Preliminary study of electric stimulation on premature ejaculation in

Sexologies 16 (2007) 38–42
a v a i l a b l e a t w w w. s c i e n c e d i r e c t . c o m
j o u r n a l h o m e p a g e : h t t p : / / f r a n c e . e l s e v i e r. c o m / d i r e c t / S E X O L /
ORIGINAL ARTICLE / ARTICLE ORIGINAL
Preliminary study of electric stimulation
on premature ejaculation in patients with chronic
pelvic pain syndrome or chronic prostatitis
Étude préliminaire de l’électrostimulation
dans l’éjaculation précoce chez des patients porteurs
de douleur pelvienne ou de prostatite chronique
W.-Y. Lin (MD), D.-R. Ho (MD), C.-F. Wu (MD), J.-J. Shee (MD),
C.-S. Chen (MD)*
Division of Urology, Department of Surgery, Chang Gung Memorial Hospital, 6, Chia-Pu West road, 613 Chia-Yi, Taiwan, ROC
Available online 25 September 2006
KEYWORDS
Electric stimulation;
Premature ejaculation;
Chronic prostatitis
Abstract
Purpose. — To investigate the clinical efficacy of electric stimulation on the treatment of premature ejaculation (PE) in patients with chronic pelvic pain syndrome (CPPS) or chronic prostatitis (CP).
Material and methods. — Fourteen patients who complained with voiding syndromes, defecation disorder, pelvic pain and sexual problems were included in this prospective study. The
white blood cells in prostatic expressed secretion of these patients were less than 10 per
high-power field. In addition to the therapy of alpha-blocker, muscle relaxant and anticholinergics, six weekly cessions of electric stimulation were given on lithotomy position for
specific group of patients. These patients whose PE scale scored as 4 or greater and the
intra-vaginal ejaculation latency time (IVELT) as 2 or greater were noted. PE was graded on a
scale of 0 to 8 (0 = almost never, 8 = almost always). The IVELT was graded on a scale of 0 to 3
(0 = longer than 5 min, 3 = shorter than 1 min). These scales were graded before the initiation
and 6 weeks after the treatment.
Results. — The mean age of 14 patients was 44 years old. The mean pre-treatment PE and
IVELT scale was 5.78 ± 0.14 and 2.78 ± 0.18, respectively. The PE and IVELT scale after electric
stimulation treatment was 4.0 ± 0.60 (P = 0.026) and 1.5 ± 0.35 (P = 0.006). Seven patients
(50%) reported the improvement of PE after electric stimulation. The PE and IVELT scale after
treatment was 2.2 ± 0.60 (P = 0.0022) and 0.14 ± 0.35 (P 0.0001), respectively. Seven patients
(50%) remained unchanged after treatment. The PE and IVELT scale after treatment was
5.71 ± 0.12 (P = 0.86) and 2.80 ± 0.38 (P = 0.55).
* Corresponding
author.
E-mail address: [email protected] (C.-S. Chen).
1158-1360/$ - see front matter © 2006 Published by Elsevier Masson SAS.
doi:10.1016/j.sexol.2006.06.009
Electric stimulation on premature ejaculation
39
Conclusion. — Electric stimulation seems to have a benefit on improving PE in patients with
CPPS/CP in our preliminary prospective study. Electric stimulation may be an important and
encouraging part of the treatment modalities in PE.
© 2006 Published by Elsevier Masson SAS.
MOTS CLÉS
Électrostimulation ;
Éjaculation précoce ;
Prostatite chronique
Résumé
But. — Examiner l’efficacité clinique de l’électrostimulation sur le traitement de l’éjaculation précoce (EP) chez des patients porteurs de douleur pelvienne (CPPS) ou de prostatite
(PCF).
Matériel et méthodes. — Cette étude prospective concernait quatorze malades se plaignant
de symptômes mictionnels, de troubles de la défécation, de douleur pelvienne et de problèmes sexuels. Les leucocytes retrouvés dans les sécrétions prostatiques de ces malades étaient
inférieurs à dix par champ. On a pratiqué six séances d’électrostimulation, à raison d’une par
semaine, en position de lithotomie pour un groupe spécifique de patients, en plus de la prescription d’alphabloquants, décontractants et anticholinergiques à visée musculaire. Ces
patients ont été notés, leur échelle de EP était scorée à quatre ou plus, et le temps intravaginal de latence d’éjaculation (IVELT) scoré à deux ou plus. L’éjaculation précoce a été évaluée
sur une échelle de zéro à huit (0 = presque jamais, 8 = presque toujours). L’IVELT a été évaluée
sur une échelle de zéro à trois (0 = plus long que cinq minutes, 3 = plus court qu’une minute).
Ces échelles ont été remplies avant le début des séances et six semaines après.
Résultats. — L’âge moyen des 14 patients était de 44 ans. L’échelle moyenne de EP et de
l’IVELT avant le traitement était de 5,78 ± 0,14 et 2,78 ± 0,18, respectivement. L’échelle
moyenne de EP et de l’IVELT après le traitement de l’électrostimulation était de 4,0 ± 0,60
(p = 0,026) et 1,5 ± 0,35 (p = 0.006). Sept patients (soit 50 %) ont noté une amélioration de EP
après l’électrostimulation. L’échelle de EP et d’IVELT après le traitement était de 2,2 ± 0,60
(p = 0,0022) et 0,14 ± 0,35 (p 0,0001), respectivement. Chez sept patients (50 %), aucun changement n’a été noté après le traitement. L’échelle de EP et d’IVELT après le traitement a été
de 5,71 ± 0,12 (p = 0,86) et 2,80 ± 0,38 (p = 0,55) respectivement.
Conclusion. — L’électrostimulation semble avoir un bénéfice sur l’amélioration de l’éjaculation précoce chez les patients porteurs de prostatite chronique ou de CPPS dans notre étude
prospective préliminaire. L’électrostimulation peut avoir une part importante et encourageante dans les modalités du traitement de l’éjaculation précoce.
© 2006 Published by Elsevier Masson SAS.
Version abrégée
La prostatite chronique est une maladie qui cause une morbidité substantielle du fait de symptômes urinaires associés, de troubles sexuels et de douleur pelvienne. Les
malades qui ont des douleurs pelviennes sont extrêmement
difficiles à guérir. La disparition des symptômes devrait être
le but fondamental des thérapies. Les analgésiques, les
alphabloquants, les relaxants musculaires et les antidépresseurs tricycliques devraient être utilisés soit séquentiellement, soit en même temps. De plus, des thérapies physiques telles que le biofeedback, le massage pelvien et
d’autres thérapies comportementales de soutien ou « des
thérapies conservatives » (changement du mode de vie et
de l’alimentation) semblent utiles chez certains patients.
Les troubles sexuels causés par la prostatite chronique
sont peu à peu reconnus. On a trouvé une haute prévalence
d’éjaculation précoce chez les malades porteurs de prostatite chronique, ce qui suggère que l’infection et/ou
l’inflammation de la prostate est une condition à la prédisposition de l’éjaculation précoce. L’éjaculation précoce
peut être divisée en deux types : primaire et secondaire.
Les patients ayant le type primaire sont ceux qui souffrent
de problèmes chroniques depuis le début de leur vie sex-
uelle. Au contraire, les patients ayant le type secondaire
sont ceux qui souffrent de problèmes après des années
d’activité sexuelle normale. Les causes d’éjaculation précoce sont inconnues chez la plupart des patients. Les facteurs psychologiques et biologiques sont associés à la pathogénie. L’apparition de l’éjaculation précoce pendant une
vie sexuelle où le contrôle de l’éjaculation était satisfaisant
durant des années est souvent conséquence d’une cause
organique.
Une étude neurophysiologique a montré que les possibilités concernant la latence et l’amplitude somatosensorielle du gland sont plus courtes et plus importantes chez
les hommes souffrant d’éjaculation précoce pendant toute
une vie, que chez des patients tests à éjaculation normale.
Ce rapport et d’autres études concernant de tels potentiels
sacrés ont suggéré qu’il s’agit d’un problème d’hyperexcitabilité sensorielle.
On a fait l’hypothèse que l’électrostimulation est capable d’inhiber le réflexe du détrusor en dépolarisant les
fibres afférentes sensibles des nerfs honteux. Les mécanismes de l’électrostimulation de l’éjaculation précoce
chez les patients CPPS–CP pourraient être attribués à un
ou plus des facteurs suivants. D’une part, soulager les
spasmes du plancher pelvien peut améliorer le reflux
40
d’urine dans les conduits de la prostate. Par conséquent, le
traitement de cet élément de l’infection prostatite et/ou
l’inflammation prostatite peut être bénéfique pour diminuer l’éjaculation précoce. D’autre part, dépolariser les
fibres afférentes sensibles des nerfs honteux pourrait
moduler l’hyperexcitabilité sensorielle du pénis. Selon
notre étude préliminaire : approximativement 50 % des
patients qui ont une éjaculation précoce et un CPPS et/ou
PCF peuvent être améliorés après six séances d’électrostimultaion du plancher pelvien. Malgré cela, nous ne comprenons pas le véritable mécanisme qui explique cette réponse
clinique encourageante de l’électrostimulation dans ce
groupe spécifique, et nous avons soulevé une possibilité
d’interruption du processus pour les études à venir. L’électrostimulation peut décontracter le spasme des muscles du
plancher pelvien. Cette relaxation peut arrêter le cercle
vicieux des douleurs de l’éjaculation précoce. De plus,
l’électrostimulation, qui est une sorte de modulation des
nerfs honteux, peut bloquer l’hyperexcitabilité sensorielle
du pénis. Néanmoins, la physiologie exacte de l’impact de
l’électrostimulation pour l’éjaculation précoce nécessite
des études complémentaires. Des études cliniques continues et consciencieuses sont nécessaires pour déterminer
l’efficacité à long terme de ce genre de traitement de
l’éjaculation précoce.
Full version
Introduction
Chronic prostatitis (CP) is a common frustrating condition
that is primarily associated with pain at urogenital area. It
disturbs voiding function, pelvic pain and ejaculation (Krieger et al., 1996; Collin et al., 1999). Erectile dysfunction is
reported in patients with chronic pelvic pain syndrome
(CPPS) also, but it is not a pathognomic presentation of
this syndrome (Neal and Moon, 1994; Nickel and Sorensen,
1996; Screponi et al., 2001). However, high prevalence of
premature ejaculation (PE) in patients with CP suggests
that infection and/or inflammation of prostate is a possible
predisposing condition for PE (Screponi et al., 2001). In
addition, CPPS is regarded as the spasm of pelvic floor muscles around the prostate. Relief of pain originated from pelvic floor muscle spasm is experienced by electrical stimulation on the perineum (Tracy and Jeffrey, 1993). Thus, we
investigated the efficacy of electric stimulation on PE in
patients with CPPS/CP.
Materials and methods
A total of 14 consecutive men aged 27–53 years (mean age
44 years old) whom presented with symptoms of CP such as
dysuria, frequency of micturition, burning sensation of perineum, lower abdominal discomfort and/or supra-pubic
pain. These patients were included and classified as having
CPPS/CP after exclusion of bacterial infection. Infection
was identified with Meares-Stamey technique for Gramnegative bacteria. In addition to the negative finding of
Chlamydia trachomatis and Ureaplasma urealyticum, the
microscopic examination of the expressed prostatic secretion should have the white blood cells less than 10 per high-
W.-Y. Lin et al.
power field. These patients had no confirmed infection,
although most of them had been treated empirically and
unsuccessfully. These patients underwent a routine urological evaluation, including prostate specific antigen, a digital
rectal examination, X-ray of kidney–ureter–bladder and urinalysis to exclude occult urinary tract pathology such as
prostate cancer, urolithiasis which can have similar symptoms.
Study protocol
The use of alpha-blockers and muscle relaxants were prescribed as suggested by guideline (Nickel, 2002). Anticholinergics as well as tri-cyclic anti-depressants were also
given for these irritation symptoms in all patients. A
multiple-choice questionnaire was designed and administered by author at the first appointment of electric stimulation. The questionnaire consisted of medical and sexual
history, and self-grading of their PE and intra-vaginal ejaculatory latency time (IVELT) (Morales, 2000).
Premature grading (Morales, 2000)
Patients graded their ejaculatory dysfunction by answering
the questionnaires as such as how often did you ejaculate
prematurely during intercourse during the past 3 months?
The answers were graded on a scale from 0 to 8 (0: almost
never; 2: sometimes; 4: about one half the time, 6: most of
the time, and 8: almost always). Patients with CP/CPPS who
graded their PE as 4 or greater were enrolled in this study.
IVELT (Morales, 2000)
Patients graded their IVELT on a scale of 0 to 3 (0: longer
than 5 min; 1: between 3 and 5 min; 2: between 1 and
3 min; and 3: less than 1 min). Those with IVELT score of 2
or greater were enrolled in this study. PE was defined as an
IVELT less than 2 min and occurred in more than half of sexual encounters. The inclusion criterion was a steady relationship with a female partner for at least 1 year and
6 months history of PE (Krieger et al., 1996; Nickel, 2002).
The exclusion criteria for this study were major psychiatric
disease, mellitus diabetes, vascular disease, hypertension
and heart diseases, and those patients took pills that affect
sexual function.
In addition to the previous treatment including alphablocker, muscle relaxant and anti-cholinergics, weekly pelvic electric stimulation was given on lithotomy and which
kept continuous for six secessions. Patient was in a supine
position with knees flexed. The electric stimulation
machine is Myomed 932. An interferential current was
used with superficial electrodes over perineum. Pulse frequency was 4000 Hz with continuous mode. The electric stimulation was kept for 30 min.
We interviewed and accessed each patient every week
to confirm whether there was an improvement in the voiding function, rigidity, duration of the erection, pain relieve
and quality of life. Patients graded their PE and IVELT
before the treatment initiated and the seventh week after
completion of electric stimulation treatment. Simple t-test
(unpaired t-test and paired t-test) was applied for statistical analysis.
Electric stimulation on premature ejaculation
41
Table 1 Scale of PE and IVELT before vs. after pelvic electric
stimulation for 14 patients with CPPS or CP
Échelle d’éjaculation précoce et de temps de latence
d’éjaculation intravaginale avant et après électrostimulation chez 14 patients ayant des douleurs pelviennes ou une
prostatite chronique
N = 14
Pre-treatment
PE
IVELT
5.78 ± 0.14
2.78 ± 0.18
Posttreatment
4.0 ± 0.60
1.5 ± 0.35
P value
0.026
0.006
PE: premature ejaculation; IVELT: intra-vaginal ejaculatory
latency time.
Results
The pre-treatment PE and IVELT score of 14 patients was
5.78 ± 0.14 and 2.78 ± 0.18. After 6 weeks secessions of
electric pelvic floor treatment, revealed the improvement
of PE and IVELT score (4.0 ± 0.60, P = 0.026 vs. 1.5 ± 0.35,
P = 0.006) (Table 1).
Seven patients (50%) reported the improvement of PE
after 6 weeks secessions of electric stimulation. The PE
and IVELT scale after treatment was 2.2 ± 0.60 (P = 0.0022)
and 0.14 ± 0.35 (P < 0.0001). Seven patients (50%) remained
unchanged after treatment. The PE and IVELT scale after
treatment was 5.71 ± 0.12 (P = 0.86) and 2.80 ± 0.38
(P = 0.55) (Table 2).
Discussion
CP is a condition that causes substantial morbidity through
the associated urinary symptoms, sexual dysfunction and
the pelvic pain (Anonymous, 2002). Patients with CPPS are
extremely difficult to be cured. Symptom free should be
the primary goal of therapies. Analgesics, alpha-blockers,
muscle relaxants and tri-cyclic anti-depressants should be
used either sequentially or concurrently. In addition, physical therapies such as biofeedback, pelvic floor massage and
other supportive or conservative behavior therapies (diet
and lifestyle modification) appear to be helpful in some
patients (Nickel, 2002).
Inappropriate spasm of distal urethral and external
sphincter unit may be the underlying cause of these symptoms; therefore, leads to an increased pressure in the prostatic urethra with resultant reflux of urine into the prostatic ducts. Presence of urine (sterile or infected) within
Table 2 Scale of PE and IVELT between improvement vs.
non-improvement group after pelvic electric stimulation
Échelle d’éjaculation précoce et de temps de latence
d’éjaculation intravaginale dans les groupes améliorés ou
non après électrostimulation
Group
Scale
Improvement
(N = 7)
Nonimprovement
(N = 7)
PE
IVELT
PE
IVELT
Pretreatment
5.77 ± 0.14
2.8 ± 0.18
5.77 ± 0.14
2.8 ± 0.18
Posttreatment
2.20 ± 0.60*
0.14 ± 0.35
5.71 ± 0.12
2.80 ± 0.38
P value
0.0022
< 0.0001
0.86
0.55
the prostatic ducts could induce ductal and periductal
inflammation, which could further trigger the deteriorated
spasm of the involved pelvic musculature. This is a vicious
circle. Eventually, the voiding dysfunction is exacerbated
(Shelly et al., 2002). How to block this circle is the key
stopcock in treating these patients. The modality to relieve
pelvic floor spasm has two major directions, either to treat
pelvic spasm directly or to decrease or mask the pelvic
pain.
On the contrary, sexual dysfunction caused by CP is gradually recognized. High prevalence of PE was noticed in
patients with CP suggests that infection and/or inflammation of prostate is a predisposing condition for PE (Screponi
et al., 2001). PE can be divided into primary and secondary
types. Patients with primary PE are those experiencing with
the problems chronically since the beginning of their sexual
lives. On the contrary, patients with secondary PE are those
experiencing with the problems after years of normal sexual activity (Ibrahim, 2004; Godpodinoff, 1989). The causes
of PE are unknown in most patients. Both psychological and
biological factors are contributed to the pathogenesis.
Appearance of PE during subsequent sexual life after years
of a satisfied ejaculatory control is often attributed to the
consequence of an organic cause.
A neuro-physiologic study showed that latency and
amplitude of somatosensory evoked potentials from the
glans penis in men with lifelong PE is shorter and greater
than in matched normal controls (Waldinger, 2002, Xin et
al., 1997). Above reports and other studies of sacralevoked potentials suggested that its a problem of sensory
hyper-excitability (Opsomer et al., 1986; Colpi et al.,
1986; Fanciullaci et al., 1988).
It has been postulated that the electric stimulation is
able to inhibit the detrusor reflex by depolarizing sensitive
afferent fibers of pudendal nerve (La Pera and Nicastro,
1996; Sundin et al., 1974; Voduseck et al., 1986). The
mechanisms of electric stimulation for PE in CPPS/CP
patients could be attributed to one or more of the following
factors. First, relieve pelvic floor spasm can improve the
reflux of urine into the prostatic ducts. Consequently, the
cure of the predisposing condition such as prostatic infection and/or inflammation may be beneficial to alleviate the
PE (Screponi et al., 2001). The second, depolarizing the
sensitive afferent fibers of pudendal nerve could modulate
the sensory hyper-excitability of penis. From our preliminary study, about 50% patients who have PE and CPPS and/or
CP can be improved with six cessions of pelvic floor electric
stimulation. Although, we do not understand the real
mechanism to explain the encouraging clinical response of
electric stimulation in this specific group, we raised a possible key stopcock for future studies. The electric stimulation may relax the spasm of pelvic floor musculatures. This
relaxation may block pain-PE vicious circles. In addition,
electric stimulation, a kind of pudendal nerve modulation,
may block the sensory hyper-excitability of penis. Nevertheless, the exact physiology of electric stimulation for PE
needs further study. Continuous and thorough clinical studies are mandatory to determine the long-term effectiveness of this kind of therapy for PE.
42
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