(232) A Novel Dual-Zone Injection Protocol Using Hyaluronic Acid for the Treatment of Premature Ejaculation

Abstract Introduction For over a decade, hyaluronic acid (HA) injections have been used for penile girth augmentation. Interestingly, there have been numerous studies exploring its use in treating premature ejaculation (PE) as well. HA is a naturally occurring glycosaminoglycan, a complex sugar found in the skin, eyes, and joints. Its unique chemical composition enables HA to bind and retain water. Given these unique properties and excellent biocompatibility, HA has been used as an injectable filler since the early 2000s. PE is a multifactorial condition with both physiological and psychological components. Some experts theorize that penile hypersensitivity is a major contributor to PE, and numerous studies have shown that HA penile injections can significantly increase the time that it takes to ejaculate after penetration, also known as intravaginal ejaculation latency time (IELT). While the exact mechanism of action is unknown, it is postulated that HA injections may decrease this hypersensitivity by reducing tactile stimulus transmission through the penile dorsal nerve branches. Several HA injection techniques have been tested and shown to be effective at prolonging IELT. Objective Here we describe an HA penile injection protocol for treating PE. This protocol was developed to reduce penile hypersensitivity by injecting an even coverage of HA filler into the most sensitive areas of the penis, the glans and ventral frenulum. Methods The penis should be prepped and draped in a sterile fashion. Topical numbing agent then applied to the entire glans, including the ventral frenulum. Following sterile technique, a total of 2.4 mL of HA filler is injected into the penis using a 22–28-gauge needle. There are seven injection sites to target. First, imagine the glans divided horizontally into a proximal half and distal half. Then divide the proximal half into three regions evenly spaced along the base of the glans following the curved path of the corona. Then divide the distal half vertically into two evenly sized regions. 0.4 mL of HA filler is injected into each of these five sites to the depth of the deep dermis. Care should be taken to maintain appropriate depth. Adjusting the angle of the syringe needle can help ensure even distribution of filler. With the remaining 0.4 mL of filler, 0.2 mL is injected on each side of the ventral penile frenulum, avoiding injection directly into the frenulum. Figure 1 illustrates targeted injection sites. Figure 2 shows desired injection depth. Results Numerous studies have shown HA injections into the glans consistently increases IELT by 2 to 8-fold within the first month of treatment. This increase is followed by a predictable decrease in IELT, which is still significantly longer than pre-treatment IELT, at 3-, 6-, and 12-months. Notably, patients treated with HA have documented prolongation in IELT lasting up to 5 years. Conclusions HA injections have been shown to be an effective treatment for PE with prolongated IELT lasting 1-5 years after a single treatment. Given these promising findings, a standard protocol should be developed. Here, we propose one such protocol. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: UroFill®, Coloplast corp., Boston Scientific, Rigicon