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Premature Ejaculation

Ahmed Rashid - 7 Jun, 2018

It’s usually towards the end of a consultation that it comes up. After the benign sore throat or the ingrowing toenail. And it can sometimes take a few seconds to work out what’s being asked. Once you have, though. Once you’ve established that the man in front of you has plucked up enough courage to tell you that he’s having problems with premature ejaculation. What do you do next?

Well, a recent paper in the International Journal of Urology helpfully summarises the current evidence on premature ejaculation (PE) from across the world. The authors acknowledge that prevalence is difficult to estimate due to embarrassment from both patients and doctors, but it is undoubtedly the most common sexual dysfunction in men and could affect up to 30% of the male population. Needless to say, we see only a small fraction presenting to us in practice.

Although there have been suggestions that the diagnosis should be made exclusively on subjective feelings, there seems to be consensus that PE should be considered only when ejaculation is within one minute of vaginal penetration and where there is significant distress. With this definition in mind, the authors of this review considered the treatment goal to be extending the time between penetration and ejaculation rather than subjective sexual satisfaction scores.

The first step when assessing patients is to complete a full urological history and examination. Perhaps not feasible when the issue is raised in the last minute of a consultation, so a follow-up appointment might be needed to get through this. The authors suggest that if there are associated erectile dysfunction issues, PDE-5 inhibitors should be used first line and if there is either hypertension or prostatic enlargement, alpha blockers should be the initial drug of choice. If neither of these are present, though, the first line drug should be an SSRI or SNRI. Local anaesthetic preparations can be considered if there are no initial improvements, as can sexual counselling and yoga for patients thought to have a psychosocial component.

The paper also discusses common behavioural therapies used in the treatment of PE, including the “start–stop” technique and the “squeeze” technique, which are exactly what they sound like they might be. Although early evaluations of these approaches many decades ago reported suspiciously promising results, these have not been replicated in follow up studies. There are, though, a number of experimental treatments on the horizon, including medical and surgical devices, botox injections, and dorsal nerve stimulation. 

As ever, the best approach is to take time to explore each presentation and tailor the treatment according to individual circumstances. Although there is no ‘solution’ to PE, by exploring possible anatomical and psychological causes, we can work with patients to try and do our best to make things better for them. 


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Review of Q&A Headache Webinar

Rob Walker - 21 Jun, 2018

We hope you enjoyed our first NB Webinar. We have now reviewed all of your questions and have summarised the themes of those questions below:

Red Flag Headaches

  • Brain tumour as a cause of headache - is rare. A case control study in 2007 suggested that presentation of isolated headache in primary care had a PPV for brain tumour of 0.09% (<1:1000)
  • Could TIA be a cause of headache? The guidelines do not list TIA as a cause of headache but the CKS 2017 on stroke and TIA (https://cks.nice.org.uk/stroke-and-tia#!diagnosissub) suggests we should consider stroke if there is headache – ‘sudden, severe and unusual headache which may be associated with neck stiffness. Sentinel headache(s) may occur in the preceding weeks.’
  • Headache on defecation as a ‘red flag’? Not listed specifically in the guidelines but one could argue that this is a headache on valsalva which would be classed as a red flag
  • Headaches on waking as a red flag or being caused by brain tumour? NICE state that ‘orthostatic headache (headache that changes with posture)’ is a red flag and BASH advise that ‘Persistent morning headache with nausea’ is a warning sign

Migraine

  • Can we use migraleve in migraine? This contains codeine and NICE advise codeine should not be offered for migraine (and similar for tension type headache)
  • Is migraine associated with stroke? Yes, there is now evidence that migraine is a risk factor for both IHD and stroke, hence it’s inclusion in the new QRISK3 algorithm. What we don’t know yet is whether treating migraine/improving symptoms/recurrence reduces that vascular risk
  • How long do we trial migraine prophylaxis before considering if it is effective?

SIGN recommend that we should use maximal doses of prophylactic treatment for a minimum of 3 months before deciding on effectiveness

  • We had lots of good questions on migraine in pregnancy (see very good BMJ review Jan 2018 - https://www.bmj.com/content/360/bmj.k80)
  • Can we use aspirin in pregnancy? The BMJ article above suggests aspirin 75mg OD until 36/40 is an option for prophylaxis, but that paracetamol should be the first line acute treatment
  • One delegate quite rightly pointed out as we were discussing candesartan as an option for migraine prophylaxis that this needs to be withdrawn before pregnancy due to teratogenic risks, particularly the 2nd/3rd trimester - see UK

teratology service for more information on drugs in pregnancy (http://www.uktis.org)

  • The BMJ article highlights the importance of considering serious underlying causes of headache in pregnancy, particularly pre-eclampsia, gestational hypertension, arterial and venous thrombosis; it also highlights that many women with migraine will see an improvement in pregnancy, although those with aura have a more variable course

Medication overuse headache

  • Confirmation of when patients are at risk of medication overuse headache (MOH):
  • Simple analgesics used on ≥15 days/month for ≥ 3 months
  • Triptans or codeine used on ≥ 10 days/month for ≥ 3 months
  • Any treatments available to help withdrawal in MOH? No - the only treatment available is withdrawal of the over used medication (although we could consider adding prophylaxis for the underlying headache type if known)
  • ‘How do you personally bridge the period of no medication?’ Good question! As always we need to individualise treatment but my (personal) basic principles for managing withdrawal are a) be brutally honest what will happen - symptoms will worsen for 2-4 weeks but once over that a very good chance symptoms will improve; b) consider a sick note for 2 weeks (BASH recommend considering this) c) don’t rush into it - make sure the patient is ready, willing and able to withdraw, consider setting a ‘quit date’ like with smoking cessation
  • Patient resources for MOH:
  • Although slightly more specific talking about migraine, principles are exactly the same - good info from Migraine Trust - Click Here
  • Also -https://patient.info/health/headache-leaflet/medication-overuse-headache

Tension type headache (TTH)

We had a few questions on TTH:

  • How common is TTH? Estimated in ~80% of the general population with ~3% having chronic TTH
  • Prophylaxis for TTH? BASH recommend amitriptyline 10-150mg nocte; NICE do not recommend any medications but advise to consider acupuncture; also important to review triggers (stress, musculoskeletal pain etc.) and consider non drug options

Cervicogenic headache

Cluster headache

We had lots of good questions around the referral/primary care/secondary care interface with cluster headaches:

  • Routine or urgent referral? This is not specified in the guidelines and the urgency of referral is likely to revolve around factors such as severity of symptoms and any potential red flag symptoms
  • How can you differentiate between cluster headache and acute glaucoma? Acute glaucoma is going to be a differential for cluster headache and NICE make the following comment on this - ‘Symptoms of acute glaucoma may include headache with a painful red eye and misty vision or haloes, and in some cases nausea. Acute glaucoma may be differentiated from cluster headache by the presence of a semi‑dilated pupil compared with the presence of a constricted pupil in cluster headache’
  • BASH recommend that ‘Cluster headache management is usually better left to experienced specialists who see this disorder frequently’
  • NICE advise that all patients with new suspected cluster headache need referral to/advice from secondary care regarding imaging
  • Getting oxygen for cluster headache was flagged as a problem by some - OUCH (https://ouchuk.org) has good patient support and information including access to a pre-filled HOOF; but in practice I would hope that as most of these patients with be under secondary care guidance our neurology colleagues could help us out here

Migraine and HRT

Professional resource - good GP information from the British Menopause Society - Click Here


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