MOHAMMAD HARIS BURKI (M.B.B.S., Ph.D.)
MAHRUKH MASOOD (M.Sc., M.Phil)
Master and Johnson have argued that premature ejaculation and erectile dysfunction are inter-related sexual dysfunctions. Premature ejaculation leads to erectile dysfunction due to the self imposed numbness to the erotic stimulation from the partner, in order to delay the ejaculation.
To explain the relationship between premature ejaculation and erectile dysfunction in terms of psychiatric illness; mediated by the functional imbalance of different neurotransmitters.
Several websites were searched for the words like depression, anxiety, premature ejaculation, erectile dysfunction, serotonin, noradrenaline and dopamine. It was followed by manual search for research papers, books and articles from sexology, psychiatry, and urology.
Studies quoted prove that anxiety is closely related to the premature ejaculation. Later on anxiety gets converted into the depression, which in itself is an etiological factor of erectile dysfunction.
It is concluded that premature ejaculation causes erectile dysfunction, same way as anxiety leads to the depression. Neurochemical changes in both the phenomenon are similar.
DECLARATION OF INTEREST
Premature ejaculation (PME) and depression are reciprocally interrelated. Premature ejaculation can lead to erectile dysfunction (ED) and erectile dysfunction can cause premature ejaculation. Dual problem of PME and ED are the most daunting challenge in the field of sexology. Determining the cause and effect relationship between two is of great clinical importance for adequate treatment. Most of the time behavioral interpretation is given to explain the association between ED and PME. According to this model patient of premature ejaculation would try to delay orgasm through distraction method. They shift their attention from sex to nonsexual pursuits like business or would divert their focus by mental exercise e.g., reverse counting in order to postpone orgasm. On other time they produce counter sensation by nail biting pulling of hairs, tightening of buttocks and etc. As a matter of fact these methods were suggested by ancient sexologists. Master and Johnson have argued that such methods were counter productive. Sensation, received from the female are the chief source of arousal. Methods of attention diversion deprive the person of erotic stimulus. Gradually over the time, the practice of curtailing sensory sexual in put, results in development of erectile dysfunction 1,15.
With the unprecedented advancement in psychiatry and psychopharmacology alternative interpretation are now available. Most of the phenomenons are thus explained with reference of neurotransmitter imbalances. So this particular phenomenon can be described in terms of psychiatric disorders of anxiety, depression, and serotonergic, noradrenergic and dopaminergic dysfunction.
Purpose of this overview is to analyze the association between premature ejaculation and erectile dysfunction. And to study associated psychiatric disorder and neurotransmitter dysfunction.
Internet search was made using key words of anxiety, depression, somatoform disorder, premature ejaculation, erectile dysfunction, serotonin, noradrenaline and dopamine on various electronic database websites like Medline, Pubmed, emedicine and www.psychiatrist.com, followed by manual search of books, published papers and surveys on this topic in the field of sexology, psychiatry and urology.
The results revealed few studies which showed that the basic mechanism of neurotransmitter action for premature ejaculation (PME) and erectile dysfunction (ED) are the similar. It further suggested that anxiety and premature ejaculation are correlated. In addition, it substantiates that anxiety gets converted into the depression, which in itself is one of the etiological factor of erectile dysfunction.
Anxiety And Premature Ejaculation
Orgasmic dysfunctions are the commonest sexual problems presented. Among orgasmic disorders premature ejaculation (PME) is the most frequently reported dysfunction. It amounts to 40% of total sexual dysfunctions 2.
Cooper et al has described basic clinical picture and differences between primary and secondary premature ejaculation. Primary premature ejaculators (PPE) are those who had been suffering since beginning of active sex life. Secondary premature ejaculators (SPE) develop after one year of satisfactory sexual activity. SPE have comorbid ED, reduced libido, and decreased arousal during sex stimulation. PPE fared poorly on satisfaction scale than SPE. Anxiety score on Hamilton Anxiety Rating Scale (HARS) of PPE was higher than SPE indicating a closer association of anxiety and PPE 3.
An anonymous postal questionnaire has depicted association of anxiety and premature ejaculation 4. Premature ejaculation is most frequent sexual problem in the male social phobic patient 5. Clonazepam- a long acting high potency benzodiazepam is proved effective in social anxiety but concomitantly high rate of anorgasmia has also been reported 6. Thus logically, ejaculatory latency and social anxiety are linked at some level. Comorbid premature ejaculation and panic disorder are treated with same pharmacological agent like fluoxetine. Serotonin is involved in pathophysiology of both PME and panic disorder. SSRI’s has proven efficacy for both disorders. A 20mg dose of fluoxetine showed improvement in PME at week 2 of study. Variables of panic disorder and sexual satisfaction become statistically significant only as of week 4. Family of serotonergic receptors is concerned with panic as well as premature ejaculation. SSRI’s regulate serotonergic and noradrenergic receptors simultaneously by their action 7. Norepinephrine plays important role in induction of rapid ejaculation. Depressed patient with reduced libido but normal erection and orgasm did not responded to fluoxetine but there were no adverse side effects observed. When the same patient was switched to 4mg BD dose of reboxetine his depression responded but developed spontaneous ejaculation and premature ejaculation 8. Seminal emission and ejaculation are under control of anterior thalamic nuclei, preoptic nuclei, and median forebrain bundle on which dopamine has facilitatory effect.
There are reports of penile anesthesia with use of fluoxetine 9,10. But it is not specific to fluoxetine. Similar studies with use of other SSRI’s like sertraline have been published. Common factor is increase of serotonin firing in central nervous system with the use of SSRI’s. All the patients have reported concomitant reduction of all other sensations. But penile anesthesia is perceived more exclusively. In the rats modulation of nocicetive sensation and opiod analgesia is considered. Reduction of 5HT found in panic or depression possibly produces exactly opposite effects in the form of hypersensitivity in general and penile in specific.
Different serotonergic receptors got different action on ejaculation process 5HTIA facilitatory and 5HT2 have inhibitory effects. Nor epinephrine controls spinal center of emission, ejaculation and closure of bladder neck during ejaculation. 5HT antagonists, 5HT1A agonists 8-OH-DAPT and adrenergic agents like ephedrine, pseudoephedrine and phenylephrine can reduce ejaculatory time. Subnormal growth hormone’s response to clonodine has been observed in patients with panic, major depression, and GAD which is an indication of reduced post synaptic adrenergic 2 receptors functioning due to noradrenergic over activity 11. Both HPA and locus coeruleus which are activated simultaneously in response to stress facilitate encoding of negatively charged memories. This unbridle over activity of locus coeruleus would result in chronic anxiety. In social anxiety and panic disorder level of norepinephrine is raised during orthostatic drop 12. Association of these disorders with PME has already been discussed. It can therefore be deduced that PME and anxiety are having common adrenergic and serotonergic basis.
Relationship Between Anxiety And Depression
Robust association exists between anxiety and depression 13. Anxiety is associated with depression in the range of 47 to 57% and 56% of anxious patients have comorbid depression 14.Social anxiety disorder may precede major depressive disorder in 90% or more cases, with lag time of about 13 years. Depression is mostly of atypical nature. Possibly two have common neurobiological features. Both respond to MAO’s and need dopaminergic augmentation. Again, overlap between PTSD and depression are significant. Some authors consider complex somatic, cognitive, affective and behavioral effects of psychogenic trauma instead of treating them as separate phenomenon of anxiety and depression. 48% of PTSD subjects had life time major depression. Correlation between GAD and depression are very strong. Subjects with current GAD have 39% major depression or 22% has dysthymia. In GAD patients with lifetime psychiatric illness there was history of major depression in 62% or dysthymia 39%. Harvard Brown anxiety research project study has demonstrated that 54% GAD patient had major depression or dysthymia.
In an important study subjects with PME were divided in to two groups E1 and E2. Former group had less neurotic features than later group. On psychological evaluation close resemblance was found between E2 and those who were having psychogenic ED. Levels of depression in all groups under study except E1 was significantly high 16. Level of anxiety among persons suffering from neuroticism is always very high. This particular study highlights interrelationship between neuroticism, anxiety, depression and erectile dysfunction.
Study by Symond suggests that premature ejaculation (PME) has similar effects on the person as erectile dysfunction (ED) 17,19. Most prominent predictor risk factor of development of depressive disorder from anxiety is severe impairment. Development of depression as result of erectile dysfunction is very common clinical observation. Quality of life gets disturbed in PME in same manner as in ED. This particular study indicates that PME can lead to ED. Premature ejaculation give crushing blow to one’s self esteem when one realizes that he not capable to satisfy his sexual partner. His futile attempts of delaying the orgasm add to his feelings of helplessness. This provides strong ground for depression to overwhelm. Number of base line anxiety disorder increase risk of developing major depression. Depression and performance anxiety are closely linked. Anxiety begins in childhood or adolescence, while start of depressive disorder takes place later during young to middle adult hood 15.
Epidemiological studies lend strong support to prove close relationship between depressive symptoms and erectile dysfunction 24,28. They got bidirectional relationship 22. Bilateral relationship between ED and depression has been described in the study by Nicolosi et al .Relationship between ED, depression, sexual activity and sexual satisfaction was evaluated 18. A population survey of men aged 40 to 70 years was conducted in different countries. Only those men were included who had sexual partner and were not taking psychotropic drugs. 02% of them were clinically depressed and 21% had depressive symptoms. Prevalence of moderate or complete ED was 17.8%. Sexual satisfaction was inversely related to depressive symptoms. It was suggested that interrelationship between depressive symptoms and ED is mediated by reduced frequency of intercourse and frustration generated by poor sexual life.
Depression, substantially affects sexual performance 25. The Massachusetts Male Aging Study (MMAS) data indicate an odds ratio of 1.82. Other associated factors, both cognitive and behavioral, may contribute. A Zurich cohort study indicates that sexual dysfunctions are about twice as common in depressed patients as in general population 27. So, ED alone can induce depression 20.
Yet, evidence has been provided by a neurological study in which activity of brain was monitored during sexual stimulation in depressed and healthy subjects. In subjects with depression, brain activation during erotic visual stimulation was considerably less than in healthy subjects especially in thalamus, caudate nucleus and inferior and superior temporal gyri. Both the groups- depressed and healthy showed no tangible differences in activation when were exposed to neutral stimuli 21.
Epidemiological studies reveal vital role played by psychiatric factors in the genesis of erectile dysfunction. Psychiatric factors involved in ED are depressive disorder (18-35%), anxiety disorder (37%), OCD and psychotic disorder (46-47%) and antipsychotic medication 23.
These studies and observations testify that a strong relationship exist among anxiety, PME, depression and ED. Frequent comorbidity of erectile dysfunction, PME and disorder of desire is of paramount importance 26. In a typical case initially there is a combination of anxiety and PME with occasional psychogenic erectile dysfunction, as seen in young adults 13. Later on combination of depression and ED is more common. This is because anxiety is more common among young adult which is converted into depression with the advancement of age15. And so is the PME which is more common among in young adult which degenerate into ED with the ageing. This psychiatric approach would help predict and treat depression induced ED more efficiently.
In this paper it is argued that premature ejaculation is closely associated with different forms of anxiety. Different forms of anxiety degenerates into depression. Relationship of major depression and ED is very strong. From this syllogism an alternative explanation of development of ED from PME can be deduced.
Still we cannot predict with certainty that which kind of anxieties would be converted into depression. Secondly it is yet not possible to predict what type of depression would develop ED. No classification of depression on basis of neurotransmitter has been proposed.
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