Blogs of Professor(Dr.) Pranab Kumar Bhattacharyya MD(calcutta.Univ) Pathology; : September 2015

A 26 year old unmarried truck driver from North east region of India complains of premature ejaculation and passing? Turbid urine since three months. He says that there is discharge of a few drops of semen before micturition everytime followed by passage of slightly cloudy urine. Has mild and vague pain in the left flank. No h/o fever, no dysuria. He has reportedly lost 3 kgs of weight in a span of 3 months. Has a single sexual partner, a virgin from college, who is said to be loyal to him. But he had exposure to another lady previously whose credentials are unknown. He has not had coitus since one month. He smokes cigarettes and takes alcohol but not physically or psychologically dependent on them, and no substance abuse. Due to the current problem his sleep and appetite are affected and he is worried. He is not known diabetic or hypertensive and clinical examination is unremarkable. Routine blood and urine examination including VDRl and Urine culture and sensitivity have been ordered.
Need guidelines about this case.

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Answers

Dr. Chandra Kumar
Sep 13 2015

I feel that this guy, after ruling out any organic or metabolic malady, needs counselling and anti anxiety medication. A combination of Escitalopram 10 mg and 0.5mg Clonazepam at bedtime for 3-4 months along with nutrional supplements will suffice for the time being. Needs REPEATED counselling by an expert and follow up by an experienced Psychitrist.

Dr. M.Ramasamy
Sep 14 2015

Needs tests to confirm STD esp HIV testing since he has multiple sexual partners whatever may be their credentials. If positive needs appropriate therapy plus counselling

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Dr. Purnanandam.Y.
Sep 14 2015

This the most common presentation of young men who have multiple artners and that too in the early phases of such liberal activity.
However before labelling the patient, it is wise to exclude organic problems
In view of the possibility of HIV, You need to rule it out also.The investigations ordered by you are not enough. He also needs a semen culture/expressed prostatic secretion culture and sensitivity aa well.
The treatment has to strictly according to the sensitivity report.
If there is infection in the EPS he may need cyclical antibiotics for an extended period of time. He should also use a condom in this period His partner also should be evaluated for 1. Urinary and 2. STDs and treated accordingly.

Dr. P.R.B. Prasad
Sep 15 2015

I agree with above protocol

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Dr. Mohammed Jiauddin
Sep 14 2015

Premature ejaculation is best treated with Dapoxetine 30mg tablets 2 hrs before intercourse once daily. Psychotherapy and open discussion regarding the issue with the partner is very essential. And regarding semen following micturition try using Dutaseride (urodart) once daily. This will stop the prostatorrhea.
i need to know his urine reports and VDRL reports. Also let me know if he is an alcoholic and i would also request for his Tuberculosis test profile

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Dr. Yudhvir singh
Sep 14 2015

Dapoxetine is not permanent solution.
Its cost too high.
If use each time from where will arrange lunch and dinner

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Dr. Yudhvir singh
Sep 14 2015

Rule out any organic cause or associated organic cause and treat them. Otherwise counselling counselling counselling etc.

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Dr. Prashant J Patel
Sep 14 2015

Please provide the reports which are ordered?

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Dr. Samit Inamdar
Sep 14 2015

Its DHAT syndrome common in Asia.
Need scientific diagramatic sexual counselling with antianxiety medicine for 10 days

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Dr. Purnanandam.Y.
Sep 14 2015

Well said. After a thorough workup dose not uncover any aetiology of course.The fluoxetine and its derivatives like duloxetine and the newer dupoxetine are waste of time and money.

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Dr. professor Pranab kumar Bhattacharya
Sep 14 2015

Young Male's erectile dysfunction defined as “the inability to achieve or maintain an erection sufficient for sexual intercourse with or without premature ejaculation problem”—is one of the most common sexual dysfunctions also seen in young or adolescence men besides organic or metabolic cause. Although erectile dysfunction can be primarily psychogenic in origin, most patients have an organic disorder, commonly with some psychogenic overlay.Some men assume that erectile failure is a natural part of the aging process and tolerate it; for others it is devastating. Withdrawal from sexual intimacy because of fear of failure can damage relationships and have a profound effect on overall wellbeing for the couple. Since in this case erectile dysfunction did not accompanied chronic illnesses, such as diabetes mellitus, heart disease, hypertension, and or a variety of neurological diseases, the most probable diagnosis may be psychogenic however hormonal levels particularly testosterone level to be measured along with psychological counselling and anxiolytic medicine. He should be advised to avoid cigarette and alcohol as it causes endothelial injuries and a cause of ED.

Dr. Kameswara Sharma
Sep 14 2015

Urine should be examined for spermatozoa to rule out retrograde ejaculation, Semen and urine culture are a must. Order for USG Abdomen to R/O urolithiasis. Advise to practice safe sex.

Dr. J.S Ahluwalia
Sep 14 2015

Please evaluate for metabolic factors in addition to uti evaluation.Considering the life style of truck driver Gonorrhea is very common in them & appropriate antibiotic must be given at the earliest.

Dr. Subhash Jain
Sep 14 2015

He should consult sex expert with investigation already asked

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Dr. Yudhvir singh
Sep 14 2015

In india there is no qualified sex expert.
Such pts. Are Reffered to either urologist or psychologist .
And rare timr to psychiatrist

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Dr. Purnanandam.Y.
Sep 15 2015

In 1980 American urological association made a statement "90% of sexual /erection problems are due to pscychiatric causes"
In 1990 aua 's position was "90% of the sexual problems/edf are due to organic causes and only 10% psychiatric causes"
In 2000 aua position was " unless proved otherwise all sexual / edf problems are due to organic causes only".
The only person who has the expertise, the investigative tools and the treatment capability - medical or surgical- is a urologist.
When found necessary, the urologist will refer the patient to psychiatrist.
As an axiom- no surgeon would like to hang on to a patient, who does not have a surgically correctable problem - including a urologist . And the urologist rarely tries to treat
a nonurological problem himself.
As a urologist who established and ran a multi-speciality tertiary care andrology center for nearly 10 years, the input of psychiatrist, endocrinologist and a physician was always taken before the treatment plan was decided at our center.!

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Dr. Marappan Balachandar
Sep 14 2015

Dear Doctor,
You must rule out HIV, send urine & semen C&S. Time being after giving for the C&S, you can start with Moxyflox IV then Tab, along with Amikacin.

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Dr. vijayalakshmi
Sep 14 2015

He needs to be excluded HIV

Dr. Yudhvir singh
Sep 14 2015

ED include many thing
Non errction
Delayed erection
Delayed ejaculatation
No orgasm
Loss of libido premature ejaculatation may be symptom of ED but its management will be definitely diffrent or must be refer to psychologist and may requires psychiatric.

Dr. Yudhvir singh
Sep 14 2015

Furthr its not mentioned whether satisfactory erection achieved or not.

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Dr. Yudhvir singh
Sep 14 2015

Further

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Dr. Javaid Aftab Shah
Sep 15 2015

Most likely the young man is suffering from Prostatitis that needs to be further evaluated and triple regime therapy may solve his problem.SSRIs may help temporarily no doubt.

Dr. Srinivasa Rao Chillapalli
Sep 15 2015

Thanks for all,
Greetings and sharing with Good Question and very common problem in Young and Adolescents in day to day Practice.
My opinion is please check the levels of Testosterone Hormone, counselling and treat with Mild Anti-Psychotics along with Nutritional Supplements would help the patient. At the same time advice to role out Investigation Pathology like Urine and Semen analysis.

Dr. S P Singh
Sep 19 2015

Dear doctor,
Go for Aids serology test.

Dr. S P Singh
Sep 19 2015

Karnataka.

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