E.S.A.U. Highlights Paolo Verze University Federico II Naples, Italy

1. E.S.A.U. Highlights Paolo Verze University Federico II Naples, Italy ESAU

2. Update on ejaculatory disorders ESAU

3. Embriology and anatomy of seminal tract E. Meuleman • Crucial role of Y Chromosome • Passive regression of Wolff ducts and passive differentiation of female genitals ESAU

4. Physiologic modulation: peripheral system F. Fusco ESAU

5. somatic THORACO- LUMBAR SYMPATHETIC SYSTEM Emission autonomic Spinal Ejaculation Generator SACRAL PARASYMPATHETIC NUCLEUS autonomic ONUF’s NUCLEUS somatic Expulsion ESAU somatic

6. Physiologic modulation: central system F. Giuliano ESAU

7. Central Neurophysiology of Ejaculation Spinal generator of ejaculation Sympathetic centres IMG T12-L1 • Lumbar Spino-thalamic (LSt )neurons at the L3-L4 level connect to prostate and BS muscle • LSt neurons are in position to coordinate and synchronize emission ans expulsion phases of ejaculation L3-L4 LSt cells HN PN DM (VH) Sacral parasympathetic nucleus L5-S1 MPG Prostate BS muscles Pud N Supraspinal control of ejaculation • Supraspinal sites exert both inhibitory andexcitatory effects on spinal command of ejaculation • Main neurotransmitters :SEROTONIN, DOPAMINE, OXYTOCIN

8. Animal models of ejaculatory behaviour M. Waldinger - There are stable phenotypic differences in ejaculatory behavior between sluggish, normal and rapid ejaculators in rats - Studying these phenotypes may be a promising approach to gain more insight into the neural correlates underlying Premature Ejaculation ESAU

9. Psycho-neuro-uro-endocrinology of ejaculatory disorders Current approaches to definition and classification F. Lombardo • It is now clear that ejaculatory disorders are symptoms of many physical diseases which need medical diagnosis • The aim of the medical sexologist is to identify the “specific weight” of each etiology and to start etiological and symptomatic therapies in an holistic way, taking into account the potency of the drugs and the couple’s dynamics as well as providing specific sexual counselling ESAU

10. Prevalence of ejaculatory disorders A. Martin Morales Spectrum of EjD • Premature or Rapid ejaculation (PE or RE) • Delayed Ejaculation (DE), complete Inability to Ejaculate (IE) or Anejaculation (AE) • Retrograde Ejaculation • Painful Ejaculation ESAU

11. PE Prevalence and Attitudes (PEPA) study • PE is the most common male sexual dysfunction • ~25-30% prevalence rate • PE prevalence is constant across age groups • Epidemiology not fully established • Regional variation • Cultural variation ESAU

12. PE or ED • Voluntary control of ejaculation • IELT • Degree of distress • Medical history • Sexual history • Physical examination • Penile hypersensitivity (evaluating somatosensory evoked potential) • Other somatic or cognitive factors Diagnostic flow-chart N. Sofikitis ESAU

13. Diagnostic flow-chart N. Sofikitis • Patients barriers • PE is stigma or social embarrassment • Perception that the problem is transient • Belief that PE is psychological • Clinical barriers • Time constraints • Discomfort talking about sex • Lack of expertise ESAU

14. Therapeutical approach A. Jungwirth vs C. Bettocchi Peripheral approachA. Jungwirth • There is clear evidence that a SEG exists • In men with spinal cord injury above Th10 an ejaculation can be achieved by vibratory stimulation of the glans penis • PET scan shows no specific „ejaculatory“ activity • The most therapeutical approaches apply to a therapy of the penis or the structures of the pelvis and not to the brain ESAU

15. Therapeutical approach A. Jungwirth vs C. Bettocchi Central approachC. Bettocchi • There is clear evidence that a suvraspinal control exists • Efficacious drugs (SSRI, tricyclic antidepressants) • Psychotherapy can support pharmacologic treatments ESAU

16. ESSM Lecture S. Meryn Testosterone, Metabolic syndrome and ED ESAU

17. High prevalence of hypogonadism and ED in metabolic syndrome and its components • Hypogonadism is a predictor of diabetes II • Hypogonadism is associated with high mortality in aging men • ED is highly associated with the metabolic syndrome and its components • ED is a predictor of the development of metabolic syndrome and a calculator of CV risks, thus offering the opportunity for early detection and prevention Testosterone, Metabolic syndrome and ED ESAU

18. New Definition: METABOLIC SYNDROME International Diabetes Federation • Waist circ. > 94 cm for men and > 80 cm for women plus two of the four following factors: • Fasting triglycerides > 150 mg/dL • 2. HDL Cholesterol < 40 mg/dL for men and < 50 mg/dL for women • 3. Systolic blood pressure > 130 or diastolic blood pressure > 85 mm Hg • 4. Fasting glucose > 100 mg/dL or known DM Type 2. http://www.idf.org/webdata/docs/MetSyndrome_FINAL.pdf ESAU

19. Androgen deprivation therapy for prostate cancer is associated with increased risk of diabetes, coronary heart disease, MI, sudden cardiac death and worsening of existing diabetes • Testosterone therapy may improve insulin sensitivity and reduce abdominal obesity Testosterone, Metabolic syndrome and ED • ED may be the first symptom driving men to seek medical help • It is therefore an opportunity but also a responsibility for physicians seeing patients with ED to look for concomitant risk factors and diseases ESAU