Erectile and ejaculatory disorders

man and woman reading on the computer together

Dr. Alain Bitton

Urologists-Andrologists, Geneva and Milan

March 12, 2021

Sex is an important part of our lives. Erectile and ejaculatory disorders can negatively affect that. Around 20% of men have erectile dysfunction, and it gets progressively worse and more likely to happen as we age. People still think the issue is coming from the head even though it’s been proven that it’s a mix of organic problems. Cardiovascular risk factors like smoking, obesity, diabetes, and more, all negatively impact erection. Viagra does help, however, with the erection problem. On the other hand, we have ejaculatory disorders. They include premature ejaculation which is the most common one. Around 28%-36% of men suffer from premature ejaculation. 

Want to learn more? Keep reading the article by Dr. Alain Bitton!

Panic onboard!

Sexuality is an important parameter of quality of life. Yet today, sexuality, sex, and love are confused. We talk more about sex, that’s for sure, but the subject of sexuality is still taboo and love is still a vague notion and an ideal to be reached, difficult to define, especially for men. Even if we have succeeded since the introduction of Sildenafil (the famous Viagra) and other drugs that reinforce the erection mechanisms, in better treating and understanding sexual disorders, especially erectile and ejaculatory problems, the evolution of morals and our society seems to complicate human relations.

The caregiver is alerted daily by increasing awareness of the impact of sexuality on the life of the couple, but also of the anxiety that haunts many men, particularly in the case of sexual dysfunction. The anguish of talking about it of course, but above all the inability to put words to it, to verbalize, to express themselves, or simply to try to understand the normal or pathological mechanisms of the sexual function.

Flashback on the mechanisms of the European Union

The erection is a mechanism that is currently better understood. For many men, and fortunately for many years, it has been a natural physiological mechanism that allows them to obtain a hard penis in response to erotic or sensitive stimulation, thanks to a very complex automatism controlled by the brain centers. The hypothalamus generates influxes and stimuli which, along the spinal cord, reach the erector nerves and then the effector nerve endings in the corpora cavernosa and in particular the smooth muscle cell. This stimulation leads to a relaxation of the network of smooth muscle cells of the penis, formed by the two corpora cavernosa. The blood then inflates the organ and when it reaches maximum pressure the system locks. This is the mechanism of the erection!

The corpora cavernosa have a very similar structure, forming a sponge with connections through the interstices. At the junction between the nerve ending and the smooth muscle cell of the corpus cavernosum, there is a release of a very specific neurotransmitter, NO (nitric oxide) which, in a biochemical cascade, leads to an increase in cyclic GMP, a powerful vasodilator.

Erectile dysfunction: causes and effects on men

The overall prevalence of erectile dysfunction is 20% with the proportion increasing sharply with age. Indeed, about 10% of men aged 40-50 are affected and 20% of men aged 50-60. Statistics for 2025 speak of 325 million people worldwide affected by erectile dysfunction. For a long time, everyone thought it was all in the head. Indeed, didn’t Hippocrates say that the woman was the cause of male impotence. Today, we can consider that 70 to 80% of dysfunctions are mixed, with a large proportion attributed to organic problems such as all the cardiovascular risk factors like obesity, smoking, hypercholesterolemia, and diabetes, which are really silent killers of the erection by destroying the oxidative function of the endothelial cell of the corpora cavernosa. Obviously, from a certain age, the aging of the corpus cavernosum and the decrease in the production of nitric oxide, which is the main neuromodulator of the erection phenomenon, will play a preponderant role in the dysfunction. In the younger patient, it will be more a question of anxiety about failure, a desire to perform, sexual immaturity, or fragile sexuality. Apart from being a true barometer of the patient’s state of health, erectile function is of immense importance to men and any dysfunction will have a catastrophic impact not only on the physical but above all on the male psyche and the life of the couple.

What is the status of treatments more than fifteen years after the debut of Viagra?

The little blue pill has come a long way! After Sildenafil, which caused a real revolution in the treatment of patients with erectile dysfunction, other equally effective and very interesting drugs have been put on the market. At present, the three main treatments: Sildenafil (Viagra), Vardenafil (Levitra), and tadalafil (Cialis), have – apart from minor structural differences – the same efficacy and solve the problem in 80% of cases. Their mechanism of action is very similar to the physiological functioning of the erection. They are drugs that prolong erection time by inhibiting a very specific enzyme for the degradation of GMP-Cyclic. Tadalafil has also been tested at a daily dose of 5 mg, which is very interesting for younger patients. The use of Tadalafil in different dosages is currently expanding rapidly in the treatment of benign prostatic hyperplasia. Some patients, particularly those suffering from diabetes or after surgery or radiotherapy for prostate cancer, will still resort to the use of intracavernous injections of prostaglandins.

Standards and the quest for performance: a guaranteed fiasco

Although sexuality is a non-vital physiological function, it is nevertheless felt to be vital and essential for many. In spite of medical and communication progress, many individuals, even young people, think that they no longer correspond to a sexual or desire norm, and come to terms with their dysfunction or sometimes resign themselves to it out of hand. Sexuality is not and should not be part of any norm. Although not really new, the area of performance anxiety has gained momentum with the focus on women’s sexual demands and male-female relationships. Indeed, until not so long ago, women were subjected to the sexual act, the relationship, and even the man, diluting their dissatisfaction through renunciation or adultery. Marriage was often the obligatory step towards sexuality. Nowadays, women are more materially and physically independent and want to combine their careers with their lives as women, including maternal and sexual fulfillment. They demand a pleasure that they consider as a right and give themselves the right to obtain it. Women can now experience and claim pleasure. Nowadays, unions are no longer eternal. Partners are no longer dependent. They have experienced, they compare and often they choose. The man then becomes “naked” and imagines that he does not have a good sex life, that he will be rejected, mocked, or dethroned. He often prefers to flee rather than face the act. The brain will then anticipate failure and it’s a fiasco. Medicated erectile aid must then often be backed up by work on oneself, aided by sex therapy or even psychotherapy. It will then be necessary to fight against these false norms and try to rehabilitate the couple to sexuality based on listening to the other and on the emotional. It cannot be repeated often enough that there is no normative behavior that is exempt from responsibility.

Ejaculatory problems: love life killers

Premature ejaculation, the most common problem of ejaculatory disorders, is defined as ejaculation occurring within one minute of penetration. It is estimated today that premature ejaculation affects 28-36% of men and is the most common sexual disorder and reason for consultation. Despite its high frequency, the etiology of premature ejaculation remains debated. Beyond Kaplan’s original description, which gave a psychodynamic explanation centered on sadistic and narcissistic tendencies, the modern vision of the etiology of this disorder would rather be a penile hypersensitivity. More recently, more precise studies of anatomy and neurophysiology have made it possible to discover a preponderant role for serotonin and its receptors, on the basis of new and very promising treatments.

Neuro-Anatomy & Neuro-pharmacology of ejaculation

Clinical observations, as well as anatomical and pharmacological data, have provided a comprehensive view of the peripheral autonomic control of ejaculation: cholinergic parasympathetic mechanisms participate in the control in the case of ejaculation, the thelium of the accessory sex glands, and the sympathetic adrenergic mechanisms are responsible for the contraction of the smooth muscle fibers of the seminal tract and the bladder neck. Both phases of ejaculation are mediated by reflexes organized at the thoracolumbar and lumbosacral spinal levels.

The extensive brain network responsible for the ejaculatory response involves the participation of various neurotransmitters and neuromodulators. Of these, dopamine, 5-hydroxytryptamine (5-HT), and oxytocin (OT) play a particularly important role. In humans, selective serotonin reuptake inhibitors (SSRIs), which increase serotonin tone, have an inhibitory effect on ejaculation and recent clinical trials show that their use represents an effective pharmacological strategy in the treatment of premature ejaculation.

Disruption of the couple and the relationship dimension

For many couples, the problem of premature ejaculation can be a real handicap to their love life, far more embarrassing than an erectile disorder. Surprisingly, many become accustomed to it. However, when the patient is treated and cared for effectively, the partner notices a very clear difference and realizes the importance of having treated the ejaculatory disorder, as the quality of the relationship is greatly improved. Furthermore, this phenomenon, like male sexual disorders in general, takes away pleasure because it leads to performance anxiety or anxiety about failure. Being convinced that you are systematically a premature ejaculator is bound to prove you right! Partners of men with premature ejaculation report significantly more sexual dysfunction with reduced satisfaction, increased distress, personal difficulties, and orgasmic disturbances than those of patients without premature ejaculation. The couple dimension should therefore be encouraged and integrated if possible into the treatment, using individual and couple approaches, and combining the different therapies available (pharmacological, psychological, sexological, behavioral).

Available treatments

Drug treatments that can improve premature ejaculation have been the subject of recent meta-analyses. Only dapoxetine (marketed as Priligy) has marketing authorization in Europe. Dapoxetine (30 mg and 60 mg) was evaluated in five randomized, double-blind, placebo-controlled studies in 6081 men over the age of 18. The results were excellent with satisfactory prolongations of ejaculatory times for the patients. The most common side effects were nausea, dizziness, and headache. The potential modes of action of these molecules on ejaculation are to increase the This can lead to an increase in self-confidence, perceived control of ejaculation, overall sexual satisfaction, and a decrease in the post-orgasmic refractory period allowing a second, faster erection to be achieved. Amongst other classic treatments, topical local anesthetics such as EMLA used at 5% a few minutes before the sexual activity remains a very useful background treatment, even if its use is not always very practical. It has the advantage of being simple, reproducible, and without significant side effects. Whatever the drug treatment, sex therapies are also important in the overall management of the premature ejaculator and his couple. The most commonly used therapies are behavioral, which allow the patient to feel the point of no return. The patient gradually learns to control his arousal during several types of exercise. The psychotherapies aim to strengthen the patient’s confidence in his sexual performance, to reduce performance anxiety, to improve the couple’s communication and the quality of the couple’s relationship.

Conclusion

Although medical and pharmacological advances have given us a better understanding of sexual and ejaculatory dysfunction, there is still much to be done in the management of patients and their partners. We need to remove fears and taboos and encourage patients to seek help. Listening is essential and enables the problem to be better targeted according to the complaints, allowing effective and multidisciplinary management. Since their introduction, PDE5 inhibitors have remained the drugs of the first choice used by millions of patients worldwide thanks to their efficacy and safety, despite the noises that are echoed in the general public. The therapeutic arsenal has recently been strengthened by dapoxetine, a very promising drug for the treatment of patients with premature ejaculation. The next few decades will surely see further advances in treatment and reinforcement of care, allowing for a real sexual revolution, but one that is very different from that of the hippie era, since it is better understood and adapted to the needs of modern men.

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