Non-pharmacological approaches for treatment of premature ejaculation – impact of covid-19

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Premature ejaculation (PE) is a common sexual disorder that affects many men around the world. It is defined as the inability to control ejaculation, resulting in ejaculation occurring within one minute of penetration or before the individual wishes it to occur. This can cause significant distress and can have negative effects on sexual satisfaction and relationships.

However, it is not just men who are impacted by this condition. Women who have partners with premature ejaculation may experience a range of negative emotions and physical discomfort during sexual activity, which can lead to long-lasting effects on their sexual health and overall wellbeing.

One of the most significant ways premature ejaculation affects women is through their emotional experiences. Women whose partners experience premature ejaculation may feel frustrated, disappointed, and anxious during sexual activity. These negative emotions can lead to a decreased desire for sexual activity, a decrease in sexual satisfaction, and a lack of intimacy and emotional connection between partners.

Women may also experience physical discomfort during sex if their partners have premature ejaculation. This can include vaginal dryness, irritation, and pain, making sex a painful or uncomfortable experience. As a result, women may become less interested in sex or develop a negative association with sexual activity altogether.

Additionally, premature ejaculation can lead to a lack of communication between partners, particularly about sexual needs and desires. Women may feel uncomfortable discussing their sexual needs and preferences with their partner due to the perceived taboo around sex, or the fear of making their partner feel insecure. This lack of communication can lead to further relationship problems, decreased intimacy, and a sense of emotional disconnection between partners.

Furthermore, women may begin to feel inadequate or undesired as a result of their partner’s premature ejaculation. They may blame themselves for not being able to “satisfy” their partner, even though premature ejaculation is a common condition that is not caused by a lack of attraction or desire. These negative feelings can lead to a decrease in self-esteem and confidence, and may also contribute to feelings of guilt or shame.

PE is broadly defined as when semen leaves the body (ejaculate) sooner than wanted during sex.1 The exact prevalence of PE in various populations groups is debated. Rosen has described PE as the most common sexual dysfunction in men and found that it was reported by approximately 30% of the population.2

Gao and Zhang found that 30–50% of the male population are affected by this condition,3 whereas Shaeer and Shaeer found a much higher prevalence of approximately 83%.4

The large variations are likely owing to a lack of a widely accepted, standardised definition of PE, which makes study design and conduction of clinical trials more difficult. Moreover, differences in reporting PE are likely influenced by cultural context and patient expectation.

The first definition of PE was introduced by Masters and Johnson in 1970 as ‘the inability of a man to delay ejaculation long enough for his partner to reach orgasm on 50% of intercourse attempts’.5

The International Society of Sexual Medicine defined PE in 2014 as ejaculation that always or nearly always occurs prior to or within about one minute of vaginal penetration from the first sexual experience (lifelong PE) or a clinically significant and bothersome reduction in latency time, often to about three minutes or less (acquired PE).6

PE is often considered as a stand-alone condition; however, up to 50% of PE patients also suffer from erectile dysfunction.

Thus, Colonnello et al. proposed a unifying definition for PE that is associated with erectile dysfunction in one entity: ‘loss of control of erection and ejaculation (LCEE)’.7

This change of paradigm has clinical implications for patients in relation to PE and ED screening as well as treatment of this condition.

The impact of premature ejaculation on sexual satisfaction and relationships can be significant. Men with premature ejaculation may experience anxiety, embarrassment, and a lack of confidence in their sexual abilities. This can lead to avoidance of sexual activity, which can further exacerbate the problem and negatively impact relationships.

Premature ejaculation is a common sexual problem that affects many men at some point in their lives. The exact causes of premature ejaculation are not fully understood, but it is believed to be caused by a combination of psychological, physiological, and environmental factors.

The process of premature ejaculation can be broken down into several stages.

  • The first stage is sexual arousal, which begins when a man becomes sexually stimulated. This can be triggered by physical contact with a partner or by sexual fantasies. During sexual arousal, the sympathetic nervous system is activated, causing the heart rate and blood pressure to increase, and the muscles to tense up.
  • The next stage is the plateau phase, during which sexual arousal continues to build up, but ejaculation is still under voluntary control. In this phase, the man’s penis becomes fully erect, and the testicles are drawn up towards the body. The breathing rate also increases, and muscle tension continues to build up.
  • The third stage is the orgasm phase, during which ejaculation occurs. This is triggered by a series of rhythmic contractions of the pelvic muscles, which propel semen out of the penis. In men with premature ejaculation, this phase occurs too quickly, before the man or his partner is fully sexually satisfied.
  • The final stage is the resolution phase, during which the body returns to its normal state. This involves the relaxation of the muscles, the decrease in heart rate and blood pressure, and the loss of erection. After ejaculation, men often experience a refractory period, during which they are unable to achieve another erection or orgasm.

Fortunately, there are effective treatments available for premature ejaculation, including psychological therapy, behavioral therapy, and pharmacological interventions. These treatments can improve sexual function and satisfaction, as well as improve overall quality of life.

It is important for individuals with premature ejaculation to seek help from a healthcare provider, as there are many factors that can contribute to the disorder.

A healthcare provider can help to identify any underlying psychological or medical conditions that may be contributing to premature ejaculation, and can recommend appropriate treatment options.

There has been a growing concern about the impact of pornography on sexual function, including the development of premature ejaculation. While there is no direct link between pornography and premature ejaculation, studies have shown that excessive use of pornography can have a negative impact on sexual performance and lead to difficulties in achieving and maintaining an erection.

One of the main ways that pornography can contribute to premature ejaculation is through desensitization. When a person repeatedly watches pornography, they can become desensitized to sexual stimuli. This means that they may require more intense or extreme content in order to become aroused. As a result, when they engage in sexual activity with a partner, they may find it difficult to become aroused or maintain an erection, leading to premature ejaculation.

In addition to desensitization, pornography can also contribute to performance anxiety. When a person watches pornography, they are often exposed to a highly idealized and unrealistic version of sexual activity. This can create unrealistic expectations and lead to feelings of inadequacy during sexual encounters. As a result, a person may become anxious about their sexual performance, which can further contribute to premature ejaculation.

Furthermore, pornography can also lead to a lack of communication and intimacy in sexual relationships. When a person relies heavily on pornography for sexual satisfaction, they may be less likely to communicate with their partner about their desires and needs. This lack of communication can lead to a lack of intimacy and emotional connection during sexual activity, which can further contribute to premature ejaculation.

There are several approaches to treating premature ejaculation, including psychological therapy, behavioral therapy, and pharmacological interventions. In this report, we will explore each approach in detail, discussing the underlying principles and techniques used.

Psychological Therapy:

Psychological therapy is a type of treatment that focuses on the underlying psychological factors that contribute to premature ejaculation. This can include anxiety, stress, and depression. By addressing these factors, psychological therapy can help men overcome premature ejaculation and improve sexual satisfaction.

One common psychological therapy for premature ejaculation is cognitive-behavioral therapy (CBT). CBT is a type of talk therapy that helps individuals identify and change negative thought patterns and behaviors that contribute to premature ejaculation. This therapy may include relaxation techniques, such as deep breathing or progressive muscle relaxation, as well as exercises to increase control over ejaculation.

Another form of psychological therapy is sex therapy. Sex therapy involves working with a trained therapist to address sexual issues, including premature ejaculation. Sex therapy may involve education about sexual function and communication techniques to improve sexual intimacy.

Behavioral Therapy:

Behavioral therapy focuses on changing specific behaviors related to sexual function. This approach may be used in conjunction with psychological therapy to address both the psychological and behavioral aspects of premature ejaculation.

One common behavioral therapy for premature ejaculation is the squeeze technique. This technique involves the partner squeezing the penis just before ejaculation to delay ejaculation. This technique can be practiced during masturbation or sexual activity.

Another behavioral therapy is the stop-start technique. This technique involves stopping sexual activity when the individual feels close to ejaculation, then starting again once the urge to ejaculate has subsided. This technique can help individuals learn to control their ejaculation and improve sexual satisfaction.

Pharmacological Interventions:

Pharmacological interventions involve the use of medication to treat premature ejaculation. There are several types of medication that may be used to treat premature ejaculation, including topical anesthetics, selective serotonin reuptake inhibitors (SSRIs), and phosphodiesterase-5 (PDE-5) inhibitors.

Topical anesthetics, such as lidocaine or prilocaine, can be applied to the penis to reduce sensitivity and delay ejaculation. These medications are typically applied before sexual activity and should be used with caution to avoid reduced sensation and sexual pleasure.

SSRIs are a type of antidepressant medication that can also be used to treat premature ejaculation. SSRIs work by increasing the level of serotonin in the brain, which can help to delay ejaculation. These medications may need to be taken daily to be effective, and they can have side effects such as nausea, headache, and sexual dysfunction.

PDE-5 inhibitors, such as sildenafil or tadalafil, are commonly used to treat erectile dysfunction. However, they may also be used to treat premature ejaculation. PDE-5 inhibitors work by increasing blood flow to the penis, which can improve sexual function and delay ejaculation.

Kegel exercises: Kegel exercises are a type of pelvic floor muscle training that help to strengthen the muscles responsible for controlling ejaculation. These exercises involve contracting and relaxing the pelvic floor muscles, which can help to improve ejaculatory control. A study published in the Journal of Sexual Medicine found that men who performed Kegel exercises for 12 weeks experienced a significant improvement in their ejaculatory control compared to a control group.

Stop-start technique:

The stop-start technique involves stopping sexual stimulation when the man feels like he is about to ejaculate, waiting until the urge to ejaculate subsides, and then resuming sexual activity. This technique can help to increase the man’s control over ejaculation and improve his sexual performance. A study published in the International Journal of Impotence Research found that the stop-start technique was effective in improving ejaculatory control and sexual satisfaction in men with premature ejaculation.

Squeeze technique:

The squeeze technique involves squeezing the penis near the base when the man feels like he is about to ejaculate, which can help to delay ejaculation. This technique can be done by the man himself or with the help of his partner. A study published in the Journal of Sex and Marital Therapy found that the squeeze technique was effective in increasing the time to ejaculation and improving sexual satisfaction in men with premature ejaculation.

Aerobic exercise:

Aerobic exercise, such as running, swimming, or cycling, can help to improve overall physical health and reduce stress, which can have a positive impact on sexual function. A study published in the Journal of Sexual Medicine found that men who participated in regular aerobic exercise experienced a significant improvement in their erectile function and overall sexual satisfaction.

Yoga and meditation: Yoga and meditation practices can help to reduce stress and anxiety, which are common factors that can contribute to premature ejaculation. A study published in the Journal of Sexual Medicine found that men who practiced yoga and meditation experienced a significant improvement in their ejaculatory control and sexual satisfaction.

Covid-19

Recent evidence suggests that COVID-19 infection may be a risk factor for ED. The underlying reason for COVID-19-driven ED could be the associations established between endothelial dysfunction and the SARS-CoV-2 virus, which corrupts the physiological pathways involved in the regulation of erection.

Endothelial cells and neurons play an active and dynamic role in the vascular smooth muscle tonus, and the presence or emergence of ED facilitates the risk of future progressive cardiovascular events, cerebrovascular events, and all-cause mortality, with an incline towards a higher risk of cardiovascular mortality.

ED is associated with various causal factors such as age, diabetes mellitus, dyslipidemia, hypertension, cardiovascular disease, BMI/obesity/waist circumference, and metabolic syndrome. Alongside the developments in the conception of cardiovascular physiology, the most vigorous efforts in understanding the physiology of penile erection have focused on enlightening mechanisms related to the functions of the endothelium and vascular smooth muscle of the corpus cavernosum. Therefore, ED could be a manifestation of coronary artery and peripheral vascular disease and also as a potential indicator of cardiovascular disease.

The relationship of comorbidity factors, SARS-CoV-2, and vascular dysfunction/injury has been extensively reported along with the role of comorbidity factors and SARS-CoV-2 in vascular dysfunction and vascular injury. Endothelial dysfunction is related to factors such as aging, hypertension, and diabetes. SARS-CoV-2 can also cause vascular damage directly or indirectly by stimulating the immune response, which results in excessive cytokine production (cytokine storm) that can also lead to vascular damage.

Epidemiological data also highlights the relationship between ED and the immuno-inflammatory system, such as inflammatory bowel disease, kidney disease, rheumatic disease, psoriasis, gouty arthritis, and ankylosing spondylitis, as other potential risk factors. Moreover, inflammatory cytokines such as TNF-α, IL-6, and IL-1β that occur in hyperinflammation of COVID-19 have been shown to be associated with the clinical progression of sexual dysfunction.

A well-known fact is that nitric oxide (NO) synthesized with healthy endothelial cells is the primary mediator in the endothelium-dependent relaxation process in the corpus cavernosum. Diminished nitric oxide synthase (eNOS) expression-driven lowered NO bioavailability is the primary cause of endothelial dysfunction.

Limited bioavailability of the endothelium-synthesized dilating molecule NO resulting from oxidative stress is the main mechanism mediating limited endothelium-dependent dilation with aging. Immunohistochemical analyses have revealed suppressed endothelial eNOS expression in the corpus cavernosum of COVID-19 (+) male patients compared to non-COVID-19 (–) cases, in line with endothelial dysfunction.

One of the most important pieces of evidence shows the presence of viral RNA in COVID-19 (+) specimens subsequent to SARS-CoV-2 viral spikes in penile vascular endothelial cells of COVID-19 (+) patients. This condition can be considered as an important notion for widespread endothelial cell dysfunction and ED.

Therefore, the endothelial dysfunction induced by SARS-CoV-2 infection could have negative effects on erectile function, contributing to the development of ED in COVID-19 patients. Furthermore, the inflammatory response triggered by the virus may also contribute to ED development, as inflammation has been linked to endothelial dysfunction and ED [34].

Another potential mechanism through which COVID-19 could lead to ED is by inducing hypoxia. Hypoxia is a condition in which the body is deprived of adequate oxygen, and it has been shown to have negative effects on erectile function [35]. In COVID-19 patients, hypoxia is commonly observed due to the respiratory complications associated with the disease [36]. Therefore, it is possible that the hypoxia induced by COVID-19 may contribute to ED development.

In addition to the direct effects of COVID-19 on the endothelium and hypoxia, the disease may also have indirect effects on erectile function through its impact on mental health. COVID-19 has been associated with high levels of stress, anxiety, and depression, which can all have negative effects on sexual function [37]. These mental health issues may lead to decreased libido and difficulty achieving or maintaining an erection, contributing to ED development.

Overall, while the direct effects of COVID-19 on the endothelium and hypoxia may be the primary mechanisms through which the disease leads to ED, the indirect effects of mental health issues cannot be overlooked. It is important for healthcare providers to be aware of these potential complications in COVID-19 patients and to provide appropriate management and treatment options for ED.

Testicular affinity of ACE2 receptors for SARS-CoV-2 has been a topic of research and discussion. ACE2 receptors are present in various human systems, including the respiratory, cardiovascular, gastrointestinal, neuroendocrine, genitourinary, and reproductive systems. Human testicular tissue also contains these receptors on both germ and somatic cells. A study showed that the testicular tissue has the highest concentration of ACE2 receptors compared to other human tissues, even higher than the lung tissue, which is the primary target of the virus.

The presence of another transmembrane protease named TMPRSS2 seems to play an essential role in the clinical infection of SARS-CoV-2. This protease assists the breakdown of the viral S protein, favoring its fusion and invasion into the cell. Both ACE2 and TMPRSS2 are shown to be androgen-regulated, suggesting that the tissue of the testicles may be vulnerable to contamination by this new virus.

Studies have shown that SARS-CoV-2 infection in males may lead to decreased testosterone levels and increased levels of luteinizing hormone (LH), which may contribute to erectile dysfunction (ED). Testicular damage may be a harmful consequence of the infection and may contribute to other components causing ED, such as endothelial dysfunction and physiological burden.

To date, there is no definite consensus regarding COVID-19 infection and its effect on the male reproductive system. Studies regarding the presence of SARS-CoV-2 mRNA or virus in the semen or testicular tissue have shown contradictory results. Some studies report no evidence of the presence of SARS-CoV-2 in the semen or testicular tissue, while others report the presence of SARS-CoV-2 in testicular tissue with clinical evidence of hypergonadotropic hypogonadism or damage to spermatogenesis.

The mechanisms for testicular damage may include direct viral invasion to testicular tissue through ACE2 receptors, temperature-related testicular damage resulting from persistent high fever, secondary inflammatory and autoimmune responses, and viral infection-related oxidative stress. Further studies are needed to fully understand the effects of COVID-19 on the male reproductive system and to develop appropriate treatment strategies.

In conclusion, COVID-19 has been shown to have negative effects on erectile function, likely through the direct and indirect mechanisms discussed above. Given the potential long-term effects of ED on quality of life and overall health, it is important to further investigate the relationship between COVID-19 and ED and to develop effective strategies for prevention and management of ED in COVID-19 patients.

reference link : https://wchh.onlinelibrary.wiley.com/doi/10.1002/tre.903

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