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MARGARET REDELMAN
Unusual Case of PE
17 May 2009: 30 messages
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A good looking 40 year old Caucasian ex-athlete tertiary referred for primary premature ejaculation. No previous PE. Sexually active since age 17; lasting 5-20 minutes at intercourse. New
relationship started 10 m ago. No sexual difficulties till 6 m ago. Progressive inability to control ejaculation. Now ejaculating prior to penetration. Good control with masturbation. Now sexual avoidance starting. Not timed with the PE.
H/O social drug and alcohol use. No medical problems. No medications. Blood tests NAD. Some life stresses but not overwhelming and says ‘first time in love’. Not depressed. I have started him on Arapax PRN to regain confidence but would
appreciate colleagues’ opinions.
Margaret Redelman (redels@MEDEMAIL.COM.AU)
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He may have attachment difficulties and may have kept emotionally (but not sexually) distant from previous partners. The fact that he has good ejaculatory control in masturbation supports this hypothesis. So does the
fact that his sexual problem has emerged as his relationship developed. Might he fear his feelings of aggression when he becomes sexually aroused by a partner he cares about? Might he have too high a degree of self-sufficiency to allow real
emotional contact with a partner? If I was assessing this couple, I would think about their shared defence system as well as the transference and counter-transference issues operating in the therapy room.
Susan Pacey (susanpacey@YAHOO.COM)
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Recently I attended a man with a similar complaint. I agree with our colleague Susan Pacey and I think that the patient perceives his partner as a powerful woman and this makes him unsafe.
Maybe he will benefit from a direct discussion about that.
Lúcia Alves (luciaalvess@YAHOO.COM.BR)
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Re: ‘good ejaculatory control during masturbation,’ is there a condition of premature ejaculation with masturbation?
Yale Shulman (ycshulman@GMAIL.COM)
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I have to completely agree with Susan‘s opinion and I would go the same way. Perhaps include some of Masters-Johnson training with the couple, but deep inspection of the relationship is
vital. Drugs can help in this case, just partially.
Ondrej Trojan (sexuologie@CENTRUM.CZ)
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Yes, very rapid (< 1 min) orgasm, with no conscious awareness of increasing arousal, especially occurs when there is self- identification as unable to delay. While such presentations are
rare, the prevalence of these characteristics is commonplace in PE patients.
Michael Perelman (perelman@ME.COM)
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I am looking at what has changed with this man so dramatically to have this effect. Bloods and lifestyle need to be checked again. Are we looking at a precursor to ED? If a man is
relaxed, he won’t ejaculate early. In the meantime, I suggest changes in coital positions (woman on top) and pelvic floor exercises to relax. I also recommend Metz & McCarthy’s book, Coping with Premature Ejaculation.
Mary Clegg (mary@beecourse.com)
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I could not see anywhere if the patient has had a digital rectal examination. My pre-diagnosis is prostatitis (type can be clarified after evaluating prostatic secretion).
Onder Canguven (ocanguven@YAHOO.COM)
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I don’t find this case of PE so unusual. Sure we have organic causes like prostatitis, neurological diseases or BPH, but in this case the patient is healthy and doesn’t take drugs (or does he?), so I think it is an
emotional-psychological symptom. I think that couple exercises such as focalization 1 and 2 may be more helpful than dynamic behavior therapy. P.S.: What about his contraception method? Could there be any anxiety associated with fear of pregnancy?
Ida Bianchessi (idabianchessi@LIBERO.IT)
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I would agree that with this type of onset that there is some psychological overplay. Some couples’ counseling as well as medical support would be helpful.
Jack Barkin (j.barkin@ROGERS.COM)
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This is such a helpful discussion. The secret is that the masturbation pattern is unchanged so the 'first time in love' is the change. This relationship is important to him. This is Madonna
and her desirousness makes her scary to him. Can he come with her and be helped to see the real human needs she has, which he can meet. Can she help to give him excess tension feedback by noting when his thighs and buttocks are getting tense ? He
needs to understand his physiology and be praised for his great responsiveness, which shows his admiration for her. But now he needs to let her be human and not just a princess.
Ruth Hallam-Jones (ruth.hallam-jones@virgin.net)
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Dear Margaret: I tend to agree with Susan Pacey, but only after having ruled out acquired aetiology such as LUTS, hyperthyroidism, and social drug use. Should the clinical psychologist be male or female? Why are you
using PRN Aropax rather than daily ? Both psychotherapy and SSRI should be used concurrently.
Neil Palmer (njpalm@IINET.NET.AU)
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Dear Margaret: It is probably the emotional intensity of his feelings at 40 which is the major change. I assume bloods excluded hyperthyroidism. He may not want to invite the new love of his
life for couple therapy, in which case medication may be necessary, as most secondary PE cases can come off medication successfully. Paroxetine is not good for on demand use and might make things worse. It needs to be given daily. Tramadol 50mg or
dapoxetine 60mg would be alternatives with fewer stigmas than paroxetine. It all depends on whether he feels that couple therapy would enhance or threaten the new relationship.
Geoff Hackett (geoff.hackett@VIRGIN.NET)
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I think the emotional variables and the loss of erection are all important: did he start on any cold medication i.e. sympathomimetics like Sudafed ? That might have triggered off the initial
response and now he's conditioned himself to it. I have also seen this with sacral injuries, and someone else had mentioned this with other neurological issues. As an ex athlete, does he have any disc problems?
Stacy Elliott (Stacy.Elliott@VCH.CA)
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Hi All: I have the same experience with such cases as Dr. Elliott, and would like to second her recommendations.
Zbynek Veselsky (zbynek.veselsky@seznam.cz)
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Acquired PE could be due to hypo- or hyperthyroidism. I also think of difficulties in commitment. Should be given a trial of an SSRIs or clomipramine while simultaneously investigating the
relationship.
Pierre Assalian (pierreassalian@3WEB.NET)
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Dear Geoff: Why do you say that when one is on paroxetine, they feel stigma ? In fact, on dapoxetine, they have more stigma. I have a lot of patients with PE on regular clomipramine or
paroxetine and are not feeling stigmatized. In PE, we aim at spontaneity, like in ED. I hear this from some urologists. Is this industry propaganda?
Pierre Assalian (pierreassalian@3WEB.NET)
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Dear Geoff: If dapoxetine ‘is now in Europe’, is it now licensed in the UK?
Margot Huish (talk2huish@MAC.COM)
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Dear Margaret: I can see multiple clues for this case. Despite the fact that he has been normal, two dramatic changes have happened. (1) being an ex-athlete can be regarded as a co-factor but (2), which is more
important, is the change in the relationship after a period of normalcy. We have to dig into the interpersonal relationship: venerophobia, fear of pregnancy, or some other partner-related issue that pushes the problem all the way to ejaculation
before intromission. I would suggest BCT and sex therapy and an SSRI like ecitalopram 10-20 mg/day.
The possibility of any organic cause should be excluded.
Shedeed Asahour Shedeed (shedeedash@YAHOO.COM)
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Dear Margaret: Besides the already mentioned causes, I’d like to consider also possible physical aspects. In your patient, it is tempting to concentrate on the new relationship, however the fast progress should keep
our attention also at another level. Didn’t you yourself report recently about the ‘sexual side effects’ of multiple sclerosis?
(Ref:
Redelman MJ. Sexual difficulties for persons with multiple sclerosis in New South Wales, Australia. Int J Rehabil Res. 2009 May 13.
Woet Gianotten (woet@GIANOTTEN.COM)
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Saw two cases with an immediate onset of PE after cessation of cocaine abuse (DSM-IV describes this condition).
Hartmut A.G. Bosinski (hagbosi@sexmed.uni-kiel.de)
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The critical piece of information is that this is the first time this man has fallen in love. I've seen several cases where men developed various sexual problems when they were first
confronted with strong emotional attachments in a relationship. Some of these men who finally fall in love experience themselves as no longer being in control. Once a man has an episode of sexual dysfunction under these circumstances,
he loses confidence, has increased anxiety regarding his `value’, which in turn leads to repetition of the problem. We see this also in men who find themselves with a woman who they consider ‘out of their league’ in terms of attractiveness.
The solution, in my opinion, is to allow the man to regain some sense of control and self-value within this relationship.
Abraham Morgentaler (amorgent@YAHOO.COM)
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I agree with Abe but the problem I have faced is how to re-establish that power or sense of self worth? Furthermore, in an otherwise healthy man who may be convinced that ‘there is something
definitely wrong with me’, the question I have is how to get him to accept that this may be experiential/situational, and not organic? How do you keep him from thinking that you haven't a clue and are using a ‘dump diagnosis’ on him? Great
discussion!
Phil Aliotta (philip.aliotta@gmail.com)
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Abe: While the possible alternative underlying organic factors identified by our colleagues in their earlier e-mails should be ruled out, your assessment of a major potential
psychosocial-behavioral etiological variable requiring further exploration is dead on.
Michael A. Perelman (perelman@earthlink.net)
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Is the question now about how a sex therapist would approach the psychological aspects of the problem?
Sara E. Rosenquist (srquist@INTREX.NET)
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The man needs to either 1) learn to relax with partner (and consider attempting intercourse even after his rapid ejaculation) in order to have some success, or 2) be treated with PDE5
inhibitors or even penile injection to facilitate successful intercourse, even if a premature ejaculation occurs.
Abraham Morgentaler (amorgent@YAHOO.COM)
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In my experience, utilizing topical desensitizing agents actually allows the patient to delay ejaculation, maintain the erection, and most importantly have a better sense of ‘control’.
The effects of the products are titratable and therefore patients have some degree of control over clinical response (assuming they are educated appropriately).
Anthony B Balchunas (abb@HOT.RR.COM)
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I agree with Sara Rosenquist and Abe Morgentaler and wish to add that the overall goal of sex therapy is achieving pleasure and satisfaction thru various gratifying sexual activities
(intercourse, outercourse, pleasuring touch etc.). Therefore, after ruling out physical causes, we should focus on this man's ability to satisfy a woman by increasing his intimate skills (open sexual communication, ability to cope with her sexual
needs, share feelings, learn new techniques of pleasuring and reaching orgasm) and reducing his need to rely on intercourse only and on performance with perfect erections and impressive IELT. We involve the use of PDE5-I in order to reduce ED as a
side effect of PE. If possible, I would invite the woman and offer couple sex therapies. In our center we see cases very similar to this: young men characterized by having sex with female partners in non-committed short relations, and many times
under the influence of alcohol and drugs. The sex therapy intervention focuses on change of habits, concepts and expectations.
Gila Bronner (gilab@netvision.net.il)
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I couldn't agree with Gila Bronner more and add only that in some cases, we need to assess the sexual function of the partner because in some cases there is a secondary gain for the woman to have the man keep the PE
problem, especially if she is anorgasmic, i.e., she doesn't receive any pleasure anyway so she would just as soon finish earlier than later.
Linda Banner (llbanner@EARTHLINK.NET)
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I want to thank everyone for the very helpful responses to my PE case. I've excluded all the medical possibilities. Interestingly on one occasion this week my patient experienced retarded ejaculation. Explained he was
anxious about event on the next day. This seems to have greatly reassured him. He prefers pleasuring his partner to receiving pleasure so I've set homework for him to be passive recipient of outercourse with focus on his sensations and pleasure
and intimate communication time.
Margaret Redelman (redels@MEDEMAIL.COM.AU)
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