1000-2000 5 ьшò

2013;121(1):65–70.

2.Verhaegen J, Gallos ID, van Mello NM, et al. Accuracy of single progesterone test to predict early pregnancy outcome in women with pain or bleeding: meta-analysis of cohort studies. BMJ. 2012;345:e6077.

3.Elson CJ, Salim R, Potdar N, et al; for Royal College of Obstetricians and Gynaecologists. Diagnosis and management of ectopic pregnancy: Green-top Guideline No. 21. BJOG. 2016;123(13):e15–e55.

4.Mergenthal MC, Senapati S, Zee J, et al. Medical management of ectopic pregnancy with single-dose and 2-dose methotrexate protocols: human chorionic gonadotropin trends and patients outcomes. Am J Obstet Gynecol. 2016;215(5):590.e1–590.e5.

5.Practice Committee of the American Society for Reproductive Medicine. Medical treatment of ectopic pregnancy: a committee opinion. Fertil Steril. 2013;100(3):638–644.

6.American College of Obstetricians and Gynecologists. ACOG Practice Bulletin No. 94: medical management of ectopic pregnancy. Obstet Gynecol. 2008;111(6):1479–1485.

ADDITIONALREADING

Barnhart KT. Clinical practice. Ectopic pregnancy. N Engl J Med. 2009;361(4):379–387.

National Institute for Health and Care Excellence. Ectopic Pregnancy and Miscarriage: Diagnosis and Initial Management in Early Pregnancy of Ectopic Pregnancy and Miscarriage. London, United Kingdom: National Institute for Health and Care Excellence; 2012.

CODES

ICD10

O00.9 Ectopic pregnancy, unspecified

O00.1 Tubal pregnancy

O00.0 Abdominal pregnancy

CLINICALPEARLS

Ectopic pregnancy is the leading cause of 1st trimester maternal death and

mebooksfree.com

accounts for 6% of U.S. pregnancy deaths.

97% of ectopic pregnancies occur in the fallopian tube.

Diagnosis requires high clinical suspicion in the setting of abdominal pain and a positive pregnancy test until IUPis confirmed.

mebooksfree.com

EJACULATORYDISORDERS

Payam Sazegar, MD, CCFP

BASICS

DESCRIPTION

Premature ejaculation (PE): inability to control ejaculatory reflex resulting in ejaculation sooner than desired; most common type of sexual dysfunction affecting all age groups:

–Defined (ISSM 2007) as an ejaculation that always or nearly always occurs prior to or within 1 minute of penetration; an inability to ejaculate on all or nearly all penetrations and with negative personal consequences (1,2)

–Natural biologic response is to ejaculate within 2 to 5 minutes after vaginal penetration.

–Ejaculatory control is an acquired behavior that increases with experience.

Delayed ejaculation (DE): prolonged time to ejaculate (>30 minutes) despite desire, stimulation, and erection

Aspermia (lack of sperm in the ejaculate):

–Anejaculation (AE): lack of emission or contractions of bulbospongiosus muscle

–Retrograde ejaculation (RE): partial or complete ejaculation of semen into the bladder

–Obstruction: ejaculatory duct obstruction or urethral obstruction

Painful ejaculation: genital or perineal pain during or after ejaculation

Ejaculatory anhedonia: normal ejaculation lacking orgasm or pleasure

Hematospermia: presence of blood in the ejaculate

Ejaculatory duct obstruction

Synonym(s): rapid ejaculation; retarded ejaculation; inhibited orgasm in males; ejaculatory dysfunction

EPIDEMIOLOGY

Prevalence

PE is common. Reported prevalence in U.S. males ranges from 20% to 30% depending definition.

DE is reported in 5–8% of men age 18 to 59 years, but <3% experience the problem for >6 months.

mebooksfree.com

Predominant age: all sexually mature age groups

Predominant sex: male only

ETIOLOGYAND PATHOPHYSIOLOGY

Male sexual response:

Erection mediated by parasympathetic nervous system Normal ejaculation consists of three phases:

–Emission phase: Semen is deposited into urethra by contraction of prostate, seminal vesicles, and vas deferens; under autonomic sympathetic control

–Ejaculation phase: Semen forcibly propelled out of urethra by rhythmic contractions of bulbospongiosus and ischiocavernosus muscles. This is mediated by the somatic nervous system on the motor branches of the pudendal nerve. Bladder neck contracture induced by α-adrenergic receptors ensures anterograde ejaculation.

–Orgasm: the pleasurable sensation associated with ejaculation (cerebral cortex); smooth muscle contraction of accessory sexual organs; release of

pressure in posterior urethra PE has many theoretical causes:

–Penile hypersensitivity

–5-Hydroxytryptamine (5-HT) receptor sensitivity

–Sexual inexperience

–High level of sexual arousal and/or long interval since last ejaculation

–Fear of sexual transmitted infections (STIs)

–Anxiety or guilty feelings about sex

–Lack of privacy

–Interpersonal maladaptation (e.g., marital problems, unresponsiveness of partner)

DE:

–Rarely due to underlying painful disorder (e.g., prostatitis, seminal vesiculitis)

–Psychogenic

–Sexual performance anxiety and other psychosocial factors

–Medications may impair ejaculation (e.g., MAOIs, SSRIs, α- and β- blockers, thiazides, antipsychotics, tricyclic and quadricyclic

antidepressants, NSAIDs, opiates, alcohol). Never any ejaculate:

–Congenital structural disorder (müllerian duct cyst, wolffian abnormality)

–Acquired (radical prostatectomy, postinfectious, posttraumatic, T10–T12

mebooksfree.com

neuropathy)

AE:

–Retroperitoneal lymph node (LN) dissection

–Spinal cord injury or other (traumatic) sympathetic nerve injury

–Medications (α- and β-blockers, benzodiazepines, SSRIs, MAOIs, TCAs, antipsychotics, aminocaproic acid)

–Diabetes mellitus (DM) (neuropathy)

–Radical prostatectomy

RE:

–Transurethral resection of the prostate (25%) or other prostate resection procedures

–Surgery on the neck of the bladder

–Extensive pelvic surgery

–Retroperitoneal LN dissection for testicular cancer (also may produce failure of emission)

–Neurologic disorders (multiple sclerosis [MS], DM)

–Medications (α-blockers, in particular tamsulosin, ganglion blockers, antipsychotics)

–Urethral stricture (may be posttraumatic)

Painful ejaculation:

–Infection or inflammation (orchitis, epididymitis, prostatitis, urethritis)

–Ejaculatory duct obstruction

–Seminal vesicle calculi

–Obstruction of the vas deferens

–Psychological/functional

Ejaculatory anhedonia:

–Medications

–Psychological

–Hormonal imbalances

–Decreased libido

Hematospermia (often unable to find cause):

–Inflammation/infection

–Calculi: bladder, seminal vesicle, prostate, urethra

–Trauma to genital area (cycling, constipation)

–Obstruction

–Cyst

–Tumor (prostate cancer [1–3% present with hematospermia])

–Arteriovenous malformations

–Iatrogenic

mebooksfree.com

– Hypertension

COMMONLYASSOCIATED CONDITIONS

Neurologic disorders (e.g., MS)

DM

Prostatitis

Ejaculatory duct obstruction

Urethral stricture

Psychological disorders

Endocrinopathies Relationship/interpersonal difficulties

DIAGNOSIS

Ejaculation occurs before individual wishes (PE).

Ejaculation does not occur following normal stimulation (including masturbation).

HISTORY

Detailed sexual history, including:

–Time frame of the problem

–Quality of patient’s sexual response

–Sense of ejaculatory control and sexual distress

–Overall assessment of the relationship

–Ask specific questions as patients often reluctant to discuss openly.

Detailed history of recent and current medications

History of past trauma or recent infections

Past surgical history with particular attention to genitourinary (GU) surgeries

Supplements and alternative therapies tried

Many men do not distinguish initially between problems related to erection and ejaculation.

Some men have unrealistic expectations of ejaculatory response and frequency.

Include the sexual partner in the interview, especially if the patient expresses a belief that he is not meeting his partner’s needs.

In review of systems, elicit any evidence of testosterone deficiency or prolactin excess especially if anhedonia present.

mebooksfree.com

PHYSICALEXAM

Check vitals. Look for focal neurologic signs (MS, spinal cord injury) and psychiatric disorders.

Thorough GU exam, including:

–Size and texture of testes and epididymis

–Verification of the presence of the vas deferens

–Location and patency of urethral meatus

–Digital rectal examination to evaluate prostate consistency and size and possible midline lesions

DIAGNOSTIC TESTS & INTERPRETATION

Laboratory test results may be normal.

Fasting glucose or HgbA1c to rule out diabetes

Postorgasmic urinalysis will confirm RE. Semen fructose level, sperm count, and viscosity can be measured. Patient may complain of cloudy urine.

AE will have fructose negative, sperm negative, nonviscous postorgasmic urinalysis.

In painful ejaculation, urinalysis and urine culture

If prostate cancer is considered, check prostate-specific antigen (PSA).

In anhedonia, consider checking testosterone, prolactin, glucose, and thyroid levels.

In hematospermia, painful ejaculation, or if ejaculatory duct obstruction is considered, transrectal ultrasound (TRUS) may be helpful.

TRUS-guided seminal vesicle aspiration; if ejaculatory duct obstruction is present, then the aspirate will contain sperm.

If suspicious of anatomic abnormality, can get scrotal US and/or MRI

TREATMENT

GENERALMEASURES

Identifying any medical cause (even if not reversible) helps patient accept condition.

Improve partner communication.

Psychological counseling for patient and partner

Reduce performance pressure through reassurance.

Use of a variety of resources may be necessary (e.g., psychiatrist, psychologist, sex therapist, vascular surgeon, urologist, endocrinologist,

mebooksfree.com

neurologist).

PE:

–Use sensate focus therapy (gradual progression of nonsexual contact to sexual contact).

–Quiet vagina: Female partner stops moving just prior to ejaculation.

–Techniques to learn ejaculatory control (e.g., coronal squeeze technique [squeezing the glans penis until ejaculatory urge ceases] or start-and-stop technique [cessation of penile stimulation when ejaculation approaches and resumption of stimulation when ejaculatory feeling ends]) (3)[B]

DE:

–Change to antidepressant less likely to cause DE (citalopram, fluvoxamine, nefazodone)

AE/RE:

–Discontinue offending medication(s).

–Diabetic control

–If urethral obstruction present, refer to urology.

–RE may be helped if intercourse occurs when bladder is full.

–Consider penile vibratory stimulation (effective in spinal cord injuries >T10) or electroejaculation (place on monitor if lesions above T6 because

autonomic dysreflexia may result) to collect sperm in AE cases. Painful ejaculation:

–Counseling may be beneficial.

–If seminal vesicle stones are possible, refer to urology.

Hematospermia:

–Often resolves spontaneously, without known cause

–May try empiric antibiotic, but little evidence to support

–If persistent or high degree of suspicion for abnormality, refer to urologist.

MEDICATION

PE:

– Treating underlying erectile dysfunction (if identified) with PDE5 inhibitors First line:

–Topical anesthetic gel applied (2.5% prilocaine ±2.5% lidocaine [EMLA]) 2.5 g under a condom for 30 minutes prior to intercourse (4,5)[A]

–Daily dosing of clomipramine 20 to 50 mg, sertraline 25 to 200 mg, fluoxetine 5 to 20 mg, or paroxetine 10 to 40 mg can delay ejaculation within 1 to 3 weeks of starting (4)[A].

–Dapoxetine, a short-acting SSRI, used “on demand” 30 to 60 mg 1 to 2 hours prior to sex (2,4)[A]

mebooksfree.com

–Tramadol 5 to 50 mg used “on demand” 2 hours before sex; effective in many studies (6)[A]

–Some other “on-demand” options include clomipramine 20 to 40 mg 4 to 24 hours before intercourse, sertraline 50 mg 4 to 8 hours before intercourse, paroxetine 20 mg 3 to 4 hours before intercourse (2)[A].

–Consider switching antidepressants to bupropion, nefazodone, mirtazapine.

–Second line: behavioral/sex therapy, pelvic floor muscle therapy (3)[B]

DE (limited options):

–Patients who must continue SSRIs may respond to bupropion, buspirone (1) [B], or yohimbine (1)[C] before intercourse.

–Sex therapy, self-stimulation therapies (1)[B]

–Some evidence that amantadine or cyproheptadine may be helpful (2)[B]

AE/RE:

–α-agonists and antihistamines can be helpful but are not approved by the FDA.

–First line:

Pseudoephedrine 60 mg PO daily to QID (7)[A]

Imipramine 25 to 75 mg PO BID (7)[A]

–Second line: For RE, can try postejaculation bladder harvest of sperm (if fertility desired); for AE, can try midodrine, penile vibratory stimulation or electroejaculation (7)[B]

Painful ejaculation:

–Treat underlying infection/inflammatory process.

–α-Blockers may have some benefit.

ISSUES FOR REFERRAL

The following conditions, when suspected, should be referred to a urologist:

Ejaculatory duct obstruction

Seminal vesicle or prostatic stones

Urethral obstruction

Vas deferens obstruction

Calculi

Persistent or severe hematospermia

SURGERY/OTHER PROCEDURES

Surgical treatment of ejaculatory duct obstruction: Transurethral resection of the ejaculatory ducts

mebooksfree.com

ONGOING CARE

PATIENT EDUCATION

See “General Measures.”

PROGNOSIS

Often improves with therapy and counseling

COMPLICATIONS

Psychological impact on some males: signs of severe inadequacy, self-doubt, additional anxiety, and guilt

REFERENCES

1.Rowland D, McMahon CG, Abdo C, et al. Disorders of orgasm and ejaculation in men. J Sex Med. 2010;7(4, Pt 2):1668–1686.

2.McMahon CG, Jannini E, Waldinger M, et al. Standard operating procedures in the disorders of orgasm and ejaculation. J Sex Med. 2013;10(1):204–229.

3.Melnik T, Althof S, Atallah AN, et al. Psychosocial interventions for premature ejaculation. Cochrane Database Syst Rev. 2011;(8):CD008195.

4.Porst H. An overview of pharmacotherapy in premature ejaculation. J Sex Med. 2011;8(Suppl 4):335–341.

5.Wyllie MG, Powell JA. The role of local anaesthetics in premature ejaculation. BJU Int. 2012;110(11, Pt C):E943–E948.

6.Kirby EW, Carson CC, Coward RM. Tramadol for the management of premature ejaculation: a timely systematic review. Int J Impot Res. 2015;27(4):121–127.

7.Barazani Y, Stahl PJ, Nagler HM, et al. Management of ejaculatory disorders in infertile men. Asian J Androl. 2012;14(4):525–529.

ADDITIONALREADING

Gur S, Sikka SC. The characterization, current medications, and promising therapeutics targets for premature ejaculation. Andrology. 2015;3(3):424–442.

Jefferys A, Siassakos D, Wardle P. The management of retrograde ejaculation: a systematic review and update. Fertil Steril. 2012;97(2):306–312.

Siegel AL. Pelvic floor muscle training in males: practical applications. Urology. 2014;84(1):1–7.

mebooksfree.com