Facharbeit: vorzeitige Ejakulation

Diese Arbeit wurde durch einen meiner Patienten zu Unizeiten inspiriert. Der Patient kam wegen Rückenschmerz. Nach einigen Behandlungen war der Schmerz verschwunden, aber der Patient kam weiter regelmäßig, ohne dass ich verstand, warum. Irgendwann erklärte er, dass seit dem er regelmäßig Akupunktur bekäme, die Dinge im Bett besser laufen würden. Und so wurde vorzeitige Ejakulation das Thema meiner folgenden Arbeit.

The prevalence of complaints of premature ejaculation in North America, Europe + Turkey, and help-seeking behaviour for the condition: A Review aiming to assess market potential for acupuncture treatment.
Introduction

Despite its extreme commonality, discussions surrounding the definition and exact prevalence rates of premature ejaculation (PE) are still at a very early stage. Past studies have tended to define PE using their own methods, which can range from anonymous self-reporting, to in-depth case studies using stopwatch-measured intravaginal ejaculatory latency time (IELT).

The currently available management options in the indication let down many PE sufferers. These options show relatively low potency and come with a vast array of side effects, while treating only the symptoms of PE. With further study it seems that acupuncture treatment could demonstrate its effectiveness in treating the condition while having an overall positive systemic effect on the body.

Neuroscientific research has already succeeded in establishing an empirical basis for the treatment with acupuncture Manni, et al. note in a 2010 study. They showed that acupuncture facilitates the release of endogenous opioids in the central nervous system and that several classes of molecules, such as neurotransmitters, cytokines and growths factors may act as mediators for specific acupuncture effects.

The pathophysiology of PE begs further explanation, and the treatment paradigm for the condition still needs to be better defined. All these aspects, and the relatively high prevalence of PE compared to other diseases (Serefoglu & Saitz, 2012) make PE an extremely interesting field for research. In addition, the high impact of PE on sufferers‘ quality of life suggests that there exists a large market for effective treatment by acupuncture.

Methodology

The articles were found via a search on ScienceDirect. The Databases Medline, Cinahl, Google Scholar and AMED were checked too but all the material used was taken from the search on ScienceDirect. The search was started with the keywords “acupuncture” and “rapid” or “premature” “ejaculation”.

Current treatment options and their efficacy

Two major trials have been conducted to test the efficacy and safety of acupuncture in the treatment of PE – the first by Yang, et al. in 2006, and the second by Sunay, et al. in 2011. There is considerable debate regarding the chosen acupuncture treatment protocols in the two trials (Wu, 2011). To my knowledge there has been no further research conducted in this field.

Citing Sunay et al., Waldinger in 2011 noted that acupuncture had a significant effect in delaying ejaculation when compared to placebo treatments, and also when compared to sham acupuncture. However, the study also shows acupuncture treatment to be inferior to treatment by daily doses of Paroxetine, Waldinger observes.

Waldinger notes, however, that further research is required to determine whether acupuncture provides prolonged ejaculation-delaying effects after treatment has completed, or whether its benefits are only temporary.

The internet search for premature ejaculation treatments was broadened by using search terms including “pharmacological”, “non-pharmacological”, “psych*”, “Paroxetine” and “surgery”. These search terms were combined with “premature” or “rapid” and “ejaculation”.

This research showed behavioural therapies were safe but were only able to demonstrate success rates of 50% to 60% in the short term with significantly reduced efficacy in additional follow-up, Serefoglu, et al. said in a 2013 study, citing Hawton at al. (1986) and Melnik at al. (2011). Serefoglu, et al. also note that because of a paucity of well-controlled studies and well-defined treatment protocols for psychological and behavioural treatments, there is an overall lack of evidence suggesting benefits.

There also exist surgical options for the treatment of PE, but international guidelines authored by Althof, et al. in 2010 recommend that these be avoided. Nonetheless, surgical options have demonstrated their extreme efficacy: According to Namavar & Robati (2011), surgical foreskin remnant removal resulted in significant increase in IELT from a baseline of 64.25 seconds before surgery to 731.49 seconds afterwards.

Few drugs exist for the treatment of PE. The SSRI Dapoxetine, the only product with approval for the treatment of PE in the UK, has been shown to delay ejaculation. But its potency is weak, Waldinger & Schweitzer note in their 2008 letter, citing evidence showing that Dapoxetine’s very small median IELT fold increase is only slightly higher than that of a placebo.

Paroxetine has demonstrated greater benefits in regards to efficacy and side effects than other SSRIs (Waldinger, et al., 2001; Waldinger, et al., 1998; Serefoglu, et al., 2013).

Chronic SSRI treatment has been shown to have a detrimental effect on spermatogenesis, impair sperm transport, damage the sperm cell membrane, alter sperm DNA and produce various effects on hormonal homeostasis (Safarinejad, 2008; Tanrikut & Schlegel, 2007; Serefoglu, et al., 2013; Hutchinson, et al., 2012; Waldinger & Schweitzer, 2008; Porst, et al., 2010). Side-effects such as decreased libido, anorgasmia, impotence and erectile dysfunction, may continue beyond cessation of SSRI treatment. (Wang, et al., 2006; Goekce, et al., 2011; Serefoglu & Saitz, 2012)

PE definition and the operational criteria

The key terms “prevalence”, “incidence rate” combined with the search term “premature ejaculation” were used for the further research. The results were limited to trials conducted after 2003 in North America and Europe including Turkey. Prevalence studies with fewer than 2000 participants were discarded.

The treatment of PE is complex and guidelines for treatment are limited due to lacklustre definition of the disease, causing a barrier to standardized evidence-based studies, Serefoglu & Saitz noted in 2012. Indeed, the research showed that problems surrounding the definition, classification, prevalence and diagnosis of PE arise frequently:

The online study PEPA, conducted by Porst, et al. in 2007, classified men as having PE based on self-reported or low to absent control over ejaculation resulting in distress for them, their partners or both. The study reported an overall prevalence of 22.7%.

Dean’s 2007 study – The European Online Sexual Survey (EOSS): Pan-European Perspectives on the Impact of Premature Ejaculation and Treatment-Seeking Behavior – used a far stricter definition. Men were classified as having PE when they self-reported ejaculation before penetration or an IELT of less than two minutes and poor or very poor control over ejaculation (using a scale 1-5). Dean also required that the time to climax be so low as to cause distress for the respondent, their partner or both. All three criteria needed to be met for participants to be categorised as sufferers of PE. In this study, the prevalence of PE was measured at a much lower 7%.

Giuliano et al.’s Five Country European Observational study, published in 2008, used yet another set of criteria: stopwatch-measured IELT of less than two minutes, the DSM-IV-TR criteria and at least moderate self-reported distress led to the PE classification. This study was not randomized, making it difficult to estimate its representativeness.

Waldinger & Schweitzer, in their 2008 letter, were very critical of the definition used, and the results drawn, by the Five Country European Observational study. They argue that this study used outdated and excessively loose definitions of PE.

Defining PE is rendered more difficult, Jannini, et al. (2005) note, by a lack of knowledge about the underlying pathophysiology.

Methodology of prevalence studies

The lack of industry-wide standards for data acquisition adds a further and very significant challenge.

A popular method for calculating the prevalence of PE is through internet-based surveys. Dean, in his 2007 study, argues that online sampling is a well-established sampling method that may make it easier for patients to respond honestly.

The PEPA study, by Porst, et al. (2007), was an Internet-based survey recruited via two large (Greenfield and Ciao), pre-existing market research internet panels. Men were statistically representative of their respective country. Some 12,133 participants took part.

EOSS was also an online-based study, conducted in 2005. The participants were recruited via Ciao. Men who also reported erectile dysfunction were excluded from the survey.

Despite boasting large sample sizes these, like other internet studies, suffered from some of the drawbacks flagged by Wright in his 2005 study, notably sampling error and a limited ability to verify the information provided.

In contrast, Wright notes, the high level of motivation required for voluntarily participation studies has been shown to result in more complete data reporting.

One of these was the Five-Country European Observational study, conducted in 2005 and covering France, Germany, Italy, Poland and UK. It was an eight-week multicentre observational study. Heterosexual men and their partners were recruited via newspapers and radio advertisement.

In 2009, the Turkish Society of Andrology and Sexual Health survey questioned 2,593 couples in person about their sexual experience. It was a non-interventional observational cross-sectional field survey. Participating couples were randomly selected, visited at home, and asked to fill out a detailed questionnaire.

However, voluntary participation studies such as these also suffer from significant drawbacks. Symonds, et al., in their 2003 study, argue that embarrassment over PE is likely to affect the ability of some men to respond candidly to an interviewer, skewing prevalence rates downwards. This feeling of embarrassment, Symonds, et al. note, is a key reason that men sometimes to not speak to their doctor about PE.

On the other hand Waldinger, in his 2011 study, notes that large numbers of men are uncomfortable with an average or even relatively long duration of IELT. These men may incorrectly report that they suffer from PE, skewing the statistics upwards.

Treatment-seeking behaviour

To research how and whether affected men seek help, the databases were searched with keywords like “treatment-seeking behaviour” and “help-seeking behaviour” combined with the search term “premature ejaculation”.

The available studies show treatment-seeking behaviour to be very low.

PE patients‘ help-seeking behaviour was analysed in the PEPA survey conducted by Porst, et al. in 2003/2004 (published in 2007). The authors reported that 9% of men with PE consulted a physician for the condition. Similarly, in Serefoglu et al.’s study, only 10% of men with PE reported having seen a doctor.

A paper published by Papaharitou, et al. in 2006, based on the analysis of profiles of 9,536 men calling a sexual helpline in Greece, showed that men reported a mean problem duration of approximately two years, but only 2450 (of 7651) had ever consulted a doctor for their condition.

Help-line data based on callers’ specific profile are only indicative of their sexual problems but are still useful in identifying the characteristics of people seeking help and the factors that might hinder their treatment-seeking behaviour, Papaharitou, et al. argue. This becomes extremely important, the authors note, considering that sexual problems significantly affect sufferers‘ quality of life and life satisfaction.

Men’s age and relationship status significantly influence how likely they are to seek treatment. Symonds, et al.’s 2003 study showed that PE sufferers between the ages of 20 and 29, or those in a relationship, were more reluctant to discuss their sexual problem with a physician.

Several previous studies indicated that the majority of men with sexual problems would like to receive medical advice (de Boer & Bots, 2005; Papaharitou, et al., 2006); but that only a small proportion of them actually sought help (Dunn, et al., 1998).

Conclusion

Research into the treatment of PE is hobbled by a lack of agreed standards and definitions, and by low rates of treatment-seeking behaviour. But the available data strongly supports the argument that PE sufferers lack safe and effective treatment options. This suggests that there exists a large market for acupuncture treatment of PE, given its relative effectiveness.

There is, in addition, a very real need: Approximately 84% of the PE group in the EOSS felt that an increase in IELT would have an important or dramatic impact on their sexual relationship, and more than 97% felt that it would have at least some positive impact. Of the 9% of men who pursuit treatment in the PEPA study, 91.5% report little or no improvement as a result of seeking treatment.

The potential size of the market for alternative PE treatments suggests that further study on the effectiveness of acupuncture in dealing with this painful condition cannot come too soon.

Works Cited

Althof, S., Abdo, C. & Dean, J., 2010. International Society for Sexual Medicine’s guidelines for the diagnosis and treatment of premature ejaculation. Journal of Sexual Medicine, Issue 7, pp. 2947-69.

Ciocca, G. et al., 2013. Integrating psychotherapy and pharmacotherapy in the treatment of premature ejaculation. Arab Journal of Urology, Issue 11, pp. 305-12.

de Boer, B. & Bots, M., 2005. The prevalence of bother, acceptance and need for help in men with erectile dysfunction. Journal of Sexual Medicine, III(2), pp. 445-50.

Dean, J., 2007. The European Online Sexual Survey (EOSS): Pan-European Perspectives on the Impact of Premature Ejaculation and Treatment-Seeking Behaviour. European Urology Supplements, Issue 6, pp. 768-74.

Dunn, K., Croft, P. & Hackett, G., 1998. Sexual Problems: a study of the prevalence and need for health care in the general population. The Journal of Family Practice, Issue 15, pp. 519-24.

Giuliano, F. et al., 2008. Premature Ejaculation: results from a Five-Country European Observational study. European Urology, Issue 53, pp. 1048-57.

Goekce, A., Halis, F. & Dermitas, A., 2011. The effects of three phosphodiesterase type 5 inhibitors on ejaculation latency time in lifelong premature ejaculators: a double-blind laboratory setting study. British Journal of Urology International, Issue 107, pp. 503-9.

Hutchinson, K., Cruichshank, K. & Wylie, K., 2012. A benefit-risk assessment of dapoxetine in the treatment of premature ejaculation. Drug Safety, Issue 35, pp. 359-72.

Jannini, E., Lombardo, F. & Lenzi, A., 2005. Correleation between ejaculatory and erectile dysfunction. International Journal of of Andrology, Issue 28, pp. 40-5.

Mani, L. et al., 2010. Neurotrophins and Acupuncture. Autonomic Neuroscience: Basic and Clinical Journal, Issue 157, pp. 9-17.

Namavar, M. & Robati, B., 2011. Removal of foreskin remnants in circumcised adults for treatment of premature ejaculation. Urology Annals, Issue 3, pp. 87-92.

Papaharitou, S. et al., 2006. Erectile Dysfunction and Premature Ejaculation are the most frequently Self-reported sexual concerns: profiles of 9536 calling a helpline. European Urology , Issue 49, pp. 557-63.

Park, J., Shin, D. & Ahn, T., 2008. Complementary and alternative medicine in men’s health. Journal of men’s health, V(4), pp. 305-13.

Porst, A. et al., 2007. The Premature Ejaculation Prevalence and Attitudes (PEPA) Survey: Prevalence, Comorbidities, and Professional Help-Seeking. European Urology, Issue 51, pp. 816-24.

Porst, H., McMahon, C. & Althof, S., 2010. Baseline characteristics and treatment outcome for men with accquired or lifelong premature ejaculation with mild or no erectile dysfunction: integrated analyses of two phase 3 dapoxetine trials. Journal of Sexual Medicine, Issue 7, pp. 2231-42.

Safarinejad, M., 2008. Sperm DNA damage and semen quality impairment after treatment with selective serotonin reuptake inhibitors detected using semen analysis and sperm chromatin structure assay. Journal of Urology, Issue 180, pp. 2124-8.

Serefoglu, E. C. & Saitz, T. R., 2012. New insights on premature ejaculation: a review of definition, classification, prevalence and treatment. Asian Journal of Andrology, Issue 14, pp. 822-829.

Serefoglu, E. C., Saitz, T. R., Trost, L. & Hellstrom, W. J., 2013. Premature ejaculation: do we have effective therapy?. Transational Andrology and Urology, II(1), pp. 45-53.

Serefoglu, E. et al., 2011. Prevalence of the complaint of Ejaculating Prematurely and the four premature ejaculation syndromes: results from the Turkish Society of Andrology sexual health survey. Journal of Sexual Medicine, Issue 8, pp. 540-48.

Sunay, D. et al., 2011. Acupuncture Versus Paroxetine for the Treatment of Premature Ejaculation: A Randomized, Placebo-Controlled Clinical Trial. European Urology, Issue 59, pp. 765-771.

Symonds, T., Roblin, D., Hart, K. & Althof, S., 2003. How does Premature Ejaculation impact a man’s life?. Journal of Sex and Marital Therapy, Issue 29, pp. 361-70.

Tanrikut, C. & Schlegel, P., 2007. Antidepressant-assosciated changes in semen parameters. Urology, Issue 69, p. 185.

Waldinger, M., 2008. Premature Ejaculation: Advantages of a new classification for understanding etiology and prevalence rates. Sexologies, Issue 17, pp. 30-35.

Waldinger, M. D., 2011. Contribution of Acupuncture to Western Medical Knowledge of Premature Ejaculation: An Intriguing New Development. European Urology , Issue 59, pp. 772-774.

Waldinger, M., Hengeveld, M. & Zwindermann, A., 1998. Effect of SSRI antidepressants on ejaculation a double-blind, randomized, placebo-controlled study with fluoxetine, fluvoxamine, paroxetine and sertraline. Journal of clinical Psychopharmacology, Issue 18, pp. 274-81.

Waldinger, M. & Schweitzer, D., 2008. Premature Ejaculation and pharmaceutical company-based medicine: the dapoxetine case. Journal of sexual Medicine, Issue 5, pp. 966-97.

Waldinger, M. & Schweitzer, D., 2008. Re: François Giuliano, Donald L. Patrick, Hartmut Porst, et al. For the 3004 Study Group. Premature Ejaculation: Results from a Five-Country European Observational Study. Journal of European Urology, Issue 53, pp. 1048-57.

Waldinger, M., Zwindermann, A. & Olivier, B., 2001. SSRIs and Ejaculation: a double-blind, randomized, fixed-dose study with Paroxetine and Citalopram. Journal of Clinical Psychopharmacology, Issue 21, pp. 556-60.

Wang, W., Minhas, S. & Ralph, D., 2006. Phospodiesterase type 5 inhibitors in the treatment of premature ejaculation. International Journal of Andrology, Issue 98, pp. 503-9.

Wright, K., 2005. Researching internet-based populations: advantages and diadvantages of online survey research, online questionaire authoring software packages, and web survey services.. Journal of Computer-Mediated Communication , Issue 10.

Wu, X., 2011. Re: Didem Sunay, Melih Sunay, Yasin Aydogmus, et al. Acupuncture Versus Paroxetine for the Treatment of Premature Ejaculation: A Randomized, Placebo-Controlled Clinical Trial.. Chongqing: European Urology.

Yang, X., Yan, Z. & Ni, W., 2006. Clinical study on treatment of 50 cases of prospermia with chinese medicine combined with antidepressant.. Journal of Traditional Chinese Medicine, Issue 47, pp. 118-20.

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