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Avances en el tratamiento de la eyaculación precoz y la disfunción eréctil
- 1. “ Novedades, rebajas y gangas en Terapias Sexológicas” Evolución del tratamiento de las disfunciones sexuales masculinas Francisco Cabello Santamaría Instituto Andaluz de Sexología y Psicología
- 7. Incapacidad de detectar la inevitabilidad eyaculatoria
- 10. Metz & Prior (1993): Cotinuum excitación
- 16. Patrick DL, Rowland D, and Rothman M. Interrelationships Among Measures of Premature Ejaculation: The Central Role of Perceived Control. J Sex Med 2007;4:780-788.
- 19. 3-13 minutos (Corty y Guardiani, 2008)
- 30. Andersson et al. BJU International 2006; 97: 311-315 Antidepressive SSRI data based on Summary Basis of Approval and published reports Peak drug concentration (% of maximum) Hours post dosing Dapoxetina: farmacocinética comparativa
- 32. Lugar de acción de Dapoxetina, Centros cerebrales superiores Inervación motora del músculo bulboesponjoso aferente eferente Nervio dorsal del pene Los datos sugieren que el lugar de acción de Priligy está a nivel o encima del tronco del encéfalo Clement et al. (2007) Eur Urol 51(3):825–832; Giuliano & Clement ( 2006) Eur Urol 50(3):454-66; Giuliano (2007) Trends Neurosci 30(2):79-84 Nervio pudendo
- 33. Resultados medios de IELT Media de IELT por estudio y tratamiento al final † *p<0.001 frente a placebo. Análisis de covarianza † Semana 12 (datos conjuntos 012, 013, 3003) o semana 24 (3001) última observación incluída en el período siguiente McMahon et al. (2008) Presented at ESSM/ISSM; Data on file; Buvat et al. (2009) Eur Urology DOI: 10.1016/j.eururo.2009.01.025; McMahon et al. (2007) Presented at APSSM 0 . 9 0 . 9 0 . 9 0 . 9 1 . 0 1 . 9 1 . 7 1 . 8 1 . 9 2 . 4 3 . 1 2 . 9 2 . 7 3 . 1 3 . 9 3 . 6 3 . 9 3 . 3 3 . 5 4 . 2 0 . 0 1 . 0 2 . 0 3 . 0 4 . 0 5 . 0 Conjunto 012 US 013 US 3001 EU/LA 3003 Asia Basal Placebo Priligy 30 mg Priligy 60 mg * * * * * * * * * * Media de IELT (Minutos)
- 34. Mejora el control sobre la eyaculación tras el tratamiento Proporción de mejora de > 1 categoría en el control sobre la eyaculación en las semanas 9–12 Durante el último mes, ¿tu control sobre la eyaculación durante el acto sexual fue: muy bajo > muy bueno? *p<0.001 frente a placebo ; **p<0.01 frente a placebo Datos en archivo; Kaufman et al. (2008) BJU Int. doi:10.1111/j.1464-410X.2008.08165.x. Week 12 (012, 013, 3001, 3003) or Week 9 (3002) última observación incluida en el período siguiente 52 42 51 44 65 52 72 74 70 67 71 76 72 76 76 79 76 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Conjunto 012 US 013 US 3001 EU/LA 3002 US/Canada 3003 Asia Placebo Priligy 30 mg Priligy 60 mg * * * * * * * * * * **
- 35. Mejora en la angustia Buvat et al. (2009) Eur Urology DOI: 10.1016/j.eururo.2009.01.025; Kaufman et al. (2008) BJU Int. doi:10.1111/j.1464-410X.2008.08165.x Proporción de mejora de > 1 categoría en angustia personal relacionada con la eyaculación entre las semanas 9 y 12 … ¿c ómo de angustiado te econtrabas por lo que tardabas en eyacular durante el acto sexual: muy angustiado > no angustiado en absoluto? *p<0.001 frente a placebo CMH ; **p<0.01 frente a placebo CMH CMH :Cochran-Mantel-Haenszel Week 12 (012, 013, 3001, 3003) or Week 9 (3002) última observación incluida en el período siguiente 52 46 56 56 65 63 67 71 65 75 73 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% Conjunto 3001 EU/LA 3002 US/Canada 3003 Asia Placebo Priligy 30 mg Priligy 60 mg * * * * * * **
- 36. Patrick DL, Rowland D, and Rothman M. Interrelationships Among Measures of Premature Ejaculation: The Central Role of Perceived Control. J Sex Med 2007;4:780-788.
- 42. Synergist Erecaid APARATOS DE VACÍO
- 53. Estructura de los Inhibidores PDE5 Tadalafil Sildenafil Vardenafil N H N N C H 3 C H 3 O O C H 3 S N N C H 3 O O N
- 55. A POMORPHINA Pro-erectile cascade HYPOTHALAMUS (paraventricular nucleus) Dopamine receptor cGMP ERECTION SPINAL CORD ( sacral spinal erection centre) PARASYMPATHETIC NERVOUS SYSTEM ACTIVATION GTP GMP BRAIN PERIPHERY PDE5 GC NO SEXUAL STIMULATION SPINAL CORD Apomorfin LOCAL ACTIVITY + Argiolas 1987; Melis 1987; Giuliano 2000
- 59. Click here to advance to next slide Contracción y relajación de las células de músculo liso
- 61. Pacientes con tratamiento eficaz abandonan el tratamiento por falta de colaboración de la pareja (Palas, 2000).
- 68. Total de abandonos 52 participantes
- 69. SUPERAN LA DISFUNCI Ó N ER É CTIL (IIEF y GRISS) (Cabello, 2004)
- 72. Disculpen ya hablé demasiado. Gracias .
Notas del editor
- aclimatación vaginal: se concentra en la relajación del músculo PC mientras su compañera inserta su pene dentro de su vagina y entonces él tranquilamente descansa dentro. Entonces él espera, calmadamente esperando alcanzar el punto de saturación del placer físico (embotamiento sensual) en su pene -donde el pene se aclimata a la calidez y sensualidad de la vagina (o la boca, en el entrenamiento del sexo oral). Para la mayoría de los hombres, esta sensación de aclimatación se desarrolla después de aproximadamente 10 minutos (nosotros hemos visto una gama de 7 a 27 min.) de descanso dentro de la vagina. Se le permite moverse sólo mínimamente para mantener una erección y se le instruye que cuanto más se mueva, más tiempo le llevará que ocurra la aclimatación, -tan largo como 30 min. Se le advierte al hombre que después de que esta aclimatación ocurra, el pene puede comenzar a tolerar y disfrutar de un placer más intenso mientras mantiene el control eyaculatorio. El puede consiguientemente aumentar no sólo la duración del tiempo del coito sino también la calidad del placer aprendiendo a manejar su patrón de excitación.
- No existe correlación entre ILET y satisfacción, y IELT y problemas interpersonales.
- The observation that chronic treatment with selective serotonin reuptake inhibitors (SSRIs) is associated with sexual dysfunction, including delay of ejaculation, suggests that serotonergic pathways are involved in central control of ejaculation. The actions of serotonin are mediated via one of the most extensive receptor systems known. Seven 5-HT receptor classes, encompassing some 14 different receptors, are currently recognized. These receptors and the serotonin transporter are widely distributed with particularly high density in the hypothalamus, brainstem and spinal cord. SSRIs inhibit the action of the serotonin transporter system, leading to greater stimulation of postsynaptic receptors.
- Data from Giuliano and Clement shows that the action of dapoxetine in delaying ejaculation involves the lateral nucleus paragigantocellularis (LPGi) in the brainstem. The anatomical site of action of dapoxetine has been investigated in animal models and shown to be located supraspinally, in the higher centres of the brain, and involving the lateral paragigantocellularis nucleus (LPGi). Pudendal motorneurone reflex discharges (PMRDs) were measured following electrical stimulation of the dorsal nerves of the penis in rats following intrathecal administration of dapoxetine. PRMDs were significantly delayed with dapoxetine indicating a delay in the ejaculatory expulsion reflex. However, in rats with a lesion in the LPGi brain structure, the effects of dapoxetine were abolished.
- Significant increases in mean IELT from baseline to endpoint were consistent across all five pooled phase III studies.
- Dapoxetine improved subjects’ perception of control over ejaculation as measured by the PEP in each of the pooled phase III studies. In the pooled analysis, more than 70% of patients in both dapoxetine dosing groups achieved at least a 1-category improvement in control from baseline to endpoint. This was significantly greater compared with placebo, although there was a modest but demonstrable placebo effect over the course of each trial. The question asked about control was “Over the past month, was your control over ejaculation during sexual intercourse…0 = very poor, 1= poor, 2 = fair, 3 = good, 4 = very good”. A 1-category increase is, for example, a change from poor to fair or from good to very good. NB 3002 study did not include the 30mg dose of dapoxetine
- Dapoxetine improved subjects’ perception of distress related to ejaculation in each of the pooled phase III studies. The proportion of patients reporting at least a 1 category improvement in distress from baseline to endpoint was significantly greater with both dapoxetine doing groups compared with placebo. The question asked about distress was “Over the past month, how distressed were you by how fast you ejaculated during sexual intercourse…0 = not at all, 1= a little bit, 2 = moderately, 3 = quite a bit, 4 = extremely”. A 1-category increase is, for example, a change from ‘extremely’ to ‘quite a bit’ or from ‘moderately’ to ‘ a little bit’. NB 3002 study did not include the 30mg dose of dapoxetine
- Although it has yet to be proven definitively, Ixense (and indeed other dopamine agonists) is believed to trigger the erectile response by initiating a pro-erectile cascade involving oxytocinergic pathways. Dopaminergic transmission in the brain: dopaminergic pathway acts on the medial pre-optic area (MPoA) and the paraventricular nucleus (PVN) of the hypothalamus There is a strong link between central dopaminergic transmission, the PVN and penile erection, according to the following evidence from animal studies: Intraperitoneal administration of apomorphine in rats caused episodes of penile erection Micro-injection of apomorphine into the PVN of the hypothalamus in rats also caused episodes of penile erection Ixense mediates its effects by dopaminergic signalling via oxytocingeric pathways. Oxytocinergic pathways activate parasympathetic neurons in the sacral spinal centre, which in turn trigger the release of nitric oxide in the periphery. GTP is converted to cGMP, causing subsequent smooth muscle relaxation in the corpus cavernosum. This leads to penile erection. Ixense requires sexual stimulation in order to be effective. Main ref: Krane et al (2000) In Erectile Dysfunction. Health Publication Ltd. References: Heaton JPW (2001). World J Urol (in press) Ixense Summary of Product Characteristics. January 2001 Argiolas A, et al (1987). Brain Res 421: 349-352 Melis MR, et al (1987). Brain Res 415: 98-104
- The contraction of penile smooth muscle and the resulting detumescence that occurs is dependent upon a rise in intracellular calcium concentrations. Locally this is mediated by -adrenergic receptors (the subtypes 1 and 2 are heavily expressed in trabecular smooth muscle). Contraction mediated by 1 receptors is dependent upon the entry of extracellular calcium while activation of 2 receptors is dependent upon the release of both intracellular and extracellular calcium. Although the role of the adrenergic system as a mediator for detumescence has been demonstrated, its role in the maintenance of flaccidity is not clearly defined. Other compounds also play a role in the maintenance of penile flaccidity, such as endothelin and some of the eicosanoids, eg, PGF 2 and thromboxane A 2 . Endothelin is a potent constrictor of smooth muscle and potentiates the effect of catecholamines on smooth muscle contractility. PGF 2 and thromboxane A 2 are synthesized in cavernous tissue, and in vitro studies have shown that they are responsible for the tone of isolated trabecular muscle. Saenz de Tejada I et al. Anatomy, physiology and pathophysiology of ED. In: Jardin A et al, eds. Erectile Dysfunction . Plymouth, UK: Plymbridge Distributors; 2000:65-102.