9/10/2010 |
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Digest of recent discussions on ISSM mail (Sept 2008 - Dec 2008)The list this time comprises 4 cases. The 1st case discusses antidepressants and anxiolytics with least effect on orgasm. The 2nd about persistent sexual arousal disorder. The 3rd a case of post orgasmic illness syndrome in an 18 year old male. The last case about penile glandular pain .
Amr El-Meliegy, M.D. - ISSM List Manager Anejaculation (Dr. Adolfo Casabe)Dr. Casabe presented a case of a 22 years old male complaining of anejaculation following the use of escitalopram 10mg and clonazepan 1mg to treat an anxiety disorder. Lowering the escitalopram dose to 5 mg improved the sexual complaint but resumed the anxious state. The question asked was the suggestion for an antidepressant which has no ejaculatory or orgasmic side effects. Dr. Ramlachan advised the use of trazodone for mixed anxiety and depression and the use of flouvoxamine for cases with depression only. Dr. Ashour thought that using one drug only whether escitalopram or flouvoxamine and not a combination might solve the problem. Dr. Moser suggested the addition of bupropion and gradual tapering of escitalopram. Dr. Palha suggested the use of halprazolan and psychotherapy. Dr. Gimenez thought that gabapentin, thioridazine or halopridole might be useful. Dear all I have a patients, 22 years old, who was refered to our Institution due to he suffer from anejaculation an orgasmic disorder after he started with Escitalopran 10mg daily plus Clonazepan 1 mg daily in order to treat an anxiety disorder with well result to treat his symptom . When his psychiatric reduce the doses to 5 mg daily, he recover ejaculation and orgasm, but his symptoms became at the begining. He feel very bad for your anxiety. He abandom the university and his job. I need your opinion about the possibility to prescribe other antidepressant drug with lower effect over the ejaculation or the possibility to combine Escitalopran with other therapy, conductual or pharmacological. Regards Adolfo Casabé Dear Adolfo I prefer Molipaxin (trazodone ) starting at 100mg and titrating upwards to max dose of 400mg in this patient as it does not interfere with ejaculation as much as the others .Does cause priapism in some cases . If he has depression only I prefer to use Luvox (fluvoxamine) 100mg initially and titrating to max dose of 300 mg in divided doses.Hardly ever interferes with ejaculation Regards Dr P. Ramlachan Dear Adolfo and all I think what causes the problem is the combination.?? steps and stratigies to treat your pt with hope he will not have this problem -Exccessively retarded ejaculation up to the level of exhaustion and discontiuning - interpreted as anejaculation and anorgasmia. 1-Use only Escitalopram 10 mg in the morning. I hope it will work>> combine the use of special coital positions the helps to enhance the ejaculatory reflex. e.g. the rear entry but not the female superior position. lastely, i want to remind you the the picture of depression and anxiety, that are obvious, can be related to the partner herself. IF this is the case the history can reveal and treat the case as psychogenic anorgasmia and anejaculation. thanx Shedeed Ashour Shedeed often see this problem. Add bupropion XL 150mg a day for a week, then increase to 300mg a day. Bupropion is actually a very good anti-anxiety drug, but can cause anxiety during the initiation process. If you do a pubmed search on anxiety and bupropion you will find the relevant studies. Continuing the escitalopram will mitigate the side effects of starting bupropion. After 2 weeks, you can discontinue the escitalopram and the sexual side effects should dissipate. Take care and good luck, Charles Moser, PhD, MD, FACP Dear all Why not to treat anxiety symptoms with small doses(5/2,5 mgs) of halprazolan , remaining in a small dose of escitalopran,probably prescribed for a phobic case,and adding appropriate psychoterapy for the specific clinical situation. Regards. Antonio Palha - Psychiatrist-sexologist Dear all: What about using Gabapentine? If it is a matter of sensations more than anxiety. I know that paroxetine is good for delaying ejaculation, but it can also delay female orgasms. What to do and solve the problem not creating another one? Thioridazine may help but remember the adverse effects of this drug. This is also applicable to haloperidole. Opinions will be received and accepted to improve our patients' sexual health. Dr. Gerardo Gimenez Continous Orgasm (Dr. Juhana Piha)Dr. Piha presented a case of a 36 years old woman complaining of persistent orgasm (10 days) accompanied by nausea. Paroxetene was prescribed. Dr. Ashour advised to add ketoconazole to the paroxetene. Dr. Rabinowitz diagnosed it as “Persistant Sexual Arousal Syndrome” and advised the trial of haloperidol for 2-3 weeks. Dr. Porto suggested trying thioridazine. Dear all, a gyenecologist colleque asked me help because of difficult case. He had today a 36 -year old female patient who had developed a continuous orgasm that started after a sexual intrecourse and clitoral stimulation. The orgasmic sensations has lasted now 10 days and she has been unable to work. Nausea has developed gradually. The patient has asthma bronchiale and medication for that. Just now she also a antibiotica for bronchitis. The gynecological status is normal otherwise but in ultrasound a small anount of liquid in the base of the pelvis. P2 (psc)G3 (1xaap). I adviced to start paroxetine immediately. I kindly ask your help in this very rare and difficult case. Best regards, Juhana Piha Dear Colleagues This sounds like the disorder of "Persistent Sexual Arousal Syndrome" which is poorly understood. I have used very small doses of Haloperidol 0.5mg - 1mg as a single night dose for 2 - 3 weeks with some success. David Rabinowitz MD dear all Its benifical giving the Paroxitine Cr. 25 mg but I do recommend adding a ten days course of Ketoconazole 200 mg OD. its good combination. SHEDEED ASHOUR I suggest you Thioridazine (Melleril tm) Robert Porto Post Orgasmic Illness Syndrome (Dr. Sarah Ashworth)Dr. Ashworth had a case of an 18 years old male complaining of post orgasmic illness syndrome in the form of cognitive symptoms associated with anxiety and depression. Flouxetine was prescribed which had some effect with regard reducing the amount of nocturnal emissions he experiences but has had little effect regarding his other symptoms post orgasm. Dr. Moser had tried SSRI and Bupropion with limited success. Dr. Ashour suggested the trial of cymbalta or tramal. Dr. Boul thought it might be a form of General Anxiety Disorder (GAD) with the depersonalisation experienced in Panic Attacks which might be related to a past traumatic sexual experience. I am wondering whether it would be possible to post a query on your list or if you could provide me with any further information - particularly practitioners who know something about Post-Orgasmic Illness Syndrome. I am about to conduct a mental health assessment on an 18 year old young man who has given me prior information that he believes that he suffers from POIS. Certainly the symptoms he describes seems to fit with the examples I have just read on your forum. The symptoms he lists are as follows: Lack of concentration Any advice I could give him about how to get help would be appreciated. He finds his symptoms so troublesome that he has abstained from sexual behavior including masturbation for some time and states, "If I did not have a single orgasm in the rest of my life I would be so happy." He tells me he has seen two GPs, neither of whom had heard of the syndrome and has subsequently been prescribed Fluoxetine 20mg which has had some effect with regard reducing the amount of nocturnal emissions he experiences but has had little effect regarding his other symptoms post orgasm. Hope you can help and best wishes, Sarah Sarah Ashworth I do believe POIS exists, but there is no data on what the underlying problem is or how to treat it. Many of the individuals are quite disturbed about it (understandably), but it is not clear how to help them. I have used SSRI’s to help decrease sexual urges. I have had some limited success with Bupropion. I am also interested in what others have tried. Sincerely, Charles Moser, PhD, MD, FACP Dear all Yes it exists But the symptoms vary beteen patients. I do believe its a sort of neurotransmitters depletion??? but regarding this case it points to an AD or ADHD background of the pt. Pls check and if not; trial of Dual action anti depressants may help Cymbalta 60 mg. or Tramal 50 mg PRN in very limited range. Shedeed Ashour Dear Sarah The symptoms of post orgasmic illness syndrome, and the ones you describe for your young clients, sound very much like most of the symptoms of General Anxiety Disorder (GAD) with the depersonalisation experienced in Panic Attacks. My immediate thoughts, particularly with a young inexperienced client, would be around potential past traumatic sexual experiences i.e., early masturbatory trauma - being caught in the act, being ridiculed by a partner, or abused. Indeed, it could be a form of PTSD but it would appear that there haven’t been any long term studies to identify if the episodes intensify or change. The client could also have fears of such things as losing control, sexually transmitted diseases, inadequacy, and there is also a possibility of confusion over sexual identity. Medication for the physical symptoms will assist your client in engaging in therapy and exploring any underlying psychological issues. Hope this is of assistance. Lori Boul PhD Glandular pain (Dr. Amr El-Meliegy)This is a case of a 36 years old male suffering of penile glandular pain during erections and particularly during intercourse for 2 years. The condition started after an attack of acute balanitis which responded well to local measures. Urine analysis, prostatic smear and culture were all negative. Penile ultrasound showed no lesions. The patient was on Liryca 150 mg once daily for 3 months with no response. Xylocaine gel before intercourse was advised to him but caused irritation. Dr. Meliegy was inquiring for advice. In response to questions by Dr. Mulhal, Dr. Miranda-Soussa, Dr. Ashour and Dr. Khaled, Dr. Meliegy added that the pain occurred with erection not related to orgasm. It even occurred on morning erections but is more severe with penetration (friction as patient describes it). There was no blood or any kind of discharge from the meats. The attack of balanitis was not reported to be herpetic as written by the dermatologist who has seen him. The patient is circumcised. External meatus looks normal. The treatment for balanitis included potassium permengenate wash and steroids to which it rapidly responded (patient's words). Dr. Lemourt suggested doing MRI lumbosacral area. Dr. Ashour raised the possibility of a Peyronie’s disease occurring at the tip of corpora and advised treatment with colchicines. Dr. Snoy had a successful experience in treating one similar case with gabapentin 300mg given 2 hours before intercourse. Dear All, This is a case of a 36 years old, divorced male, suffering from penile glandular pain during erections and particularly during intercourse 2 years duration. No pain in the flaccid state. This started after an attack of acute balanitis 2 years ago which responded well to local measures. Urine analysis, prostatic smear and culture were all negative. Penile ultrasound showed no lesions. The patient is on Liryca 150 mg once daily for 3 months with no response.Xylocaine gel before intercourse was advised to him but caused irritation . Any suggestions ? Regards, Amr El-Meliegy, M.D. Amr Could you clarify a couple of points? Is the pain present only at or after orgasm or is it present during penetration pre-orgasm? Is the pain there with erection but without penetration? JM John P. Mulhall, MD Hi, Any blood or discharge from meatus? a cysto during erection might help identifying any anatomical abnormality not evident during the flacid state Best regards Alejandro Miranda-Sousa, MD Dear Amr pls tell us what he used for the treatment of attack of Balanitis ? like topical potent steroids etc..., 2nd tell us the nature of pain exactely. these Qs because i have a similar case and proved to be atiny fibrotic plaque within the glans that can cause irritation on erection...... thanx shedeed Ashour Dear all This is really a challenging case, but you did not mention enough information about the cause of balanitis? was it a case of herpetic balanitis that get activated by erection and sexual act with no visible clinical lesions inbetween ?is this man circumscised or not ? this may explain his poor response to lyrica tab, I wonder if you tested him for herpes ABs Igm and if there is any unusual findings in the distal urethra just deep to the external meatus . Hesham Nabil, MD Dear All, Thanks for your quick response. Regarding your inquiries: 1) The pain occurs with erection not related to orgasm. It even occurs on morning erections but is more severe with penetration (friction as patient describes it). 2) There is no blood or any kind of discarge from the meatus . 3) I did not see the patient when he had the attack of balanitis, but it was not reported to be herpetic as written by the dermatologist who have seen him. The patient is circumsized. External meatus looks normal. 4) The treatment for balanitis included potassium permengenate wash and steroids to which it rapidly responded (patient's words). Regards, Amr El-Meliegy, M.D. Hi: A few years ago I was treating several patient with different kind of pains, only in the penis, only testicle or only perineum or alternatiing joint,without organ respective lesions,I was found lumbosacral discopaty in different grades surgical and not surgical . I suggest RMN of lumbosacral area. Dr. Manuel Lemourt Dear all after all explanations; i think we have to put in mind the poosibility of the subclinical ongoing process like Peyronie's disease at the tip of one of the corpora(have one case). Follow up with a trial of cholchicine may help. Shedeed Ashour Shedeed Gentlemen, I had a similar patient. His pain was limited to one side of his glans. I treated him very successfully with gabapentin a couple of hours prior to intercourse. Worked great for him. Frederick Snoy MD May I ask the dose you used? Stacy Elliott,MD Hi, I gave him 300 mg a couple of hours before sex. Frederick Snoy MD Can you give us a probable diagnosis in your patient, I mean gabapentin worked well in this case but did it work in a non- specific way or you hit the precise underlying pathology . Hesham Nabil,M D |
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