E.S.A.U. HighlightsE.S.A.U. Highlights

Paolo VerzePaolo Verze

University Federico IIUniversity Federico IINaples, ItalyNaples, Italy

ESAU

Update on Update on ejaculatory ejaculatory disordersdisorders

ESAU

Embriology and anatomy of seminal tractEmbriology and anatomy of seminal tract

E. MeulemanE. Meuleman

ESAU

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

ESAU

Physiologic modulation: peripheral systemPhysiologic modulation: peripheral system

F. FuscoF. Fusco

ESAU

EmissionEmission

ExpulsionExpulsion

SACRAL PARASYMPATHETIC

NUCLEUS

THORACO-LUMBAR

SYMPATHETICSYSTEM

Spinal

Ejaculation

GeneratorONUF’s

NUCLEUS

ESAU

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

ESAU

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

ESAU

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

ESAU

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

ESAU

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

ESAU

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

ESAU

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

ESAU

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

ESAU

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

ESAU

Testosterone, Metabolic syndrome and EDTestosterone, Metabolic syndrome and ED

ESAU

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

ESAU

Testosterone, Metabolic syndrome and EDTestosterone, Metabolic syndrome and ED

ESAU

• 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