29yr Male patient sexually active from last 6yrs and history of mastrubations since the age of 15yr complaining premature ejaculation within seconds of intercourse prostatic fluids comes out while talking opposite sex .He is No alcoholic non smoker...weight56kgs..Blood picture is below..How to deal with these cause what will be better treatment? Right know I have adviced him kegel exercise and some TCAs..

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Common treatment options for premature ejaculation include behavioral techniques, topical anesthetics, medications and counseling. Keep in mind that it might take time to find the treatment or combination of treatments that will work. Behavioral technique Pelvic floor exercises Male pelvic floor muscles Weak pelvic floor muscles might impair your ability . Condoms Condoms might decrease penis sensitivity, which can help delay ejaculation. "Climax control" condoms are available over the counter. These condoms contain numbing agents such as benzocaine or lidocaine or are made of thicker latex to delay ejaculation. Medications: Topical anesthetics Such as benzocaine, lidocaine or prilocaine, are sometimes used to treat premature ejaculation. These products are applied to the penis 10 to 15 minutes before sex to reduce sensation and help delay ejaculation. Oral medications sildenafil 50/100mg or tadalafi 10/20mg , 15 to 20min before. Alone or with SSRI/Dapoxetine sometime Clonafit if Anxiety is prominent. Behavior therapy /Couple therapy.

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Go for stepwise approach...... STEP 1 : SEE IT'S SUBJECTIVE OR TRUE PE. Subjective PE to be treated with.... (i) Counselling (ii) Behavioral therapy (avoiding masturbation, reading porn books, watching porn contents, avoiding foreplay before sex, diverting mind during coitus, healthy thinking) (iii) Use of "Climax Condom" (thick latex condom or condom with anaesthetic jelly). /Apply anaesthetic jelly on glans prior to intercourse. (iv) Anxiolytic In True PE go to next step. STEP 2 : R/O SYSTEMIC ILLNESS. It includes...... -Spinal injury -CNS /Peripheral neuropathy -LUTS/Prostatovesiculitis -Thyroid disease -Hyperprolactinemia -CLD -CKD -Dyslipidemia -Cardiac illness -DM -HTN etc If 'YES' treat it accordingly. If 'NO' then go to next step. STEP 3 : R/O ERECTYLE DYSFUNCTION If 'YES' then treat with..... (i) PDE5i (ii) +/- Dapoxetine /Paroxetine /Fluoxetine (iii) CoQ10 Enzyme (iv) Kegel's exercise (v) Behavioral therapy (vi) Anaesthetic gel / Climax condom If 'NO' then treat same way excepting the 'PDE5i'. In non response go to next step. STEP 4 : SEMEN ANALYSIS AND FREE TESTOSTERONE. Advise free testosterone if semen analysis shows low sperm count. If it's decreased then give 'TRT'. In non response go to next step. STEP 5 : IDIOPATHIC PE. Treat with Clomiphene citrate 25 mg for 3 months.

Very elaborated & nicely explained.
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As per my understanding, Please get his TOTAL & FREE TESTOSTERONE LEVELS DONE. What I feel is that most of the cases of PME actually also suffer from ED. Let me brief over here that these levels are also misleading because of the methodological issues and the reference range choosen by the laboratories. On a CLIA system the MODE value is around 800 ng/dl (with a range if 400-1600) in general and on ELISA/ELFA system, it is 600 ng/dl (with a range if 270-1070). Most of the laboratories now a days have adopted to CLIA but are still referring ranges designed for ELISA / ELFA systems which are misleading to we treating physicians. Certain literature also mention that most of these cases of PME are in fact ED. Also, I would like to see his prolactin levels below 18 ng per ml

Tell him to practice abstinence from sex for at least 6 weeks, neither masturbation nor real sex. That will cause a lot of improvement. Also tell him to stop seeing porn in this period, as now a days porn induced sexual dysfunction or performance anxiety is common. Kegel's exercise is OK. These are conservative methods. Pharmacological approch would be to use Combination of Tadalafil & Dapoxetine (10/20+30) on alternate days. Tadafil-D can be used on alternate days. If he is having coexisting anxiety disorders, treatment of those would be needed. For that Alprazolam or Clonazepam can be used on short term basis along with Propranolol.

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He is hyperexcited personality probably nymphomanic should receive counseling and psychotherapy and if needed anxiolytic drugs

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Better to stop RCA and give fluoxetine 20 mg or paroxetine CR 12.5mg on daily basis. Rest to continue as advised.

reassurance and councelling required. Needed anxiolytic drugs.

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TD Pill (Tadalafil + Dapoxetin) will be helpful.

Reassurance and counselling required.

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There is no side effect of masturbation 90 percent does it wonder drug Viagra start with 25 mg go up to 800 mg 1 hr before sex utilising side effect of trazonil 50 hs aswaganda powder half tsf bd suggested by urologist

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