2017 eau pe guideline

1、2017 EAUPE Guideline,袁亦銘 北京大學(xué)第一醫(yī)院男科中心,1,2,早泄的流行病學(xué)、病因?qū)W和病理生理學(xué),,3,早泄的流行病學(xué),20-30%USA, National Health and Social Life Survey (NHSLS)31% (men aged 18-59 years) 30% (18-29 years) 32% (30-39 years)28% (40-49 years) 55

2、% (50-59 years)缺乏明確的PE定義，調(diào)查比例與治療比例相差較大。Yes/No問題評(píng)估早泄，歐美兩地有明顯差距。Waldinger 2.3%：lifelong PE3.9%：acquired PE8.5%：natural variable PE5.1%：premature-like ejaculatory dysfunction,4,≈5：IELT ＜2分鐘,,早泄的病理生理學(xué)與危險(xiǎn)因素,病因?qū)W：焦慮陰莖高

3、敏感性5-HT受體功能障礙病理生理學(xué) ED患者常經(jīng)歷早泄與ED有關(guān)的焦慮也可加重PE與年齡無關(guān)與婚姻狀態(tài)或收入水平無關(guān)與人種可能有關(guān)，黑人、西班牙裔、伊斯蘭背景男性教育水平低者其他因素：遺傳因素總體健康水平不良肥胖前列腺感染（慢性細(xì)菌性前列腺炎患者治療后IELT 和控制能力明顯改善）甲狀腺功能異常糖尿病情緒問題和緊張性創(chuàng)傷經(jīng)歷,5,PE對(duì)生活質(zhì)量的影響,性方面的影響性關(guān)系滿意度低性交滿意度低性交放

4、松困難性交頻率下降其他方面影響自信心下降伴侶關(guān)系惡化精神心理影響：苦惱焦慮窘迫抑郁盡管PE患者的性沖動(dòng)和總體性興趣不受影響，但伴侶對(duì)于性關(guān)系的滿足度下降可加重患者的病情。,6,PE就診現(xiàn)狀,PE就診率低78%的性功能障礙患者未尋求專業(yè)指導(dǎo)，PE就診率低于ED就診率。 PE就診率9%原因：患者原因：患者窘迫認(rèn)為無法治療醫(yī)生原因：醫(yī)生窘迫缺乏專業(yè)培訓(xùn)無專業(yè)化治療方法,7,PE定義previous t

5、wo official definitions,DSM-IV-TR: ‘persistent or recurrent ejaculation with minimal sexual stimulation before, on, or shortly after penetration and before the person wishes it. The clinician must take into account facto

6、rs that affect duration of the excitement phase, such as age, novelty of the sexual partner or situation, and recent frequency of sexual activity’持續(xù)或反復(fù)發(fā)生的，輕微性刺激下，在插入之前、之中或之后很快發(fā)生的，違背患者意愿情況下出現(xiàn)的射精。排除影響興奮期長(zhǎng)短的不利因素，如年齡、配偶新鮮度

7、或情況，近期性生活頻度。,8,PE定義two recent definitions,ISSM: the first evidence-based definitionPremature ejaculation is a male sexual dysfunction characterized by ejaculation which always or nearly always occurs prior to or within

8、 about one minute of vaginal penetration; and inability to delay ejaculation on all or nearly all vaginal penetrations; and negative personal consequences, such as distress, bother, frustration and/or the avoidance of se

9、xual intimacy’. It must be noted that this definition is limited to men with lifelong PE who engage in vaginal intercourse since there are insufficient objective data to propose an evidence-based definition for acquired

10、PE.第一個(gè)以循證醫(yī)學(xué)為基礎(chǔ)的定義。原發(fā)性PE：總是或幾乎總是，插入陰道前或1分鐘內(nèi)，即發(fā)生射精；無法延緩射精；負(fù)面?zhèn)€體情緒，如苦惱、困擾、挫敗感和或逃避性親密。繼發(fā)性PE：≤3分鐘,9,早泄的分類,經(jīng)典分類終身性（原發(fā)性）PE獲得性（繼發(fā)性）PE其他分類：變異性PE：‘Variable PE’ is characterised by inconsistent and irregular early ejaculation

11、s, representing a normal variation in sexual performance.主觀性PE：‘Subjective PE’ is characterised by subjective perception of consistent or inconsistent rapid ejaculation during intercourse, while ejaculation latency tim

12、e is in the normal range or can even last longer. It should not be regarded as a symptom or manifestation of true medical pathology.,10,PE的診斷,診斷基礎(chǔ)：病史及性生活史History should classify PE as lifelong or acquired and determine

13、whether PE is situational (under specific circumstances or with a specific partner) or consistent.關(guān)注點(diǎn)：射精持續(xù)時(shí)間性刺激程度對(duì)于性活動(dòng)的影響對(duì)于生活質(zhì)量的影響鑒別EDPE——焦慮——繼發(fā)ED。ED誤區(qū)：患者將射精后疲軟誤認(rèn)為ED，而忽視了PE,11,Common factors in different definiti

14、ons of ED? Time to ejaculation assessed by IELT? Perceived control? Distress? Interpersonal difficulty related to the ejaculatory dysfunction,PE的診斷,Intravaginal ejaculatory latency time (IELT)自我評(píng)估+秒表測(cè)定自詁IELT：偏差大秒表

15、IELT：配偶參與，多應(yīng)用于臨床試驗(yàn)PE評(píng)價(jià)問卷Premature Ejaculation Diagnostic Tool (PEDT)：A recent study reported that only 40% of men with PEDT-diagnosed PE and 19% of men with probable PE self-reported the condition.5個(gè)問題總分≥11分，診斷PE9-1

16、0分，可能診斷PE≤8分，診斷PE可能性低Arabic Index of Premature Ejaculation (AIPE): 7個(gè)問題，總分7-35分，分界值30分，范圍7-35分severe (score: 7-13),moderate (score: 14-19),mild to moderate (score: 20-25)mild (score: 26-30)體格檢查和實(shí)驗(yàn)室檢查endocrinopat

17、hy, Peyronie’s disease, urethritis or prostatitis.,12,PE診斷推薦,13,早泄的治療,偶爾早泄的患者，以心理咨詢和教育為主。治療預(yù)期ED和前列腺炎要首先治療. 不同的行為治療有利于PE治療或適用于無法耐受藥物治療的患者。原發(fā)性早泄，不推薦將行為治療作為一線治療。操作難度大，結(jié)果不明確。原發(fā)性早泄，藥物治療是基礎(chǔ). 必利勁，適應(yīng)癥用藥。非適應(yīng)癥用藥，SSRIs) and

18、clomipramine氯米帕明 , a tricyclic antidepressant 三環(huán)抗憂郁藥和表麻劑. 長(zhǎng)期效果不明確。,14,早泄的治療,15,早泄的治療,16,早泄的治療,17,早泄的治療,18,早泄的治療,19,早泄的治療,20,早泄的治療,21,PE診療推薦,a male lion,Lion couples mate at the rate of 2 to 3 times per hour, about 50 ti

19、mes per day.Each copulaton lasting around 20 seconds.,King of beasts,An amazing nature fact,So, Mr. Lion, the King of Beats, according to the PE definition of ISSM, you are diagnosed with Premature Ejaculation.,But, but

20、, …My wives had no complains.My ejaculation is just for breeding.If my IELT is more than 10 min., I have to burn out!,,Ejaculation is an instinct, like erection,,,IELT,Acquired ability after learning how to contro