This article was downloaded by: [UQ Library] On: 13 June 2015, At: 11:31 Publisher: Routledge Informa Ltd Registered in England and Wales Registered Number: 1072954 Registered office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK
Journal of Sex & Marital Therapy Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/usmt20
A Case of Comorbid Persistent Genital Arousal Disorder and Premature Ejaculation: Killing Two Birds with One Stone a
a
Tillmann H.C. Kruger MD & Uwe Hartmann PhD a
Department of Psychiatry, Social Psychiatry and Psychotherapy, Division of Clinical Psychology and Sexual Medicine, Hannover Medical School, Carl-Neuberg Strasse 1, 30625 Hannover, Germany Accepted author version posted online: 02 Jun 2015.
Click for updates To cite this article: Tillmann H.C. Kruger MD & Uwe Hartmann PhD (2015): A Case of Comorbid Persistent Genital Arousal Disorder and Premature Ejaculation: Killing Two Birds with One Stone, Journal of Sex & Marital Therapy, DOI: 10.1080/0092623X.2015.1053022 To link to this article: http://dx.doi.org/10.1080/0092623X.2015.1053022
Disclaimer: This is a version of an unedited manuscript that has been accepted for publication. As a service to authors and researchers we are providing this version of the accepted manuscript (AM). Copyediting, typesetting, and review of the resulting proof will be undertaken on this manuscript before final publication of the Version of Record (VoR). During production and pre-press, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal relate to this version also.
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http:// www.tandfonline.com/page/terms-and-conditions
ACCEPTED MANUSCRIPT Letter to the Editor A Case of Comorbid Persistent Genital Arousal Disorder and Premature Ejaculation: Killing Two Birds with One Stone Tillmann H.C. Kruger, MD* & Uwe Hartmann, PhD Department of Psychiatry, Social Psychiatry and Psychotherapy, Division of Clinical Psychology
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and Sexual Medicine, Hannover Medical School, Carl-Neuberg Strasse 1, 30625 Hannover, Germany *Corresponding author: Tillmann H.C. Kruger, M.D. Department of Psychiatry, Social Psychiatry and Psychotherapy Hannover Medical School Carl-Neuberg-Strasse 1 D-30625 Hannover, Germany Phone: 0049 511 532 2407; Fax: 0049 511 532 8407 E-mail: [email protected] Key words: Persistent genital arousal disorder (PGAD), sexual arousal, duloxetine, premature ejaculation.
1
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ACCEPTED MANUSCRIPT To the editors Persistent genital arousal disorder (PGAD) was first described in 2001 by Leiblum1 in females and is characterized by five diagnostic criteria including: (1) the persistence of genital arousal for an extended period of time, (2) is unresolved after one or more orgasms, (3) is unrelated to subjective sexual desire or feelings, (4) is experienced as intrusive and unwanted, and (5) causes distress. Concordant with the theory of a nervous system dysfunction including neuropathy2,
Downloaded by [UQ Library] at 11:31 13 June 2015
alleviation of symptoms has been observed in response to treatment with topiramate,3 pregabalin,4 duloxetine4 and botulinum toxin,5 although all these cases were restricted to women. Here, we report the successful treatment of a comorbid lifelong premature ejaculation (PE) and PGAD in an otherwise healthy man using only one drug. Case report A 39-year old man contacted our outpatient clinic after having consulted a great number of various specialists due to persistent and increasingly painful symptoms in his penis, having started 10 years ago. Initially he recognized “pins and needles” as well as unpleasant feelings after touch occurring for about 45 minutes once per month. Frequency and intensity of symptoms severely increased within the last 12 months. Specifically, he reported extended periods of genital arousal including temporary erections (without subjective feelings of sexual desire or arousal) combined with unpleasant feelings in the glans penis after touch, restlessness, sweating, and sleep problems. Triggers included urge to urinate, sexual fantasies, manual stimulation and orgasm. In contrast, symptoms were slightly alleviated during stress or distraction and after voiding. Severity of symptoms was rated as 80 on a 100 mm visual analogue rating scale (VAS).
2
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ACCEPTED MANUSCRIPT The mental burden caused interpersonal and job-related problems. Additionally, the patient reported lifelong short ejaculation latency during masturbation and intercourse of about 60-120 seconds. Medical history as well as thorough clinical, laboratory and technical examination (pelvic MRI, neurophysiology) remained without pathological findings. Symptoms of restless legs or overactive bladder were not reported. Before reference to us different pharmacological
Downloaded by [UQ Library] at 11:31 13 June 2015
approaches were initiated including six different antibiotics and the analgesic diclofenac, all without effect. Pregabalin (75 mg) was discontinued after two days by the patient due to drowsiness. The patient fulfilled all five diagnostic criteria for PGAD and an additional lifelong, generalized PE. With respect to positive experiences in a woman4, we decided to administer the serotonin and norepinephrine reuptake inhibitor (SNRI) duloxetine with a starting dose of 30 mg for two weeks and 60 mg thereafter. Notably, PGAD symptoms were reduced consecutively from initially 80 to 40 on the VAS at a dosage of 60 mg duloxetine (Figure 1). As treatment was well tolerated duloxetine was further increased to 90 and 120 mg at week 8 and 12 leading to a further reduction of symptoms with an overall severity of 20 on the VAS. As an additional and well connoted effect duloxetine substantially increased ejaculation latency which reached approximately 10 minutes after 8 weeks of treatment (as estimated by the patient after having several sexual activities). At week 36 the patient discontinued medication as the general practitioner refused a prescription due to medication costs, causing a recurrence of symptoms. After reinitiating treatment by us symptoms quickly resolved.
3
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ACCEPTED MANUSCRIPT Discussion & Conclusion With the current report we aim at increasing the awareness of practitioners of the need to screen for frequent sexual disorders (PE) and those that are less often and less understood (PGAD). Consistent with a previous report in a woman4, the dual reuptake inhibitor duloxetine was of great value in a man with comorbid PGAD and PE. Clinicians should bear in mind that: (1) proper diagnosis and consultation is essential in these patients and is highly appreciated by them,
Downloaded by [UQ Library] at 11:31 13 June 2015
(2) men may also suffer from PGAD, (3) there is a small number of reports on successful treatment that justifies the tentative use of these drugs. Conflict of interest: None Acknowledgement: Parts of this work were supported by a grant from the European Society of Sexual Medicine (ESSM) as well as funding from the European Union's Seventh Framework Programme (FP7/2007-2013) under grant agreement n° 600773.
4
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ACCEPTED MANUSCRIPT References 1. Leiblum SR, Nathan SG. Persistent sexual arousal syndrome: a newly discovered pattern of female sexuality. J Sex Marital Ther. 2001;27:365-80. 2. Waldinger MD, Venema PL, van Gils AP, et al. Stronger evidence for small fiber sensory neuropathy in restless genital syndrome: two case reports in males. J Sex Med. 2011;8:325-30.
Downloaded by [UQ Library] at 11:31 13 June 2015
3. Ramic M. A case of persistent genital arousal disorder successfully treated with topiramate in a physically healthy individual. J Clin Psychiatry. 2013;74:693. 4. Philippsohn S, Kruger TH. Persistent genital arousal disorder: successful treatment with duloxetine and pregabalin in two cases. J Sex Med. 2012;9:213-7. 5. Nazik H, Api M, Aytan H, et al. A New Medical Treatment With Botulinum Toxin in Persistent Genital Arousal Disorder: Successful Treatment of Two Cases. J Sex Marital Ther. 2014;40:170-74.
5
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severity of PGAD symptoms (VAS)
100 600 80
480
60
360
40
240
20
120
0
0
ejaculation latency (sec)
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Treatment outcome
0
4
8
12
36
40
weeks
0
60
90
120
0
120
duloxetin in mg
Figure 1: Treatment outcome Subjective severity of PGAD symptoms according to a 100 mm Visual Analogue Ratings Scale (VAS) are depicted as filled squares (n). Ejaculation latency (in seconds) as estimated by the patient is depicted as open circles (¢). At week 4 the patient did not yet report being sexually active. At week 8 and 12 sexual activity only included masturbation whereas at week 40 the patient had reinitiated sexual intercourse with the partner. At week 36 the patient discontinued taking duloxetine because his GP refused prescription due to economic reasons.
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Journal of Sex & Marital Therapy Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/usmt20
A Case of Comorbid Persistent Genital Arousal Disorder and Premature Ejaculation: Killing Two Birds with One Stone a
a
Tillmann H.C. Kruger MD & Uwe Hartmann PhD a
Department of Psychiatry, Social Psychiatry and Psychotherapy, Division of Clinical Psychology and Sexual Medicine, Hannover Medical School, Carl-Neuberg Strasse 1, 30625 Hannover, Germany Accepted author version posted online: 02 Jun 2015.
Click for updates To cite this article: Tillmann H.C. Kruger MD & Uwe Hartmann PhD (2015): A Case of Comorbid Persistent Genital Arousal Disorder and Premature Ejaculation: Killing Two Birds with One Stone, Journal of Sex & Marital Therapy, DOI: 10.1080/0092623X.2015.1053022 To link to this article: http://dx.doi.org/10.1080/0092623X.2015.1053022
Disclaimer: This is a version of an unedited manuscript that has been accepted for publication. As a service to authors and researchers we are providing this version of the accepted manuscript (AM). Copyediting, typesetting, and review of the resulting proof will be undertaken on this manuscript before final publication of the Version of Record (VoR). During production and pre-press, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal relate to this version also.
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http:// www.tandfonline.com/page/terms-and-conditions
ACCEPTED MANUSCRIPT Letter to the Editor A Case of Comorbid Persistent Genital Arousal Disorder and Premature Ejaculation: Killing Two Birds with One Stone Tillmann H.C. Kruger, MD* & Uwe Hartmann, PhD Department of Psychiatry, Social Psychiatry and Psychotherapy, Division of Clinical Psychology
Downloaded by [UQ Library] at 11:31 13 June 2015
and Sexual Medicine, Hannover Medical School, Carl-Neuberg Strasse 1, 30625 Hannover, Germany *Corresponding author: Tillmann H.C. Kruger, M.D. Department of Psychiatry, Social Psychiatry and Psychotherapy Hannover Medical School Carl-Neuberg-Strasse 1 D-30625 Hannover, Germany Phone: 0049 511 532 2407; Fax: 0049 511 532 8407 E-mail: [email protected] Key words: Persistent genital arousal disorder (PGAD), sexual arousal, duloxetine, premature ejaculation.
1
ACCEPTED MANUSCRIPT
ACCEPTED MANUSCRIPT To the editors Persistent genital arousal disorder (PGAD) was first described in 2001 by Leiblum1 in females and is characterized by five diagnostic criteria including: (1) the persistence of genital arousal for an extended period of time, (2) is unresolved after one or more orgasms, (3) is unrelated to subjective sexual desire or feelings, (4) is experienced as intrusive and unwanted, and (5) causes distress. Concordant with the theory of a nervous system dysfunction including neuropathy2,
Downloaded by [UQ Library] at 11:31 13 June 2015
alleviation of symptoms has been observed in response to treatment with topiramate,3 pregabalin,4 duloxetine4 and botulinum toxin,5 although all these cases were restricted to women. Here, we report the successful treatment of a comorbid lifelong premature ejaculation (PE) and PGAD in an otherwise healthy man using only one drug. Case report A 39-year old man contacted our outpatient clinic after having consulted a great number of various specialists due to persistent and increasingly painful symptoms in his penis, having started 10 years ago. Initially he recognized “pins and needles” as well as unpleasant feelings after touch occurring for about 45 minutes once per month. Frequency and intensity of symptoms severely increased within the last 12 months. Specifically, he reported extended periods of genital arousal including temporary erections (without subjective feelings of sexual desire or arousal) combined with unpleasant feelings in the glans penis after touch, restlessness, sweating, and sleep problems. Triggers included urge to urinate, sexual fantasies, manual stimulation and orgasm. In contrast, symptoms were slightly alleviated during stress or distraction and after voiding. Severity of symptoms was rated as 80 on a 100 mm visual analogue rating scale (VAS).
2
ACCEPTED MANUSCRIPT
ACCEPTED MANUSCRIPT The mental burden caused interpersonal and job-related problems. Additionally, the patient reported lifelong short ejaculation latency during masturbation and intercourse of about 60-120 seconds. Medical history as well as thorough clinical, laboratory and technical examination (pelvic MRI, neurophysiology) remained without pathological findings. Symptoms of restless legs or overactive bladder were not reported. Before reference to us different pharmacological
Downloaded by [UQ Library] at 11:31 13 June 2015
approaches were initiated including six different antibiotics and the analgesic diclofenac, all without effect. Pregabalin (75 mg) was discontinued after two days by the patient due to drowsiness. The patient fulfilled all five diagnostic criteria for PGAD and an additional lifelong, generalized PE. With respect to positive experiences in a woman4, we decided to administer the serotonin and norepinephrine reuptake inhibitor (SNRI) duloxetine with a starting dose of 30 mg for two weeks and 60 mg thereafter. Notably, PGAD symptoms were reduced consecutively from initially 80 to 40 on the VAS at a dosage of 60 mg duloxetine (Figure 1). As treatment was well tolerated duloxetine was further increased to 90 and 120 mg at week 8 and 12 leading to a further reduction of symptoms with an overall severity of 20 on the VAS. As an additional and well connoted effect duloxetine substantially increased ejaculation latency which reached approximately 10 minutes after 8 weeks of treatment (as estimated by the patient after having several sexual activities). At week 36 the patient discontinued medication as the general practitioner refused a prescription due to medication costs, causing a recurrence of symptoms. After reinitiating treatment by us symptoms quickly resolved.
3
ACCEPTED MANUSCRIPT
ACCEPTED MANUSCRIPT Discussion & Conclusion With the current report we aim at increasing the awareness of practitioners of the need to screen for frequent sexual disorders (PE) and those that are less often and less understood (PGAD). Consistent with a previous report in a woman4, the dual reuptake inhibitor duloxetine was of great value in a man with comorbid PGAD and PE. Clinicians should bear in mind that: (1) proper diagnosis and consultation is essential in these patients and is highly appreciated by them,
Downloaded by [UQ Library] at 11:31 13 June 2015
(2) men may also suffer from PGAD, (3) there is a small number of reports on successful treatment that justifies the tentative use of these drugs. Conflict of interest: None Acknowledgement: Parts of this work were supported by a grant from the European Society of Sexual Medicine (ESSM) as well as funding from the European Union's Seventh Framework Programme (FP7/2007-2013) under grant agreement n° 600773.
4
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ACCEPTED MANUSCRIPT References 1. Leiblum SR, Nathan SG. Persistent sexual arousal syndrome: a newly discovered pattern of female sexuality. J Sex Marital Ther. 2001;27:365-80. 2. Waldinger MD, Venema PL, van Gils AP, et al. Stronger evidence for small fiber sensory neuropathy in restless genital syndrome: two case reports in males. J Sex Med. 2011;8:325-30.
Downloaded by [UQ Library] at 11:31 13 June 2015
3. Ramic M. A case of persistent genital arousal disorder successfully treated with topiramate in a physically healthy individual. J Clin Psychiatry. 2013;74:693. 4. Philippsohn S, Kruger TH. Persistent genital arousal disorder: successful treatment with duloxetine and pregabalin in two cases. J Sex Med. 2012;9:213-7. 5. Nazik H, Api M, Aytan H, et al. A New Medical Treatment With Botulinum Toxin in Persistent Genital Arousal Disorder: Successful Treatment of Two Cases. J Sex Marital Ther. 2014;40:170-74.
5
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severity of PGAD symptoms (VAS)
100 600 80
480
60
360
40
240
20
120
0
0
ejaculation latency (sec)
Downloaded by [UQ Library] at 11:31 13 June 2015
Treatment outcome
0
4
8
12
36
40
weeks
0
60
90
120
0
120
duloxetin in mg
Figure 1: Treatment outcome Subjective severity of PGAD symptoms according to a 100 mm Visual Analogue Ratings Scale (VAS) are depicted as filled squares (n). Ejaculation latency (in seconds) as estimated by the patient is depicted as open circles (¢). At week 4 the patient did not yet report being sexually active. At week 8 and 12 sexual activity only included masturbation whereas at week 40 the patient had reinitiated sexual intercourse with the partner. At week 36 the patient discontinued taking duloxetine because his GP refused prescription due to economic reasons.
6
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