Pharmacotherapy in the Treatment of Male Sexual Dysfunction

Journal of Sex Research, August, 2000 by David L. Rowland, Arthur L. Burnett

In contrast with ED, research has failed to identify specific causes or mechanisms underlying PE. Current thinking suggests that PE may stem from either inherent or acquired somatic factors, from psychological factors, or from some combination thereof. Although an unequivocal and exclusive somatic or psychological cause for PE is occasionally identified (e.g., after spinal cord injury: Kuhr, Heiman, Cardenas, Bradley, & Berger, 1995), such cases are unusual. In most instances, PE probably results from a mix of psychogenic and organogenic factors (Strassberg, Kelly, Carroll, & Kircher, 1987) which may interact with each other to exacerbate the problem. For example, a purely somatic etiology that leads to sexual failure may induce anxiety about sexual performance and further maintain the dysfunction (Bancroft, 1989). Whatever the cause of PE, recent data suggest that the typical balance between sympathetic and parasympathetic systems during sexual response may be upset in men with this disorder. Specifically, sexual response in men without PE is characterized by parasympathetic dominance during erection but sympathetic dominance during ejaculation (DeGroat & Booth, 1980; Kedia, 1983). However, men with PE may show heightened sympathetic activation very early in the sexual response cycle. Strong sympathetic action at this point may slow the erectile process and trigger the ejaculatory reflex "prematurely" (Ertekin, Colakoglu, & Altay, 1995; Rowland, Strassberg, deGouveia Brazao, & Slob, 2000).

Nonpharmacological Treatments for PE

Even though a physiological basis for some types of PE has been suspected by researchers and clinicians for years (e.g., Damrav, 1963; Pasini, 1984), treatment options until recently relied quite heavily on behavioral and psychological procedures. The reasons for this are understandable. First, psychological factors such as anxiety and negative affect had frequently been associated with the occurrence of various sexual dysfunctions, including PE (Kaplan, 1983, 1989); in contrast there had been little or no evidence pointing to a physiological mechanism that might underlie PE. Second, until recently, few tested and well tolerated biologically-based therapeutic measures were available to clinicians for the treatment of PE. And third, the cognitive-behavioral strategies for treating PE were at least moderately successful in alleviating the dysfunction (Levine, 1992).

Two cognitive-behavioral strategies have enjoyed substantial popularity among sex therapists. The first is the stop-squeeze method, developed by Semans (1956) and later adopted by Masters & Johnson (1970) in their sex therapy clinic. The second method, advocated by Kaplan (1983), is the stop-pause method. Both methods suppress the urge to ejaculate by stopping sexual stimulation, but the former substitutes a squeeze of the glans penis for a pause in stimulation at the point of impending ejaculation. These behavioral strategies, which often incorporate instruction on optimal intercourse positions, are typically combined with a variety of other strategies, including increasing the range of sexual expression to extend beyond intercourse, developing greater awareness of the association between visceral sensations and ejaculation, and relying on imagery and cognitive strategies to increase control over the ejaculatory process (Thexton, 1992; Zilbergeld, 1992).