Guidelines For The Diagnosis And Treatment Of Premature Ejaculation With Integrated Chinese And Western Medicine
Nov 04, 2024
Premature ejaculation (PE) is the most common ejaculatory dysfunction in men. PE seriously affects the quality of life of patients and sexual partners, and often causes family disharmony and strained relationships between couples. With the continuous improvement of China's social and economic level and the changes in people's understanding of sex, the quality of sexual life has received more and more attention and importance. Therefore, the diagnosis and treatment of PE has become one of the important tasks of men's clinical medicine in China. For the diagnosis and treatment of PE, Chinese and Western medicine have different theoretical systems, and have their own characteristics and advantages. However, the current reports on the diagnosis and treatment of PE in Chinese medicine are still mostly retrospective analyses such as case analysis and expert experience reports on the etiology, dialectics, and treatment. There is a lack of unified syndrome standards and diagnostic and treatment methods, and there are few studies that follow evidence-based medicine. This has hindered the unified evaluation and improvement of the treatment level of PE in the diagnosis and treatment of PE with integrated Chinese and Western medicine. At the same time, the etiology of this disease is complicated, the syndrome classification is diverse, and there are disputes over diagnostic methods and efficacy judgment criteria. It is urgent to formulate a guideline for the diagnosis and treatment of PE with integrated Chinese and Western medicine. Therefore, the Chinese Association of Integrative Medicine and Andrology Committee has compiled this guideline based on the latest International Society for Sexual Medicine (ISSM) and Chinese andrology disease diagnosis and treatment guidelines for PE, and combined with China's national conditions. It is hoped that this guideline will provide useful guidance for clinical workers in traditional Chinese and Western medicine for the diagnosis and treatment of PE and clinical research [1].
NEW HERBAL CISTANCHE TEA FOR NATURAL FORMULATION TO PE PATIENTS
1 Definition and classification of PE
1. 1 Definition
PE can be defined in two different ways, namely "objective criteria" and "subjective feelings". The objective criteria definition is based on the actual duration of ejaculation and the number of penis twitches. The subjective feeling definition refers to the situation where men ejaculate before the time they or their partners "expect". Such men often feel "reduced control" over ejaculation, or "distress", "dissatisfaction" or "interpersonal difficulties" caused by this situation. Traditional Chinese medicine describes it as ejaculation before intercourse, or ejaculation as soon as intercourse begins.
From the perspective of evidence-based medicine, the ISSM points out that the definition of PE should include the following three points:
① Ejaculation always or almost always occurs within 1 minute of penis insertion into the vagina;
② Ejaculation cannot be delayed after the penis is fully or almost fully inserted into the vagina;
③ Negative personal psychological factors, such as distress, anxiety, frustration or avoidance of sexual activities.
This definition is limited to primary PE caused by vaginal intercourse. The published objective data are not sufficient to make an evidence-based medical definition of secondary PE [2]. Traditional Chinese medicine has long discussed PE, calling it "Zhenji" [3], "Yijing" [4], "Ji Jing", "Xie Jing" [5], etc., and points out that "the kidney is the master of hibernation, the root of storage, and the place of essence" [6]. If the kidney qi is insufficient and the storage function fails, PE will occur. Its clinical manifestations are "ejaculation before intercourse, or ejaculation as soon as intercourse begins, and uncontrollable slippery discharge..." [7].
NEW HERBAL CISTANCHE TEA FOR NATURAL FORMULATION TO PE PATIENTS
2 Epidemiology and pathophysiology of PE
Due to the lack of systematic evaluation of the prevalence of primary PE and secondary PE [10-11], there are large differences in the reported prevalence of PE. Most studies believe that the prevalence of PE is 20% to 30% [12]. The etiology of PE is still unclear, and there is little evidence to support biological and psychological hypotheses. In recent years, scholars have tended to believe that PE is caused by several factors, including: high sensitivity of the glans penis, increased excitability of the ejaculation center, susceptibility of central 5-hydroxytryptamine receptors, anxiety, adverse sexual experiences, thyroid dysfunction, prostatitis, genetic tendency, etc.
According to traditional Chinese medicine [5, 13], PE is caused by dysfunction of the five internal organs. The kidney fails to consolidate, the liver fails to release, the heart fails to dominate, the spleen fails to control, and the lung fails to descend, all of which can lead to PE.
2. 1 Sexual fatigue damages the kidney
The kidney stores essence, and if the sealing function is normal, the semen can be released in moderation. If one indulges in sexual pleasure, does not regulate the sex, releases too much, or repeatedly masturbates, the kidney qi will be damaged, the sealing function will fail, and the semen gate will not be solid, thus causing PE. Kidney yin deficiency, excessive phase fire, disturbed semen chamber, and failure to seal, so ejaculation occurs immediately after intercourse, or before intercourse.
2. 2 Fatigue damages the heart and spleen
Essence is stored in the kidney, dominated by the heart, and raised by the spleen. If fatigue and mental fatigue damage the mind, excessive thinking will damage the heart and spleen. Kidney yin is insufficient, phase fire is easy to move, and the semen gate opens early; the spleen loses its healthy function, or the middle qi sinks, and the spleen loses control, thus causing PE.
2. 3 Damp heat descends
Eating heavy food, frying, roasting, and simmering, damp heat is generated internally, or damp heat is exogenously introduced, which descends into the semen chamber, and semen cannot stay in the house, thus causing PE.
Western medicine diagnosis of PE
2. 4. Injury by the seven emotions
Fear makes the qi descend, shock makes the qi chaotic, worry makes the qi stagnant, and emotional injury makes the qi flow disorderly and the essence gate is not solid, thus PE occurs.
3 Western medicine diagnosis of PE
3. 1 Medical history
The diagnosis of PE is mainly based on medical history and sexual life history [14-15], where medical history includes general disease history and psychological disease history. Whether PE is situational (in a specific setting or with a specific partner) or consistent, should focus on IELT, level of sexual stimulation, impact on sex life and quality of life, and substance use or abuse.
3. 2 IELTS
Definition of IELT: The time from insertion of the penis into the vagina to the onset of ejaculation, which can be measured with a stopwatch or self-assessed. IELT has a significant direct effect on ejaculation self-control, but on ejaculation
There was no significant impact on related personal distress and sexual intercourse satisfaction [16].
3. 3 PE Assessment Questionnaire Scale
In order to objectively assess PE, a variety of questionnaires based on patient reported outcomes (PROs) have been designed [17]. There are currently 3 commonly used
The scales are respectively the Premature Ejaculation Profile (PEP), the Index of Premature Ejaculation (IPE), and the PE Diagnostic Tool (PEDT). Among these scales, the most widely used tool is the PEDT (a 5-item questionnaire based on focus groups and interviews in the United States, Germany, and Spain that assesses control, frequency, minimal stimulation, distress, and interpersonal difficulties).
3. 4 check
3. 4. 1 Physical examination
The focus is on the examination of male external genitalia to see if it is accompanied by genital abnormalities such as foreskin, phimosis, balanoposthitis, penile curvature deformity, and Peyronie's disease.
3 Western medicine diagnosis of PE
3. 1 Medical history
The diagnosis of PE is mainly based on medical history and sexual life history [14-15], where medical history includes general disease history and psychological disease history. Whether PE is situational (in a specific setting or with a specific partner) or consistent, should focus on IELT, level of sexual stimulation, impact on sex life and quality of life, and substance use or abuse.
3. 2 IELTS
Definition of IELT: The time from insertion of the penis into the vagina to the onset of ejaculation, which can be measured with a stopwatch or self-assessed. IELT has a significant direct effect on ejaculation self-control, but on ejaculation
There was no significant impact on related personal distress and sexual intercourse satisfaction [16].
3. 3 PE Assessment Questionnaire Scale
In order to objectively assess PE, a variety of questionnaires based on patient reported outcomes (PROs) have been designed [17]. There are currently 3 commonly used
The scales are respectively the Premature Ejaculation Profile (PEP), the Index of Premature Ejaculation (IPE), and the PE Diagnostic Tool (PEDT). Among these scales, the most widely used tool is the PEDT (a 5-item questionnaire based on focus groups and interviews in the United States, Germany, and Spain that assesses control, frequency, minimal stimulation, distress, and interpersonal difficulties).
3. 4 check
3. 4. 1 Physical examination
The focus is on the examination of male external genitalia to see if it is accompanied by genital abnormalities such as foreskin, phimosis, balanoposthitis, penile curvature deformity, and Peyronie's disease.
3. 4. 2 Auxiliary examinations
3. 4. 2. 1 Electrophysiological examination of penile nerves
It can objectively distinguish whether the nerve sensitivity of PE comes from the sympathetic nerve center or the peripheral dorsal penis nerve and its branches. Electrophysiological examination of penile nerves can be used to measure various sensory thresholds, evoked potentials, and penile sympathetic skin responses in the perineum. For patients with low values of dorsal nerve of penis somatosensory evoked potential (DNSEP) and glans penis sensory evoked potential (GPSEP) in electrophysiological examination of penile nerves, penile dorsal nerve sensitivity is considered; for patients with low values of sympathetic skin response (SSＲ), sympathetic nerve center sensitivity is considered.
3. 4. 2. 2 Measurement of penile biological sensory threshold
It can preliminarily determine the centripetal conduction function of the dorsal penis nerve.
3. 4. 2. 3 Bulbocavernosus reflex latency measurement
Electrically stimulate the surface of the penis, insert electrodes into the bulbocavernosus muscle, and measure electromyographic changes. The specificity is poor.
3. 4. 3 Other examinations
In addition, the vascular, endocrine and nervous systems should be examined to exclude other chronic diseases, endocrine diseases, autonomic neuropathy, urethritis, chronic prostatitis, etc.
The diagnosis of PE is mainly based on medical history and sexual history, usually including short IELT, poor control of ejaculation, distress about it, and difficulty in interpersonal communication. Among them, IELT is an important objective indicator for evaluating PE. In daily outpatient work, self-assessed IELT is sufficient［18］; in clinical trials, IELT measured by stopwatch is necessary［19］. In addition, clinicians can use questionnaires to assist in diagnosis. Currently, there are two types of PROs (PEDT and AIPE) that can be used to distinguish the presence or absence of PE. PEP and IPE can be used to evaluate the treatment effect of PE, but the scale can only assist in diagnosis and cannot replace the clinician's inquiry into sexual history. The auxiliary examination of PE is of limited significance, and various examination items and indicators need to be explored and improved. In the 2015 European Association of Urology's guidelines for the diagnosis and treatment of PE, routine laboratory and neurophysiological tests are still not recommended, and are only performed when abnormal findings are found in the patient's disease, sexual history, or physical examination [20].
4 Classification of TCM syndromes of PE［5,13,21-24］
The syndrome differentiation of PE requires differentiation of deficiency and excess, identification of viscera, cold and heat, and differentiation of yin and yang. The syndromes in this guideline are the common basic syndromes in clinical practice. The complex syndromes can be combined according to the basic syndromes, and the four examinations can be combined in clinical practice for comprehensive syndrome differentiation.
4.1 Syndrome of damp-heat descending
Symptoms: PE during intercourse, accompanied by frequent urination and urgency, perineal discomfort, abdominal distension and pain, heaviness of limbs, bitter and dry mouth, genital itching, and sticky stool. Red tongue, yellow and greasy coating, slippery and rapid pulse.
4.2 Syndrome of Yin deficiency and hyperactivity of fire
Symptoms: easy erection and easy ejaculation, accompanied by hypersexuality, spermatorrhea, fever in the five hearts, night sweats, dizziness and tinnitus, soreness of waist and knees. Red tongue, less coating, and thin and rapid pulse.
4. 3 Syndrome of Kidney Qi Insufficiency
Symptoms: PE, spermatorrhea, weak ejaculation, accompanied by apathy, sore waist and knees, dull complexion, clear and long urine, or weak erection. Pale tongue, thin white fur, deep and fine pulse.
4. 4 Syndrome of Heart and Spleen Deficiency
Symptoms: PE during intercourse, accompanied by fatigue, restless sleep, palpitations, dull complexion, dizziness and forgetfulness, poor appetite, abdominal distension and loose stools, or obesity. Pale tongue, enlarged tongue or teeth marks on the edges, thin white fur, and weak pulse.
4. 5 Syndrome of Liver Depression Transforming Fire
Symptoms: PE during intercourse, hypersexuality, accompanied by depression, chest and flank distension, sighing, or irritability, insomnia and dreaminess, red face and eyes, bitter mouth and dry throat, yellow urine and constipation. Red tongue, yellow fur,
Strong and rapid pulse.
4. 6 Spleen and Kidney Deficiency Syndrome
Symptoms: PE, spermatorrhea, weak ejaculation, low libido, accompanied by cold pain in waist and knees, shortness of breath and laziness to speak, excessive drooling, poor appetite and loose stools, long and clear urination, or cold limbs, abdominal pain that is easy to press, pale tongue, enlarged tongue, thin white fur, and deep, thready and weak pulse.
