What does Prof. Alessandro Natali?

These are the uro-andrological clinical fields in which Prof. A. Natali practices his profession both from the medical and surgical point of view

CLINICAL FIELDS

Ejaculation Disorders

Ejaculation is a complex phisiological reflex involving physical and psychological components.

For simplicity we can describe it essentially as a "reflection" whereby a given stimulus at the level of the genital area is reflected by a reflex response, represented by the ejaculation itself. Ejaculation is the emission, through the urethra, of seminal fluid, following the achievement of orgasm.

Ejaculation generally lasts a few minutes and is influenced by physical factors (duration of contractions, number and strength), quantities (productivity of the prostate gland and seminal vesicles) and psychological (perception of pleasure).

It is usually associated with a feeling of extreme pleasure as during the course of the sexual act as it approaches the achievement of orgasm, a situation of strong tension is generated in man.

At the time of orgasm repeated involuntary spasms cause the emission of the liquid through the urethra and the consequent immediate sensation of sudden cessation of tension and contentment. Ejaculation ends in the detumescence phase, in which the nerve centers stop sending impulses to the genital apparatus and the blood drains from the penis, with relative disappearance of the erection.

There are many ejaculation disorders: Premature ejaculation (the most frequent), delayed ejaculation, retrograde ejaculation, painful ejaculation and lack of ejaculation.

PREMATURE EJACULATION

Premature ejaculation (PE) is the difficulty or inability of the man to exercise voluntary control over ejaculation and is considered by far the most common male sexual disorder, as it affects 25% -30% of men ( about 4 million Italians are affected by PE.

According to Masters & Johnson, the American psychologists who first faced the problems of sexuality as a couple in the 1960s, a man suffers from PE if he ejaculates before the partner reaches orgasm in more than half of sexual intercourse. This definition has been followed over time by other interpretations of the phenomenon, which correlate the precociousness of ejaculation to the duration of sexual intercourse, the number of coital thrusts, the perception of control over ejaculation etc.

Recently (2007), according to the principles of evidence-based medicine, a definition has been proposed that takes into account the time between intravaginal penetration and ejaculation (less than a minute in premature ejaculation), the ability or not to delay ejaculation and the degree of frustration of the man and woman secondary to the anticipated ejaculatory event.

Classification

PE is distinguished, classically, in "lifelong" or primary (70% of cases) and "acquired" or secondary (30% of cases). The "lifelong" PE is characterized by an inability, from the first sexual intercourse, to control the ejaculatory reflex (measured by a parameter - called IELT - which is the intravaginal ejaculatory latency time) and by the persistence of the disorder also in the continuation of life subject's sexuality.

The "acquired" PE is characterized by the onset of the disorder in the context of a normal ejaculatory control. The subject in the course of his sexual life is "secondarily" to something that no longer has adequate control of his ejaculation.

Many men often fear, unjustly, to suffer from PE: this fear is so widespread because, in fact, most men reach orgasm too quickly compared to the times they would like, especially when they are in stress or one is particularly excited.

We know that biologically man and woman have different "timing" in achieving sexual pleasure. It is therefore possible to speak correctly of PE only when the disorder is persistent and recurrent in every penetrative event that the subject tries to perform.

Causes

Today a genetic hypothesis is increasingly emerging for the "lifelong" PE. According to this hypothesis , men suffering by PE might have, at the level of their brain, genetic low levels of production of a substance, serotonin, which is important in the control of ejaculation's speed. Surely even performance and / or constitutional anxiety is an important element in the genesis of "lifelong" PE.

For what concerns “acquired” PE, risk factors that must be sought are prostatitis, thyroid hormone disorders, stress, family or work conflict, reduced self-esteem, guilt arising from masturbatory activity or relationships with prostitutes.

Diagnosis

The diagnosis of PE is based on the detailed collection of the subject's clinical history, both for habits and behaviors, and for any diseases or morbid conditions. Furthermore, it is necessary to investigate in depth the patient's sexual life, frequency and type of sexual relations.

There are questionnaires to be submitted to the patient, of which the most widespread is the PEDT, which with 5 simple questions allows to verify the existence or not of PE and its entity.

Then you have to examine the patient, with particular reference to the genital area. It is necessary a rectal exploration to detect the conditions of the prostate gland. Finally, there are investigations, instrumental and laboratory examinations, to understand the prevailing organic component of the ejaculatory problem.

Therapy

There is no single therapy of PE. There are therefore various therapeutic approaches depending on the factors involved. If there are organic alterations: prostatitis, hormonal disorders, neurological alterations, these problems must first be solved. Thus doing at least 50-60% of cases of PE are resolved.

In the remaining cases, the association between cognitive-behavioral psychotherapies, relaxation techniques and lowered levels of performance anxiety, together with targeted drug therapies, resolves PE permanently.

From 1 July 2009 the first drug approved by the EMEA (European Medicine Agency) for the treatment of premature ejaculation is available in Italian pharmacies.
The active ingredient is Dapoxetine, the commercial name of the drug is PRILIGY®. Dapoxetine is a SSRIs (selective serotonin re-uptake inhibitors), that is a particular type of antidepressant drugs that were in the past used off-label (out of indication) for the treatment of PE.

PRILIGY® is the first oral drug in this category (SSRIs) that is approved and marketed specifically for the treatment of PE.

Unlike the other SSRIs, it has a short duration of action (a few hours) and should be taken 1 to 3 hours before the sexual intercourse, ideally about 1-1.5 hours before.

The indication of its use must be given by the specialist after adequate clinical evaluation. In 2017 another drug entered the market, a spray for topical use, for the treatment of PE, is a combination of two medicines (lidocaine and prilocaine).

The trade name is FORTACIN®, it is indicated for the treatment of "lifelong" PE present since the first sexual intercourse in adult men. It works by reducing the sensitivity of the glans to prolong the time before ejaculation. The recommended dose of the drug is 3 sprays (3 sprays = 1 dose) on the glans before sexual intercourse. Within 24 hours a maximum of 3 doses can be used, at least 4 hours apart

 

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