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Digest of recent discussions on ISSM mail (May 2009 - Aug 2009)
Sudhakar Krishnamurti - ISSM List Manager Case 1: was an unusual case of premature ejaculation posted by Margaret Redelman.This is a progressively worsening case of primary premature ejaculation in a 40 year old Caucasian ex-athlete, sexually active since age 17. Earlier able to last 5-20 minutes at intercourse, this man is now ejaculating prior to vaginal intromission to the extent that he is now avoiding sex altogether. However, he has good ejaculatory control during masturbation. There is h/o social drug and alcohol use. There is no other relevant psychological or organic medical or sexual history. The patient says that this is the first time he is in love. He has been started on Arapax. Further help is now solicited from the International Society for Sexual Medicine’s (ISSM) membership. 29 messages were received in response to this. The following etiologic possibilities were suggested: Attachment difficulties, emotional anxiety, altered power equations, Madonna syndrome, fear of pregnancy, venerophobia, drug withdrawal, reduced sense of self value, possible anorgasmia in the partner etc. were all proffered as probable psychosexual causes. Organic differential diagnoses suggested included prostatitis, LUTS, hyperthyroidism, use of sympathomimetics, sacral injuries, intervertebral disc problems, thyroid disease, multiple sclerosis and cocaine withdrawal. Therapeutic interventions recommended included Masters and Johnson training, changes in coital positions, pelvic floor exercises, self-help books, couple focalization exercises, excess tension feedback, intimacy skills training, non-coital sexual intimacy and BCT. In addition, medical treatment with SSRIs, tramadol, dapoxetine, clomipramine, ecitalopram, PDE-5 inhibitors, penile injections, and topical de-sensitizing agents was recommended. Case 2: Fréderique Hédon raised a question about use of Cialis on one of his patients who is in a complicated relationship. This patient has undergone a nerve sparing prostatectomy 18 months earlier.He wanted to know, specifically, whether the side effects of Cialis would reduce over time and whether low dose daily Cialis was a suitable treatment option in this patient. The knowledge and experience of the ISSM membership seemed to suggest that:
Case 3: Pierre Assalian presented the case of a patient with a very hard proximal erection at the base of his penis on arousal but with distal flaccidity beyond that. However, the patient reports being able to sometimes obtain a perfectly normal erection along the entire penile shaft, though this is very rare. The penile ultrasound study shows no fibrotic or other lesion.The diagnoses wagered by the ISSM membership included non-palpable/hour glass type Peyronie’s disease without psychogenic overlay, or a vascular lesion. Further investigations such as dynamic MRI, NPTR monitoring, DICC and high frequency echography were suggested. Treatment recommendations included L-carnitine, pentoxifylin, PABA, topical gels, iontophoresis and inflatable penile prostheses. Case 4: Irwin Goldstein invited contributions to the JSM from the ISSM membership of experiences with unwanted skin-to-skin topical testosterone gel transfer from user-patients to others e.g. spouses, partners, children etc..Of the nine respondents, only one had actually seen a case of such gel transfer. This was in a patient who had developed graft vs. host disease following a bone marrow transplant. This patient’s female partner had presented to the clinic with severe acne. A few members cited references of case reports from the international literature on this subject. All discussants were unanimous about the need for a high index of clinical suspicion for the occurrence of this complication and recommended that detailed warnings about this possibility be given to all patients at the time of prescription. It was also emphasized that all patients must be urged to read the product literature in detail. Case 5: Stacy Elliott presents the case of fit 29 year old lifeguard who is in a steady relationship for over five years. This patient presented with a complaint of diminishing libido and reduced orgasmic sensation, but reported normal erections and ejaculation. However, he has lost his REM sleep erections for some time, his orgasm component has gone to zero, and the projectile strength of his ejaculation too has diminished. His urological and neurological examinations were normal, as was an extensive endocrine workout. His fiancée and he have been undergoing sex therapy. He is doing approx. 100 Kegel’s per day and the couple is undergoing sex therapy. Nothing seems to change or improve his anhedonic orgasms. Any suggestions?One discussant advised exploration of the unconscious, emotional and relational aspects of the couple. Another advised checking out the man’s masturbatory habits to rule out excessive masturbation, and to also identify specific orgasm trigger points. Another advised a look at this man from a developmental perspective. Or could it simply be that he is no longer in love with his fiancée? Daily tadalafil 5 mg with testosterone gel was recommended by another. Other suggestions included SSRI with pelvic floor exercises and pramipexole. Case 6: John Cotterill presents the case of a 35 year old male who has been having trouble ejaculating intra-vaginally. He has ejaculated intravaginally with his wife, only on three occasions in the last five years.John suggested that this could be a case of sexual addiction because the patient was accustomed to the use of homosexual fantasy for sexual arousal, but not everybody agreed. Some felt that this was a case of inhibited male orgasm (retarded ejaculation), hypogonadism, sexual conditioning to specific imagery, latent homosexuality, or a variant of retarded ejaculation. Treatment suggestions included vibrator therapy, oral sildenafil, visual sexual stimulation (VSS), masturbation by wife, sex therapy and Buproprion 150 mg or 300 mg. Case 7: Dr T R Murali initiated a discussion on the subject of small penises in overweight boys aged 10-12 and described how he used a course of HCG injections to improve penis and testis size and pubic hair growth, thus allaying the anxiety of boy and parents.Not everybody agreed with this approach. Most advocated watchful follow up and observation, reassurance of the boy and his parents, physical exercise and weight loss - up to age of 14, with the occasional use of SSRIs for reassurance. Endocrine evaluation and treatment was advocated only after age 14 by most discussants. Case 8: Kevan Wylie wanted to know the association between hyperprolactinemia and retrograde ejaculation. One of his patients had wanted to know if there is any long term risk from retrograde ejaculation. Not everybody was aware of a causal relationship between the two. One discussant reported having seen a reversible case of drug induced hyperprolactinemia causing anejaculation. Here, ejaculation was restored on reduction/stoppage of drug. Another discussant emphasized the need to distinguish between retrograde ejaculation and failure of emission.No discussant was aware of any real long term risk from retrograde ejaculation. Case 9: Carol Featherstone reported the case of a female patient who presented with a pulling intra/supravaginal pain that came on half way through sexual intercourse and lasted for as long as 24 hours. No physical cause for the pain was found on examination. The patient believes that the pain is psychological and ascribes it as being possibly due to a traumatic relationship that ended fifteen years ago.Opinion was divided among the discussants about whether the case was physical or psychological. While it was admitted that the case could be psychological, it was advised that physical causes such as UTI, interstitial cystitis or gynecological problems should also be ruled out. Case 10: Carol Featherstone presented another case of a man who ejaculates without orgasmic sensation. This man has had tests to rule out neurological disease, hormonal tests, and has tried Kegel’s exercises but with no benefit.Some discussants labeled this a case of orgasmic anhedonia or sexual anhedonia. Apart from a detailed psychological evaluation, an enquiry into any history of medication (esp. of SSRI/SNRI), food fads, neurological pathology, hypogonadism, and idiosyncratic sexual or masturbatory techniques was advised. Recommended treatment strategies included Welbutrin, vibrator therapy and EMDR. Case 11: Matt Rosenberg began a discussion about the possible association between pelvic pain and the use of ketamine.Most discussants with experience on ketamine bladders were from South East Asia where, ostensibly, ketamine abuse is fairly common. The urinary complications following ketamine abuse include cystitis, dysuria, pain, bleeding and eventually bladder scarring, and consequent back pressure changes. Treatment is with elmiron and anticholinergics and, if these do not work, surgery of the bladder. It takes about 6-12 months of regular ketamine abuse to cause bladder symptoms. The disease stops progressing when ketamine use is discontinued. Bladder complications with ketamine are known only with ‘street’ ketamine and have not been reported with the use of anesthetic ketamine. |
Between May and August, 2009, there were eleven case discussions.