Local Treatment OF Premature Ejaculation

Lidocaine–Prilocaine Cream (Emla)
Local (topical) anesthetic preparations have been used to treat premature ejaculation. Very limited data are available on their use, however. An example of these preparations is Emla® cream (Astra U.S.A. Inc., Westborough, Massachusetts), which consists of a eutectic mixture of lidocaine 2.5% and prilocaine 2.5%. The onset, depth, and duration of dermal analgesia provided depend primarily on the duration of application. Generally, the topical anesthetic creams are applied to the glans penis and penile shaft under occlusive cover (condom) for at least one half-hour prior to the sexual encounter. Dermal analgesia reaches its maximum at two to three hours and persists for one to two hours after removal. Some authors, however, advocate not removing the condom during intercourse, as this practice will not only prevent the transfer of remnant anesthetics to the partner’s genitalia, but also provide a physical barrier and thus help to reduce penile sensitivity. Patients should be advised that dermal application of Emla cream may cause transient, local blanching followed by a transient, local redness or erythema. A recent study by Berkovitch et al. in 11 patients with premature ejaculation who used the Emla cream without the condom found:

  • a significant improvement in the ejaculatory latency in five patients,
  • improvement in four patients,
  • no change in two patients.

Lidocaine–Prilocaine Spray
One small open-label pilot study has described the use of a new lidocaine–prilocaine spray that delivers 7.5 mg lidocaine and 2.5 mg prilocaine, applied using a metered-dose aerosol delivery system. The spray is applied to the glans penis, left on for 10 to 15 minutes, and then wiped off carefully before intercourse. Eleven of the 14 patients completed the study, reporting an average eightfold increase in intravaginal ejaculation latency time (IVELT) from 1 minute and 24 seconds to 11 minutes and 21 seconds (p = 0.008). No subjects reported a decrease in IVELT, and the average satisfaction score for both patients and partners was 1.0 (–1 = worse, 0 = same, +1 = better, +2 = much better). Thus, topical lidocaine–prilocaine spray appears to prolong ejaculation time and improve sexual satisfaction for both men with premature ejaculation and their partners. Glandular numbness, noted in two cases, was not reported to affect the quality of orgasm. Occasionally, patients reported difficulty maintaining erection while waiting the required 15 minutes between application of the spray and the initiation of intercourse.

LOCAL TREATMENT OF FAILURE OF DETUMESCENCE

Prolonged erection is a small but significant risk in patients treated with intracorporeal injections of vasoactive drugs. Patients receiving this form of therapy should be adequately counseled on the risk of priapism and advised on the use of minimum effective dose of chosen agent(s) . Younger individuals and patients with psychogenic and/or neurogenic impotence usually exhibit satisfactory erectile responses to small doses of vasoactive drugs, but they also have a higher risk for the development of priapism than patients with vascular insufficiency. Mild cases of prolonged erection may be treated with the oral intake of α-receptor agonists such as pseudophedrine 30 mg once or twice at 30-minute intervals. Also, the β-receptor agonist terbutaline has been used orally to treat priapism of less than four hours duration in traumatic paraplegic patients. More severe cases of priapism extending for longer than four hours usually require corporeal aspiration and irrigation with a solution containing heparin (5000 U/L) and epinephrine (1 mg/L). Another method involves the aspiration of 10 to 20 mL of blood from the corpora with a 19-gauge needle, followed by injection of phenylephrine, beginning with doses of 200 mg every five minutes and increasing to 500 mg, if necessary. This appears to be effective in resolving erections of less than 12 hours duration .

Phenylephrine doses of 500 mg in 2 mL saline have also been injected into the corpus cavernosum every 15 minutes without aspiration until detumescence is achieved. Other adrenergic agonists such as norepinephrine, ephedrine, and metaraminol have been used to stimulate corporeal vasoconstriction and to reverse priapism. All of these agents can cause a significant increase in blood pressure, and the use of metaraminol was reported to cause death in two cases. Occasionally, prolonged priapism (usually of more than 36 hours’ duration) due to vasoactive drug injection requires the surgical placement of an arteriovenous shunt. This will cause a venous leakage, however, and the possible failure of response to future vasoactive drug injections. Recently, the association of a positive erectile response to visual sexual stimulation and a penile brachial index (PBI) of more than 0.8 was identified as an indicator of a high risk for postinjection priapism, but such risk was reduced to 1% with careful adjustment of vasoactive drug doses administered.

Other forms of medical therapy may include local or systemic glucocorticoids and the intralesional injection of a collagenase or a calcium channel blocker. These locally administered agents appear to have approximately the same therapeutic effects as the systemic medications. Medical therapy may help patients with moderate disease, whereas surgical correction is the treatment of choice for those with severe penile deformity.

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