2017 EAU PE Guideline

2017 EAUPE Guideline,袁亦铭 北京大学第一医院男科中心,1,2,早泄的流行病学、病因学和病理生理学,3,早泄的流行病学,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% (50-59 years)缺乏明确的PE定义，调查比例与治疗比例相差较大。Yes/No问题评估早泄，欧美两地有明显差距。Waldinger 2.3%：lifelong PE3.9%：acquired PE8.5%：natural variable PE5.1%：premature-like ejaculatory dysfunction,4,5：IELT 2分钟,早泄的病理生理学与危险因素,病因学：焦虑阴茎高敏感性5-HT受体功能障碍病理生理学 ED患者常经历早泄与ED有关的焦虑也可加重PE与年龄无关与婚姻状态或收入水平无关与人种可能有关，黑人、西班牙裔、伊斯兰背景男性教育水平低者其他因素：遗传因素总体健康水平不良肥胖前列腺感染（慢性细菌性前列腺炎患者治疗后IELT 和控制能力明显改善）甲状腺功能异常糖尿病情绪问题和紧张性创伤经历,5,PE对生活质量的影响,性方面的影响性关系满意度低性交满意度低性交放松困难性交频率下降其他方面影响自信心下降伴侣关系恶化精神心理影响：苦恼焦虑窘迫抑郁尽管PE患者的性冲动和总体性兴趣不受影响，但伴侣对于性关系的满足度下降可加重患者的病情。,6,PE就诊现状,PE就诊率低78%的性功能障碍患者未寻求专业指导，PE就诊率低于ED就诊率。 PE就诊率9%原因：患者原因：患者窘迫认为无法治疗医生原因：医生窘迫缺乏专业培训无专业化治疗方法,7,PE定义previous two 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 factors that affect duration of the excitement phase, such as age, novelty of the sexual partner or situation, and recent frequency of sexual activity持续或反复发生的，轻微性刺激下，在插入之前、之中或之后很快发生的，违背患者意愿情况下出现的射精。排除影响兴奋期长短的不利因素，如年龄、配偶新鲜度或情况，近期性生活频度。,8,PE定义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 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 sexual 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 PE.第一个以循证医学为基础的定义。原发性PE：总是或几乎总是，插入阴道前或1分钟内，即发生射精；无法延缓射精；负面个体情绪，如苦恼、困扰、挫败感和或逃避性亲密。继发性PE：3分钟,9,早泄的分类,经典分类终身性（原发性）PE获得性（继发性）PE其他分类：变异性PE：Variable PE is characterised by inconsistent and irregular early ejaculations, representing a normal variation in sexual performance.主观性PE：Subjective PE is characterised by subjective perception of consistent or inconsistent rapid ejaculation during intercourse, while ejaculation latency time 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的诊断,诊断基础：病史及性生活史History should classify PE as lifelong or acquired and determine whether PE is situational (under specific circumstances or with a specific partner) or consistent.关注点：射精持续时间性刺激程度对于性活动的影响对于生活质量的影响鉴别EDPE焦虑继发ED。ED误区：患者将射精后疲软误认为ED，而忽视了PE,11,Common factors in different definitions of ED Time to ejaculation assessed by IELT Perceived control Distress Interpersonal difficulty related to the ejaculatory dysfunction,PE的诊断,Intravaginal ejaculatory latency time (IELT)自我评估+秒表测定自诂IELT：偏差大秒表IELT：配偶参与，多应用于临床试验PE评价问卷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个问题总分11分，诊断PE9-10分，可能诊断PE8分，诊断PE可能性低Arabic Index of Premature Ejaculation (AIPE): 7个问题，总分7-35分，分界值30分，范围7-35分severe (score: 7-13),moderate (score: 14-19),mild to moderate (score: 20-25)mild (score: 26-30)体格检查和实验室检查endocrinopathy, Peyronies disease, urethritis or prostatitis.,12,PE诊断推荐,13,早泄的治疗,偶尔早泄的患者，以心理咨询和教育为主。治疗预期ED和前列腺炎要首先治疗. 不同的行为治疗有利于PE治疗或适用于无法耐受药物治疗的患者。原发性早泄，不推荐将行为治疗作为一线治疗。操作难度大，结果不明确。原发性早泄，药物治疗是基础. 必利劲，适应症用药。非适应症用药，SSRIs) and clomipramine氯米帕明 , a tricyclic antidepressant 三环抗忧郁药和表麻剂. 长期效果不明确。,14,早泄的治疗,15,早泄的治疗,16,早泄的治疗,17,早泄的治疗,18,早泄的治疗,19,早泄的治疗,20,早泄的治疗,21,PE诊疗推荐,a male lion,Lion couples mate at the rate of 2 to 3 times per hour, about 50 times 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, My wives had no complains.My ejaculation is just for bre