Document Type : Research Paper
1 MB,ChB, FIBMS, Consultant Urologist at Basrah Teaching Hospital, Basrah.
2 MB,ChB, FIBMS, Assistant Professor of urology at Basrah College of Medicine, University of Basrah.
3 MB,ChB, Senior House Officer at Basrah Teaching Hospital, Basrah, IRAQ.
Premature ejaculation (PE) is the most common sexual dysfunction in men with a prevalence rate reaching up to 75%. Varicocele is defined as elongated, dilated, and tortuous veins of the testicular pampiniform plexus. The link between PE and varicocele was demonstrated in many studies. This study aimed to evaluate the effect of varicocelectomy in improving PE in men with both PE and varicocele.
This prospective study was conducted on sixty patients (age range 19-40 years) who had clinical varicocele and premature ejaculation. The study period was from January 2018 to January 2020 and was performed in Basrah Teaching Hospital. Forty patients met the inclusion criteria of this study. All patients had varicocelectomy and were followed up for the improvement of their PE.
The study showed that majority of patients with concomitant PE and varicocele (26 patients, 65%) had improvement of PE after varicocelectomy with an ability to delay ejaculation.
The development of PE in patients with varicocele may be related to the occurrence of prostatitis due to the backflow of blood from the varicocele to the prostatic venous plexus. The study concluded that improvement of PE in patient with concomitant varicocele could be achieved by performing varicocelectomy.
Key words: Varicocele, premature, ejaculation, improvement, varicocelectomy.
remature ejaculation (PE) is largely frequent sexual dysfunction in men, with the prevalence rate get to 75%1,2. Premature ejaculation is when male orgasm occurs within 1 min of vaginal penetration3. Although Intra-vaginal ejaculation latency time (IELT) covers only one parameter of PE, namely “short time interval between penetration and ejaculation” and ignores other patient-reported outcomes (PROs) such as “lack of control over ejaculation” and “distress experienced by one or both partners,” it was welcomed by the research community as it provided a tool to objectively assess the efficacy of pharmacological or surgical interventions4. The PE is classified by Manual of Mental Disorder and International Classification of Diseases (ICD) into four PE categories: lifelong PE, acquired PE, natural variable PE, and premature-like ejaculatory dysfunction. According to this new classification, there are different pathophysiologies of and treatment options for premature ejaculation depending on the underlying premature ejaculation syndrome5.
Varicocele; is defined as elongated, dilated, and tortuous veins of the testicular pampiniform plexus6. Varicocelectomy is the gold standard treatment of the varicoceles7. The link between PE and varicocele has been shown in many studies8,9. Although the underlying mechanism is so complex and not well established9, improvement of PE after varicocelectomy in patients with PE and varicocele have been shown in few studies10,11.
The aim of this study is to determine the role of varicocelectomy in improving premature ejaculation in patient with concomitant premature ejaculation and varicocele and to correlate that improvement with different grades of varicocele.
Patients and Methods
This prospective study was conducted on sixty patients (19-40 years) who had clinical varicocele and premature ejaculation. Those patients were selected from those attending Al-Basrah Teaching Hospital, urology department, from January 2018 to January 2020. All patients underwent sub-inguinal or inguinal varicocelectomy because of impairment of spermiogram or symptomatic varicocele. All patients were evaluated preoperatively by questionnaire, complete history taking and detailed physical examination including; Grade of varicocele, Site of varicocele , Medical treatment for PE, Testicular size Testosterone level, Indication of surgery, Erectile dysfunction, Chronic prostatitis, Diabetes mellitus, Neurological disease, External genital malformation, and Improvement on follow-up.
Patients were evaluated by color Doppler ultrasound to find out the grade of varicocele, and testicular size. Semen analysis and testosterone level were assessed to find the presence of abnormal semen parameters or hypogonadism. Premature ejaculation was evaluated based on patient’s report of dissatisfaction about duration of intercourse and inability to control ejaculation. Postoperative follow-up was done for three months including inquiry about patient satisfaction regarding the duration and ability to control the ejaculation.
The exclusion criteria were; Erectile dysfunction, Chronic prostatitis, Diabetes mellitus, Neurological disease, External genital malformation, and refusal to participate. Accordingly to this, 20 patients were excluded from the study and the final number was 40 patients. Statistical analysis was done and a p-value <0.05 was regarded as significant.
Forty patients met the inclusion criteria in this study; the oldest was 40 years old whereas the youngest was 19 years old and the mean age was 24.3±0.8 years. Six patients (15%) had bilateral varicocele while in the rest (34 patients, 85%) had unilateral. The majority of patients had grade II varicocele (27 patients, 67.5%) while 9 patients (22.5%) had grade III and only 4 patients (10%) belonged to grade I category.
Regarding the preoperative medical treatment of premature ejaculation only three patients (7.5%) were treated medically while the rest (37, 92.5%) didn’t take any medications as shown in fig. 1.
Figure 1: Distribution of patients according to preoperative medical treatment for PE.
Thirty six patients were operated upon due to impaired spermiogram (90%) and four patients due to scrotal pain; however, no patient had operation because of premature ejaculation as an indication for surgery (Fig. 2).
Figure 2: Distribution of patients according to the indications for surgery.
The mean testicular size preoperatively was 13.23±3.57 cc while in the postoperative follow-up, the size increased to 14.31±1.76 cc; however, it was statistically insignificant (p-value > 0.05). There was an increase in the mean testosterone level from 343.23±17.8 ng/dl in the preoperative period to 410.63±31.52 ng/dl postoperatively. However, the result was statistically
insignificant (P value > 0.05).
Twenty six patients (65%) in this study reported an improvement in their ability to delay ejaculation and subjectively longer intercourse time during the follow-up period compared to their status preoperatively while the rest (14.35%) didn’t notice such a change. This result was statistically significant (p-value 0.043) (Fig. 3).
Figure 3: Distribution of cases according to the improvement of premature ejaculation.
The mean age in the improved group was 22.3±0.34 years compared to 28.1± 0.91 years in the non-improved group. Twenty three patients (67.65%) out of 34 patients with unilateral varicocele reported improvement postoperatively.
Regarding the grade of varicocele; 18 patients (66.7%) out of 27 patients with grade II, 6 patients (66.6%) out 9 patients with grade III and three patients (75%) out of four patients with grade I, reported an improvement in their premature ejaculation postoperatively. Twenty three patients (63.9%) in whom operation was performed due to impaired spermiogram and 3 (75%) of patients who underwent surgery due to pain, reported improvement in their postoperative premature ejaculation status. The mean testicular size was higher (16.1±2.13 cc) in the improved group compared to 12.72±1.32 cc in the non-improved group (Fig. 4).
Fig. 4: Correlation between the outcome and patients' parameters.
The mean testosterone level was clearly higher in the group of patients who reported improvement in their premature ejaculation status (443.89±33.41 ng/dl) as compared to those in whom improvement was not reported (349.47±13.92 ng/dl)
Regarding IELT, the mean preoperative value was 1.15±0.16 and 4.85±0.66 minutes postoperatively. This increment was statistically significant (p-value< 0.05).
Fig. 5: Correlation between the outcome and mean testosterone level.
Premature ejaculation is an underestimated problem in our society. It seems that our patients consider this condition as a social stigma; therefore they try to neglect it or deny its existence. However, it remains an important problem that negatively affects the healthy sexual relationship between partners.
The presence of communication between the testicular and prostatic venous system may result in backflow of venous blood to the prostate which in turn can lead to intrapelvic venous congestion and subsequent prostatitis12. The resultant prostatic inflammation could be the primary initiator for the onset of PE in some patients13.
The mean age of patients in this study was 24.3±0.8 year which is close to that reported by other study14.
The majority of patients in this study had a unilateral varicocele (85%). This incidence is higher than what was reported by other studies15. The majority of our patients had Grade II varicocele (67.5%) while (22.5%) had Grade III and the rest had grade I, these results were higher than other study16.
Almost all of our patients apart from 3 (7.5%) didn’t receive any sort of medical treatment for their premature ejaculation prior to surgery, which clearly contradicts with what was reported by other investigators who stated that medical treatment was the first line option for this condition in their study17, this is probably due to less number of men seeking treatment for PE.
Most of the patients in this study underwent surgical treatment due to impaired spermiogram (30.90%) while the rest did so due to scrotal pain and none of them required surgery due to premature ejaculation. This result was close to that reported by El-Hamd et al18.
Our results clearly showed an increase in the testicular size, a result that is comparable to other study19. We have observed an increase in the mean testosterone level postoperatively. This finding is similar to what was reported by other studies18,20.
Around two thirds of patients in this study (65%) have shown improvement in their premature ejaculation, a result that is close to the study of Asadpour et al10 who showed 63% improvement of PE, but unlike the study of Ahmed et al21 which showed a rate of improvement of 41.1% only.
In conclusion, this study showed that varicocelectomy could be an effective line of treatment for premature ejaculation in patients with varicocele. A significant number of patients with Grade II-III varicocele who were not well responding to the medical treatment of premature ejaculation, could have benefit from varicocelectomy to improve their PE. The significant improvement in IELT after varicocelectomy in patients with PE supports the option of doing this surgery as a therapeutic measure.
The main points to know are: Premature ejaculation is a common sexual problem seen in clinical practice that can adversely affect the patient’s relation with his partner; it isn’t uncommon that a patient may have concomitant premature ejaculation and symptomatic varicocele. Testicular pain or fertility problems may predominate the clinical picture in such patients, the study has found that varicocelectomy in patients with both PE and varicocele can improve this sexual dysfunction and eliminate the need for medical treatment