Survey of patient and partner satisfaction following collagenase Clostridium histolyticum treatment for Peyronie's disease.

Intralesional injection of collagenase Clostridium histolyticum (CCH) is a minimally invasive, Food and Drug Administration-approved, effective treatment for Peyronie's disease (PD). To assess the satisfaction of patients and their female sexual partners (FSP) following CCH therapy for PD, we conducted a retrospective review of the records of all patients treated with CCH for PD between 04/2014 and 03/2016. Collected variables included demographics, pre- and post-treatment sexual function, penile curvature, penile vascular findings, and treatment outcomes. Patients and their FSPs were subsequently contacted by telephone and queried regarding their ability to have intercourse and their satisfaction with treatment. A total of 24 couples responded to our questionnaire and constitute the subjects of this analysis. Patient and FSP satisfaction with treatment were 67% and 71%, respectively. Significant predictors of FSP satisfaction with treatment included recall of penile trauma during prior sexual intercourse, improved ability to have sexual intercourse following treatment, and absence of post-procedural glans hypoesthesia. In conclusion, CCH imparts a significant benefit on a couple's sexual health. Partner satisfaction with treatment is correlated with improved ability to have sexual intercourse and absence of patient glans hypoesthesia.

Therapeutic effect of ozone and rutin on adriamycin-induced testicular toxicity in an experimental rat model.

To evaluate the cytoprotective effects of rutin, ozone and their combination on adriamycin (ADR)-induced testicular toxicity, 50 male albino rats were classified into five groups of ten animals each as follows: placebo group; ADR group; ADR + rutin group; ADR + ozone group and ADR + rutin + ozone group. Sperm functions, testosterone (T), luteinising hormone (LH), follicle stimulating hormone (FSH), testicular enzymes, oxidant/antioxidant status, C-reactive protein, monocyte chemoattractant proteins-1 and leukotriene B4 were determined. After ADR injection, a decline in sperm functions was observed. FSH and LH levels were increased, T level and testicular enzymes were decreased, significant enhancement in oxidative stress with subsequent depletion in antioxidants was detected and inflammatory markers were significantly elevated. Treatment with rutin and/or ozone, however, improved the aforementioned parameters. Ozone therapy alone almost completely reversed the toxic effects of ADR and restored all parameters to normal levels.

Characterisation of pomegranate juice effects on human corpus cavernosum.

Pomegranate (POM) juice may benefit the erectile process, but the scientific evidence is lacking. This study evaluates the molecular characterisation and confirmation of POM's action on human corpus cavernosum (HCC) obtained from patients (n = 16) undergoing penile prosthesis implantation. After phenylephrine contraction, the relaxant effects of POM with various inhibitors in the presence and absence of palmitic acid (PA)-induced acute oxidative stress were investigated. Electrical field stimulation (EFS)- and acetylcholine (ACh)-induced relaxation were performed using organ bath preparation. Expression of neuronal nitric oxide synthase (nNOS), endothelial (eNOS), phosphodiesterase (PDE)-5A and cGMP levels were assessed in cells from ex vivo organ cultures of HCC, using RT-PCR, ELISA and immunohistochemistry techniques. POM induced marked relaxation of HCC (maximum response: 97.0 ± 3.1%) and reversed the PA-induced decrease of EFS (20 Hz). nNOS transcription was increased by 7-fold in POM-treated cells without influencing eNOS and PDE5A expressions. We conclude that POM induced marked relaxation of HCC via: (i) nNOS stimulation, and (ii) downstream relaxation stimulated by nNOS and cGMP and bypassing the NO and PDE5. This action provides a rationale for the therapeutic or preventative use of POM in men with erectile dysfunction who do not respond well to PDE5 inhibitors.

Collagenase Clostridium histolyticum for the pharmacological management of Peyronie's disease.

Peyronie's disease (PD) is defined as the abnormal accumulation of connective tissue in the tunica albuginea of the penis, and is an ongoing physical and psychological challenge for thousands of Americans. In vitro studies in the 1950s uncovered the potential of collagenase Clostridium histolyticum (CCH) to disrupt the collagen-containing plaques in PD, and opened the door to more in-depth clinical trials. Results indicated that with multiple dosage cycles followed by plaque modeling, penile curvature can be corrected, on average, in up to 35% of cases, with the majority of patients achieving ≥ 25% improvement in penile curvature. Most studies also indicated an improvement in patient-reported symptoms from the Peyronie's Disease Questionnaire. Adverse events from treatment with CCH included penile bruising, pain and edema, but most were mild to moderate in severity and usually resolved without intervention, suggesting that CCH is an effective and safe treatment for PD.

Failure to attain stretched penile length after intracavernosal injection of a vasodilator agent is predictive of veno-occlusive dysfunction on penile duplex Doppler ultrasonography.

Penile duplex Doppler ultrasound (PDDU) assesses the etiology of erectile dysfunction. Peak systolic velocity (PSV), end-diastolic velocity (EDV), and resistive index (RI) are common PDDU parameters. We assessed whether stretched penile length (SPL) in the flaccid state and measured penile length at peak erection after intracavernosal injection (ICI) of a vasodilator during PDDU correlated with the etiology of erectile dysfunction. We performed a retrospective review of 93 patients who underwent PDDU for erectile dysfunction. Normal and stretched penile length were measured, both at a flaccid state prior to ICI and at peak erection during PDDU. Collected data included patient demographics, vascular, and anatomic parameters. The mean age was 52 years. SPL was equivalent to peak penile length after ICI in 60 patients (65%, group 1) and did not match in 33 (35%, group 2). There were no significant differences between the two groups in terms of flaccid, stretched, and post-ICI erect penile lengths, IIEF score, PSV, percent rigidity or tumescence, and vasodilator dose used. Patients in group 2 had less of a change in penile length from flaccid to erect state (36% vs. 44%, p = 0.02), higher EDV (12.0 vs. 8.5, p = 0.041), lower RI (0.6 vs. 1.0, p = 0.046), and more veno-occlusive dysfunction (82% vs. 53%, p = 0.001). On multivariate analysis, failure to reach maximum SPL at peak ICI erection (OR 2.255, CI 1.191-4.271, p = 0.0126), EDV (OR 1.281, CI 1.115-1.471, p < 0.001) and RI (OR 0.694, CI 0.573-0.723, p = 0.009) predicted veno-occlusive dysfunction. Failure to reach maximal SPL during PDDU using ICI with a vasodilator agent predicted veno-occlusive dysfunction, which is independent of both penile rigidity and tumescence. This measurement could serve as another diagnostic tool for predicting veno-occlusive dysfunction when PDDU is not readily available. Limitations include the subjective nature of penile measurements and different PGE1 doses used.

Differential expression of novel biomarkers (TLR-2, TLR-4, COX-2, and Nrf-2) of inflammation and oxidative stress in semen of leukocytospermia patients.

Chronic genitourinary inflammation results in Leukocytospermia (LCS), an elevated number of white blood cells (WBCs) in semen, which, in association with oxidative stress, may suppress sperm function, and manifest as male factor infertility. The current clinical diagnosis of LCS employs manual enumeration of WBCs and requires complex staining and laboratory skills or measurement of inflammatory cytokines and chemokines levels. Many patients with idiopathic infertility are asymptomatic. In search of better inflammatory markers for LCS, we evaluated expression of toll-like receptors 2 and 4 (TLR-2/4), cyclooxygenase-2 (COX-2), and nuclear factor (erythroid-derived 2)-like 2 (Nrf-2) in semen samples of age-matched infertile patients with and without LCS. We employed the usage of specific Western blot evaluation, cytokine array; immunofluorescence microscopy (IFM) followed by computer-based analysis, and other molecular approaches. As compared with non-LCS patients (n = 38), semen samples from LCS patients (n = 47) displayed significantly lower total sperm count (p < 0.01), motility (p < 0.0001), normal head count (p < 0.0001), and a significantly higher white blood cell count (p < 0.0001). Differential cytokine profiling of seminal plasma by antibody array revealed up-regulation of several pro-inflammatory chemokines in LCS samples. Western blot analysis of LCS seminal plasma (n = 15) also showed a significant increase in expression of TLR-2 (p < 0.001) and 4 (p < 0.01), COX-2 (p < 0.001), and Nrf-2 (p < 0.001) as compared with semen samples from non-LCS patients (n = 15). Computer-based objective IFM analysis of spermatozoa from LCS patients showed increased expression of TLR-4 (p < 0.001), Cox-2 (p < 0.01), and (Nrf-2) (p < 0.01). Significant differences in the subcellular localization of these proteins were evident in the sperm head and tail segments of LCS samples. Altogether, these observations suggest that TLR-2/4, COX-2, and Nrf-2 can serve as novel biomarkers of inflammation and oxidative stress. Therefore, developing a rapid assay for these biomarkers may facilitate early diagnosis and management of LCS especially in idiopathic and asymptomatic male infertility patients.

Therapeutic advances in the treatment of Peyronie's disease.

Peyronie's disease (PD) is an under-diagnosed condition with prevalence in the male population as high as 9%. It is a localized connective tissue disorder of the penis characterized by scarring of the tunica albuginea. Its pathophysiology, however, remains incompletely elucidated. For the management of the acute phase of PD, there are currently numerous available oral drugs, but the scientific evidence for their use is weak. In terms of intralesional injections, collagenase clostridium histolyticum is currently the only Food and Drug Administration-approved drug for the management of patients with PD and a palpable plaque with dorsal or dorsolateral curvature >30°. Other available intralesional injectable drugs include verapamil and interferon-alpha-2B, however, their use is considered off-label. Iontophoresis, shockwave therapy, and radiation therapy have also been described with unconvincing results, and as such, their use is currently not recommended. Traction therapy, as part of a multimodal approach, is an underused additional tool for the prevention of PD-associated loss of penile length, but its efficacy is dependent on patient compliance. Surgical therapy remains the gold standard for patients in the chronic phase of the disease. In patients with adequate erectile function, tunical plication and/or incision/partial excision and grafting can be offered, depending on degree of curvature and/or presence of destabilizing deformity. In patients with erectile dysfunction non-responsive to oral therapy, insertion of an inflatable penile prosthesis with or without straightening procedures should be offered.

Erectile dysfunction in urethral stricture and pelvic fracture urethral injury patients: diagnosis, treatment, and outcomes.

Urethral stricture disease, pelvic fracture urethral injury (PFUI), and their various treatment options are associated with erectile dysfunction (ED). The etiology of urethral stricture disease is multifactorial and includes trauma, inflammatory, and iatrogenic causes. Posterior urethral injuries are commonly associated with pelvic fractures. There is a spectrum in the severity of both conditions and this directly impacts the treatment options offered by the surgeon. Many published studies focus on the treatment outcomes and the relatively high recurrence rates after surgical repair. This communication reviews the current knowledge of the association between ED and urethral stricture disease, as well as PFUI. The incidence, pathophysiology, and clinical ramifications of both conditions on sexual function are discussed. The treatment options for ED in those patients are reviewed and summarized.

Effect of avanafil on rat and human corpus cavernosum.

We compared the activity of a new phosphodiesterase-5 inhibitor (PDE5i) avanafil with sildenafil and tadalafil in human and rat corpus cavernosum (CC) tissues. The effect of avanafil with several inhibitors and electrical field stimulation (EFS) was evaluated on CC after pre-contraction with phenylephrine. With the PDE5i, sildenafil and tadalafil, concentration-response curves were obtained and cyclic guanosine monophosphate (cGMP) levels were measured in tissues. Avanafil induced relaxation with maximum response of 74 ± 5% in human CC. This response was attenuated by NOS inhibitor and soluble guanylate cyclase (sGC) inhibitor. Avanafil potentiated relaxation responses to acetylcholine and EFS in human CC and enhanced SNP-induced relaxation and showed 3-fold increase in cGMP levels. When compared with sildenafil, avanafil and tadalafil were effective at lower concentrations in human CC. In addition, Sprague-Dawley rats underwent in vivo intracavernosal pressure (ICP) and mean arterial pressure (MAP) measurements. Avanafil increased ICP/MAP that was enhanced by SNP and cavernous nerve (CN) stimulation in rat CC tissues. Also avanafil showed maximum relaxation response of 83 ± 7% in rat CC with 3-fold increase in cGMP concentration. Taken together, these results of our in vivo and in vitro studies in human and rat suggest that avanafil promotes the CC relaxation and penile erection via NO-cGMP pathway.

Comparison of infrapubic versus transcrotal approaches for inflatable penile prosthesis placement: a multi-institution report.

Inflatable penile prostheses (IPP) are associated with excellent long-term outcomes. To date, no study has evaluated the significance of surgical approach on IPP intraoperative variables. High-volume surgeons placing the Titan 0-degree prosthesis from March-July 2012 completed questionnaires including pre-/intraoperative variables. Intraoperative data were compared between surgeons performing an infrapubic versus transcrotal approach for total length of prosthesis, proximal and distal measurements, rear-tip extender (RTE) length, reservoir size and fill volume and ability to place the reservoir in the space of Retzius. Forty-six surgeons placed 256 IPPs, with a median of 5 (range 1-10) inserted. Transcrotal placement was performed most commonly (80%). Revision procedures accounted for 13% of cases, with 19% previously undergoing robotic-assisted prostatectomy. Compared with infrapubic, transcrotal placement resulted in a longer total prosthesis (22.3 cm vs 20.6 cm, P < 0.0001), increased proximal dilation (10.1 cm vs 8.6 cm, P < 0.0001), longer RTEs (1.9 cm vs 1.2 cm, P < 0.0001) and larger reservoir fill volume (79 cc vs 71 cc, P = 0.0003). No differences were noted in distal measurements or ability to place the reservoir in the space of Retzius. Compared with the infrapubic approach, high-volume surgeons placing the Titan 0-degree IPP transcrotally achieved increased proximal dilation with an ~1-2-cm-longer prosthesis inserted.

The direction and severity of penile curvature does not have an impact on concomitant vasculogenic erectile dysfunction in patients with Peyronie's disease.

Although the association between Peyronie's disease (PD) and erectile dysfunction (ED) is well established, limited data are available correlating penile curvature and penile hemodynamic parameters. We sought to examine this association in a cohort of PD men undergoing penile duplex Doppler ultrasound (PDDU). PD patients were retrospectively evaluated to correlate the extent and direction of penile curvature with measured vascular parameters. Demographic variables, disease characteristics and PDDU parameters were tabulated and statistically compared based on extent (≤ 45° and >45°) and direction (dorsal, ventral, lateral, ventrolateral, dorsolateral) of curvature. A total of 220 PD patients (mean age of 55.0 ± 9.2 years) underwent PDDU at one institution from January 2008 to December 2010. Overall, 69.5% of patients were found to have vasculogenic ED (arterial insufficiency (AI): 10%; veno-occlusive dysfunction (VOD): 43.2%; AI + VOD: 16.4%). Mean curvature was similar among all PDDU groups (AI: 41.7 ± 5.2°; VOD: 41.3 ± 2.5°; AI+VOD: 37 ± 4.1°; no-ED: 37.3 ± 3°; P > 0.85). No significant differences were noted in the presence or type of ED among various directions of curvature (P = 0.34) or when curvatures were stratified by ≤ 45° and >45°. The direction and extent of penile curvature are not associated with altered rates of vasculogenic ED on PDDU in PD patients.

Adipose tissue-derived stem cell therapy for prevention and treatment of erectile dysfunction in a rat model of Peyronie's disease.

Peyronie's disease (PD) is a localized connective tissue disorder that involves the tunica albuginea (TA) of the penis. While surgical correction remains the gold standard, the search for an effective and less invasive therapy continues. The objective of this study was to evaluate the effects of intratunical injection of adipose tissue-derived stem cells (ADSCs) for the prevention and treatment of erectile dysfunction in a rat model of PD. Twenty-four male Sprague-Dawley rats (300-350 g) were randomly divided into four groups: sham, PD, PD + ADSC (prevention) and PD + ADSC (treatment). All rats underwent penile injections into the TA with 50 µL vehicle (sham) or 0.5 µg transforming growth factor (TGF)-ß1 (remaining groups). The ADSC groups received intratunical injections with 0.5 million rat-labelled ADSCs on day 0 (prevention) or day 30 (treatment). Forty-five days following TGF-ß1 injection, rats underwent cavernous nerve stimulation (CNS) with total intracavernous-to-mean arterial pressure ratio (ICP/MAP) and total ICP recorded to measure response to therapy. Tissues were evaluated histologically and for mRNA expression of tissue inhibitors of metalloproteinases (TIMPs), matrix metalloproteinases (MMPs) and zymographic activity of MMPs. Statistical analysis was performed by analysis of variance followed by the Tukey test for post hoc comparisons. In both prevention and treatment groups, intratunical injection of ADSCs resulted in significantly higher ICP/MAP and total ICP in response to CNS compared with the PD group. Local injection of ADSCs prevented and/or reduced Peyronie's-like changes by decreasing the expression of TIMPs, and stimulating expression and activity of MMPs. This study documents the preventive and therapeutic benefits of ADSC on penile fibrosis and erectile function in an animal model of PD.

The pre-treatment prevalence and types of sexual dysfunction among patients diagnosed with prostate cancer.

Erectile dysfunction (ED) following prostate cancer therapy is a common condition that is well documented in literature. Despite the significant focus placed on ED and prostate cancer, very little is known regarding the baseline prevalence of other aspects of sexual dysfunction (SD) in this specific cohort of patients. The objective of the current manuscript was to assess the prevalence of subtypes of SD, including ED, ejaculatory dysfunction (EjD) and decreased libido among men with newly diagnosed prostate cancer. To achieve this objective, patients presenting to our clinic with a new diagnosis of prostate cancer from July 2011 and May 2012 completed the Male Sexual Health Questionnaire (MSHQ) to assess baseline sexual function. A total of 60 patients completed an MSHQ, with a mean age of 60.28 ± 6.25 (range 44-73 years). Of patients surveyed, 14% reported no sexual activity within the previous month, while 53% had sex at least once weekly. The percentage of patients reporting ED, EjD and decreased sexual desire ≥50% of the time was 37, 26 and 48% respectively. Eleven to 18% of patients reported that these symptoms were 'very' or 'extremely' bothersome. Patients noted dissatisfaction with the quality of their sexual relationship, frequency of sexual activity and quality of sex in 18, 31 and 20%, respectively. Overall findings suggest that patients with newly diagnosed prostate cancer experience a high rate of SD at baseline. Knowledge of these prevalence rates may assist physicians managing patient's expectations with planned therapies.

PDE5 inhibitors: considerations for preference and long-term adherence.

INTRODUCTION: Erectile dysfunction (ED) is a highly prevalent condition affecting nearly one in five men worldwide. The advent of phosphodiesterase type 5 inhibitors (PDE5i) has revolutionised the ED treatment landscape and provided effective, minimally invasive therapies to restore male sexual function. MATERIALS AND METHODS: A pubmed search was performed of all English language articles from 1996 to present reviewing PDE5i, including pharmacokinetics, efficacy profiles and comparisons, where available. RESULTS: Currently available PDE5i in the United States include sildenafil, vardenafil, tadalafil and avanafil, each of which has unique side effect, pharmacokinetic and outcome profiles. Sildenafil is associated with increased rate of visual changes, vardenafil with QT prolongation and tadalafil with lower back pain. Avanafil and vardenafil orodispersible tablet rapidly achieve peak plasma concentration, which results in faster onset of action, whereas tadalafil exhibits the longest half-life. First time response to PDE5i is approximately 60-70%, with no significant differences in efficacy noted among therapies. The literature does not clearly demonstrate a preference for one drug. High-treatment success rates (89%) were reported when patients were prescribed all available PDE5i. Daily dosing with tadalafil is associated with improved erectile function (EF) over time. Finally, novel modes of patient-provider interaction, including internet-based education, communication and prescribing, may also improve long-term adherence. CONCLUSIONS: PDE5i represent first line therapy for ED with excellent overall efficacy and satisfactory side effect profiles. Enhanced communciation, coupled with increased knowledge of drug characteristics, comparative treatment regimens and optimal prescribing patterns, offer compelling tools to improve long-term treatment success.

Understanding the course of Peyronie's disease.

AIMS: To correct common misconceptions about Peyronie's disease (PD) that present obstacles to early recognition and treatment. METHODS: The prevalence, natural disease course, psychosocial effects and treatment considerations for patients with PD were reviewed. RESULTS: Studies over the past decade have shown that the prevalence of PD may be higher (up to 20%) than previously thought. PD can lead to emotional and relationship distress. Nearly 10% of men who present with PD are younger than 40. Both younger age and comorbid vascular disease have been associated with more severe and progressive PD. In the majority of patients, symptoms will either deteriorate or remain stable. PD is often associated with erectile dysfunction (ED). Effective, minimally invasive treatments used early in the disease course include unapproved and/or investigational intralesional injection therapy with verapamil, interferon (IFN) α-2b, or collagenase clostridium histolyticum (CCH). Surgical intervention is considered in patients with ED and/or penile deformity that impairs sexual functioning; however, preoperative discussion of appropriate expectations is important. DISCUSSION: The availability of effective minimally invasive and surgical therapies for PD suggests that active management should be considered over a 'wait-and-see' approach. CONCLUSION: Providing early intervention and improved education/awareness of PD as a chronic and progressive disorder may result in improved physical and psychosocial outcomes for PD patients. As general practitioners are often the first contact for men with PD, they are well positioned to recognise symptoms early and promptly refer patients for further evaluation and treatment.

Adolescent varicocoele management controversies.

Varicocoele is defined as excessive dilatation of the pampiniform venous plexus of the spermatic cord. Varicocoele frequently appears during early puberty and is recognized to be the most common surgically correctable cause of male infertility. However, the actual incidence in adolescents, pathophysiology and the association with male factor infertility all remain somewhat controversial. The most accurate diagnostic technique for identifying young men who will benefit from surgical treatment has yet to be established. Observations of testicular asymmetry and deteriorating semen quality helped establish current guidelines and recommendations for surgical treatment. Further studies, comparing observation with surgical intervention, are needed to refine the current indications for varicocoele repair in the adolescent male.

Deleterious effects of selective serotonin reuptake inhibitor treatment on semen parameters in patients with lifelong premature ejaculation.

Premature ejaculation (PE), the most common sexual dysfunctions in men, is characterized by loss or absence of ejaculatory control. PE can be classified as either a lifelong or acquired condition. Although the prevalence of lifelong PE is rather low in the general male population, recent studies demonstrated that the patients who seek treatment for their rapid ejaculation mostly report lifelong PE. Although no drug for PE has been approved by regulatory bodies, chronic selective serotonin reuptake inhibitors (SSRIs) proved to be effective in treating lifelong PE. Despite the rising use and known effects of antidepressants on ejaculation, only a few reports have evaluated the impact of these drugs on the male fertility. Thus, the aim of this review is to evaluate the efficacy and adverse effects of SSRIs on semen parameters of patients with lifelong PE as well as to assess the safety of this treatment among sexually active couples who desire to have a child.

Does a replacement or revision of an inflatable penile prosthesis lead to decreased patient satisfaction?

To analyze the reason for replacement, revision and overall satisfaction of a cohort who underwent surgical replacement of an inflatable penile prosthesis (IPP). A cohort of 105 patients who underwent IPP replacement from 2005-2007 was retrieved from the prosthesis database. Approximately 21.9% (23) underwent replacement or revision of their prosthesis because of complications, and were further analyzed. Reason for removal was stratified into infectious and non-infectious (erosion, non-function and patient discomfort). Age, race (African American vs non-African American), smoking history, hypertension, diabetes, coronary artery disease and hyperlipidemia were stratified by reason for removal. Finally, we contacted patients and recorded subjective satisfaction with their IPP. The reason for removal was most commonly because of a non-functional IPP (47.8%), followed by infection (30.4%), erosion (17.4%) and patient discomfort (4.3%). Age and race did not show a significant difference when analyzing reason for replacement (P > 0.05). Patients who were smokers (P = 0.907) had hypertension (P = 0.554), diabetes (P = 0.591) or hyperlipidemia (P = 0.219) did not have significantly higher infection rates. Approximately 58.3% were satisfied with their prosthesis, 75% would have the surgery performed again and 91.7% would still recommend prosthesis surgery. Device malfunction was the primary reason for replacement/removal at our institution. Despite the complications of prosthesis reoperation, the majority of patients were still satisfied with their prosthesis, would have the surgery performed again and would recommend prosthesis surgery to a friend.

Dapoxetine for premature ejaculation.

Premature ejaculation (PE) is the most common form of male sexual dysfunction, with an estimated worldwide prevalence of 20­30%.1 Although PE is not life threatening, it has significant impact on quality of life. The fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR)defines PE as "persistent or recurrent ejaculation with minimal sexual stimulation before, on, or shortly after penetration and before the person wishes it" that "causes marked distress or interpersonal difficulty" and "is not due exclusively to the direct effects of a substance."2 The International Society for Sexual Medicine, which recently modified the definition to include the threshold ejaculatory latency time, defines PEas "male sexual dysfunction characterized by ejaculation which always or nearly always occurs prior to or within 1 min of vaginal penetration; the inability to delay ejaculation on all or nearly all vaginal penetrations; and negative personal consequences such as distress, bother, frustration, and/or the avoidance of sexual intimacy."3 The lack of ejaculatory control is consistent among all clinical definitions of PE and is a highly sensitive predictor of the condition.