International Society For Sexual Medicine Research Articles

Advances and Missteps in Diagnosing Premature Ejaculation: Analysis and Future Directions

There are several problems with diagnostic criteria for premature ejaculation (PE) that lack objectivity, clarity and precision. They hamper accurate determination of PE prevalence estimates, investigations into the etiology of the dysfunction, impact on partners, development of validated Patient Reported Outcomes, regulatory authority oversight, and which men might benefit from specific treatment interventions. We sought to review, analyze and comment on the evolution of the definitions of PE and offer suggestions for future directions for PE definitions. Our goal is to propose strategies whereby the criterion sets are useful to researchers, clinicians and governmental oversight agencies alike and bring harmony and scientific rigor among the conflicting and confusing definitions. There are several premature ejaculation definitions published in the peer reviewed medical literature. The PUBMED electronic database from 1970 to 2021 was searched for published definitions. Search terms included the medical subject headings of premature ejaculation, definition and diagnosis. In chronological order, Table 1 lists the various diagnosis and criteria sets for PE. We discuss the process by which constructs, which make up diagnostic criteria sets, are operationalized and validated. We review definitions of PE beginning with Masters and Johnson's focus on partner orgasmic attainment and move through the nebulous and subjective criterion sets found in the early Diagnostic and Statistical Manuals and International Classification of Disease series, to the more evidenced-based definitions found in International Society of Sexual Medicine, Diagnostic and Statistical Manuals-5 and the American Urological Association (AUA) definitions. Additionally, we discuss how constructs and criteria sets have been adopted to minimize errors of inclusion and exclusion in defining disease/dysfunction. This manuscript offers a careful chronological analysis of the published definitions of PE. This historical lens allows the reader to perceive the shifting science underlying the development of PE definitions. The manuscript is limited regarding our comments on acquired PE as evidenced-based research is incomplete. Over the past 50 years there has been considerable forward momentum in defining PE based on well conducted scientific studies. We support the American Urological Association's modification in Intravaginal ejaculatory latency time to 2-minutes for lifelong PE, concur with the 11th revision of the International Classification of Diseases recommendation for changing the terminology from premature ejaculation to early ejaculation. We also recommend ongoing validation of definitions, moving away from the current heterosexist definition of PE based on penile-vaginal sex and urge further population based research into acquired PE to develop stronger evidenced-based criterion sets for this subtype. Althof SE, McMahon CG, Rowland DL. Advances and Missteps in Diagnosing Premature Ejaculation: Analysis and Future Directions. J Sex Med 2022;19:64-73.

Comprehensive History of the International Society for Sexual Medicine-Journals and Communication.

This is a comprehensive history of the International Society for Sexual Medicine (ISSM) and its founding organizations regarding the publications, including the journals and the publication committee, and the communication tools of the organization since its inception. The object of this review is to provide a detailed and comprehensive history of the publication and communication tools of the ISSM and the people who have participated in production of these efforts. Recorded Publication Committee minutes, filed letters, the various journals themselves, printed News bulletins, and Publishers reports to the society served as source documents to produce this history. The author has participated in many of the journal establishments and has kept an extensive personnel file of the events related in this history. All written history has not only relied on personal memories of these events but have been verified from the stored personal files. Printed and website stored journal and News bulletin have served as source material for this history. Also, Power Point presentations by the editors of the journals at the Publication Committee meetings have served as source material. Finally, annual, and semi-annual reports of the Publishers presented at Publication Committee meetings of the ISSM are source material. After extensive review of the historical material listed in the Methods section of this abstract, this comprehensive history of the communication efforts of this society has provided a rich and dynamic historical document for this society. This extensive, detailed, and comprehensive history of the communication tools of this society help us to record and remember the events and the people involved in this process. Sharing scientific information and information regarding the life of the International Society for Sexual Medicine have been an important function of this society from early. Lewis RW. Comprehensive History of the International Society for Sexual Medicine-Journals and Communication. Sex Med Rev 2021;9:542-567.

Comprehensive History of the International Society for Sexual Medicine.

This is a detailed comprehensive history of the International Society for Sexual Medicine (ISSM) since its beginning in 1978. This was constructed after interest was shown following an oral presentation to the Executive Committee of this organization during their 2020 virtual (Zoom) business meeting. To provide for the membership of ISSM a detailed history of their society since its inception until 2020 and have this serve as a repository document for review of the long history as needed by the society. Written documents were used as source material for this history. Some documents from my personal files included letters, minutes of meetings, program booklets. Other data published in our ISSM printed and online website served as sources. Finally, documents supplied to me by our business office regarding written files were used to provide valid documentation for the construction of this history. There were very few anecdotes from my memory that were included. The comprehensive nature of this history provides a repository of our rich history of events and people involved in the ISSM. This is the first comprehensive history of the ISSM that is collected from actual historical documents. Lewis RW. Comprehensive History of the International Society for Sexual Medicine. Sex Med Rev 2021;9:517-541.

Increased attentional network activity in premature ejaculation patients with anxiety revealed by resting-state functional magnetic resonance imaging.

Psychological account hypothesizes that premature ejaculation (PE) is a learned pattern of rapid ejaculation maintained by anxiety about sexual failure, whereas neuropsychological accounts hypothesizes that PE is the result of dysfunction of central nervous system regulating ejaculatory. However, the central neural mechanism underlying PE patients with anxiety remains unclear. Resting-state functional magnetic resonance imaging (fMRI) data were collected in 20 PE (diagnoses based on PE Guidelines drafted by the International Society for Sexual Medicine [ISSM]) patients with anxiety and 25 matched healthy controls (HCs) from January 2019 to December 2020. The values of fractional amplitude of low-frequency fluctuation (fALFF) were compared between groups. Moreover, the correlations between fALFF and the severity of PE and anxiety of patients were examined. PE patients with anxiety had increased fALFF values in the right inferior frontal gyrus (opercular part) and middle frontal gyrus. In addition, significant positive correlations were found between the scores of PE diagnostic tool (PEDT) and fALFF values of the right inferior frontal gyrus (opercular part), as well as the right middle frontal gyrus. Moreover, fALFF values of the right inferior frontal gyrus (opercular part) and middle frontal gyrus were positively correlated with the scores of self-rating anxiety scale (SAS). Our results suggested that increased attentional network activity might play a critical role in the neural basis of PE patients with anxiety.

Comparing and Contrasting Peyronie's Disease Guidelines: Points of Consensus and Deviation

BackgroundPeyronie’s disease (PD) is a challenging clinical entity. To assist clinicians with diagnosis and management, four separate organizations have published PD guidelines over the past five years, but there remains a lack of consensus and data-driven recommendations for many aspects of diagnosis and treatment. AimTo compare and contrast PD guidelines, highlighting key similarities and differences among the guideline panel recommendations and identify areas for further research. MethodsWe performed an extensive review to compare and contrast diagnosis and treatment recommendations from publically available published PD guidelines from four different organizations: American Urological Association, European Association of Urology, Canadian Urologic Association, and the International Society of Sexual Medicine. OutcomesKey similarities and differences with regards to definition, evaluation, nonsurgical and surgical treatments were compared. ResultsPoints of general consensus among the guideline panels included: History is adequate for diagnosis of PD, and intracavernosal injection is a gold standard to evaluate penile deformity prior to invasive intervention. Careful counseling with shared decision-making is required prior to treatment. In general, plication and incision and/or grafting surgery is reserved for patients with preserved erectile function whereas penile prosthesis implantation is the only surgical option for PD patients with erectile dysfunction. Overall, nonsurgical treatments have inferior evidence of efficacy with these being the main area of controversy; however, all societies recognize that intralesional injections may be used. 0Further research into the pathophysiology of PD may direct novel treatments targeted towards early intervention and rigorous outcomes research may direct best practices for the surgical treatment of PD in the future. Clinical ImplicationsPD is a challenging clinical entity. Direct comparison of the published PD guidelines highlights clear standards of care as well as areas where more research is needed to promote higher levels of evidence-based practice. Strengths & LimitationsTo our knowledge this is the first report to directly compare and contrast published guidelines pertaining to the diagnosis and management of PD. Limitations include the lack of evidence-quality review pertaining to individual guideline recommendations, although this was not the aim of this review. ConclusionWe highlight consensus of major urologic societies on many aspects of work up and management of PD with notable exceptions which may guide further research.Manka MG, White LA, Yafi FA, et al. Comparing and Contrasting Peyronie's Disease Guidelines: Points of Consensus and Deviation. J Sex Med 2021;18:363–375.

A clinical pathway for the management of Peyronie’s disease: integrating clinical guidelines from the International Society of Sexual Medicine, American Urological Association and European Urological Association

To provide a clinical framework and key guideline statements to assist clinicians in the evidence-based management of Peyronie's disease (PD). We conducted a review of the published literature relevant to PD management, with an emphasis on published clinical guidelines. References used in the text have been assessed according to their level of evidence, and guideline recommendations have been graded based on the Oxford Centre for Evidence-based Medicine Levels of Evidence. The management of PD involves taking a detailed penile and sexual history, with a focused penile examination to identify plaque and hourglass deformity, and digital photographs of the erect curved (deformed) penis. Penile colour Duplex ultrasonography evaluates tunical plaque and underlying cavernosal smooth muscle and blood flow variables. The current therapy for PD can be divided into two main groups, namely, medical therapy and penile reconstructive surgery, and the patient should be counselled on the benefits and risks of each treatment option. Peyronie's disease remains a clinical challenge and presents a considerable therapeutic dilemma as the current therapy addresses existing penile curvature only and is not very effective in preventing future penile fibrosis and/or reversing underlying erectile dysfunction.

Majoon-E-Piyaz: A Potent Unani Formulation for Premature Ejaculation

Surʻat-e-Inzāl (Premature Ejaculation) is the most prevalent male sexual dysfunction affecting 25 - 40% global population of men. It is a universal disorder and is independent of age, social or marital status. It has a significant impact on both- patients and their partners, causing distress, anxiety and relationship difficulties affecting the quality of life. Several aetiologies have been proposed by various researchers which are not evidence-based but speculative. Accordingly the International Society for Sexual Medicine (ISSM) issued treatment guidelines for Premature Ejaculation (PE) recommending Serotonergic Antidepressants (SSRIs) and Local Anaesthetics (LA) for its management in modern medicine. However, these treatments were not actually developed for PE, and have limitations associated with their off-label use. Furthermore, nearly all the recommended drugs have a wider spectrum of adverse effects and serious drug interactions which sometimes could be fatal. On the other hand, centuries old Unani medicine offers a complete line of treatment for Surʻat-e-Inzāl based on traditional knowledge and experience. Unani physicians devised a large number of poly-herbal recipes which are still in vogue. Majoon-e-Piyaz (MP) is one of the compound Unani formulations which are in use for the treatment of premature ejaculation since centuries. This article is an attempt to summarize scientific investigations in support of the claim made by Unani physicians regarding Majoon-e-Piyaz (MP). 
 Keywords: Surʻat-e-Inzāl, Premature Ejaculation, Majoon-e-Piyaz, Unani Medicine

Treatment of Estrogen Levels in the Management of Hypogonadism: An Anonymous Survey of ISSM Members

ObjectiveTo assess the variability in management of estrogen levels in men treated with testosterone therapy (TTh). With the significant increase in the last 2 decades in the treatment of hypogonadism and the use of TTh, detailed guidelines for the management of estrogen levels are necessary.1 Materials and MethodsAn anonymous survey was electronically distributed to the membership of the International Society for Sexual Medicine including questions on demographics, symptoms, and their approach to management of estrogen in patients on TTh. Chi-square test was used to determine associations. ResultsThe response rate was 22.5% (489/2168). A total 62.4% of respondents indicated that they check serum estrogen at initial evaluation, but only 54.7% monitor levels in patients on TTh (P = .02). Fellowship-trained and North American respondents were more likely to monitor patients (P < .05). A total of 69.4%, 47.7%, and 14.4% respondents prescribe antiestrogenic medications in symptomatic patients with elevated estrogen levels, for asymptomatic-elevated estrogen levels, and prophylactically, respectively. Academic respondents were more likely to prescribe an antiestrogen medication to symptomatic patients and prophylactically (P < .05). Anastrozole was the most common medication prescribed for symptomatic hyperestrogenemia (62.3%), but starting doses varied significantly, from 1 mg weekly to 1 mg daily. ConclusionApproximately 50% of practitioners treating men with TTh monitor estrogen levels. Symptoms play a role in prescribing patterns and significant variability in aromatase inhibitors regimens exists. Increased monitoring of estrogen levels in men on TTh will facilitate an understanding of the symptoms, effects of high and low estrogen levels, and aid in standardization of research and therapy.

Dapoxetine for the management of premature ejaculation

Premature ejaculation is the most prevalent male sexual disorder and is more common in South Asia. Bangladesh is no exception. Premature ejaculation causes dissatisfaction in the relationship, frustration for the patient and partner as well as reason of marital failure. Since 1970s sex therapy was the mode of treatment for premature ejaculation. Now treatment with drugs also seems effective. Now a days dapoxetine is used in Bangladesh for the treatment of premature ejaculation. The aim of the study was to determine the efficacy and tolerability of dapoxetine in patients with premature ejaculation. It was a prospective study conducted in private chamber of Dhaka city during the period of March 2016 to February 2017. A total of 60 patients within 21 to 75 years were enrolled in the study according to criteria of International Society for Sexual Medicine (ISSM). We determined the efficacy of dapoxetine 30 mg/day for 12 weeks. The primary endpoint was intra vaginal ejaculatory latency time (IELT) measured by stopwatch. Safety and tolerability were assessed. All analysis was done on an intention-to-treat basis. The results showed that, dapoxetine significantly prolonged IELT (p&lt;0.001) after 12 weeks. After treatment of 1st, 4th ,8th week mean IELT were 1.71 (SD±0.50) minutes, 2.36 (±0.46) minutes and 2.98 (±0.66) minutes respectively. At the end of 12th week 3.89 (±0.87) minutes was evaluated. Common adverse effects were observed as nausea (11.0%), diarrhoea (3.5%), headache (5.6%), dizziness (5.8%), insomnia (2.1%) and backache (1.8%). So from this study it could be said that, dapoxetine was an effective and generally well tolerated treatment for men with premature ejaculation.&#x0D; Bang J Psychiatry June 2017; 31(1): 15-19

Premature Ejaculation: 2020 Update

Premature ejaculation (PE) is one of the most common forms of male sexual disorder. There are still different opinions and point of view regarding its definition, classification, prevalence, pathophysiology and treatment alternatives. For these reasons, we aim to recap the recently accumulated data on definition, classification, pathophysiology and treatment alternatives of PE. The literature pertaining to PE has been reviewed by the authors. All the related articles were critically analyzed and examined. Levels of evidence (Les) and grades of recommendation (Grs) are provided based on a thorough analysis of the literature and consensus. After the initial evidence-based definition developed for lifelong PE, the International Society for Sexual Medicine (ISSM) advertised another unified definition for lifelong and acquired PE and confirmed the time criterion for the diagnosis of PE. The ISSM has also acknowledged the presence of the two more PE subtypes (variable and subjective PE) underlining the fact that more research is required to develop an evidence-based definition of these sexual problems. Although the pathophysiology of these four PE syndromes has not been completely elucidated yet, pharmacotherapy must be considered the treatment of choice for lifelong PE patients whereas treating the underlying pathology must be the initial goal for patients with acquired PE. To treat PE, we can use daily or on-demand use of SSRIs, on-demand use of topical anaesthetics, on-demand tramadol or phosphodiesterase type-5 inhibitors. Psychotherapy can be offered to patients who describe variable and subjective PE. Despite the recent progress reached in the field of PE, there are on-going debates regarding the definition, classification, pathophysiology and treatment of this common problem. Future clinical trials must be performed to understand the actual aetiology of the four PE syndromes and develop more effective and safe treatment alternatives.

Premature Ejaculation: Aetiology and Treatment Strategies.

Premature ejaculation (PE) is a highly prevalent male sexual dysfunction that is often neglected, presenting a currently unmet therapeutic need. The classification of PE has historically been varied and at times ambiguous, contributing to inaccurate prevalence estimates. This review uses the International Society for Sexual Medicine (ISSM) definition of PE, which includes reduced ejaculatory latency, lack of control and associated negative personal consequences. Patient assessment and management options differ depending on the classification of PE and it is the role of the clinician to appropriately classify patients and be aware of the correct management strategies. This review provides an overall background of PE in terms of classification and underlying physiology, patient assessment and management strategies along with the scientific rationale for treatment. Patients with lifelong and acquired PE are most likely to benefit from combination therapy of pharmacological treatment in the form of selective serotonin re-uptake inhibitor dapoxetine, psychosexual behavioural therapy and psychological therapy.

Guideline of guidelines: testosterone therapy for testosterone deficiency.

We analysed the guidelines for testosterone therapy (TTh) produced by major international medical societies including: the American Urological Association, European Association of Urology, American Association of Clinical Endocrinologists, British Society for Sexual Medicine, Endocrine Society, International Society for Sexual Medicine, and the International Society for the Study of the Aging Male, and compared their recommendations. All the organisations were in general agreement concerning the following key points: Only men meeting the criteria for testosterone deficiency (TD) should be treated. Consider screening asymptomatic men with certain conditions that increase the risk of TD. Exogenous TTh causes impairment of spermatogenesis. There is no evidence that TTh causes prostate cancer. Men on TTh require careful laboratory monitoring.

Global Consensus Position Statement on the use of Testosterone Therapy for Women

This Statement is being simultaneously published in the journals Climacteric, Maturitas, Journal of Sexual Medicine, and Journal of Clinical Endocrinology and Metabolism on behalf of the International Menopause Society, The European Menopause and Andropause Society, The International Society for Sexual Medicine, and The Endocrine Society, respectively. This Position Statement has been endorsed by the International Menopause Society, The Endocrine Society, The European Menopause and Andropause Society, The International Society for Sexual Medicine, The International Society for the Study of Women's Sexual Health, The North American Menopause Society, The Federacion Latinoamericana de Sociedades de Climaterio y Menopausia, The Royal College of Obstetricians and Gynaecologists, The International Society of Endocrinology, The Endocrine Society of Australia, and The Royal Australian and New Zealand College of Obstetricians and Gynaecologists.

Testosterone Deficiency: A Review and Comparison of Current Guidelines

BackgroundThere is much controversy regarding the appropriate evaluation and management of testosterone deficiency (TD). AimTo compare current guidelines on the evaluation and management of TD to provide clarity for patients and clinicians, as well as to highlight areas of controversy. MethodsA literature search of MEDLINE, Embase, Cochrane Library, and various association websites was performed to identify guidelines for TD. OutcomesKey aspects in the approach were compared, with a focus on the biochemical definition (cutoff) for low testosterone (T), principles of management, and recommendations for testosterone therapy (TTh) in special patient populations. ResultsGuidelines from the Canadian Medical Association Journal, American Urological Association, European Association of Urology, Endocrine Society, International Society for Sexual Medicine, and British Society for Sexual Medicine were included for review. Recommendations were generally consistent across guidelines. Key differences include the biochemical cutoff for low T, and recommendations for patients with low to normal T, prostate cancer, or cardiovascular disease. We highlight several case scenarios in which management differs depending on the guideline adopted. Clinical ImplicationsAlthough general diagnostic and management principles are in agreement across the guidelines, notable differences may impact patient diagnosis and eligibility for TTh. Strengths & LimitationsOnly guidelines written in English were included. The quality of the included guidelines was not evaluated, but this was beyond the scope of this review. ConclusionWe highlight the limitations of relying exclusively on guidelines in managing patients with TD.Kwong JCC, Krakowsky Y, Grober E. Testosterone Deficiency: A Review and Comparison of Current Guidelines. J Sex Med 2019;16:812–820.

Ten-Year Interval Changes in the Prevalence of Self-Identified Premature Ejaculation and Premature Ejaculation Based on an Estimated Intravaginal Ejaculation Latency Time of

IntroductionBecause the prevalence of premature ejaculation (PE) may change with time, few studies have been conducted over a 10-year time interval. AimA 10-year time interval survey to determine whether there was a change in the prevalence of self-identified PE and PE defined on the basis of an estimated intravaginal ejaculation latency time of <3 minutes in adult Korean men, even after adjusting for various sociocultural factors. MethodsWe sent an e-mail to the panels registered in the same Internet survey agency in 2006, asking them to participate in a questionnaire-based survey of the same study design. 1,401 participants were enrolled in the 2016 study that included 800 subjects in their 20s–50s. The PE prevalence adjusted for age was evaluated because the proportion of participants per age was different between the 2 surveys. The age-adjusted prevalence of self-identified PE and PE with an estimated intravaginal ejaculation latency time of 3 minutes, which meets the diagnostic criteria for PE set by the International Society for Sexual Medicine (PE), was evaluated. Main Outcome MeasuresChanges in the overall prevalence of self-identified PE and PE in over a decade were evaluated. ResultsThe overall age-adjusted prevalence of self-identified PE increased from 19.0% in 2006 to 21.6% in 2016; however, the result was not statistically significant (P = .244). The overall age-adjusted prevalence of PE increased from 1.8–4.0% in 2006 and 2016, respectively (P = .012). The risk factors of self-identified PE were few intercourses per month, masturbation, and self-identified erectile dysfunction. In addition, the risk factors of PE were aging, high body mass index, few intercourses per month, and masturbation. Clinical ImplicationThe prevalence of PE has increased over 10 years. However, this increase may be due to sociocultural changes and should be more concerned with these factors. Strength & LimitationsThis study was the first to conduct a 10-year interval Web-based survey on the prevalence and risk factors of PE. However, this was not a cohort study with the same participants. ConclusionThe overall age-adjusted prevalence of PE increased significantly over a decade, and sociocultural factors such as lifestyle were associated with the difference of PE prevalence for 10 years. However, more research is needed to determine how these sociocultural changes affect PE prevalence.Song WH, Yoo S, Oh S, et al. Ten-Year Interval Changes in the Prevalence of Self-Identified Premature Ejaculation and Premature Ejaculation Based on an Estimated Intravaginal Ejaculation Latency Time of <3 Minutes in the General Population: The Korean Internet Sexuality Survey (KISS) 2016. J Sex Med 2019;16:512–521.

Content Validity of the Premature Ejaculation Profile, Original and Per-Event Formats, in Men with Lifelong Premature Ejaculation

BackgroundThe Premature Ejaculation Profile (PEP) is a patient-reported outcome (PRO) measure that is widely used in clinical research in men with premature ejaculation (PE) but has not been fully validated for men meeting the current International Society for Sexual Medicine (ISSM) definition of lifelong PE. AimTo explore the content validity of the PEP (original 1-month recall version and new event-driven version) in men meeting current definitions of lifelong PE and to understand the relevance of the concept of ejaculation control. MethodsIn-depth individual interviews were conducted with 24 men in a stable heterosexual relationship, including 15 with lifelong PE, 4 with acquired PE (with intravaginal ejaculation latency time values confirmed during a 4-week period of no treatment), and 5 with no sexual dysfunction. Initial concept elicitation explored individual experiences of having PE (in those with PE), experiences of control, and impact on sexual life. This was followed by a cognitive debriefing of the PEP versions. Main Outcome MeasureThematic analysis was used to identify key concepts of PE, understand the experience of control in men with and without PE, and confirm understanding and relevance of questions from original and event-driven versions of the PEP. ResultsThe interviews confirmed substantial negative consequences for men with lifelong PE. Men with and without PE could describe ejaculation control (or lack of it). The PEP was shown to cover the key concepts in PE, and the questions were easily understood in both the original or event-driven versions. The items were comprehensive, and the concept of ejaculation control was confirmed. A 1- or 2-category change in each item of the PEP was considered clinically meaningful. Clinical ImplicationsThe PEP (original and per-event) has strong content validity for use in clinical research studies of men meeting the ISSM definition of lifelong PE. Strengths & LimitationsThis study addressed gaps in previously published research on the development and validation of the PEP and also confirmed that a new event-driven version is also suitable for use in research. However, the study was limited mainly to men meeting a strict definition of lifelong PE; in addition, homosexual men and those not in stable long-term relationships were not studied. ConclusionBoth the original and per-event PEP versions were shown to have strong content validity and be acceptable for use in men with lifelong PE.Burbridge C, Symonds T, Osterloh IH, et al. Content Validity of the Premature Ejaculation Profile, Original and Per-Event Formats, in Men with Lifelong Premature Ejaculation. J Sex Med 2019;16:569–576.

Sildenafil/Viagra in the treatment of premature ejaculation.

The arrival of Pfizer's blue pill Sildenafil in 1998 brought a great relief both to patient and physician signalling the start of a great era of medical therapy in sexual medicine. Since then the sexual medicine experts have been prescribing sildenafil in erectile dysfunction with acceptable minor adverse events. But the use of sildenafil in premature ejaculation (PE) is still debated. 2018 being the 20th anniversary of sildenafil, we have compiled interesting facts about the role of sildenafil in PE from various original articles, systematic reviews, meta-analyses, economic brochures and sexual medicine committee guidelines. The major issues in most of these studies were the heterogeneity in the definition of PE and estimating the exact ejaculatory latency time. This perspective article highlights the positive role of sildenafil in the management of PE (even without ED) with acceptable adverse events. Now that we have a standardised definition of PE from International Society of Sexual Medicine (ISSM) and a psychogenic component in PE definition, more randomised placebo-controlled studies are required to further establish its role.

Variation in collagenase Clostridium histolyticum practice patterns: a Survey of ISSM Members.

Collagenase clostridium histolyticum (CCH, Xiaflex, Xiapex) is the only FDA-approved medication for treatment of Peyronie's disease. It is unclear how practitioners actually use CCH in their own practices. The objectives of the study were: (1) to identify variability in practice patterns for CCH among practitioners, (2) to assess adherence to the package insert instructions, and (3) to evaluate whether provider satisfaction was associated with adherence to instructions. A 30-question online survey was distributed to 1270 members of the International Society for Sexual Medicine (ISSM) from the EU, USA, Canada and Australia. Of the 30 questions, 10 survey questions had only one response consistent with the CCH package insert recommendations. An "adherence" score was calculated for each survey participant depending on how many of these questions were answered correctly. The average adherence scores of various groups were compared using a student's t-test. A chi-squared test was used to determine association between categorical variables. Of 202 total responses, 132 practitioners reported using CCH out of 1270 ISSM members from countries where CCH is available (10.4% response rate). Practitioners from outside the USA were more likely to be satisfied with CCH (p = 0.006), and more experienced users (>20 uses) were more likely to be satisfied than less experienced users (<10 uses) (p = 0.046). Satisfied users of CCH did not have significantly different adherence scores than non-satisfied users. Even though 67% of practitioners believed they followed the package insert guidelines, only 11% adhered to all the recommendations evaluated by the survey. Treatment adherence to package insert guidelines does not appear to be associated with provider satisfaction. We believe there is utility in seeing a snapshot of these practice patterns so practitioners may feel more comfortable adapting their own practice in light of newer data supporting alternative administration methods.

Current practice in the management of ischemic priapism: an anonymous survey of ISSM members.

Penile shunting is the standard of care in management of ischemic priapism refractory (IPR) to non-surgical interventions. Due to high rates of impotence, corporal fibrosis, and loss of penile length, recent literature suggests these patients benefit from immediate penile prosthesis (PP) placement. An IRB-exempt anonymous electronic survey of the 2,168 members of the International Society for Sexual Medicine (ISSM) was conducted. The survey included demographic information, confidence and experience related management of IPR. The aim was to evaluate current practice patterns in management of IPR and to investigate the role of immediate PP implantation in the management of prolonged (>36-hours) IPR. The survey response rate was 11.6% (n=251). Most respondents were urologists (173), from the USA (49.1%), and had completed a fellowship in male sexual medicine, men’s health, reconstruction, or andrology (71.1%). The majority (91.3%) see at least one case of prolonged priapism (>36 hours) that requires surgical management yearly. When looking at volume in training and after, our respondents had a significantly higher experience with penile prostheses (over 70%, >=10) as compared to shunts (less than 40%, >=10). Overall, 70.9% of respondents felt more comfortable with a malleable PP than a shunt. However, penile shunts are still preferred as the first line of surgical management by nearly 80% of respondents as compared to 12.7% who instead prefer a PP. We also found that under 40% of respondents currently use penile MRI or corporal biopsies in their management of prolonged assessment. This is the first study to assess current clinical practices in management of IPR globally. As in any anonymous self-reported survey-based research, recall bias, sampling bias are an inherent limitation. Penile shunting for IPR continues to be the preferred treatment despite emerging data. Respondents performed PP surgery routinely and feel more confident placing PP than performing penile shunting procedures.

Medical Management of Premature Ejaculation

Premature ejaculation (PE) is the most common form of male sexual dysfunction across all age groups. PE is associated with negative psychological consequences including frustration, distress, and low self-confidence, which can create an obstacle while forming new partner relationships. Given the subjective and highly variable nature of sexual dysfunction, there are multiple and often inconsistent definitions PE. The International Society for Sexual Medicine provides the most comprehensive definition of PE: both acquired and lifelong PE are characterized by ejaculation that always or nearly always occurs approximately within 1 min of vaginal penetration or when the patient has a clinically bothersome reduction in intravaginal ejaculatory latency time or due to an inability to delay ejaculation in all or nearly all vaginal penetrations–all of which lead to the accumulation of negative psychosocial burden. The etiology of PE may stem from genetic predisposition or psychologic components; however, the precise mechanism has not been elucidated and likely differs from individual to individual. There is a well-established link between PE and neurotransmitter signaling through which SSRIs (selective serotonin reuptake inhibitor) have a tangible therapeutic effect. There have been significant advances in management of PE with the use of psychosexual therapy and pharmacotherapy, mainly local anesthetics and SSRIs. This review contains 3 figures, 2 tables, and 36 references. Key Words: classification, epidemiology, male sexual dysfunction, medical management, premature ejaculation