MOHAMMAD HARIS BURKI (M.B.B.S., Ph.D.) 1
MAHRUKH MASOOD (M.Sc., M.Phil) 2
SALEEM UZ ZAMAN ADHAMI (MRCP) 3
SEXUAL HEALTH INSTITUTE OF PAKISTAN1 , SHALAMAR HOSPITAL LAHORE 2,3
Orgasmic dysfunctions are the commonest sexual problems encountered. Before the introduction of SSRIs, behavioral techniques were the mainstay for the management of premature ejaculation. Pause method, pubococcygeal muscle training, cognitive and behavior pacing strategies and squeeze technique figure prominently amongst them. But the popularity of behavioral technique declined sharply after the dawn of SSRI era. However, SSRIs have certain side effects especially anorgasmia and erectile dysfunction. A strong need was felt to develop a more effective and self administrable technique.
An extensive electronic search was made regarding techniques for delaying premature ejaculation on various database websites. Manual search for such material from various journals and books was also made. Orgasm was studied in detail; anatomically and physiologically.
In the first stage the basis of emission was understood to be as follows:
First is the contraction of vasa efferentia of testis. Secondary contraction travel along epididymis to vas deferense and finally these pulsate in close conjunction with seminal vesicles. Regular prostatic contractions are recorded during the process. Prostatic fluid is poured into urethra. Later secretion stored in ampullae and seminal vesicle is discharged into prostatic urethra. Spermatic cords appear to be most strategic point as nerve impulse for initiating orgasm passes down and emission reflex passes upward through them.
Considering the anatomy and physiology of orgasm, a simple method to block orgasm has been developed. Sympathetic impulses for orgasm and sub threshold orgasmic impulses prior to emission can be blocked by compressing two spermatic cords simultaneously at upper half of right and left folds or margin of scrotum close to deeper part of penis. These spots can be pressed firmly by middle and ring finger with penis in the cleft between index and middle finger. If penis is thicker, cleft between middle and index finger can be used. That is what has been termed as Burki’s maneuver.
In the field of Sexology the topic of PME is one of the most vehemently debated issues. It is the most stigmatizing disorder of sexology after impotence. The disturbance causes marked distress and, or interpersonal difficulty. Ejaculatory problems are most prevalent sexual disorder. Rapid ejaculation is the most common presentation of ejaculatory dysfunction1. It should be the focus of discussion, since viagra and other phosphodiaestrases inhibitors 5 have solved the problem of erectile dysfunction to a great extend. Phenomenon of PME has wide ranging repercussions, which can affect physical psychological, social and spiritual aspects of life. Among non-Pharmacological techniques commonly employed are squeeze technique, Kegal exercise30, pause methods and pulling down of the testis2, 12, 22, 23. Other psychosexual techniques include physiological relaxation, pubococcygeal muscle training30, cognitive and behavior pacing strategies and involvement of partner in the therapy Premature Ejaculation. Only a small proportion of patients were treated successfully with behavioral techniques and these remained effective for approximately three years after treatment had ended. Different studies show that psycho- sexual techniques are only marginally effective15,16,17. Still other techniques for the treatment of Premature Ejaculation focus different intercourse positions and involvement of partner in the therapy18,19,20,21.
Data of controlled clinical studies does not support long term efficacy of psychosexual counseling in the management of rapid ejaculation. Psychological treatment relies heavily on the patient’s acceptance of the psychological technique and his partner’s participation in the therapy, hence fails because of rejection by the patient or when partner is unwilling to cooperate in the treatment. Focus has been shifted more towards pharmacological treatment3.
Clomipramine and SSRIs have evolved as most effective treatment of rapid ejaculation. Whether there is clinical depression present or not, Clomipramine, fluoxetine, Paroxetine, and sertaline are considered as best available choices. All SSRIs have comparable efficacy and Paroxetine was found superior to pause squeeze technique in terms of efficacy13. This is even true when psychological treatment is unsuccessful. But pharmacological treatment is not devoid of side effects. Their most disturbing side effects include anorgasmia and erectile dysfunction 4, 5, 6, 7, 8, 11.
The low success ratio of behavioral techniques and side effects of SSRIs led the researchers to develop a new technique which could prove more useful to such patients. Therefore, a technique for delaying ejaculation has been proposed- Burki’s maneuver.
Different techniques for delaying premature ejaculation were searched on various electronic database websites. Manual search for such material from various journals and books were also made. Orgasm was also studied in detail; anatomically and physiologically. Majority of the studies found on databases were nonscientific in nature. For the purpose of this research, scientific and authentic researches were selected and only eight researches were found.
Premature ejaculation (PME) also known as rapid ejaculation is the most common male sexual problem effecting about 28% of all men14. Control studies show traditional treatment for PME is not very effective on long term bases15.
In the orgasm, first step is contraction of vasa efferentia of testis. Secondary contraction travels along epididyms to the ampulla of vas deferense, which pulsate in close conjunction to seminal vesicles. Regular prostatic contraction is recorded during ejaculation. Firstly, prostatic fluid is poured into urethera. Later secretions stored in ampulla and seminal vesicles are discharged into prostatic urethra. Recurring prostatic contraction continues regularly during ejaculation. Secretions from accessory gland are added to bulk of semen9, 10.(Diagram 1)
This new technique is based on patient’s focus on the orgasm and blocking the impulse. The mechanism of this simple method to block orgasm is as follows:
Sympathetic impulses for orgasm and sub threshold orgasmic impulses prior to emission can be blocked by compressing two spermatic cords simultaneously at upper half of right and left folds or margins of scrotum close to deeper part of penis. These spots can be pressed firmly by middle and ring finger with penis in the cleft between ring and middle finger. If penis is thicker, cleft between middle and index finger can be used. This is what has been termed as Burki’s maneuver.( Diagram 2,3,4) This technique can be combined with basilar squeeze technique for better results. (Diagram 5)
Premature ejaculation, also known as rapid ejaculation is the commonest sexual dysfunction encountered. It amounts to almost 40% of the total sexual dysfunctions. Various behavioral techniques have been employed for delaying ejaculation with variable success. Some of the techniques, e.g. distraction technique commonly used by the people either are not effective or are counter productive. Pharmacological treatment though is more successful but is not devoid of undesirable side effects. Sexologists have devised various strategies to cope with the problem of PME. Burki’s maneuver is one such technique which can be easily applied and allows better control.
First we will review physiology and anatomy of ejaculation reflex with regards to Burki’s maneuver technique. Emission begins with contraction of vas deference and its ampulla to cause expulsion of sperms into internal urethra. This is followed by contraction of muscular coat of prostate gland and then that of contraction of seminal vesicle which expels prostatic fluid and seminal fluid (10). These fluids mix in internal urethra with the mucous already secreted by bulbo urethral glands to form semen. The filling of internal urethra then elicits necessary signals that are transmitted through pudendal nerve to sacral regions of the cord, giving the feeling of sudden fullness in the internal genital organs. All these sensory signals further excite the rhythmic contractions of internal genital organs and also cause contractions of ischocavernous and bulbo spongiosus muscle that compress bases of penile erectile tissue. These effects, together causes rhythmic wave like increase in pressure in the genital ducts and the penile urethra which ejaculate the semen from urethra to the exterior.
Anatomical structures of the spermatic cord. Spermatic cord is composed of vas deferense and its own artery and veins, a nerve plexus around these vessels, testicular artery, pampiform plexus and few other structures that are not related to ejaculation. In author’s opinion spermatic cord serves as intersection of structure involved in ejaculation reflex24, 25.
Vas deferense is the first structure which initiates emission. Reflex first reaches to the ampulla and then to seminal vesicle. So if the reflex is arrested at the level of vas deferense, it would stop the initiation of emission reflex. It would be interesting to study nerve and blood supply of the vas deferense 25. The vas deferense receive its main supply from artery to ductus which is a branch of inferior vesicle artery. This artery supplies the vas deferense, the seminal vesicle and the lower urethra. Nerve to ductus seems to come mainly from sympathetic through hypogastric plexuses. Its nerve supply has a very unique feature that is; each of its muscle fibers appears to have individual innervations. As discussed SNS is chiefly implicated in the processes of emission and ejaculation; and major transmission line is the plexuses which are around artery to ductus.
In case of visceral smooth muscles autonomic nerve fiber does not make direct contact, rather a diffuse junction is formed .The nerve fibers secrete their transmitter substance into interstitial fluids; transmitter substance then diffuses into the cell. In multilayered structures nerve fibers often innervate only outer layer, and muscle excitation travel from this outer layer to the inner layer by action potential conduction in the muscle mass or by subsequent diffusion of transmitter substance. The pattern of innervations of vas deferense is different and is called multiunit type. Obviously it should exhibit superior finer control over its graded activity. We would discuss its importance in subsequent section. Erotic stimulation increases general myotonia so is sympathetic discharge which brings about contraction of vas deferense. If stimulation is stopped at plateau phase (pre emissionary phase) one would have what is called dry orgasm. This manifests that sub threshold orgasmic reflex was already underway. But this phenomenon is rarely seen in a premature ejaculator because they got very short plateau phases. These sub threshold reflexes accumulate to give rise to full fledge emission. We call this feeling that precedes emission as pre- emissionary sensation which is different from pre- ejaculatory sensation. Let us study phenomenon of summation to understand this point (10). Different gradation of intensity can be transmitted either by utilizing increasing number of parallel fibers or by sending more impulses along a single fiber. As we know Vas deferense is a multiunit system with number of nerve fibers recruited, which can be adjusted to the activity of SNS. Before proper emission sub threshold impulses would have been passing along vas deferense. One can curtail sympathetic discharge and block sub threshold impulses by compressing two spermatic cords simultaneously at certain points. In Burki’s technique, it has been suggested that the most suitable spot is upper half of right and left folds or margin of scrotum close to deeper part of penis (Diagram No. 2 and 4). Spermatic cord can be pressed against hard buried portion of erect penis. This spot can be pressed firmly by middle and ring finger with penis in the cleft between ring and middle finger. If penis is thicker, cleft between middle and index finger can be used. That is called Burki’s maneuver or cord compression technique. Before applying Burki’s maneuver individual is taught to focus on the responsiveness of body sensation and arousal. He is taught to concentrate on sexual enjoyment by improving his sensual cognitive awareness27, 28.
Sensual Awareness Training
Patient is taught to familiarize himself with his body, both visually and tactilely. This helps in creating awareness of his bodily responses to touch. He learns about Mohser’s model of sexual arousal based on in-body vs out-of-body focus. Premature Ejaculators unconsciously uses erotic stimulus for sexual arousal because of their out- of- body focus. They are surprised when they ejaculate because they do not focus on their body response and sensations. They learn better ejaculatory control when they are aroused by focusing on their own body sensations.
This method is superior to all previous techniques because of following visible advantages.
It is simple and easy, applied quickly with no fumbling.
It can be self administered unlike coronal squeeze technique.
It is not painful or hazardous.
Perhaps greatest advantage is that it can be used during intercourse. One needs not to withdraw his penis.
This technique can be integrated with basilar squeeze technique so to produce even better results.
Its application with Basilar Technique
Basilar squeeze technique is the modified form of the squeeze technique. In this technique base of the penis just at the point where it joins the body is pressed in between thumb and index finger just before the urge to ejaculate becomes inevitable 26, as shown in the diagram (see diagram no.3). Burki’s maneuver and basilar squeeze can be applied in conjunction as with slight modification in the basilar technique. Subject applies Burki’s maneuver with one hand and with the middle finger of the other hand he compresses base of the penis as shown in the diagram. When these two techniques are applied in random the ejaculatory control improves considerably
DIAGRAM 1 SHOWING DIFFERENT STRUCTURES OF MALE GENITAL SYSTEM
DIAGRAM 2 SPOTTING APPROPIATE POINTS AT SPREMATIC CHORD
DIAGRAM 3 APPLYING BURKI, S MANEUVER JUST AFTER INITIATION OF EMISSSION
DIAGRAM 4 PALPATING SPREMATIC CHORDS IN THE MARGIN OF SCORTUM
DIAGRAM 5 APPLYING BASILAR SQUEEZ
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