Premature ejaculation and chronic prostatitis

A.A. Kamalov et al. (2000) believe that sexual dysfunction in patients with chronic prostatitis is characterized by a staged development that corresponds to the course of the inflammatory process. At first, premature ejaculation appears (or is accelerated compared to previous indicators), then the quality of adequate erections worsens, and then libido decreases. Ejaculation disorder is sometimes combined with painful orgasmic sensations. In some cases, increased nocturnal erections are noted due to increased hyperemia of the prostate. Changes in orgasmic sensations are associated with the fact that approximately 1/3 of patients have chronic prostatitis combined with posterior urethritis and colliculitis, and the areas of the seminal tubercle are the place where the sensation of orgasm arises when ejaculating through narrow ejaculatory openings. A chronic sluggish process in the urethroprostatic zone leads to constant irritation of the seminal tubercle with afferent impulses to the spinal sexual centers. Clinically, this is manifested by prolonged inadequate nocturnal erections, and then their weakening due to the functional exhaustion of the erection center.

One of the most common types of sexual dysfunction in chronic prostatitis is premature ejaculation. According to O.B. Laurent et al. (1996), 35% of 420 patients with chronic prostatitis had premature ejaculation, and half of them also had a characteristic picture of colliculitis during urethroscopy. Liang C.Z. et al. (2004) found PE in 26% of Chinese patients with chronic prostatitis. E. Screponi et al., (2001), E. Jannini et al., (2002) also associate premature ejaculation with the inflammatory process in the prostate: the authors found chronic prostatitis in 56.5% of patients with premature ejaculation, of which bacterial prostatitis - in 47.8% of patients.

In chronic inflammation of the prostate, the posterior part of the urethra and the seminal tubercle, the sensitivity of the peripheral nerve endings is impaired, which reflexively entails changes in the excitability of the corresponding spinal centers. Thus, premature ejaculation resulting from urological diseases is closely related to spinal premature ejaculation, only in the first case the spinal sexual centers are involved in the process secondarily by reflex.

Some authors indicate that patients with chronic prostatitis have signs of erectile dysfunction in 60-72% of cases, which significantly exceeds this indicator in the general population. However, damage to the erectile component of the copulatory cycle in chronic prostatitis is no more, and in some cases even less pronounced, than in chronic somatic diseases of other localizations. According to A.L. Vertkin and Yu.S. Polupanova (2005), the frequency of erectile dysfunction in hypertension is 35.2%, in ischemic heart disease - 50.7%, in diabetes mellitus type I - 47.6%, type II - 59.2%.

Berghuis JP et al. (1996) reported that prostatitis leads to a reduction in the frequency of sexual intercourse in 85% of patients, prevents or leads to the termination of existing sexual relations (67%) and prevents the establishment of new sexual relations in 43% of cases. The reason for this is hypochondria, depression and hysteria, which are more often manifested in patients with chronic prostatitis of an autoimmune nature.

As for libido, its weakening may occur on a psychogenic basis due to depression and increased anxiety of the patient, orgasm disorder and secondary weakening of erection. The patient, fearing failure, consciously and subconsciously avoids sexual intercourse. In addition, this phenomenon can be explained by hypoandrogenism, inherent in patients with protracted prostatitis, according to some data. According to researchers, the prostate gland and testicle are in a positive correlative dependence, and if one of the organs is impaired, the other suffers. In this case, the testicle produces a smaller amount of androgens. On the other hand, the prostate is an organ responsible for the metabolism of sex hormones, which can be impaired when the gland is diseased.

Scientists examined 638 patients with chronic prostatitis of infectious nature and non-infectious prostatitis aged from 19 to 60 years (on average 36.1 + 11.9). Of these, 216 people (33.9%) complained of various sexual disorders. Among these 216 patients, 32 complained of decreased libido (14.8% of patients with sexual disorders and 5% of all patients with chronic prostatitis). Deterioration in the quality of erection was found in 134 patients (62 and 21%, respectively), including deterioration in the quality of spontaneous and adequate erections in 86 people (39.8 and 13.47%) and deterioration in the quality of adequate erections in 48 people (22.2 and 7.5%).

Ninety patients (41.7 and 14.1%) complained of accelerated ejaculation. Eight patients (1.25 and 3.70%) had blurred emotional coloring of orgasm, and one patient (0.46 and 0.16%) had a complete absence of orgasm.

Traditionally, erectile dysfunction is considered the main sexual disorder that most worries men. Accordingly, the efforts of the pharmaceutical and medical industries, scientific research have been aimed mainly at improving/restoring erection. It should be recognized that the successes in this field have been impressive: with rare exceptions, erectile function can be restored in one way or another. However, sexual intercourse cannot be reduced to erection only, it also includes desire (libido) and ejaculation - an expression of orgasm. Unfortunately, these two components of sexual intercourse are not given enough attention. As a result, we often have a patient with an excellent erection, but, nevertheless, dissatisfied with his sex life.

The main parameter in determining premature ejaculation is IELT - the period of time between the introduction of the penis into the vagina and the onset of ejaculation. There is no clear and unambiguous definition of premature ejaculation as a pathological condition. One of the first definitions was proposed by American sexologists Masters and Johnson in 1970, who considered ejaculation to be premature if it occurred before the woman achieved orgasm in 50% of cases or more.

The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) published by the American Psychiatric Association (1994) offers the following definition of premature ejaculation: "Persistent or recurrent ejaculation with minimal sexual stimulation during or shortly after penetration of the penis into the vagina before the partners desire it; this condition causes distress or bother to the partners and disrupts the relationship." However, it does not specify what "recurrent" means - every 2, 5, 7 times? "Minimal sexual stimulation" is different for each couple, "soon after" - when exactly, "causes bother" - is very individual.

There is similar ambiguity in the American Urological Association's 2004 guidelines for the management of premature ejaculation, which defines premature ejaculation as "ejaculation that occurs earlier than desired, before or shortly after penetration, and that is bothersome to one or both partners."

In 1992, in the USA, through a direct survey of 1243 men aged 18 to 59 years, it was found that 28 to 32% of them noted premature ejaculation; the frequency depended on age, sexual habits, etc. When analyzing the responses to questionnaires of 100 married men, premature ejaculation was noted in 36. According to Aschaka S. et al. (2001), 66 out of 307 patients experienced premature ejaculation at least once in their lives.

Waldinger MD et al. (2005) consider premature ejaculation to be a neurobiological dysfunction with an unacceptably high risk of developing sexual and psychological problems during life. The authors measured the duration of sexual intercourse with a stopwatch in 491 patients from five countries (the Netherlands, Great Britain, Spain, Turkey and the USA) and came to the conclusion that men with an IELT of less than 1 min can be classified as “definitely” premature ejaculators, and with an IELT of 1 to 1.5 min - as “possibly” suffering from it. The degree of severity of premature ejaculation (absent, mild, moderate, severe) was proposed to be determined by the psychological state.

The wide range of figures is due to the lack of a clear definition and diagnostic criteria, the lack of quantitative expression of premature ejaculation. In other words, we are not yet able to assess the true prevalence of premature ejaculation in the population, although such a problem is obvious. Patients do not often consult a doctor with the problem of premature ejaculation due to shyness, ignorance of the possibilities of modern medicine, not understanding the danger of this disease. Premature ejaculation, of course, reduces sexual self-esteem, negatively affects family relationships. The quality of sexual life of male partners with accelerated ejaculation, as a rule, is also reduced.

There is primary premature ejaculation, which is observed from the beginning of sexual activity; in the case of the formation of persistent premature ejaculation after several years of normal sexual activity, we should talk about an acquired disease.

The most comprehensive description of primary premature ejaculation was proposed by Waldinger MD et al. (2005) - as a combination of the following symptoms:

• ejaculation occurs too early in almost every intercourse;
• with almost any partner;
• noted from the first sexual experience;
• about 80% of sexual acts are completed in 30-60 seconds and in 20% of cases last 1-2 minutes;
• The time to ejaculation is constant throughout life (70%) or even decreases with age (30%).

Some men ejaculate during foreplay, before the penis is inserted into the vagina. The prospects for drug therapy in such cases are low, but sometimes improvement can be achieved.

Acquired (secondary) premature ejaculation has a different nature and depends on the somatic and psychological state of the patient. As a rule, the man previously had a normal sex life, but at a certain point this disorder suddenly or gradually arose. The cause of acquired premature ejaculation can be urological diseases, especially erectile dysfunction and chronic prostatitis, thyroid dysfunction and other endocrine disorders, family problems, etc., so a patient with secondary premature ejaculation needs a comprehensive clinical and laboratory examination.

[ 1 ], [ 2 ], [ 3 ], [ 4 ], [ 5 ], [ 6 ], [ 7 ], [ 8 ]

Treatment of premature ejaculation

Acquired forms of premature ejaculation, like primary ones, can be extremely severe, manifested by ejaculation already during foreplay or at the moment of entering the vagina, but the secondary disease can be cured.

• Daily use of serotonergic drugs. Several controlled studies have been conducted to study the effectiveness of daily use of antidepressants: paroxetine, sertraline, clomipramine, fluoxetine. Meta-analysis has shown the absolute effectiveness of antidepressants in terms of prolonging the IELT, but this method of treatment is fraught with serious side effects: increased fatigue, nausea, weight gain, decreased libido and erectile function.

However, daily antidepressant use is the treatment of choice for primary premature ejaculation. Its advantage over on-demand medication is the possibility of spontaneous intercourse. The effect usually occurs by the end of the 2nd week, but it is unknown what percentage of men received long-term treatment and what the long-term results are.

• On-demand antidepressants. There are only a few studies on this treatment method; since they all differ greatly in methodology, it is impossible to draw a unified conclusion about the results. The main disadvantage of on-demand use is the need to accurately calculate the time of administration - 4-6 hours before sexual intercourse.
• Local anesthesia. It is possible to apply a spray or ointment containing lidocaine to the head of the penis 15-20 minutes before the start of sexual intercourse. Although this method has been known for a long time, there have been virtually no scientific studies to determine its effectiveness. Local anesthesia is not always effective; in some patients it causes irritation of the mucous membrane of the urethra and reduces erection. Nevertheless, this method should be recommended to patients who refuse to take antidepressants, as well as the first, trial type of treatment for those who seek help for the first time.
• On-demand use of phosphodiesterase type V (PDE5) inhibitors. Several studies have shown the effectiveness of drugs of this group in patients with premature ejaculation. However, the design of these studies does not allow for a definitive conclusion; a double-blind, placebo-controlled study of the effect of PDE5 inhibitors on the speed of ejaculation is needed. The explanation of the mechanism of action through an increase in the threshold of ejaculation seems speculative.
• Behavioral therapy. For a long time, premature ejaculation was considered a psychological problem, and various special positions and special sex techniques were proposed to solve it. However, there is no evidence of the effectiveness of these methods, except for the personal experience of individuals.

None of the described treatments for premature ejaculation (antidepressants, PDE5 inhibitors, local anesthesia) are approved by the US Food and Drug Administration, since there are no randomized, placebo-controlled studies proving their effectiveness.

Thus, premature ejaculation is quite common and is very disturbing for both the patient and his partner. However, there is still no effective and safe treatment method.

An open, non-comparative prospective study was conducted to determine the effectiveness of domestic herbal preparations Prostanorm and Fito Novosed in normalizing the neurophysiological parameters of sexual intercourse.

The study involved 28 patients with chronic prostatitis aged 21 to 58 years, 36.4±5.7 years on average, who also reported premature ejaculation. The disease duration was 2 to 18 years, 4.8±2.3 years on average. The frequency of exacerbations was 1-3 times a year. All patients had previously, before developing chronic prostatitis, had normal sexual intercourse, satisfying both the patients themselves and their partners in terms of duration and quality of orgasm. At present, all complained of decreased sexual desire, accelerated ejaculation, and blurred orgasm.

Standard examinations were performed upon admission and one month after the start of therapy: complete blood count, 3-glass urine test, Nechiporenko test, biochemical tests (blood sugar, cholesterol, bilirubin, transaminases), and blood pressure monitoring. All patients underwent rectal examination with gentle prostate massage. Light microscopy of native and Gram-stained prostate secretion and its sowing to identify non-specific microflora, a detailed study of the ejaculate, PCR diagnostics of the secretion and scraping of the mucous membrane of the urethra for DNA of the main sexually transmitted infections (chlamydia, mycoplasma, ureaplasma) were performed. The main parameters of the spermogram that were analyzed were the volume of ejaculate, its viscosity, the number of spermatozoa, the specific gravity of motile forms, the presence of an increased number of leukocytes and erythrocytes in the ejaculate.

The patients also filled out a questionnaire to assess their sexual function. The severity of the feature was assessed by points (6 points):

• 0 - no feature;
• 1 - very poor (very weakly expressed);
• 2 - poorly expressed;
• 3 - satisfactory (moderately expressed);
• 4 - good (well expressed);
• 5 - excellent (strongly expressed).

All patients received the same type of treatment for 4 weeks: at 8:00 and 14:00 - 0.5 teaspoon of prostanorm extract in water or sugar 30-40 minutes before meals; at 20:00 - 0.5 teaspoon of phyto novosed extract dissolved in a small amount of water, 1-1.5 hours after dinner.

The choice of the treatment regimen was determined by the following considerations. Prostanorm is a liquid extract of St. John's wort, Canadian goldenrod, licorice root and rhizomes with roots of purple coneflower. Fito Novosed is also an extract of plant materials: lemon balm, rose hips and hawthorn, motherwort and purple coneflower. The properties of these medicinal plants help to normalize the processes of excitation and inhibition in the central nervous system, which helps to regulate sexual intercourse. In addition, by beneficially influencing the course of inflammatory processes in the prostate, Prostanorm removes the prerequisites for such complications (or manifestations) of prostatitis as decreased sexual desire and premature ejaculation. At the same time, these drugs are devoid of all the negative properties inherent in the above-described treatment methods.

All 28 patients complained of loss of interest in sex, weakening of erection, and accelerated ejaculation. We did not try to express this indicator (PE) in time units, but relied on the points in which the patient subjectively assessed his condition. All men associated their disease with chronic prostatitis, noting a significant deterioration in sexual function during an exacerbation and for several weeks after antibacterial therapy.

The hemogram and three urine samples were within normal limits both at admission and at the end of treatment; hidden leukocyturia was not detected either. In the prostate secretion, a moderate number of leukocytes (10-25) was initially detected in 17 patients, in the remaining 11 patients the number of leukocytes exceeded 25 in the field of vision. In all cases, a reduced number of lecithin grains was detected. No growth of microflora was observed in any case. The PCR diagnostic method revealed mycoplasmas in 2 subjects and ureaplasmas in 1. None of the patients had a normal spermogram: a decrease in volume was noted in 28 (100%), a decrease in ejaculate viscosity in 26 (92.9%), asthenozoospermia was detected in 15 (53.6%), oligospermia in 8 (28.6%), and hypozoospermia in 12 (42.9%).

Blood pressure was moderately elevated (140/100 mmHg) in 6 patients, while the rest had normotension.

Thus, all 28 patients had CAP complicated by sexual dysfunction at the time of inclusion in the study. Given the absence of growth of pathogenic microorganisms in the experimental gonads, as well as a normal hemogram, we considered the prescription of antibiotics not indicated and limited ourselves to phytotherapy with prostanorm in combination with Fito Novo-Sed according to the above scheme.

At the control examination after 4 weeks, 27 patients noted significant improvement; 1 patient, a student, discontinued the therapy, since the course of treatment coincided with the exam period, and the resulting increase in libido distracted him from his studies. In 22 patients (81.5%), the prostatic secretion was sanitized, in the rest it improved significantly; the average number of leukocytes was 8.1 cells in the field of vision. The saturation of the smear with lecithin grains increased in 25 patients, in 3 this indicator did not change. The spermogram parameters also improved: the number of patients with asthenozoospermia decreased 3 times, with oligo- and hypozoospermia - 2 times. The volume of ejaculate increased on average 2.3 times.

Almost all parameters showed reliable improvement, with the exception of orgasm quality - the positive dynamics in this parameter did not seem so pronounced to our patients on average. In no case was any significant side effect noted (except for excessive effectiveness in the student). No negative effect of the drugs on hemodynamics was registered: neither patients with initial normotension, nor patients with initial hypertension had an increase in arterial pressure. On the contrary, among 6 patients with hypertension, 4 had a decrease in arterial pressure by an average of 12.4 mm Hg.

Since a subjective method of assessing male sexual function was used, 14 regular sexual partners of the patients were also interviewed for greater reliability. Women were asked to assess their sexual life before and after treatment using the same scale. It should be noted that initially the ladies viewed their sexual life more pessimistically than their partners, but they rated the results higher.

Thus, all women were satisfied with the results of their sexual partners' treatment, and even more satisfied than the patients themselves. At the time of their visit to the doctor, all 14 women assessed their sexual life with the patient as "bad", did not feel a desire for intimacy, sexual intercourse took place in a nervous atmosphere, and did not receive sexual satisfaction. A month later, 13 (92.9%) of the patients' wives noted an improvement, and 9 of them (69.2%) assessed the result as "significant improvement". One woman surveyed found the results unconvincing, although her husband was pleased with them.

Thus, the use of herbal preparations Prostanorm and Fito Novosed is highly effective as monotherapy for patients with chronic prostatitis complicated by sexual dysfunction. The preparations do not cause complications and side effects, have a beneficial effect on the general somatic condition of the patient, on the course of the inflammatory process in the prostate and on all components of sexual intercourse.

Modern scientific achievements leave no doubt that ejaculation is a neurobiological phenomenon. The process of ejaculation is regulated by the brain through neurotransmitters, the leading ones being serotonin, dopamine and oxytocin. Serotonin and oxytocin are produced by neurons in the brain. A brain cell must be excited quickly and repeatedly in response to a stimulus. The first to react to the signal are sodium channel proteins (sodium enters the cell), almost immediately followed by potassium channels (potassium leaves the cell, providing its inhibition and preparing it for the arrival of a new impulse). But already in the middle of the potential rise, calcium channels are activated, which provide calcium entry into the cell and activation of all functional processes of the cell. Without calcium, the neuron does not function: it does not produce serotonin, oxytocin, etc., does not transmit impulses.

The production of neurotransmitters, as well as other functions of the neuron, can be disrupted due to dysfunction of the brain-specific protein S 100, which plays a key role in the ion-exchange processes of the neuron. S 100 is an antigen, so the appearance of antibodies to it in the cerebrospinal fluid causes increased stimulation of the synthesis of this protein, restores the function of the neuron, removes foci of congestive excitation / inhibition, normalizes the production of neurotransmitters. The appointment of the drug tenoten, which is affinity purified antibodies to the brain-specific protein S 100. 1 tablet 2-3 times a day for 6-8 weeks sublingually allows you to achieve a stable anxiolytic, antidepressant, stress-protective, antiasthenic effect. At the same time, tenoten does not cause a sedative, muscle relaxant and anticholinergic effect. Conducting complex treatment with tenoten in combination with local low-intensity laser therapy for patients with chronic prostatitis complicated by ejaculation disorders allows for prolongation of sexual intercourse to an acceptable duration, relieves the patient's anxiety about this and significantly improves his quality of life.