E.S.A.U. HighlightsE.S.A.U. Highlights
Paolo VerzePaolo Verze
University Federico IIUniversity Federico IINaples, ItalyNaples, Italy
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Update on Update on ejaculatory ejaculatory disordersdisorders
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Embriology and anatomy of seminal tractEmbriology and anatomy of seminal tract
E. MeulemanE. Meuleman
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Crucial role of Y ChromosomeCrucial role of Y Chromosome Passive regression of Wolff ducts and passive Passive regression of Wolff ducts and passive
differentiation of female genitalsdifferentiation of female genitals
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Physiologic modulation: peripheral systemPhysiologic modulation: peripheral system
F. FuscoF. Fusco
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EmissionEmission
ExpulsionExpulsion
SACRAL PARASYMPATHETIC
NUCLEUS
THORACO-LUMBAR
SYMPATHETICSYSTEM
Spinal
Ejaculation
GeneratorONUF’s
NUCLEUS
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Physiologic modulation: central systemPhysiologic modulation: central system
F. GiulianoF. Giuliano
Central Neurophysiology of Central Neurophysiology of EjaculationEjaculation
Sympathetic centres
LSt cells
Sacral parasympathetic
nucleus
BS muscles
Prostate
IMG
PN
HN
MPG
T12-L1
L3-L4
L5-S1DM(VH)
• Lumbar Spino-thalamic (LSt )neurons at the L3-L4 level connect to prostate and BS muscle
• LSt neurons are in position to coordinate and synchronize emission ans expulsion phases of ejaculation
Pud N
Spinal generator of ejaculation
Supraspinal control of ejaculation
• Supraspinal sites exert both inhibitory and excitatory effects on spinal command of ejaculation• Main neurotransmitters : SEROTONIN, DOPAMINE, OXYTOCIN
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Animal models of ejaculatory behaviour Animal models of ejaculatory behaviour
M. WaldingerM. Waldinger
- - There are stable phenotypic differences in ejaculatory
behavior between sluggish, normal and rapid ejaculators in rats
- Studying these phenotypes may be a promising approach to gain more insight into the neural correlates underlying Premature Ejaculation
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Current approaches to definition and classificationCurrent approaches to definition and classification
F. LombardoF. Lombardo
Psycho-neuro-uro-endocrinology of ejaculatory disorders
• It is now clear that ejaculatory disorders are
symptoms of many physical diseases which need
medical diagnosis
• The aim of the medical sexologist is to identify the
“specific weight” of each etiology and to start
etiological and symptomatic therapies in an holistic
way, taking into account the potency of the drugs
and the couple’s dynamics as well as providing
specific sexual counselling
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Prevalence of ejaculatory disordersPrevalence of ejaculatory disorders
A. Martin MoralesA. Martin Morales
Spectrum of EjD Premature or Rapid ejaculation (PE or RE)Premature or Rapid ejaculation (PE or RE) Delayed Ejaculation (DE), complete Inability Delayed Ejaculation (DE), complete Inability
to Ejaculate (IE) or Anejaculation (AE)to Ejaculate (IE) or Anejaculation (AE) Retrograde EjaculationRetrograde Ejaculation Painful EjaculationPainful Ejaculation
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PE Prevalence and Attitudes (PEPA) PE Prevalence and Attitudes (PEPA) studystudy
PE is the most common male sexual dysfunctionPE is the most common male sexual dysfunction– ~25-30% prevalence rate~25-30% prevalence rate– PE prevalence is constant across age groupsPE prevalence is constant across age groups
Epidemiology not fully establishedEpidemiology not fully established– Regional variationRegional variation– Cultural variationCultural variation
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Diagnostic flow-chartDiagnostic flow-chart
N. SofikitisN. Sofikitisa) PE or EDb) Voluntary control of ejaculation c) IELTd) Degree of distress e) Medical history f) Sexual historyg) Physical examination h) Penile hypersensitivity (evaluating somatosensory
evoked potential)i) Other somatic or cognitive factors
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Diagnostic flow-chartDiagnostic flow-chart
N. SofikitisN. Sofikitis
• Patients barriersPatients barriersa)a) PE is stigma or social embarrassmentPE is stigma or social embarrassment
b)b) Perception that the problem is transient Perception that the problem is transient
c)c) Belief that PE is psychological Belief that PE is psychological
• Clinical barriersClinical barriersa)a) Time constraints Time constraints
b)b) Discomfort talking about sex Discomfort talking about sex
c)c) Lack of expertiseLack of expertise
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Therapeutical approachTherapeutical approach
A. Jungwirth vs C. BettocchiA. Jungwirth vs C. Bettocchi
Peripheral approachPeripheral approach A. JungwirthA. Jungwirth
There is clear evidence that a SEG existsThere is clear evidence that a SEG exists In men with spinal cord injury above Th10 an ejaculation In men with spinal cord injury above Th10 an ejaculation
can be achieved by vibratory stimulation of the glans peniscan be achieved by vibratory stimulation of the glans penis PET scan shows no specific „ejaculatory“ activityPET scan shows no specific „ejaculatory“ activity The most therapeutical approaches apply to a therapy of The most therapeutical approaches apply to a therapy of
the penis or the structures of the pelvis and not to the brainthe penis or the structures of the pelvis and not to the brain
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Therapeutical approachTherapeutical approach
A. Jungwirth vs C. BettocchiA. Jungwirth vs C. Bettocchi
Central approachCentral approach C. BettocchiC. Bettocchi
There is clear evidence that a suvraspinal control There is clear evidence that a suvraspinal control existsexists
Efficacious drugs (SSRI, tricyclic antidepressants)Efficacious drugs (SSRI, tricyclic antidepressants) Psychotherapy can support pharmacologic Psychotherapy can support pharmacologic
treatmentstreatments
ESSM LectureESSM Lecture
S. MerynS. Meryn
Testosterone, Metabolic syndrome and Testosterone, Metabolic syndrome and
EDED
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Testosterone, Metabolic syndrome and EDTestosterone, Metabolic syndrome and ED
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High prevalence of hypogonadism and ED in metabolic High prevalence of hypogonadism and ED in metabolic syndrome and its componentssyndrome and its components
Hypogonadism is a predictor of diabetes II Hypogonadism is a predictor of diabetes II
Hypogonadism is associated with high mortality in aging Hypogonadism is associated with high mortality in aging menmen
ED is highly associated with the metabolic syndrome and ED is highly associated with the metabolic syndrome and its componentsits components
ED is a predictor of the development of metabolic ED is a predictor of the development of metabolic syndrome and a calculator of CV risks, thus offering the syndrome and a calculator of CV risks, thus offering the opportunity for early detection and preventionopportunity for early detection and prevention
Waist circ. > 94 cm for men and > 80 cm for women plus
two of the four following factors:
1.Fasting triglycerides > 150 mg/dL
2. HDL Cholesterol < 40 mg/dL for men and < 50 mg/dL for women
3. Systolic blood pressure > 130 or diastolic blood pressure > 85 mm Hg
4. Fasting glucose > 100 mg/dL or known DM Type 2.
New Definition: METABOLIC SYNDROME International Diabetes Federation
http://www.idf.org/webdata/docs/MetSyndrome_FINAL.pdf
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Testosterone, Metabolic syndrome and EDTestosterone, Metabolic syndrome and ED
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• Androgen deprivation therapy for prostate cancer is Androgen deprivation therapy for prostate cancer is associated with associated with increased risk of diabetes, coronary heart disease, MI, sudden cardiac death and worsening of existing diabetes
• Testosterone therapy may improve insulin sensitivity and Testosterone therapy may improve insulin sensitivity and reduce abdominal obesityreduce abdominal obesity
ED may be the first symptom driving men to seek ED may be the first symptom driving men to seek medical help medical help
It is therefore an opportunity but also a It is therefore an opportunity but also a responsibility for physicians seeing patients with ED responsibility for physicians seeing patients with ED to look for concomitant risk factors and diseasesto look for concomitant risk factors and diseases