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 Table of Contents  
ORIGINAL ARTICLE
Year : 2016  |  Volume : 3  |  Issue : 4  |  Page : 121-125

The Role of Varicocelectomy on Patients with Premature Ejaculation and Varicoceles


1 Department of Dermatology, Venereology and Andrology, Faculty of Medicine, Sohag University, Sohag, Egypt
2 Department of General Surgery, Faculty of Medicine, Sohag University, Sohag, Egypt

Date of Web Publication7-Nov-2016

Correspondence Address:
Mohammed Abu El-Hamd
Department of Dermatology, Venereology and Andrology, Faculty of Medicine, Sohag University, Sohag
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2394-2916.193515

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  Abstract 

Objectives: This study aimed to assess the role of varicocelectomy in the improvement of premature ejaculation (PE) in patients with clinical varicoceles and PE. Materials and Methods: In a prospective clinical study, it conducted on 85 male patients with clinical varicoceles and PE. Those patients were selected from whom attending the Outpatient Clinics of Andrology and General Surgery at Sohag University Hospital, Upper Egypt, between February 2015 and May 2016. All patients were subjected to preliminary assessment included a detailed medical and sexual history and general and genital examination. Patients were treated with open bilateral subinguinal varicocelectomy under spinal anesthesia. All patients were evaluated before and 6 months after the varicocelectomy by PE diagnostic tool (PEDT). The intravaginal ejaculatory latency times (IELTs) per minute and overall sexual satisfaction scores were evaluated before and 6 months after varicocelectomy. All patients were asked to indicate their sexual satisfaction on a scale of 0-5, with 0 being extremely dissatisfied and 5 being extremely satisfied. Results: The mean scores of the five questions of the PEDT measuring ejaculation control, frequency of inability of ejaculation control, ejaculation with minimal stimulation, feel of distress, and interpersonal difficulty owing to PE had statistically significant improvements at 6 months after varicocelectomy. The mean IELTs per minute and overall sexual satisfaction scores were significantly improved at 6 months after varicocelectomy. Conclusions: The study concluded that varicocelectomy improve PE in patients with bilateral clinical varicoceles and PE. Further prospective, controlled studies are needed to provide further characterization of this potential relationship.

Keywords: Intravaginal ejaculatory latency times, premature ejaculation, premature ejaculation diagnostic tool, varicocelectomy, varicoceles


How to cite this article:
El-Hamd MA, Abdel Hameed HF. The Role of Varicocelectomy on Patients with Premature Ejaculation and Varicoceles. J Integr Nephrol Androl 2016;3:121-5

How to cite this URL:
El-Hamd MA, Abdel Hameed HF. The Role of Varicocelectomy on Patients with Premature Ejaculation and Varicoceles. J Integr Nephrol Androl [serial online] 2016 [cited 2018 Dec 14];3:121-5. Available from: http://www.journal-ina.com/text.asp?2016/3/4/121/193515


  Introduction Top


Premature ejaculation (PE) is the most frequently encountered sexual complaint of men. [1] PE exerts a significant psychological burden on men, their partners, male/partner relationship, and their overall relationship. [2],[3] The etiology of PE has been traditionally divided into psychogenic and biogenic factors. [4] Psychogenic factors include psychodynamic principles, early experience, sexual conditioning, anxiety, technique, and frequency of sexual activity. Biogenic factors include penile hypersensitivity, hyperexcitable ejaculatory reflex, hyperarousability, endocrinopathy, genetic predisposition, and 5-hydroxytryptamine receptor dysfunction (neurobiological theory). [5],[6],[7] Urologic causes, including chronic prostatitis, have also been implicated. [8]

Varicocele is clinically defined as a palpable elongated, dilated, and tortuous testicular pampiniform plexus of veins in the spermatic cord. It is found in approximately 15-20% of the normal adult male population and is thought to be the most common treatable cause of male infertility factor. [9],[10] Varicocelectomy is the surgical varicocele repair and the gold standard treatment of the varicoceles. [11]

There are many studies reported a high prevalence of PE in patients with varicoceles. [12],[13],[14],[15] However, the mechanisms linking varicoceles with PE appear to be complex and difficult to explain. [15] Few studies found that varicocelectomy could improve PE in patients with varicoceles and PE. [16],[17]

Hence, this study aimed to assess the role of varicocelectomy in the improvement of PE in patients with clinical varicoceles and PE.


  Materials and methods Top


In a prospective clinical study, it conducted on 85 male patients with clinical varicoceles and PE. Those patients were selected from whom attending the Outpatient Clinics of Andrology and General Surgery at Sohag University Hospital between February 2015 and May 2016. The study was approved by the Research and Ethical Committees at Sohag Faculty of Medicine. Informed consent was signed by all patients after full explanation of the surgical procedure and possible benefits and side effects. All patients were subjected to preliminary assessment included a detailed medical and sexual history and general and genital examination.

Patients were considered to have PE if fulfilled the criteria of International Society for Sexual Medicine that defined PE as a male sexual dysfunction characterized by (1) ejaculation which always or nearly always occurs prior to or within 1 min of vaginal penetration, either present from the first sexual experience or following a new bothersome change in ejaculatory latency; (2) inability to delay ejaculation on all or nearly all vaginal penetrations; and (3) negative personal consequences, such as distress, bother, frustration, and/or the avoidance of sexual intimacy. [18] Furthermore, those included patients were ≥20 years, married, and in a stable sexual relationship for at least 3 months before this study.

Patients with history suggestive of one of the following conditions were excluded: (1) erectile dysfunction, (2) diabetes mellitus (DM), (3) chronic renal failure, (4) chronic prostatitis, (5) neurological diseases, and (6) central nervous system medications. Patients who received medications for PE over the last 3 months before the enrolment in the study were also excluded from the study.

All patients were evaluated before this study by the International Index of Erectile Function 5-item questionnaires to exclude the patients with erectile dysfunction (score will be more than 22). [19] Varicoceles were diagnosed and graded (Grade 1, 2, or 3) on the basis of clinical genital examination.

All patients underwent scrotal Doppler ultrasonography to confirm the diagnosis of varicoceles and to assess the accurate testicular size before and 6 months after the varicocelectomy.

Serum total testosterones levels were measured before and 6 months after the varicocelectomy.

The indications for varicocelectomy were as follows: infertility with abnormal semen parameters in 80 (94.2%) patients and scrotal pain in 5 (5.8%) patients.

Patients were treated with open bilateral subinguinal varicocelectomy under spinal anesthesia. A 2-3 cm transverse skin incision 1 cm above and lateral pubic tubercle was done. The spermatic cord was delivered and placed over an artery forceps. With the using of magnifying loupe, all identifiable external spermatic veins and internal spermatic veins were separated, ligated, and divided. The identified artery (or arteries) and lymphatics were preserved. Patients were discharged on the same day of the operation.

All patients were instructed to do sexual intercourse 2-3 times/week and not take any medication for PE or ED during the follow-up period.

All patients were evaluated before and 6 months after the varicocelectomy by PE diagnostic tool (PEDT). [20] The PEDT questionnaires include five questions about inability of ejaculation control, frequency of inability of ejaculation control, ejaculation with minimal stimulation, feel of distress, and interpersonal difficulty owing to PE. Response to each question is scored on a scale from 0 to 4. PEDT total score of ≥11 was used to define PE. All patients were instructed to record intravaginal ejaculatory latency time (IELT) using stopwatch before and after varicocelectomy. All patients were asked to indicate their sexual satisfaction on a scale of 0-5 as proposed by Kim and Paick, with 0 being extremely dissatisfied and 5 being extremely satisfied. [21]

Statistical analysis

Statistical analysis was carried out using Statistical Analysis Software version 16 (SAS Institute, Inc., Cary, NC, USA). Data were recorded as mean ± standard deviation (SD). Comparisons of data within the group were performed using paired t-test. P ≤ 0.05 was considered statistically significant.


  Results Top


The present study included 85 male patients with clinical varicoceles and PE. Twenty-one patients were excluded (ten patients refused to participate in the study, seven patients with DM on oral hypoglycemic therapy, two patients with history suggestive of chronic prostatitis, and two patients with history of erectile dysfunction).

The mean age of the patients was 29.37 ± 4.42 years. The mean duration of marriage of the patients was 7.87 ± 0.84 years. The mean duration of PE of the patients was 4.02 ± 1.93 years. The mean frequency of intercourse of the patients was 3.54 ± 0.69/week.

The clinical genital examination and scrotal Doppler ultrasonography revealed that at the left side, 11 (13%) patients had 1 st Grade varicoceles, 34 (40%) had 2 nd Grade varicoceles, and 40 (47%) patients had 3 rd Grade varicoceles, while at the right side, 32 (37.7%) patients had 1 st Grade varicoceles, 28 (33%) had 2 nd Grade varicoceles, and 25 (29.4%) patients had 3 rd Grade varicoceles.

The mean scores of the five questions of the PEDT measuring ejaculation control, frequency of inability of ejaculation control, ejaculation with minimal stimulation, feel of distress, and interpersonal difficulty owing to PE had statistically significant improvements at 6 months after varicocelectomy (P = 0.0001). Total scores (mean ± SD) at 6 months after varicocelectomy were significantly lower as compared to initial preoperative evaluations (9.84 ± 2.01 and 16.81 ± 2.29, respectively) [P = 0.0001, [Table 1].
Table 1: Comparisons of mean (±standard deviation) scores of the five-item questionnaire and total scores of premature ejaculation diagnostic tool at initial prevaricocelectomy evaluations and at 6 months postvaricocelectomy evaluations


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The mean IELTs per minutes at 6 months after varicocelectomy were significantly higher as compared to initial preoperative evaluations (5.14 ± 0.77 and 0.93 ± 0.16, respectively) [P = 0.0001, [Table 2]. The mean values for the overall sexual satisfaction scores at 6 months after varicocelectomy were significantly higher as compared to initial preoperative evaluations (3.56 ± 0.58 and 1.03 ± 0.93, respectively) [P = 0.0001, [Table 2].

The mean testicular size significantly increased from 10.97 ± 2.23 to 13.80 ± 1.54 at 6 months after varicocelectomy (P = 0.0001). The mean serum testosterone significantly increased from 311.87 ± 23.84 to 34.48 ± 22.4 at 6 months after varicocelectomy [P = 0.0001, [Table 2].
Table 2: Comparisons of mean (±standard deviation) of the intravaginal ejaculatory latency time/min, testicular size/cc, serum testosterone/ng/dL, and sexual satisfaction scores at initial prevaricocelectomy evaluations and at 6 months postvaricocelectomy evaluations


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In addition, this study found that there was an overall improvement in the semen parameters of the patients at 6 months postoperative in (n = 40) 50% of the patients with abnormal semen parameters. The scrotal pain was improved in (n = 3) 60% of the patients with varicoceles and pain at 6 months postoperative.


  Discussion Top


There are many studies reported a high prevalence of PE in patients with varicoceles. [12],[13],[14] Lotti et al. found an association between varicocele and PE in patients consulting for sexual dysfunction and the mechanisms linking varicocele with PE appear to be complex and difficult to explain. [15] However, many studies speculated that varicocele, leading to intrapelvic congestion and prostatic inflammation, could be the primum movens for the onset of PE, at least in some patients. It has been reported that varicocele is associated with an underlying systemic venous abnormality and with an increased diameter of the prostatic venous plexus in particular. [22],[23],[24]

Gat et al. demonstrated that the presence of a venous blood reflux from the high pressure testicular venous drainage system to the low-pressure prostatic drainage system through a direct communication represented by the deferential vein and the vesicular plexus. It was speculated that the presence of communication between the testicular and the prostatic venous system might justify a backflow of venous blood from the testis to the prostate, which can lead to intrapelvic venous congestion. This could facilitate the onset of symptoms of prostatitis. [25]

This study aimed to assess the role of varicocelectomy in the improvement of PE in patients with clinical varicoceles and PE.

The mean scores of the five questions of the PEDT measuring ejaculation control, frequency of inability of ejaculation control, ejaculation with minimal stimulation, feel of distress, and interpersonal difficulty owing to PE had statistically significant improvements at 6 months after varicocelectomy evaluations. In addition, the mean of the total scores of PEDT at 6 months after varicocelectomy had statistically significant improvements. This finding concurred with that from the study of Ahmed et al., who concluded that varicocelectomy was clearly related to improvement of PE and testicular hormonal function in varicocele patients. [17] In addition, Asadpour et al. found that in a significant number of patients who had clinical varicoceles and not well responded to medical treatments for PE, varicocelectomy could effectively improve PE. [16]

The present study reported that the mean IELTs per minutes at 6 months after varicocelectomy evaluations were significantly higher as compared to initial preoperative evaluations. The mean values for the overall sexual satisfaction scores at 6 months after varicocelectomy were significantly higher as compared to initial preoperative evaluations.

The present study found that there was a significant increase in testicular size and correlated with a significant increase in serum testosterone levels at 6 months after varicocelectomy. These results suggest that PE in the patient with clinical varicoceles was related to testicular hormonal dysfunction. These significant increases in serum testosterone levels within normal range may associate with improvement in overall sexual functions including ejaculatory control reflex. However, Corona et al. [26] reported that abnormal high levels of testosterone may associate with PE.

The present study showed that varicocelectomy could be an effective line of treatment for PE in patients with clinical varicoceles and PE because it improved PEDT, ILET, and overall sexual satisfaction scores. This improvement may relate to the significant increase in serum testosterone levels at 6 months after varicocelectomy.


  Conclusion Top


Finally, this study concluded that varicocelectomy could improve PE in patients with clinical varicoceles and PE. Further prospective, controlled studies are needed to provide further characterization of this potential relationship.

Acknowledgment

We are grateful to all the faculty and postgraduates in our scientific departments for their invaluable help in conducting this study.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

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