A 35-year-old man comes to the office due to a lack of sexual interest. He says, "I started seeing this woman 9 months ago and am really attracted to her. We get along well and things are great, but I just don't want to have sex with her anymore." On further questioning, the patient reluctantly admits that whenever they have intercourse he has an orgasm in less than a minute and finds this very embarrassing. He does not have the same problem when he masturbates. He says, "I'm worried that my girlfriend will leave me, and it's really affecting my self-esteem." The patient has no other concerns. His other medical conditions include type 1 diabetes mellitus, chronic insomnia, and a history of major depression. His medications include insulin glargine, short-acting insulin, and trazodone. He does not use illicit substances. Vital signs are within normal limits. Laboratory results are significant for hemoglobin A1c of 7% and fasting glucose of 130 mg/dL. Which of the following is the most likely diagnosis?

Question

A 35-year-old man comes to the office due to a lack of sexual interest.  He says, "I started seeing this woman 9 months ago and am really attracted to her.  We get along well and things are great, but I just don't want to have sex with her anymore."  On further questioning, the patient reluctantly admits that whenever they have intercourse he has an orgasm in less than a minute and finds this very embarrassing.  He does not have the same problem when he masturbates.  He says, "I'm worried that my girlfriend will leave me, and it's really affecting my self-esteem."  The patient has no other concerns.  His other medical conditions include type 1 diabetes mellitus, chronic insomnia, and a history of major depression.  His medications include insulin glargine, short-acting insulin, and trazodone.  He does not use illicit substances.  Vital signs are within normal limits.  Laboratory results are significant for hemoglobin A1c of 7% and fasting glucose of 130 mg/dL.  Which of the following is the most likely diagnosis?

Quizplus · Accepted Answer

Evaluation of sexual dysfunction requires ruling out medical conditions and substance use, as well as obtaining a history of psychosocial stressors, including stressors in the relationship itself. This patient has features of premature ejaculation, characterized by unwanted episodes of early ejaculation accompanied by a sense of lack of control. Although concern over the time to ejaculation is common, only an estimated 4% of men will meet diagnostic criteria (ejaculation within one minute of penetration, occurring most of the time for at least 6 months). The diagnostic criteria for premature ejaculation are based on ejaculation during partnered sexual activity, therefore a normal time to ejaculation during masturbation does not negate this diagnosis. (Choice A) Erectile disorder is characterized by a persistent inability to attain or sustain an erection. (Choice B) The symptom reported initially was a lack of sexual interest. However, on further questioning, it was found to be related to his embarrassment over premature ejaculation rather than to a pervasive lack of desire. It is common for men with premature ejaculation to develop anxiety and resultant aversion to sexual intercourse. (Choice D) Medical conditions, including diabetes, that affect nerve function or blood flow to the pelvic tissue tend to result in erectile dysfunction rather than premature ejaculation. Medical conditions linked to premature ejaculation include prostatitis and thyroid disease. (Choice E) Sexual dysfunction may occur in the context of psychiatric conditions, such as depression and anxiety. Apart from the distress secondary to his ejaculatory disorder, this patient reports no depressive symptoms. (Choice F) Trazodone is a serotonin modulator used primarily for the treatment of insomnia. It may cause priapism (ie, persistent erection), but it does not cause premature ejaculation (nor does insulin). Educational objective: Premature ejaculation is characterized by recurrent episodes of early ejaculation accompanied by a sense of lack of control. Evaluation of any sexual disorder requires taking careful medical and substance use histories and assessing psychosocial stressors and comorbid psychiatric conditions. __________ References: Advances in understanding and treating premature ejaculation. (http://www.ncbi.nlm.nih.gov/pubmed/26502991) Pharmacotherapy for premature ejaculation. (http://www.ncbi.nlm.nih.gov/pubmed/26579971)

A 35-Year-Old Man Comes to the Office Due to a Lack