Premature ejaculation- causes, diagnosis and treatment

What is premature ejaculation ?

Premature ejaculation is defined when a man ejaculates sooner during sexual intercourse than he would like to. Nearly one third male experience this problem at some point of time. Premature ejaculation is diagnosed by a doctor when a male presents with complaints such as –

  • Always or nearly always ejaculate within one minute of penetration
  • Are unable to delay ejaculation during intercourse all or nearly all of the time
  • Feel distressed and frustrated, and tendency to avoid sexual intimacy therefore

What is the presentation of premature ejaculation ?

Premature ejaculation can be either of two types – Primary (Lifelong) and Secondary (Acquired). When a male presents with history of premature ejaculation nearly all of the times during sexual acts since the start of his first sexual encounter, it is called as primary type. Secondary type or acquired premature ejaculation is the one where a man who did not had ejaculation problems to begin with, start having early ejaculation now.

What are the causes of premature ejaculation ?

Premature ejaculation can be broadly divided into – Psychological causes and organic causes.

Psychological causes – Various factors such as poor body image, depression, previous sexual experiences, sexual abuse etc can lead on to the premature ejaculation.

Organic causes – Erectile dysfunction, anxiety disorder, hypogonadism (Testosterone and Testosterone deficiency syndrome), abnormal hormone levels etc.

How the diagnosis of premature ejaculation made ?

The diagnosis of premature ejaculation is made on the patient’s history. Repeated or very often episodes of very early ejaculation which cannot be delayed or postpone by the person, points towards premature ejaculation. There is high chances of patient with premature ejaculation who is also suffering from erectile dysfunction and hence the evaluation of such disorder is also done.

What is the treatment for premature ejaculation ?

There are various methods to treat premature ejaculation, and often either one or combination of these used for the any patient.

  • Pelvic floor muscle exercises – Kegal exercises where the pelvic floor muscles are tightened and to hold it in contraction for three seconds, and then relax for three seconds. This is tried a few times in a sequence. Kegel exercises can be done while sitting, standing or walking.
  • Squeeze technique – In this method, the sexual activity is started as usual till the level of stimulation and at the peak of stimulation before the ejaculation, the sexual activity is stopped and either partner or male himself squeeze the penis till the urge to ejaculate goes off and then subsequently sexual activity can be resumed. This process can then be repeated again.
  • Use of condoms – Condom application leads to decrease in sensation and helps delaying ejaculation therefore.
  • Topical anesthetics – Anesthetic creams and sprays that contain a numbing agent, such as benzocaine, lidocaine or prilocaine, are sometimes used to treat premature ejaculation. These products are applied to the penis 10 to 15 minutes before sex to reduce sensation and help delay ejaculation. Side effect include that some men report temporary loss of sensitivity and decreased sexual pleasure.
  • Medications – Many oral medications are used to delay the ejaculations. These medicines include SSRI (escitalopram, paroxetine, fluoxetine, dapoxetine), Tricyclic antidepressant (Clomipramine), tramadol, phosphodiesterase inhibitors (sildenafil, tadalafil). Use of SSRI and clomipramine may take few days to show its effect completely.

Whom to consult if someone suffering from premature ejaculation ?

You should consult your nearby andrologist if you or your partner suffering from premature ejaculation.

Prostate cancer – Part I

What is prostate ?

Prostate is a lemon sized reproductive gland, found only in men, below the bladder. Its function is to produce fluid which helps providing nourishment to sperms in semen. Urinary passage goes through prostate, before reaching the penis.

What all diseases can occur in prostate ?

BPH (BPH (Enlarged prostate) Symptoms), Prostatitis (Infection in prostate), Prostate cancer (Prostate cancer)are the most common diseases that originate from prostate.

What is prostate cancer ?

Like rest of the body cancers, prostate can harbour cancer in it. Malignant growth inside the prostate is called prostate cancer. Most of the prostate cancers are slow growing.

What are the risk factors for prostate cancer ?

Older age, African – American race, family history of ovarian/breast and prostate cancer increases the likelihood of a man being diagnosed with prostate cancer. As men increase in age, the risk of prostate cancer increases. About 60% of prostate cancers are diagnosed in men over the age of 65 years. Besides these, diet high in animal fat has been associated with risk of developing prostate cancer.

What are the symptoms of prostate cancer ?

Prostate cancer can be asymptomatic; meaning there can be no symptoms of cancer. If it does causes symptoms, these can be urinary symptoms or more generalised symptoms, depending upon the stage of prostate cancer. Most common symptoms include- urinary symptoms such as frequency or weak urinary stream, blood in urine (hematuria), erectile dysfunction (ED), Hematospermia (Blood in semen), urinary and bowel incontinence, pain in hips/back/legs etc.

Can we detect prostate cancer in patient who does not have symptoms ?

Prostate cancer can be easily screened with combination of Digital rectal examination (DRE), conducted by doctor and blood test called PSA (Prostate specific antigen). (Prostate cancer and PSA testing). These tests are recommended annually in men over 50 years of age. Combination of these tests can diagnose prostate cancer in men, in whom there are no symptoms of this disease.

What is PSA test ?

The PSA is a blood test which is commonly used to detect possible prostate cancer in a person. Elevated PSA levels may indicate the presence of prostate cancer, but it can be also elevated in certain conditions of prostate such as BPH, prostate infections (prostatitis), UTI (Urinary tract infection), retention urine etc.

If initial tests shows risk of prostate cancer, what happens next ?

The final diagnosis of prostate cancer is made after prostate biopsy done most commonly by ultrasound guidance called TRUS (Trans rectal Ultrasound). Sometimes doctor orders MRI called mpMRI (multiparametric MRI) prostate before undertaking biopsy. Once biopsy shows evidence of prostate cancer, the cancer is staged to look for the extent of cancer spread into the body. This is done by combination of various modalities such as CT scan, MRI , Bone scan and more recently PSMA PET scan.

Testosterone and Testosterone deficiency syndrome

What is testosterone ?

Testosterone is the male hormone which helps in the physical, sexual and psychological well being of the person.

What is the role of testosterone hormone in male body ?

Testosterone helps in development of male secondary characters at puberty such as growth of facial hairs, penis and testes enlargement, deepening of voice, bony and muscle growth etc. In grown adults, this hormone helps in maintaining muscle and fat mass, safeguarding cardiovascular health and producing blood cells, keeping emotional stability, maintaining sexual life while keeping libido, sexual desire, penile erection and fertility normal.

What are sign and symptoms of testosterone deficiency in men ?

Sexual symptoms – Decreased libido; erectile dysfunction; decreased frequency of
morning erections; decreased performance

Physical symptoms – Increased visceral body fat/obesity; decreased lean muscle mass;
decreased strength; fatigue/loss of energy; decreased physical activity/
vitality; low bone mineral density; anemia; flushes; loss of facial, axillary
and pubic hair/slow beard growth; decline in general feeling of well-being

Psychological symptoms – Depression/depressed mood; mood changes; irritability;
inability to concentrate; insomnia/sleep disturbances

Which persons are at risk of developing testosterone deficiency syndrome ?

Persons with poorly controlled diabetes, high BMI, kidney failure on dialysis, chronic alcohol consumer, liver disease, on cancer chemotherapy , drug addicts, COPD etc are at risk for testosterone deficiency and its symptoms.

How to check and evaluate for the testosterone deficiency ?

Testosterone is checked by the blood sample, taken in fasting state early morning between 8 am to 11 am. Normal levels of total testosterone in adult male is usually between 275 ng/dl – 875 ng/dl. Level below this range suggests testosterone deficiency.

How to treat if someone having low testosterone levels ?

If someone is having low serum testosterone levels, complete history and examination for sign and symptoms is must for such patients, as only low testosterone levels does not warrants its treatment. If there are corroborative sign and symptoms along with low testosterone level, the treatment is usually initiated with either intramuscular (i.m.), oral and gel preparations.

Whom to consult for if someone has low testosterone levels ?

You should meet Andrologist for the evaluation and treatment of low testosterone levels.

Ten signs and symptoms of low testosterone levels in adults

  1. Sexual symptoms – Most prominent symptom, Decreased erections, loss of erectile function (erectile dysfunction), decreased semen volume, decreased frequency of ejaculations
  2. Hair loss
  3. Cognitive symptoms – Low mood, low sexual desire, memory impairement, sleep disturbances, concentration difficulties, decreased motivation
  4. Reduced muscle mass, increase in body fat
  5. Decreased physical strength/activity, decreased energy
  6. Increased risk of heart diseases
  7. Hot flushes
  8. Gynecomastia/increased breast tissue
  9. Persistent fatigue
  10. Loss of bone tissue, increased risk of osteoporosis

Read more about testosterone and testosterone deficiency syndrome at Testosterone and Testosterone deficiency syndrome

Short Frenulum (Tight Frenulum, Frenulum Breve)

What is frenulum ?

Frenulum is the elastic fold of skin that joins the underside of the glans of the penis with the inner surface of the foreskin.

What are risks of having short frenulum ?

short frenulum (also called frenulum breve) is when the frenulum is so short in length that there is restriction in free and smooth retraction of the foreskin. This often leads to the pain and discomfort during sexual intercouse. Also, it can increase the risk of infections, as it is difficult to clean under the foreskin. Short frenulum can also get torn while sexual activity and hence can lead to bleeding. Read how this condition is different from Phimosis

What is the treatment for short frenulum ?

It can be managed conservatively if not causing any discomfort or pain. In some cases, steroid creams and stretching exercises can be enough to sufficiently elongate the frenulum. However in majority of cases, surgery is required to alleviate the symptoms. Frenuloplasty (Frenular release) is the mainstay of surgery. Sometimes, the resection of the frenulum (frenulectomy) or circumcision (removal of foreskin) is required. This surgery is done on day care basis with same day discharge of the patient after surgery.

Whom to consult for short frenulum ?

Urologist and Andrologist are the doctors, who look after such problems.

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