ejaculation

well-The DSM-IV criteria are arbitrary and not based on quantified research.For example, consider the sentence “orgasm in a male following a normalsexual excitement phase during sexual activity that the clinician, taking intoaccount the person’s age, judges to be adequate in focus, intensity, and duration,”what one wonders is meant by “normal” and how may a clinician judge that theexcitement phase has been adequate in focus, intensity, and duration There are

no well-controlled studies regarding average or “normal” time of stimulationand therefore it is difficult to determine what is a delayed time of stimulation

In the absence of objective standards on orgasmic latency, the clinicianmust rely on the subjective judgment of the patient Generally, if the patientfeels that it takes too long to reach orgasm, the diagnosis of delayed orgasmwill be considered

RETROGRADE EJACULATION

Definition

Retrograde ejaculation (ejaculation sicca, dry orgasm) is the propulsion of semenfrom the posterior urethra into the bladder instead of being ejected externallyfrom the urethra (96)

Symptoms

Men with retrograde ejaculation do experience emission and expulsion and dofeel the subjective feeling of orgasm, but semen is not propelled from thepenis Some men may be able to urinate during erection

A definite diagnosis is made when examination of the urine followingorgasm shows the presence of fructose and spermatozoa The sperm, however,may be absent in cases of genital duct obstruction.

Etiology

Owing to a congenital or acquired anatomical and/or functional failure of closure

of the internal sphincter of the bladder (“bladderneck”) during the ejaculatoryprocess, sperm passes into the bladder Most frequently the cause is a transure-thral prostatectomy, a surgical treatment of benign prostatic hypertrophy Butany traumatic, neurogenic or drug-induced interference with the thoracolumbarsympathetic nervous system may lead to retrograde ejaculation Spinal cordinjury through trauma, birth defect, neoplasm, or surgery and abdominopelvicsurgery, retroperitoneal lymph node dissection or total lymphadenectomy, anddiabetes may also result in retrograde flow of semen

The medications that may give rise to retrograde ejaculation include adrenergic blockers (e.g., prazosin, tamsulosin), peripheral sympatholytics (e.g.,guanethidine), and antipsychotics (e.g., thioridazine)

alpha-Treatment

Treatments for retrograde ejaculation focus on closing the bladder neck usingsurgical bladder reconstruction or pharmacotherapy with sympathicomimeticagents (e.g., ephedrine) or anticholinergics (e.g., imipramine) If sperm isneeded for procreation and retrograde ejaculation cannot be corrected pharmaco-logically, vibratory stimulation of the penile shaft and glans penis (93) can beused For those men who fail vibrator therapy, transrectal stimulation (94) may

be used to obtain sperm

ANESTHETIC EJACULATION (EJACULATORY ANHEDONIA)

Definition

Men with anesthetic ejaculation have a normal propulsive ejaculation, but theaccompanying sensation of orgasm is absent The mechanism of the emissionand expulsion phase of ejaculation are intact (97)

Symptoms

Both at masturbation and at intercourse, ejaculation occurs without sense of sure or orgasmic sensation The lack of enjoyable ejaculation may lead to a ratherindifferent attitude of some of these men to have intercourse

Anesthetic ejaculation is probably a rare syndrome Only 4 publications, ing a total of 13 cases, have been published In 1923, Stekel (98) described onecase In 1975, Dormont (99), using the term ejaculatory anhedonia, describedfour cases and suggested that the problem was distinctly psychological innature but concluded that the condition is very difficult to treat Williams (97)described seven case vignettes He could not find any organic causative factors

describ-or common psychological dynamics Treatment of these patients with varioussex therapy procedures was ineffective In contrast, Garippa (100) published asuccessful sextherapy of a man with anesthetic ejaculation

In my opinion, it may well be possible that anesthetic ejaculation is due to adisturbance in the neural circuitry that mediates the sensation of orgasm, leavingthe circuitry of ejaculation intact One of the ways to elucidate the neurobiologi-cal cause of this syndrome is to perform a PET-scan study in these men duringorgasm

Treatment

There are no controlled studies supporting a psychological cause and success ofpsychotherapy for this disorder The most ethical way is to inform the patient thatthe syndrome is rare, the cause is unknown, that psychotherapy has no guaranteefor success and that drug treatment is as yet not available

PARTIAL EJACULATORY INCOMPETENCE

Definition

Men with partial ejaculatory incompetence lack a forceful propulsive ejaculation,

by which semen seeps out of the penis The associated orgasmic experience may

Although hardly any study has been published, case reports suggest that therapy and drug treatment may be beneficial According to Kaplan (85),partial ejaculatory incompetence is frequently psychogenic and responds favor-ably to psychotherapeutic intervention Riley and Riley (101) mentioned 11cases of partial ejaculatory incompetence; 2 men responded to behavioraltherapy, 3 men were lost to follow up The remaining 6 men did not respond

psycho-to psychotherapy, antidepressant therapy or ephedrine taken before intercourse

A placebo-controlled study with the selective alpha-adrenoceptor agonistmidodrine in 6 patients was effective

infec-be severe In rare cases, painful ejaculation may also infec-be a side-effect of tricyclicantidepressant drugs (102)

Treatment

Following bacteriological investigation, appropriate antibiotical treatment needs

to be prescribed Painful ejaculation induced by tricyclic antidepressants seems

to be dose-dependent Treatment should therefore consist of discontinuing orreducing the dosage of the antidepressant

POSTORGASMIC ILLNESS SYNDROME

Definition

In postorgasmic illness syndrome (103), the patient feels extremely fatigue anddevelops a flu-like state immediately or 20 – 30 min after the occurrence of ejacu-lation and/or orgasm There are no disturbances in the sexual performance itself

This peculiar syndrome has been discovered and described for the first time byWaldinger and Schweitzer in 2002.

Symptoms

Immediately or 20 – 30 min after the occurrence of ejaculation and/or orgasm,the patient feels extremely tired, and may develop symptoms of a flu-like rhinitis,sneezing, painful muscles, iching eyes It is often associated with irritability and adepressed mood and may last 3 – 7 days after which the symptoms gradually dis-appear These patients very characteristically plan their intercourses in order notthe get in trouble with their work in the days after

In this chapter, I omitted all sorts of methodologically weak publications in the field

of psychotherapy that have been published during the last 30 years Unfortunately,

in last decade hardly any or even no progress has been made in the development ofevidence-based research into the psychology and psychotherapy of ejaculatory dis-turbances Instead, I have tried to provide you with up-to-date knowledge about theneurobiology and pharmacological treatment of ejaculatory disorders Most of it,however, pertains to premature ejaculation I hope and am also convinced that inthe near future, with the development of new animal models of ejaculatory disturb-ances, the use of brain-imaging techniques in humans, and interest of pharma-ceutical companies, also the other ejaculatory and orgasm disturbances, willbecome amenable for effective drug treatment Nevertheless, one should always

“talk” with patients, inform them about the most recent knowledge of their latory problem, and most of all “listen” to their complaints

ejacu-REFERENCES

1 Waldinger MD, Berendsen HHG, Blok BFM, Olivier B, Holstege G Premature culation and SSRI-induced delayed ejaculation: the involvement of the serotonergicsystem Behav Brain Res 1998; 92:111 – 118

eja-2 Olivier B, van Oorschot R, Waldinger MD Serotonin, serotonergic receptors, tive serotonin reuptake inhibitors and sexual behavior Int Clin Psychopharmacol1998: 13(suppl 6):S9 – S14

3 Ahlenius S, Larsson K, Svensson L, Hjorth S, Carlsson A, Linberg P et al Effects of

a new type of 5-HT receptor agonist on male rat sexual behavior PharmacolBiochem Behav 1981; 15:785 – 792

4 Foreman MM, Hall JL, Love RL The role of the 5-HT2 receptor in the regulation ofsexual performance of male rats Life Sci 1989; 45:1263 – 1270

5 Waldinger MD The neurobiological approach to premature ejaculation (review)

8 MacLean PD Brain mechanisms of primal sexual functions and related behavior.In: Sandler M, Gessa GL, eds Sexual Behavior: Pharmacology and Biochemistry.New York: Raven Press, 1975

9 Veening JG, Coolen LM Neural activation following sexual behavior in the maleand female rat brain Behav Brain Res 1998; 92:181 – 193

10 Coolen LM, Peters HJ, Veening JG Fos immunoreactivity in the rat brain followingconsummatory elements of sexual behavior Brain Res 1996; 738:67 – 82

11 Coolen LM, Olivier B, Peters HJ, Veening JG Demonstration of induced neural activity in the male rat brain using 5-HT1A agonist 8-OH-DPAT.Physiol Behav 1997; 62:881 – 891

ejaculation-12 Coolen LM, Peters HJ, Veening JG Anatomical interrelationships of the medialpreoptic area and other brain regions activated following male sexual behavior:

a combined fos and tract-tracing study J Comp Neurol 1998; 397:421 – 435

13 Truitt WA, Coolen LM Identification of a potential ejaculation generator in thespinal cord Science 2002; 297:1566 – 1569

14 Holstege G, Georgiadis JR, Paans AMJ, Meiners LC, van der Graaf FHCE,Reinders AATS Brain activation during human male ejaculation J Neurosci2003; 23:9185 – 9193

15 Waldinger MD Lifelong premature ejaculation: from authority-based to based medicine BJU Int 2004; 93:201 – 207

evidence-16 Gross S Practical Treatise on Impotence and Sterility Edinburgh: YJ Pentland, 1887

17 von Krafft-Ebing RF Psychopathia Sexualis 11th ed Germany: Publishing HauseEnke in Stuttgart, 1901

18 Abraham K Ueber Ejaculatio Praecox Zeitschrift fur Aerztliche Psychoanalyse1917; 4:171

19 Schapiro B Premature ejaculation: a review of 1130 cases J Urol 1943; 50:374 – 379

20 Godpodinoff ML Premature ejaculation: clinical subgroups and etiology J SexMarital Ther 1989; 15:130 – 134

21 Masters WH, Johnson VE Premature ejaculation In: Masters WH, Johnson VE, eds.Human Sexual Inadequacy Boston, MA: Little, Brown and Co, 1970:92 – 115

22 Semans JH Premature ejaculation: a new approach South Med J 1956;49:353 – 357

23 Waldinger MD, Rietschel M, Nothen MM, Hengeveld MW, Olivier B Familialoccurrence of primary premature ejaculation Psychiatric Genet 1998; 8:37 – 40

24 Frank E, Anderson C, Rubinstein D Frequency of sexual dysfunction in “normal”couples N Engl J Med 1978; 299:111 – 115

25 Gebhard PH, Johnson AB The Kinsey Data: Marginal Tabulations of the 1938 –

1963 Interviews Conducted by the Institute for Sex Research Philadelphia:W.B Saunders, 1979

26 Sackett DL, Rosenberg WMC, Muir Gray JA, Haynes RB, Richardson WS.Evidence based medicine: what it is and what it isn’t BMJ 1996; 312:71 – 72

27 Althof SE, Levine SB, Corty EW, Risen CB, Stern EB A double-blind crossovertrial of clomipramine for rapid ejaculation in 15 couples J Clin Psychiatry 1995;56:402 – 407

28 Segraves RT, Saran A, Segraves K, Maguire E Clomipramine vs placebo in thetreatment of premature ejaculation: a pilot study J Sex Marital Ther 1993;19:198 – 200

29 Waldinger MD, Hengeveld MW, Zwinderman AH Paroxetine treatment ofpremature ejaculation: a double-blind, randomised, placebo-controlled study Am JPsychiatry 1994; 151:1377 – 1379

30 Waldinger MD, Hengeveld MW, Zwinderman AH Ejaculation retarding properties

of paroxetine in patients with primary premature ejaculation: a double-blind,randomised, dose-response study Br J Urol 1997; 79:592 – 595

31 Waldinger MD, Hengeveld MW, Zwinderman AH, Olivier B Effect of SSRI depressants on ejaculation: a double-blind, randomized, placebo-controlled studywith fluoxetine, fluvoxamine, paroxetine and sertraline J Clin Psychopharmacol1998; 18:274 – 281

anti-32 Mendels J, Camera A, Sikes C Sertraline treatment for premature ejaculation J ClinPsychopharmacol 1995; 15:341 – 346

33 Kara H, Aydin S, Agargun Y, Odabas O, Yilmiz Y The efficacy of fluoxetine in thetreatment of premature ejaculation: a double-blind, placebo controlled study J Urol1996; 156:1631 – 1632

34 DeAmicis LA, Goldberg DC, LoPiccolo J, Friedman J, Davies L Clinical follow-up

of couples treated for sexual dysfunction Arch Sex Behav 1985; 14:467 – 490

35 Hawton K, Catalan J, Martin P, Fagg J Prognostic factors in sex therapy Behav ResTher 1988; 24:377 – 385

36 Trudel G, Proulx S Treatment of premature ejaculation by bibliotherapy: an imental study Sex Marital Ther 1987; 2:163

exper-37 Mosher DL Awareness in Gestalt sex therapy J Sex Marital Ther 1979; 5:41 – 56

38 Zeiss RA, Christensen A, Levine AG Treatment for premature ejaculation throughmale-only groups J Sex Marital Ther 1978; 4:139 – 143

39 Lowe CJ, Mikulas WL Use of written material in learning self control of prematureejaculation Psychol Rep 1975; 37:295 – 298

40 Waldinger MD Towards evidence-based drug treatment research on prematureejaculation: a critical evaluation of methodology Int J Impot Res 2003; 15:309 – 313

41 Waldinger MD, Zwinderman AH, Schweitzer DH, Olivier B Relevance of logical design for the interpretation of efficacy of drug treatment of prematureejaculation: a systematic review and meta-analysis Int J Impot Res 2004; 16:369– 381

methodo-42 Waldinger MD, Zwinderman AH, Olivier B Antidepressants and ejaculation: adouble-blind, randomized, placebo-controlled, fixed-dose study with paroxetine,sertraline, and nefazodone J Clin Psychopharmacol 2001; 21:293 – 297

43 Waldinger MD, Zwinderman AH, Olivier B Antidepressants and ejaculation:

a double-blind, randomized, fixed-dose study with mirtazapine and paroxetine

J Clin Psychopharmacol 2003; 23:467 – 470

44 Waldinger MD, Zwinderman AH, Olivier B SSRIs and ejaculation: a double-blind,randomised, fixed-dose study with paroxetine and citalopram J Clin Psychopharma-col 2001; 21:556 – 560.

45 Novaretti JPT, Pompeo ACL, Arap S Selective serotonin uptake inhibitor in thetreatment of premature ejaculation Braz J Urol 2002; 28:116 – 122

46 Atmaca M, Kuloglu M, Tezcan E, Semercioz A The efficacy of citalopram in thetreatment of premature ejaculation: a placebo-controlled study Int J Impot Res2002; 14:502 – 505

47 American Psychiatric Association Diagnostic and statistical manual of mentaldisorders 4th ed Washington, DC: American Psychiatric Association, 1994

48 Waldinger MD, Hengeveld MW, Zwinderman AH, Olivier B An empiricaloperationalization study of DSM-IV diagnostic criteria for premature ejaculation.Int J Psychiatry Clin Pract 1998; 2:287 – 293

49 Waldinger MD, Olivier B Selective serotonin reuptake inhibitors (SSRIs) andsexual side effects: differences in delaying ejaculation In: Sacchetti E, Spano P,eds Advances in Preclinical and Clinical Psychiatry, Vol I: Fluvoxamine: Estab-lished and Emerging roles in Psychiatric Disorders Milan, Italy: Excerpta Medica,2000:117 – 130

50a Waldinger MD, Olivier B Selective serotonin reuptake inhibitor-induced sexual function: clinical and research considerations Int Clin Psychopharmacol 1998;13(suppl 6):S27 – S33

dys-50b Waldinger MD, Schweitzer DH, Olivier B On-demand SSRI treatment of prematureejaculation: pharmacodynamic limitations for relevant ejaculation delay and con-sequent solutions J Sex Medicine 2005; 2:120 – 130

51 Eaton H Clomipramine in the treatment of premature ejaculation J Int Med Res1973; 1:432 – 434

52 Goodman RE An assessment of clomipramine (Anafranil) in the treatment ofpremature ejaculation J Int Med Res 1980; 3:53 – 59

53 Porto R Essai en double aveugle de la clomipramine dans l’e´jaculation premature(French) Med Hyg 1981; 39:1249 – 1253

54 Girgis SM, El-Haggen S, El-Hermouzy S A double-blind trial of clomipramine inpremature ejaculation Andrologia 1982; 14:364 – 368

55 Assalian P Clomipramine in the treatment of premature ejaculation J Sex Res 1988;24:213 – 215

56 Haensel SM, Klem TMAL, Hop WCJ, Slob AK Fluoxetine and premature tion: a double-blind, crossover, placebo-controlled study J Clin Psychopharmacol1998; 18:72 – 77

ejacula-57 Biri H, Isen K, Sinik Z, Onaran M, Kupeli B, Bozkirli I Sertraline in the treatment ofpremature ejaculation: a double-blind placebo controlled study Int Urol Nephrol1998; 30:611 – 615

58 McMahon CG Treatment of premature ejaculation with sertraline hydrochloride.Int J Impot Res 1998; 10:181 – 184

59 Kim SC, Seo KK Efficacy and safety of fluoxetine, sertraline and clomipramine inpatients with premature ejaculation: a double-blind, placebo controlled study J Urol1998; 159:425

60 Ugur Y, Tatlisen A, Turan H, Arman F, Ekmekcioglu O The effects of fluoxetine onseveral neurophysiological variables in patients with premature ejaculation J Urol1999; 161:107 – 111

61 McMahon CG, Touma K Treatment of premature ejaculation with paroxetinehydrochloride Int J Impot Res 1999; 11:241 – 246.

62 Rowland DL, De Gouveia Brazao CA, Slob AK Effective daily treatment withclomipramine in men with premature ejaculation when 25 mg (as required) isineffective BJU Int 2001; 87:357 – 360

63 Cooper AJ, Magnus RV A clinical trial of the beta blocker propranolol in prematureejaculation J Psychosom Res 1984; 28:331 – 336

64 Choi HK, Jung GW, Moon KH, Xin ZC, Choi YD, Lee WH et al Clinical study

of SS-cream in patients with lifelong premature ejaculation Urology 2000;55:257 – 261

65 Greco E, Polonia-Balbi P, Speranza JC Levosulpiride: a new solution for prematureejaculation Int J Impot Res 2002; 14:308 – 309

66 Matuszcyk JV, Larsson K, Eriksson E The selective serotonin reuptake inhibitorfluoxetine reduces sexual motivation in male rats Pharmacol Biochem Behav1998; 60:527 – 532

67 Waldinger MD, Plas A vd, Pattij T, Oorschot RV, Coolen LM, Veening JG,Olivier B The SSRIs fluvoxamine and paroxetine differ in sexual inhibitoryeffects after chronic treatment Psychopharmacology 2001; 160:283 – 289

68 Haensel SM, Rowland DL, Kallan KTHK, Slob AK Clomipramine and sexualfunction in men with premature ejaculation and controls J Urol 1996;156:1310 – 1315

69 Strassberg DS, de Gouveia Brazao CA, Rowland DL, Tan P, Slob AK mine in the treatment of rapid (premature) ejaculation J Sex Marital Ther 1999;25:89 – 101

Clomipra-70 Kim SW, Paick J-S Short-term analysis of the effects of as needed use of sertraline at

5 PM for the treatment of premature ejaculation Urology 1999; 54:544 – 547

71 McMahon CG, Touma K Treatment of premature ejaculation with paroxetinehydrochloride as needed: 2 single-blind, placebo-controlled, crossover studies

J Urol 1999; 161:1826 – 1830

72 Abdel-Hamid IA, El Naggar EA, El Gilany AH Assessment of as needed use ofpharmacotherapy and the pause-squeeze technique in premature ejaculation Int

J Impot Res 2001; 13:41 – 45

73 Chia SJ Management of premature ejaculation—a comparison of treatment outcome

in patients with and without erectile dysfunction Int J Androl 2002; 25:301 – 305

74 Salonia A, Maga T, Colombo R, Scattoni V, Briganti A, Cestari A et al A tive study comparing paroxetine alone versus paroxetine plus sildenafil in patientswith premature ejaculation J Urol 2002; 168:2486 – 2489

prospec-75 Waldinger MD, Zwinderman AH, Olivier B On-demand treatment of premature culation with clomipramine and paroxetine: a randomized, double-blind fixed-dosestudy with stopwatch assessment Europ Urol 2004; 46:510 – 516

eja-76 Mos J, Mollet I, Tolboom JT, Waldinger MD, Olivier B A comparison of the effects

of different serotonin reuptake blockers on sexual behavior of the male rat EurNeuropsychopharmacol 1999; 9:123 – 135

77 Berkovitch M, Keresteci AG, Koren G Efficacy of prilocaine – lidocaine cream in thetreatment of premature ejaculation J Urol 1995; 154:1360 – 1361

78 Xin ZC, Choi YD, Lee SH, Choi HK Efficacy of a topical agent SS-cream in thetreatment of premature ejaculation: preliminary clinical studies Yonsei Med J1997; 38:91 – 95

79 Choi HK, Xin ZC, Choi YD, Lee WH, Mah SY, Kim DK Safety and efficacystudy with various doses of SS-cream in patients with premature ejaculation in adouble-blind, randomised, placebo controlled clinical study Int J Impot Res 1999;11:261 – 264.

80 Choi HK, Xin ZC, Cho IR The local therapeutic effect of SS-cream on prematureejaculation Korean J Androl Soc 1993; 11:99 – 106

81 Xin ZC, Seong DH, Minn YG, Choi HK A double blind study of SS-cream onpremature ejaculation Korean J Urol 1994; 35:533 – 537

82 Xin ZC, Choi YJ, Choi YD, Ryu JK, Seong DH, Choi HK Local anesthetic effects

of SS-cream in patients with premature ejaculation J Korean Androl Soc 1995;13:57 – 62

83 Waldinger MD Klaar is Kees: Een Nieuwe Visie op Vroegtijdige Zaadlozing.Amsterdam: Uitgeverij de Arbeiderspers, 1999

84 Nathan SG The epidemiology of the DSM-III psychosexual dysfunctions J SexMarital Ther 1986; 12:267 – 281

85 Kaplan HS Retarded ejaculation (chapter 17) In: Kaplan HS, ed The New SexTherapy New York: Brunner/Mazel, 1974:316 – 338

86 Munjack DJ, Kanno PH Retarded ejaculation: a review Arch Sex Behav 1979;8:139 – 150

87 Shull GR, Sprenkle DH Retarded ejaculation reconceptualization and implicationsfor treatment J Sex Marital Ther 1980; 60:234 – 246

88 Delmonte MM Case reports on the use of meditative relaxation as an tion strategy with retarded ejaculation Biofeedback and self-regulation 1984;9:209 – 214

interven-89 Delmonte M, Braidwood M Treatment of retarded ejaculation with psychotherapyand meditative relaxation: a case report Psychol Rep 1980; 47:8 – 10

90 Gagliardi FA Ejaculatio retardata; conventional psychotherapy and sex therapy in asevere obsessive-compulsive disorder Am J Psychother 1976; 30:85 – 94

91 Apfelbaum B Retarded ejaculation: a much-misunderstood syndrome In:Leiblum R, Rosen RC, eds Principles and Practice of Sex Therapy Update forthe 1990s 2nd ed New York/London: The Guilford Press, 1989:168 – 206

92 Dekker J Inhibited male orgasm (Chapter 10) In: O’Donohue W, Geer JH, eds.Handbook of Sexual Dysfunctions Massachusetts: Simon and Schuster, Inc.,1993:279 – 301

93 Beckerman H, Becher J, Lankhorst GJ The effectiveness of vibratory stimulation in

an ejaculatory man with spinal cord injury Paraplegia 1993; 31:689 – 699

94 Brindley GS Reflex ejaculation: its technique, neurological implications and uses

J Neurol Neurosurg Psychiatry 1981; 44:9 – 18

95 Waldinger MD Use of psychoactive agents in the treatment of sexual dysfunction.CNS Drugs 1996; 6:204 – 216

96 Sandler B Idiopathic retrograde ejaculation Fertil Steril 1979; 32:474 – 475

97 Williams W Anesthetic ejaculation J Sex Marital Ther 1985; 11:19 – 29

98 Stekel W Die Storungen des Orgasmus beim Manne In: Die Impotenz des Mannes.Wien, Austria: Verlag der Psychotherapeutischen Praxis, 1923:347 – 391

99 Dormont P Ejaculatory anhedonia Medical Aspects of Human Sexuality 1975;9:32 – 48

100 Garippa PA Case report: anesthetic ejaculation resolved in integrative sex therapy

J Sex Marital Ther 1994; 20:56 – 60

101 Riley AJ, Riley EJ Partial ejaculatory incompetence: the therapeutic effect ofMidodrine, an orally active selective alpha-adrenoceptor agonist Eur Urol 1982;8:155 – 160.

102 Aizenberg D, Zemishlany Z, Hermesh H, Karp L, Weizman A Painful ejaculationassociated with antidepressants in four patients J Clin Psychiatry 1991; 52:461 – 463

103 Waldinger MD, Schweitzer DH Postorgasmic illness syndrome: two cases J SexMarital Ther 2002; 28:251 – 255

Dyspareunia

Caroline F PukallQueen’s University, Kingston, Ontario, Canada and

McGill University, Montreal, Quebec, CanadaKimberley A Payne and Alina KaoMcGill University, Montreal, Quebec, Canada

Samir Khalife´

McGill University and Sir Mortimer B DavisJewish General Hospital, Montreal, Quebec, Canada

Yitzchak M BinikMcGill University and McGill University Health Center

(Royal Victoria Hospital), Montreal, Quebec, Canada

Why Is it Important to Study and Treat Dyspareunia? 251

Postmenopausal Dyspareunia 256

Characteristics of the Vulvar Vestibule in Affected and

What Does the Term “Dyspareunia” Mean?

In 1874, Barnes (1) coined the term dyspareunia He felt that it would be aconvenient way of summarizing the different conditions underlying painfulintercourse: “ just as ‘dyspepsia’ is used to signify difficult or painful diges-tion, we want a word to express the condition of difficult or painful performance

of the sexual function” (p 68) Although the usefulness of the term dyspepsia is amatter of some controversy (2), the diagnosis of dyspareunia has not beenseriously challenged and is still used by all major classificatory systems, such

as the DSM-IV-TR (3) and the ICD-10 (4) The lack of specificity of the worddyspareunia is evidenced by the growing number of overlapping terms (e.g., vul-vodynia, vulvar vestibulitis syndrome, dysesthetic vulvodynia, vestibulodynia)denoting presumed “disease entities.” The majority of these terms originatefrom a recent renewed interest in painful vulvar conditions Even prior tothis increased interest, the term dyspareunia was often used interchangeablywith the terms vaginismus or chronic pelvic pain This unrestricted creation ofdiagnostic labels plagues many mental health and medical domains and often

results in much confusion In our view, the term dyspareunia has outlived itsutility as a nosological entity Although this suggestion might be consideredradical, we believe that it is justifiable both on the basis of logical/theoreticalconsiderations as well as on empirical data.

In this chapter, we will standardize our use of the terminology as follows:The term dyspareunia denotes any form of recurrent or chronic urogenital painthat interferes with sexual and nonsexual activities in women of any age,and which may be experienced in a variety of different locations (e.g., at thevaginal opening or deep inside the pelvic area) with various qualities and patterns(e.g., as an acute stabbing sensation on contact, or a chronic throbbing pain thatwaxes and wanes throughout the day) It is important to note that dyspareuniaalso occurs in men (5), but is relatively rare compared with its frequency inwomen Why there is such a gender disparity remains unclear and is worthy ofstudy; however, this chapter will focus on dyspareunia in women Followingthe criteria outlined by Friedrich (6), vulvar vestibulitis syndrome refers tosevere pain experienced in the vulvar vestibule upon contact Unlike vestibulitis,vulvodynia denotes chronic vulvar pain or discomfort that can occur in theabsence of overt stimulation

Why Is it Important to Study and Treat Dyspareunia?

Recent epidemiological surveys indicate that dyspareunia affects between 15%and 21% of women between the ages of 18 and 59 (7 – 9) Although dyspareunia

is a common problem, many sufferers do not pursue treatment because ofthe embarrassment associated with talking about genital pain and sexuality

Of those who do consult, many do not receive adequate care; it is reported that40% of dyspareunic women who sought treatment did not receive any diagnosiseven after multiple consultations (8) These women may also be told, after severalpotentially invasive and painful evaluations, that all is well physically, implyingeither that their pain is “not real” or that they suffer from psychological problems

In addition to problems encountered in the health care system, women withdyspareunia suffer negative impacts in both sexual and nonsexual areas of theirlives In terms of sexuality, women with dyspareunia report lower frequencies ofintercourse, lower levels of sexual desire, arousal, and pleasure, and less orgas-mic success than non-affected women (10 – 12) It is therefore not surprisingthat women with dyspareunia also report difficulties with relationship adjustmentand psychological distress, including depression and anxiety (10) Outside

of sexuality and intimate relationships, activities such as gynecological ations, bicycle riding, or sitting for long periods of time may also be affected(10,11,13,14) Given the significant negative impact dyspareunia can have

examin-on multiple aspects of life, it is crucial to provide women suffering from thiscondition with information, validation of their pain, and appropriate treatment.However, the classification of dyspareunia has precluded this in many cases byfocusing on the sexual aspects of dyspareunia, to the exclusion of focusing on

the pain and the complexity of factors (e.g., emotional, interpersonal) that areinvolved.

CLASSIFICATION

Barnes derived the term dyspareunia from the Greek term meaning “difficult orpainful mating” (1) This definition, based on interference with sexual inter-course, is understandable given that it is this interference that brings manywomen to clinical attention Unfortunately, the focus on “difficult mating”has resulted in the classification of dyspareunia as a sexual dysfunction (3),and has deflected attention away from the major clinical symptom of pain Thenosological questions concerning dyspareunia are further complicated by amore general theoretical issue: the distinction between organic and psychogenic.For example, both the DSM-IV-TR (3) and the ICD-10 (4) differentiate betweenorganic (i.e., due to a medical condition) and idiopathic (i.e., no known physicalcause, usually attributed to psychogenic origin) dyspareunia The apparent pre-sumption in the case of psychogenic dyspareunia is that it is a distinct category,though there is little specification of its underlying determinants In contrast,organic dyspareunia is seen as the result of many underlying types of gynecolo-gical pathologies, as well as a symptom of inadequate lubrication or of naturallyoccurring menopausal vulvovaginal atrophy

The reality of the situation is that there are no empirically or theoreticallyvalid guidelines to distinguish psychogenic vs organic dyspareunia The notionthat these terms reflect easily diagnosable qualitative categories is questionableboth on empirical and theoretical grounds The typical presumption made bymany health professionals and the general public is that there must be an under-lying physical cause for the pain In clinical practice, this typically results innumerous physical investigations ranging from standard gynecological exami-nations and tests for infections, to invasive procedures such as colposcopy andlaparoscopy If such investigations yield negative findings, the default is toassume a psychogenic causation (“it is all in your head”) and refer the patient

to a mental health professional Depending on the orientation of the mentalhealth professional, dyspareunia may be attributed to factors ranging frominadequate arousal to childhood sexual abuse Because most women with dyspar-eunia present without an identifiable physical explanation for their pain, rarely isthere a primary focus on the pain or on direct pain control in the case of dyspar-eunia However, other idiopathic pain conditions are afforded this approach.For example, 85% of back pain patients present without identifiable pathology(15), yet they are still provided with treatment alternatives, such as analgesicmedication and/or physical therapy

As in the case of back pain, we recommend a similar multidimensional painapproach to the understanding and treatment of dyspareunia (16) This approach

is consistent with current biopsychosocial pain perspectives that evolved from the

Gate Control Theory of Pain, which states that the experience of pain includessensory and emotional components and that psychological factors play a role

in pain control (17) This theory has helped explain the powerful influence of nitive processes on pain perception via descending modulation from the brain,and scientists have since learned that the complex experience of pain cannot

cog-be simply equated with tissue damage (18) The Classification of Chronic Painmanual published by the International Association for the Study of Pain (IASP)(19) has also inspired a new multidimensional approach for dyspareunia treatmentand research (16) According to the IASP classification system, pain is defined

as “an unpleasant sensory and emotional experience associated with actual orpotential tissue damage, or described in terms of such damage” (italics added;page 210) The italicized portion of this definition is reserved for pain patientswithout identifiable physical pathology, as in most cases of dyspareunia andother chronic pain conditions Within this framework, the study of underlyingphysiology is ascribed great importance, but is not sufficient in order to charac-terize the whole pain experience Therefore, pain classification is furtherorganized according to five axes assessing the region affected, system involved,temporal characteristics, intensity, and duration

ASSESSMENT AND DIAGNOSIS

Once treatable causes for the pain of dyspareunia (e.g., infections, dermatologicalconditions, sexually transmitted diseases) are ruled out, the pain needs to be care-fully characterized Questions about the location, quality, and temporal charac-teristics (e.g., When did the pain start? When does the pain occur? How longdoes it last?) of the pain are crucial to obtain a solid understanding of the painexperienced and may also help in diagnosis In terms of pain history, manywomen link the pain onset to their first intercourse experience, but it may actuallyhave long preceded this Similarly, women with vulvar vestibulitis have beenfound to describe their pain in a consistent manner (14) Some patients,however, may have limited knowledge of their pelvic/genital anatomy, inwhich case a diagram is often helpful It is also important for the physician totry and locate the affected region by attempting to replicate the pain through pal-pation and/or pelvic examination This, however, can be a very painful andupsetting experience for the patient, therefore, it is vital to adequately preparethe patient and inquire about the intensity of the pain prior to the examination

If upon examination, pain is experienced, the physician should then determinewhether this is the same pain experienced during intercourse This can beassessed by inquiring about pain location, quality, and intensity during both inter-course and examination In the case that the gynecologist fails to replicate thepain, it is important to clarify to the patient that the gynecological examination

is not the same scenario as the bedroom and that there are many factors thatcould produce variability in the pain experienced For example, emotional reac-tions to the pain may vary; some women may react very strongly by vocalizing

and moving away from the painful stimulation, whereas others may “grin andbear it.” It is therefore necessary to distinguish between the intensity of thepain and the unpleasantness associated with it, as these two components formseparate dimensions of the pain experience A further assessment of thesefactors includes inquiring about activities that produce the pain (e.g., differentsexual positions, certain kinds of exercise) and assessing the temporal character-istics of the pain (e.g., does the pain vary with menstrual cycle) to name a few Tothis end, keeping a pain diary can be extremely informative for both the physicianand the patient.

Asking questions about the pain not only provides useful diagnostic mation, but is also of therapeutic benefit to the patient by validating her experi-ence, since many times, the pain is the last thing that medical professionals mayinquire about, if at all Asking about past treatments, previous diagnoses, andremedies that helped/worsened the pain are also key in obtaining a completepicture of the problem Furthermore, careful questioning about how the painhas affected the patient’s relationships, sexuality, psychological well-being,and overall quality of life will provide a more thorough understanding of thepain and clarify potential treatment options (e.g., physical therapy, psychologicaltreatment for the pain and/or couple problems)

infor-Vulvar Vestibulitis Syndrome

Case Study

Following numerous yeast infections after using a new oral contraceptive pill 2years ago, Sandra, a 25-year old primary school teacher, started experiencing anintense burning pain at the entrance of her vagina during sexual intercourse Thepain started with initial penetration, lasted throughout intercourse, and waspresent for 30 min afterwards Thinking that it was caused by yet anotheryeast infection, Sandra purchased her usual treatment from the pharmacy:over-the-counter antifungal vaginal suppositories However, this only increasedher pain to the point that, 6 months later, she had become apprehensive aboutsexual activity with her long-term partner She also noticed a “tensing up” ofher pelvic floor muscles while engaging in foreplay and a marked decrease inher sexual desire and arousal levels, which further contributed to her pain.Sandra began avoiding all sexual activities, even nonpenetrative ones Shesought treatment from several medical professionals, underwent severalpainful examinations, and tried various topical creams and lubricants withoutany improvement in her pain or answers as to what her pain was She begandoubting her love for her partner, thinking that the pain was indicative

of relationship problems Finally, through one of her friends at work,Sandra obtained the phone number of a gynecologist who diagnosed her withvulvar vestibulitis syndrome and recommended physical therapy and painrelief therapy

Friedrich (6) proposed the following diagnostic criteria for vulvar vestibulitis:(1) severe pain upon vestibular touch or attempted vaginal entry, (2) tenderness

to pressure localized within the vulvar vestibule, and (3) physical findings limited

to vestibular erythema of various degrees Although the third criterion has notreceived much support in terms of its validity and reliability, the first two have(14) Typically, vestibulitis patients present with provoked pain at the entrance

of the vagina, their main complaint usually being painful intercourse Thecotton-swab test, a standard gynecological tool for diagnosing vestibulitis,consists of the application of a swab to various areas of the genital region Ifthe woman reports pain when pressure is applied to the vestibule during thistest, then the diagnosis of vestibulitis is made The cotton-swab test is usuallyperformed in a clockwise manner around the vestibule; however, research hasshown that pain ratings increase with each successive palpation Therefore, werecommend a randomized order of cotton-swab application with adequatepauses after each palpation to avoid sensitization of the vulvar vestibule andunnecessary pain to the patient (16,20)

Although the cotton-swab test for the diagnosis of vulvar vestibulitis drome is considered the clinical method of choice since it is fast and easy toperform, it is not necessarily the standard tool for research purposes First, theamount of pressure applied during the cotton-swab test is not standardizedeither between or within gynecologists (16,20,21) Indeed, it has been shownthat different gynecologists apply different pressures and can elicit significantlydifferent pain ratings in the same women (16,20) Second, the amount of pressureapplied using this method are above pain threshold level, that is, the point at whichwomen report the first sign of pain, making the cotton-swab test highly painful anddistressing for patients In order to overcome these problems, Pukall et al (20)have developed a device called a vulvalgesiometer, which holds much promise

syn-in terms of standardized genital pasyn-in measurement by allowsyn-ing for the application

of known pressures using a spring-based device The vulvalgesiometer replicatesthe quality of pain that women with vulvar vestibulitis report experiencing duringintercourse, and is currently being used in numerous studies

Vulvodynia

Case Study

Joanne, a 39-year-old lawyer, reported a constant tingling and burning sensationover her entire vulvar area, including her labia, perineum, vestibule, and clitoris,for the past 3 years The sensations started progressively, initially with shortperiods of discomfort, but gradually became more frequent and intense to thepoint that she always felt some degree of pain during a 24-h period The painincreased sharply with both sexual and nonsexual activities (e.g., walking orsitting for long periods of time), but she sometimes experienced these increases