tNT[! ',:2AVERNOUS MEDICATION FOR TREA TMENT OF [:I ];MATURE EJACULATION RtCt[:k;{D L. FEtN, M.D. From ]e~ Division of Urology, North Miami Medicat Center, North Miami, Florida
~,CT---Sixto:~:*t men complained of premature eiacutation durirzg a five-mor~th period be[W, 1987, arid ~ ctobe,, 1987. Eight patie~ts e'~tered this stud,j usfr~g intracat~ernous vasoacg.s as treatr~,~,r~t for their problem. The patients, ages tu:ent!#;four through fift~-eight i42 gears), ",:,~:ereall phgsicaU!,f heatth!] a~d taking no medications. Five patients had ~orm, aI on r~octurnat tumescence monitog u~hile 3 patients did not use the motzitor A mixture Of imine mes~jlme, 1.0 mg/mL, and papaverirw h,jdrochloride, 30 mg/~r~,L, u,~as used. The ieqmr~:a' ' ' was jr'ore 0,t0 mL to 0.40 mL. All 8 patients responded sucees@dlg, to this treat.:hree patiel~t! ~:tated the~! ~,ere cured arm stopped the treatmer~L The oth, er 5 'pat:ier~ts co,> sitig the me~ icatio~ ajter.fourteet~ mo~ths. The drug-induced erection lasted bettt~een~ two 'hours despife ejaculation. There have been no side effects th,rough April, 1988. All patients ~ffsfaetio'n ,v~:t ~ the results of this treatmer~,t. The study shou:ed that intracap, ernous medicarap!j ca~ be s'uceessfut i~ the treatme~tt of premature ejaculatio~.
o~l may be considered a netion. ~ Although the dedysfunction leading to irn,eptable to the aging and hale, premature ejaeula7 accepted by the average ~ere is an organic cause of m, such as prostatitis or m, which ean be treated. with premature ejaculai n s psychologic origin of a type. 2 These patients are a hypnotist,, psychologist, losexual therapist. Masters d a 92-percent success rate eehnique." In contrast, my i therapy has been dismal ng the male patient with :ho eomplained of premahas been gained with the g-induced erection treatenee. 4 This pharmacologic used successfully in the APRIi ! , 9 9 0
\'OI,[IME XXXV, NUMBEt:{ 4
treatment of psychogenic impotence, ~ Since premattlre ejaculation, like psychogenic hnpotenee, is a perforrnanee-anxiety problem in an otherwise normal male, it could be an{icipated that intracavernous drugs would work in the treatment of premature ejaculation. This study was undertaken to evaluate the effeetivenc~s of intracavernous vasoactive drugs in the treatment of premature ejaculation, Material and Methods Sixteen men presented between May 21, 1987, and October 6, 1987, complaining of premature ejaculation throughout their adult lives, They alI defined their problem as ejaculating just prior to, at:, or immediately on vaginal penetration. The problem was not changed even on a sec'ond attempt at intercourse during the same session. The patients underwent a histor), physical examination, urinalysis, and prostatic smear, which were all normal. None was impotent. They were then lust:rutted on, and tried, four 301
teehniqt es to help prevent premature ejac~flation: (1) the Masters aad Johnson's penile squeeze ~echnique, (2) the glutea! muscle con{:faction technique, (3) mental divergence, and (4) the fif[een-mim:~e mastt~rbation exercise° None of these patients had success with these simple, noninvasive measures° The patients were then given a simple, informational questionnaire regarding the intracavernous pharmacologic self&tjeetion erection program° Eight of the 16 patients we:re willing to enter this study using intracavernous medication as the treatment for their problem. Tim other 8 patients opted not eo be treated in this manner stating, they "did not want to inject a needle into their per:is." Following a lengthy discussion and after reading and signing an involved consent form, the program was initiated. All patients were encouraged to seek psychologic help. Five of t:he 8 patients had portable nocturnal tumescence monitoring for tumescence and rigid it): * The patients were instructed on the use of the por~able machine. As expected,, all nocturnal tumescence recordings were normal~ The drugs used were a mixture of papaverine hydroehloride, 30 mg/mL, and phentolamine mesyla~:e, t .00 mg/mL. The patient was injected by me with 0.20 mL using a 27-gauge needle unilaterally h:4o the corpus cavernosum base, while being instructed in the technique, Tile patient compressed the injection! site for five minutes and was then observed for at least twenty minutes, arid }it had at: teas,': one blood pressure reading taken during this time. The degree of penile tume,.~eence and rigidity was observed prior ~o the patient being sent home and encouraged to have sexual intercourse. On the second visit, ~:he patient performed the entire procedure of drawing up the medication and injecting his penis while being monitored by me. The dosage used was adjusted according to the patient's repor~ on the previous injec[ion response. He was then seir~ home with a l()--mL multidose vial of ~he mixed medication, fifteen 2%gauge diabetic syringe,s, a &awing of the pharmacologic self-injection technique, and detailed injection insCructions, The patient w~s instructed to ~efurn every two to four rnon~hs for a }fistor> penile examfi?afion, biochemical profne, and new medication. Success was defined by the patien{: as mMntaining an erection for satisfact:ory intercourse Rigiscam Dacomed Cocpora~fon, Minneapolis, Mi~mesota.
302
despite ejaculation, and a desire to eontinue{~: program, Results The 8 patients were all healthy }lad success with the intraeavernm treatment. The dosages ranged fx ko 0.40 mL. The erections lasted and four hours despite Nacu!atio tients stated they were eured an having successful, normal intercc premature eiaeulation. The other still using the medication and re tion with the treatment. There } side effects after fourteen monfhs None of the patients has seen a even though it was encouraged at Comment Premature ejaculation as dysfunction has only infre( dressed in the urologic lite problem stems from de~ermii definition of premature ejae most men, women, psyehiati pists, and urolog~sts have th~ of premature ej aeulation. Aec 75 percent of men ejaculated utes, yet did not consider thi: ters and Johnson a considered ture e j a c u l a t o r if he can ejaeula~ory process for a su time during intravaginal toni his partner in at least 50 pert connections." A less complex an ejaculation that happens b to occur. The men in this stu an ejaculation just prior, on ei ter penetrating the vagina, The techniques for treating tation have concentrated on duet pain, or 1earning to cot sexual arousal, or to deerea: Most young men have erie, raining lubricants or~ their per eohol, and ingestion of pi "'downers" to enhance ejacul~ squeeze technique champion( Johnson a required the paten trolled pain on the penis. Tt percent improvement rate, T the mental distraction teehr arousal. The squeezing of tll UROI,OGY
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APRtI, 1990
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VOI,LME
external sptlineter and cause de, but most men find it difficult uteal muscle contraction while rate the vagina. The fifteen-m/non exercise, with or without ~ t-roduced by Semans 7 as a means ~ulatory eontrot, This technique ~e technique are similar. As the able to delay ejaculation for ~)f time with norm ai stimulation, ~w that intercourse should last ejaculating. In my experience, not follow the techniques, are o involve their partners in the not follow the t e e h n i q u ~ eorrec~y do not work. They, therefore, and still seek treatment. :emature ejaculation is not: psy~tence, it is a performanee-anx~ading to sexual dysfunction. Psy~otenee is n o w being t r e a t e d ,ith intracavernous medication Lting a t t e m p t s at psychologic ~tudy demonstrates equal success at of nonorganic premature ejaedysfunction with intraeavernous 'hese patients, as in the psycho-
/
AP~IlI, 1990
/
VOI,UME XXX\ I, NUMBEB 4
?~:uie impotence group, realize tt~at they still t~ ~.~e a psychologic problem, but at leasl, they a':_~ able to enjoy ir~tereourse using the in~ra?; ~ernous injection of vasoaetive s~lbstances. A !!~:~ patients even st:ated that their premature ei a,,,ulation disappeared and stopped therapy. ~;bviously, more studies need to be perf'ormed regarding this therapy for premature ejaeutatiara, and it should be cautioned that this is riot the treatment for every mate complaining of p :emat~lre ejaculation. 12900 N.E. 17th Avenue, Ste. 30I Nor~:h Miami, Florida 88181 References 1. Smith AD: Causes and classification of impotence, Ur(ll Clin Nordl Am 8:79 (198l). iL Osborn D: Psycholo~eal asps,ors of male sexual dysfunekion~ Ur~fl Clin North Am 8:135 (1981), 3. Masters WH, and Johnson VE: Human Sexual Inadequae}; gosk,n, Little, Br~wn & Compan); 1970, p 92, 4. Sidi AA, Reddy P, and Chen KK: Pa[ient aceeptanee of and satisfaction wRh vasoaetive intraeavernous pharmaeotherapy for impoLenee, J Urol 140:293 (1988). ~5. Ndlans RE, Ellis LR, and KrameroLevien D: Pharmacological erection: diagnosis and treatment apt)Iieations in (~9 patie~ is, JUrot I38:52 (I987). ft, Kinsey AC: Sex behavior in ~he human animal, Ann NY Acad Sei 47:635 (I9,~7), 7. Semans JH: Fremat,re ejaculation: a new approach, South Med J 49:353 (!966).
303
~,CT---Sixto:~:*t men complained of premature eiacutation durirzg a five-mor~th period be[W, 1987, arid ~ ctobe,, 1987. Eight patie~ts e'~tered this stud,j usfr~g intracat~ernous vasoacg.s as treatr~,~,r~t for their problem. The patients, ages tu:ent!#;four through fift~-eight i42 gears), ",:,~:ereall phgsicaU!,f heatth!] a~d taking no medications. Five patients had ~orm, aI on r~octurnat tumescence monitog u~hile 3 patients did not use the motzitor A mixture Of imine mes~jlme, 1.0 mg/mL, and papaverirw h,jdrochloride, 30 mg/~r~,L, u,~as used. The ieqmr~:a' ' ' was jr'ore 0,t0 mL to 0.40 mL. All 8 patients responded sucees@dlg, to this treat.:hree patiel~t! ~:tated the~! ~,ere cured arm stopped the treatmer~L The oth, er 5 'pat:ier~ts co,> sitig the me~ icatio~ ajter.fourteet~ mo~ths. The drug-induced erection lasted bettt~een~ two 'hours despife ejaculation. There have been no side effects th,rough April, 1988. All patients ~ffsfaetio'n ,v~:t ~ the results of this treatmer~,t. The study shou:ed that intracap, ernous medicarap!j ca~ be s'uceessfut i~ the treatme~tt of premature ejaculatio~.
o~l may be considered a netion. ~ Although the dedysfunction leading to irn,eptable to the aging and hale, premature ejaeula7 accepted by the average ~ere is an organic cause of m, such as prostatitis or m, which ean be treated. with premature ejaculai n s psychologic origin of a type. 2 These patients are a hypnotist,, psychologist, losexual therapist. Masters d a 92-percent success rate eehnique." In contrast, my i therapy has been dismal ng the male patient with :ho eomplained of premahas been gained with the g-induced erection treatenee. 4 This pharmacologic used successfully in the APRIi ! , 9 9 0
\'OI,[IME XXXV, NUMBEt:{ 4
treatment of psychogenic impotence, ~ Since premattlre ejaculation, like psychogenic hnpotenee, is a perforrnanee-anxiety problem in an otherwise normal male, it could be an{icipated that intracavernous drugs would work in the treatment of premature ejaculation. This study was undertaken to evaluate the effeetivenc~s of intracavernous vasoactive drugs in the treatment of premature ejaculation, Material and Methods Sixteen men presented between May 21, 1987, and October 6, 1987, complaining of premature ejaculation throughout their adult lives, They alI defined their problem as ejaculating just prior to, at:, or immediately on vaginal penetration. The problem was not changed even on a sec'ond attempt at intercourse during the same session. The patients underwent a histor), physical examination, urinalysis, and prostatic smear, which were all normal. None was impotent. They were then lust:rutted on, and tried, four 301
teehniqt es to help prevent premature ejac~flation: (1) the Masters aad Johnson's penile squeeze ~echnique, (2) the glutea! muscle con{:faction technique, (3) mental divergence, and (4) the fif[een-mim:~e mastt~rbation exercise° None of these patients had success with these simple, noninvasive measures° The patients were then given a simple, informational questionnaire regarding the intracavernous pharmacologic self&tjeetion erection program° Eight of the 16 patients we:re willing to enter this study using intracavernous medication as the treatment for their problem. Tim other 8 patients opted not eo be treated in this manner stating, they "did not want to inject a needle into their per:is." Following a lengthy discussion and after reading and signing an involved consent form, the program was initiated. All patients were encouraged to seek psychologic help. Five of t:he 8 patients had portable nocturnal tumescence monitoring for tumescence and rigid it): * The patients were instructed on the use of the por~able machine. As expected,, all nocturnal tumescence recordings were normal~ The drugs used were a mixture of papaverine hydroehloride, 30 mg/mL, and phentolamine mesyla~:e, t .00 mg/mL. The patient was injected by me with 0.20 mL using a 27-gauge needle unilaterally h:4o the corpus cavernosum base, while being instructed in the technique, Tile patient compressed the injection! site for five minutes and was then observed for at least twenty minutes, arid }it had at: teas,': one blood pressure reading taken during this time. The degree of penile tume,.~eence and rigidity was observed prior ~o the patient being sent home and encouraged to have sexual intercourse. On the second visit, ~:he patient performed the entire procedure of drawing up the medication and injecting his penis while being monitored by me. The dosage used was adjusted according to the patient's repor~ on the previous injec[ion response. He was then seir~ home with a l()--mL multidose vial of ~he mixed medication, fifteen 2%gauge diabetic syringe,s, a &awing of the pharmacologic self-injection technique, and detailed injection insCructions, The patient w~s instructed to ~efurn every two to four rnon~hs for a }fistor> penile examfi?afion, biochemical profne, and new medication. Success was defined by the patien{: as mMntaining an erection for satisfact:ory intercourse Rigiscam Dacomed Cocpora~fon, Minneapolis, Mi~mesota.
302
despite ejaculation, and a desire to eontinue{~: program, Results The 8 patients were all healthy }lad success with the intraeavernm treatment. The dosages ranged fx ko 0.40 mL. The erections lasted and four hours despite Nacu!atio tients stated they were eured an having successful, normal intercc premature eiaeulation. The other still using the medication and re tion with the treatment. There } side effects after fourteen monfhs None of the patients has seen a even though it was encouraged at Comment Premature ejaculation as dysfunction has only infre( dressed in the urologic lite problem stems from de~ermii definition of premature ejae most men, women, psyehiati pists, and urolog~sts have th~ of premature ej aeulation. Aec 75 percent of men ejaculated utes, yet did not consider thi: ters and Johnson a considered ture e j a c u l a t o r if he can ejaeula~ory process for a su time during intravaginal toni his partner in at least 50 pert connections." A less complex an ejaculation that happens b to occur. The men in this stu an ejaculation just prior, on ei ter penetrating the vagina, The techniques for treating tation have concentrated on duet pain, or 1earning to cot sexual arousal, or to deerea: Most young men have erie, raining lubricants or~ their per eohol, and ingestion of pi "'downers" to enhance ejacul~ squeeze technique champion( Johnson a required the paten trolled pain on the penis. Tt percent improvement rate, T the mental distraction teehr arousal. The squeezing of tll UROI,OGY
/
APRtI, 1990
/
VOI,LME
external sptlineter and cause de, but most men find it difficult uteal muscle contraction while rate the vagina. The fifteen-m/non exercise, with or without ~ t-roduced by Semans 7 as a means ~ulatory eontrot, This technique ~e technique are similar. As the able to delay ejaculation for ~)f time with norm ai stimulation, ~w that intercourse should last ejaculating. In my experience, not follow the techniques, are o involve their partners in the not follow the t e e h n i q u ~ eorrec~y do not work. They, therefore, and still seek treatment. :emature ejaculation is not: psy~tence, it is a performanee-anx~ading to sexual dysfunction. Psy~otenee is n o w being t r e a t e d ,ith intracavernous medication Lting a t t e m p t s at psychologic ~tudy demonstrates equal success at of nonorganic premature ejaedysfunction with intraeavernous 'hese patients, as in the psycho-
/
AP~IlI, 1990
/
VOI,UME XXX\ I, NUMBEB 4
?~:uie impotence group, realize tt~at they still t~ ~.~e a psychologic problem, but at leasl, they a':_~ able to enjoy ir~tereourse using the in~ra?; ~ernous injection of vasoaetive s~lbstances. A !!~:~ patients even st:ated that their premature ei a,,,ulation disappeared and stopped therapy. ~;bviously, more studies need to be perf'ormed regarding this therapy for premature ejaeutatiara, and it should be cautioned that this is riot the treatment for every mate complaining of p :emat~lre ejaculation. 12900 N.E. 17th Avenue, Ste. 30I Nor~:h Miami, Florida 88181 References 1. Smith AD: Causes and classification of impotence, Ur(ll Clin Nordl Am 8:79 (198l). iL Osborn D: Psycholo~eal asps,ors of male sexual dysfunekion~ Ur~fl Clin North Am 8:135 (1981), 3. Masters WH, and Johnson VE: Human Sexual Inadequae}; gosk,n, Little, Br~wn & Compan); 1970, p 92, 4. Sidi AA, Reddy P, and Chen KK: Pa[ient aceeptanee of and satisfaction wRh vasoaetive intraeavernous pharmaeotherapy for impoLenee, J Urol 140:293 (1988). ~5. Ndlans RE, Ellis LR, and KrameroLevien D: Pharmacological erection: diagnosis and treatment apt)Iieations in (~9 patie~ is, JUrot I38:52 (I987). ft, Kinsey AC: Sex behavior in ~he human animal, Ann NY Acad Sei 47:635 (I9,~7), 7. Semans JH: Fremat,re ejaculation: a new approach, South Med J 49:353 (!966).
303
