Management of ejaculatory disorders in infertile men

Ejaculatory dysfunction is a highly prevalent clinical condition that may be classified along a continuum that ranges from premature ejaculation （PE）, through retarded or delayed ejaculation （DE）, to complete anejaculation （AE）. Retrograde ejaculation （RE） represents a distinct entity in which ejaculate is expelled either partially or completely into the bladder. While DE and PE are significant sources of sexual dissatisfaction among men and their partners, patients with these disorders retain normal fertility in most cases. Conversely, men with AE and RE are unable to deliver sperm into the female genital tract and are therefore rendered subfertile. Therefore, in reviewing ejaculatory disorders as they relate to fertility, this paper will primarily focus on the diagnosis and management of AE and RE. Physiology, diagnostic strategies, pharmacological treatments, and procedural interventions relevant to AE and RE are discussed.

Ectopic Opening of Ejaculatory Duct into Mülerian Duct Cysts:Report Two Cases

Two cases of ectopic openings of ejaculatory ducts into Mlerian duct cysts were reported. Hemospermia and hematuria were the presenting symptoms and the diagnosis could be confirmed by vasiculography and stained urethroscopy. Endoscopic shearing of the anterior walls of Mllerian duct cysts longitudinally, cure was achieved in one patient, and some imporvement was noted in the other.

Role of the ejaculatory bulb in biosynthesis of the male pheromone cis-vaccenyl acetate in Drosophila melanogaster

In Drosophila melanogaster,the male ejaculatory bulb is the site of synthesis of a male-specific pheromone,cis-vaccenyl acetate,which functions as both an attractant and an anti-aphrodisiac.This long monounsaturated acetate is structurally similar to a number of shorter gland-synthesized moth pheromones.The cell monolayer that forms the Drosophila male ejaculatory bulb wall is responsible for the production and secretion of cis-vaccenyl acetate into the seminal fluid.When dissected bulbs were incubated with sodium[14-C]-acetate(or deuterated acetate),a labeled acetate ester was synthesized.The labeled acetate ester co-migrated with cis-vaccenyl acetate in thin layer chromatography.Incubation of the abdomens of males from which the ejaculatory bulbs had been removed,or the abdomens of females,with radiolabeled acetate did not yield any acetate ester,but did yield other lipid products,including hydrocarbons.When the isolated labeled acetate ester was hydrolyzed,no radioactive vaccenol was formed.This strongly suggests that the acetyl group is incorporated via a transacetylation reaction,but that the vaccenyl moiety is not synthetized in the blub.The transacetylation enzyme activity was localized in the microsomal subfraction of the bulb homogenate,and its affinity for vaccenol was not very different from that reported for monounsaturated alcohol substrates in moths.

New insights on premature ejaculation： a review of ：lefinition, classification, prevalence and treatmeni

There are ongoing debates about the definition, classification and prevalence of premature ejaculation （PE）. The first evidence-based definition of PE was limited to heterosexual men with lifelong PE who engage in vaginal intercourse. Unfortunately, many patients with the complaint of PE do not meet these criteria. However, these men can be diagnosed as one of the PE subtypes, namely acquired PE, natural variable PE or premature-like ejaculatory dysfunction. Nevertheless, the validity of these subtypes has not yet been supported by evidence. The absence of a universally accepted PE definition and lack of standards for data acquisition have resulted in prevalence studies that have reported conflicting rates. The very high prevalence of 20%-30% is probably due to the vague terminology used in the definitions at the time when such surveys were conducted. Although many men may complain of PE when questioned for a population-based prevalence study, only a few of them will actively seek treatment for their complaint, even though most of these patients would define symptoms congruent with PE. The complaints of acquired PE patients may be more severe, whereas complaints of patients experiencing premature-like ejaculatory dysfunction seem to be least severe among men with various forms of PE. Although numerous treatment modalities have been proposed for management of PE, only antidepressants and topical anaesthetic creams have currently been proven to be effective. However, as none of the treatment modalities have been approved by the regulatory agencies, further studies must be carried to develop a beneficial treatment strategy for PE.

The impact of minimally invasive surgeries for the treatment of symptomatic benign prostatic hyperplasia on male sexual function： a systematic review

A systematic review of randomized controlled trials and cohort studies was conducted to evaluate data for the effects of minimally invasive procedures for treatment of symptomatic benign prostatic hyperplasia （BPH） on male sexual function. The studies searched were trials that enrolled men with symptomatic BPH who were treated with laser surgeries, transurethral microwave therapy （TUMT）, transurethral needle ablation of the prostate （TUNA）, transurethral ethanol ablation of the prostate （TEAP） and high-intensity frequency ultrasound （HIFU）, in comparison with traditional transurethral resection of the prostate （TURP） or sham operations. A total of 72 studies were identified, of which 33 met the inclusion criteria. Of the 33 studies, 21 were concerned with laser surgeries, six with TUMT, four with TUNA and two with TEAP containing information regarding male sexual function. No study is available regarding the effect of HIFU for BPH on male sexual function. Our analysis shows that minimally invasive surgeries for BPH have comparable effects to those of TURP on male erectile function. Collectively, less than 15.4% or 15.2% of patients will have either decrease or increase, respectively, of erectile function after laser procedures, TUMT and TUNA. As observed with TURP, a high incidence of ejaculatory dysfunction （EjD） is common after treatment of BPH with holmium, potassium-titanyl-phosphate and thulium laser therapies （〉 33.6%）. TUMT, TUNA and neodymium：yttrium aluminum garnet visual laser ablation or interstitial laser coagulation for BPH has less incidence of EjD, but these procedures are considered less effective for BPH treatment when compared with TURP.

Transrectal ultrasonography in infertile patients with persistently elevated bacteriospermia

Aim： To identify and define prostate and seminal vesicle abnormalities in patients with chronic male accessory gland infection （MAGI） who failed to respond to antibacterial treatment. Methods： We selected 67 consecutive patients with MAGI and persistently elevated bacteriospermia （≥ 10^6 colony forming units [CFU]/mL） after three antibiotic courses. Fourteen infertile patients with initial chronic microbial （≥ 10^6 CFU/mL） MAGI who responded to antibacterial treatment （〈 10^3 CFU/mL） served as a control group. All patients and controls underwent transrectal ultrasonography （TRUS） scans and semen analysis. Patients with low seminal plasma volume （〈 1.5 mL） underwent both preejaculatory and post-ejaculatory TRUS examination. Results： TRUS revealed multiple abnormalities indicative of： （i） bilaterally extended prostato-vesiculitis （group A： 52 cases, 77.6%） （nine of these patients also had micro-emphysematous prostate abscess）; and （ii） prostato-vesiculitis with unilateral or bilateral sub-obstruction of the ejaculatory ducts （group B： 15 cases, 22.4%）. Mean sperm concentration, total sperm number, ejaculate volume and pH value were significantly higher in group A than in group B. In addition, sperm forward motility and the percentage of normal forms were significantly worse than in controls, whereas leukocyte concentration was significantly higher in group A. Group B patients had all sperm parameters, but their pH values, significantly different from those of controls. Conclusion： Although antibiotic therapy is considered suitable when microbial MAGI is suspected, it is impossible to account for a poor response to antibiotics merely on the basis of conventional criteria （clinical history, physical and ejaculate signs）. Thus, TRUS may be helpful in the follow-up of these patients.

Age-Specific Clinical Features of Erectile Dysfunction

Sexual health can be considered as a mirror of general health and, in turn, general health is a prerequisite for sexual heath. The aim of this study was to compare the different clinical features of erectile dysfunction (ED) in young and elderly males. From June 2011 to December 2011, 224 patients were included and divided into two groups. Elderly ED group consisted of 120 patients with ED and all were 61 - 90 years old, and young ED group consisted of 104 patients with ED and all were 21 - 45 years old. Questionnaires, physical examination, blood sample test, ultrasound monitor, time of achieving erection (TAE), intra-vaginal ejaculation latency time (IELT), ECG and penis-brachial blood pressure index (PBI) were investigated. There were significant differences between the two groups, regarding the top three complications, the body mass index (BMI), International Index of Erectile Function-5 (IIEF-5) scores, Self-rating Depression Scale (SDS) total scores, TAE, IELT and PBI. We concluded that clinical features of ED were age-specific, which will be helpful for treatment strategies and evaluation of the treatment efficacy.

Short‐term effect of the prone masturbation training on premature ejaculation

Background:Whether conventional behavioral therapies for premature ejaculation can significantly improve the intravaginal ejaculatory latency time is still controversial.Prone masturbation is rare and observed in some patients with delayed ejaculation.Therefore,we tried to verify whether the regular prone masturbation training method had a therapeutic effect on premature ejaculation.Methods:From July to December 2018,a total of 21 patients met the enrollment criteria and volunteered to participate.Participants were diagnosed with premature ejaculation with an intravaginal ejaculatory latency time of less than 3min and a Premature Ejaculation Diagnostic Tool score greater than 9.Participants performed 12‐week prone masturbation training.Results:Ten patients completed the entire treatment regimen.The mean age of the 10 participants was 30.4±6.1 years,the mean frequency of sexual intercourse was 1.9±0.83 times a week,and the median duration of premature ejaculation was 1.5 years.After 3 months of prone masturbation training,the median self‐reported intravaginal ejaculatory latency time significantly increased from 60 to 105 s(p=0.011),and the mean Premature Ejaculation Diagnostic Tool scores decreased from15.0±3.7 to 12.7±3.7 points(p=0.119).Conclusions:The regular prone masturbation training method,as a novel behavioral therapy,probably has a therapeutic effect on premature ejaculation.

Premature ejaculation:an update on definition and pathophysiology

Premature ejaculation(PE)is the most comm on male sexual dysfunction,which represents a diag no stic as well as a therapeutic challenge for physicians.However,no universally accepted definition is currently available for PE.As a result,physicians continue to diagnose patients with PE according to major guidelines set by the professional societies.These guidelines either recommend the use of validated questionnaires or patient-reported outcomes.Recent efforts directed toward classifying PE may help provide a better understanding of the prevalence and risk factors of this disorder.While the exact etiology of PE has not been clearly elucidated,several risk factors have been strongly reported in the literature.Clearly,to understand the revised definition of PE,its etiology and pathophysiology is necessary to improve the clinical management of this medical condition and form the basis of future research in this regard.In this review,we highlight the past and current definitions of PE and present an appraisal on the classifications and theories suggested for the etiopathogenesis of PE.

Pelvic muscle floor rehabilitation as a therapeutic option in lifelong premature ejaculation： long-term outcomes

The aim of the study was to evaluate the long-term outcomes of pelvic floor muscle （PFM） rehabilitation in males with lifelong premature ejaculation （PE）, using intravaginal ejaculatory latency time （IELT） and the self-report Premature Ejaculation Diagnostic Tool （PEDT） as primary outcomes. A total of 154 participants were retrospectively reviewed in this study, with 122 completing the training protocol. At baseline, all participants had an IELT 〈60 s and PEDT score 〉11. Participants completed a 12-week program of PFM rehabilitation, including physio-kinesiotherapy treatment, electrostimulation, and biofeedback, with three sessions per week, with 20 min for each component completed at each session. The effectiveness of intervention was evaluated by comparing the change in the geometric mean of IELT and PEDT values, from baseline, at 3, 6, and 12 months during the intervention, and at 24 and 36 months postintervention, using a paired sample 2-tailed t-test, including the associated 95% confidence intervals. Of the 122 participants who completed PFM rehabilitation, 111 gained control of their ejaculation reflex, with a mean IELT of 161.6 s and PEDT score of 2.3 at the 12-week endpoint of the intervention, representing an increase from baseline of 40.4 s and 17.0 scores, respectively, for IELT and PEDT （P 〈 0.0001）. Of the 95 participants who completed the 36-month follow-up, 64% and 56% maintained satisfactory eiaculation control at 24 and 36 months oostintervention, respectively.

Psychological burden prediction based on demographic variables among infertile men with sexual dysfunction

There has been increasing interest in the psycho-socio-relational and sexual disorders of infertility,as the risk of psychological burden among in fertile men with sexual dysf un ctio ns is sign ifica nt.The purpose of this study was to develop and to validate a predictive model to estimate in dividual psychological burde n among in fertile men with sexual dysf unction and study the associati on betwee n them.Comprehe nsive data were collected for in fertile men(n=480)who sought treatme nt for infertility in a reproductive medici ne center between June 2012 and December 2013.Using independent predictors of psychological burden from the least absolute shrinkage and selection operator,univariable and multivariable analyses were developed into two models.Predictive accuracy was compared between the models.We explored the association between sexual dysfunction and psychological burden.A total of 480 patie nts were an a lyzed using 10-fold cross-validatio n.In depende nt predictors of psychological burde n were incorporated into a model to measure anxiety(corrected-area under curve(AUC):77.3%)and a model to measure depression(corrected-AUC:70.2%).Anxiety and depression were both associated with erectile dysfunction(P<0.05),with anxiety demonstrating the strongest association.Only anxiety was associated with premature ejaculation(P>0.05).Premature ejaculation was not found to be associated with depression(P>0.05).Predictive models for psychological burden among infertile men with sexual dysfunction are presented,and we found that there is an association between psychological burden and sexual dysfunction.According to the models,proper counseling and treatment of sexual dysfunction in infertile men may reduce the psychological burden,help attain natural pregnancy,and improve the quality of life.

A 30-year retrospective study of rare ectopic seminal tract opening cases

Ectopic seminal tract openi ng is a rare con genital malformation.Until rece ntly,there has been a lack of comprehensive reporting on the condition.The purpose of this retrospective study is to summarize the experience of diagnosis and treatment of this condition based on 28 clinical practice cases throughout the past 30 years.We conducted auxiliary examinations on such patients including routine tests,imaging examinations,and endoscopy.Among these 28 cases,there were ectopic opening of vas deferens into enlarged prostatic utricles(6 cases);ejaculatory ducts into enlarged prostatic utricles,Mullerian ducts cysts,and urethras(18 cases,2 cases,and 1 case,respectively);and ectopic opening of the unilateral vas deferens and the contralateral ejaculatory duct into enlarged prostatic utricle(1 case).The size of the enlarged prostatic utricle,the type of ectopic seminal tract opening,and the opening's location effectively assisted in the selection of clinical treatment methods,including transurethral fenestration of the utricle,transurethral cold-knife incision,open operation,laparoscopic operation,and conservative treatment.Satisfactory effect was achieved during follow-up.In conclusion,a definite diagnosis and personalized treatment are especially important for patients with ectopic seminal tract opening.