Effect of SSRI antidepressants on ejaculation: a double-blind, randomized, placebo-controlled study with fluoxetine, fluvoxamine, paroxetine, and sertraline

Counseling Patients About Sexual Issues

In recent years, the frequency of antidepressant drug-induced sexual dysfunction has increased, along with the use of new drugs for the treatment of erectile dysfunction and premature ejaculation. It has thus become common for pharmacists to counsel patients about sexual issues. Pharmacists must not only become knowledgeable about these drugs and their indications, but they must also become skilled and comfortable with counseling patients and answering questions from both patients and other health care providers. In addition to therapeutic information, pharmacists' discussions with patients should take into account factors that contribute to treatment nonadherence and treatment failure. Patient education is essential to ensure optimum outcomes for pharmacologic treatments for both erectile dysfunction and premature ejaculation. Improper use of phosphodiesterase-5 inhibitor drugs for erectile dysfunction accounts for most nonresponsiveness and discontinuation of treatment. Drug-induced sexual dysfunction is common with some psychotropic drugs. Up to 50% of men will experience delayed ejaculation, and at least 30% of men and women will experience anorgasmia from antidepressant drugs with serotonin agonist activity. Trazodone is the drug most commonly associated with the rare but very serious adverse effect of priapism. The pharmacist who is both competent and comfortable discussing sexual function and dysfunction with patients can make positive contributions to their therapeutic outcomes as well as their quality of life.

Efficacy and tolerability of dapoxetine in treatment of premature ejaculation: an integrated analysis of two double-blind, randomised controlled trials

BACKGROUND

No drugs are approved for treatment of premature ejaculation. Our aim was to determine the efficacy and tolerability of on-demand dapoxetine in patients with severe premature ejaculation.

METHODS

We determined the efficacy of dapoxetine in a prospectively predefined integrated analysis of two 12-week randomised, double-blind, placebo-controlled, phase III trials of identical design done independently, in parallel, at 121 sites in the USA. Men with moderate-to-severe premature ejaculation in stable, heterosexual relationships took placebo (n=870), 30 mg dapoxetine (874), or 60 mg dapoxetine (870) on-demand (as needed, 1-3 h before anticipated sexual activity). The primary endpoint was intravaginal ejaculatory latency time (IELT) measured by stopwatch. Safety and tolerability were assessed. All analyses were done on an intention-to-treat basis. The trials are registered at ClinicalTrials.gov, numbers NCT00211107 and NCT00211094.

FINDINGS

672, 676, and 610 patients completed in the placebo, 30 mg dapoxetine, and 60 mg dapoxetine groups, respectively. Dapoxetine significantly prolonged IELT (p<0.0001, all doses vs placebo). Mean IELT at baseline was 0.90 (SD 0.47) minute, 0.92 (0.50) minute, and 0.91 (0.48) minute, and at study endpoint (week 12 or final visit) was 1.75 (2.21) minutes for placebo, 2.78 (3.48) minutes for 30 mg dapoxetine, and 3.32 (3.68) minutes for 60 mg dapoxetine. Both dapoxetine doses were effective on the first dose. Common adverse events (30 mg and 60 mg dapoxetine, respectively) were nausea (8.7%, 20.1%), diarrhoea (3.9%, 6.8%), headache (5.9%, 6.8%), and dizziness (3.0%, 6.2%).

INTERPRETATION

On-demand dapoxetine is an effective and generally well tolerated treatment for men with moderate-to-severe premature ejaculation.

Psychopharmacology of male rat sexual behavior: modeling human sexual dysfunctions?

Most of our current understanding of the neurobiology, neuroanatomy and psychopharmacology of sexual behavior and ejaculatory function has been derived from preclinical studies in the rat. When a large population of male rats is tested on sexual activity during a number of successive tests, over time individual rats display a very stable sexual behavior that is either slow, normal or fast as characterized by the number of ejaculations performed. These sexual endophenotypes are postulated as rat counterparts of premature (fast rats) or retarded ejaculation (slow rats). Psychopharmacology in these endophenotypes helps to delineate the underlying mechanisms and pathology. This is illustrated by the effects of serotonergic antidepressants and serotonergic compounds on sexual and ejaculatory behavior of rats. These preclinical studies and models contribute to a better understanding of the neurobiology of ejaculation and boost the development of novel drug targets to treat ejaculatory disorders such as premature and retarded ejaculation.

Comparison of Dapoxetine Versus Paroxetine in Patients With Premature Ejaculation

PURPOSE

To compare the efficacy and safety of dapoxetine, paroxetine, and placebo for the oral pharmacotherapy of premature ejaculation.

MATERIALS AND METHODS

Three hundred forty potent men with premature ejaculation were recruited to this study. Patients were randomly assigned to receive 60 mg dapoxetine (group 1, n = 115), or 20 mg paroxetine (group 2, n = 113) or placebo (group 3, n = 112) orally daily during a 12-week period for each agent. The efficacy of the 3 treatments was assessed every 2 weeks during treatment and at the end of study using responses to International Index of Erectile Function (IIEF), intravaginal ejaculatory latency time (IELT) evaluation, mean intercourse satisfaction domain, mean weekly coitus episodes and adverse drug effects.

RESULTS

At the end of the 12-week treatment with dapoxetine, paroxetine, and placebo, the mean IELT was increased from 38, 31 and 34 seconds to 179, 370 and 55 seconds, respectively (P = 0.01 in group 1 and P = 0.001 in group 2). Baseline mean intercourse satisfaction domain values of International Index of Erectile Function of 10, 11, and 11 reached 14, 17 and 12 at the end of the 12-week treatment in groups 1, 2, and 3 respectively (P = 0.03 in groups 1, 2). The mean weekly intercourse episodes increased from pretreatment values of 1.4, 1.3, and 1.3 to 2.2, 2.5 and 1.4, for dapoxetine, paroxetine and placebo, respectively (P = 0.04 in groups 1, 2). The incidence of adverse effects with dapoxetine and paroxetine was significantly higher (P = 0.04 in groups 1, 2) compared to that of placebo.

CONCLUSIONS

Paroxetine appears to provide significantly better results in terms of IELT and intercourse satisfaction versus dapoxetine. Each treatment was well tolerated.

Serotonin and Premature Ejaculation: From Physiology to Patient Management

INTRODUCTION

Premature ejaculation (PE), whose pathophysiology is still not clearly identified, is the most common male sexual dysfunction, yet it remains underdiagnosed and undertreated. The aims of this paper are to provide a scientific and pharmacologic rationale, and to discuss to what extent selective serotonin reuptake inhibitors (SSRIs) can help patients with PE.

MATERIALS AND METHODS

A comprehensive evaluation of available published data included analysis of published full-length papers that were identified with Medline and Cancerlit from January 1981 to January 2006. Official proceedings of internationally known scientific societies held in the same time period were also assessed.

RESULTS

The central ejaculatory neural circuit comprises spinal and cerebral areas that form a highly interconnected network. The sympathetic, parasympathetic, and somatic spinal centers, under the influence of sensory genital and cerebral stimuli integrated and processed at the spinal cord level, act in synergy to command physiologic events occurring during ejaculation. Experimental evidence indicates that serotonin (5-HT), throughout brain descending pathways, exerts an inhibitory role on ejaculation. To date, three 5-HT receptor subtypes (5-HT1A, 5-HT1B, and 5-HT2C) have been postulated to mediate 5-HT's modulating activity on ejaculation. Pharmacologic manipulation of the serotonergic system has been performed in rats, with the antidepressant selective serotonin reuptake inhibitors (SSRIs) exhibiting the greatest efficacy in delaying ejaculation. The mechanism of action by which SSRIs modulate central 5-HT tone has been studied in depth, but gaps in this knowledge prevent an explanation of the efficacy of acute treatment in delaying ejaculation. Emerging clinical evidence indicates chronic and on-demand dosing of SSRIs has a beneficial effect for the treatment of men with PE, at least for paroxetine. On-demand dapoxetine, and SSRI with a short half-life, recently has been shown to significantly increase intravaginal latency time and PE patient-related outcomes in phase 3 clinical trials.

CONCLUSIONS

Nowadays there is no doubt that PE can be treated effectively by SSRIs. Nevertheless their mechanism of action is not yet well understood and deserves more research. In particular it is not understood why all the SSRIs are not equal in terms of their ability to delay ejaculation. Therefore, there is a need for more research to better characterize the mechanism of action of SSRIs as well their clinical benefit in patients affected by PE.

Current and Future Pharmacotherapies of Premature Ejaculation

INTRODUCTION

There are currently no oral or topical agents approved by government regulation agencies for the management of premature ejaculation (PE).

AIM

To review pharmacologic therapies for treatment of PE.

METHODS

The Sexual Medicine Society of North America hosted a State of the Art Conference on Premature Ejaculation on June 24-26, 2005 in collaboration with the University of South Florida. The purpose was to have an open exchange of contemporary research and clinical information on PE.

MAIN OUTCOME MEASURE

Data were obtained by extensive examination of peer-reviewed published literature.

RESULTS

Chronic administration of selective serotonin reuptake inhibitors (SSRIs) is associated with an increased adverse event profile encompassing dry mouth, nausea, drowsiness, and reduced libido. Their use may also facilitate the development of other sexual dysfunctions, such as anejaculation and erectile dysfunction (ED). Phosphodiesterase-5 (PDE-5) inhibitors have also been investigated for the management of PE, as an indirect consequence of their ability to prolong erections. Trials have found PDE-5 inhibitors to be appropriate for men with PE secondary to ED, or when they are used in conjunction with other agents such as SSRIs. Trials of topical formulations that contain either anesthetic agents or other ingredients report significant increases in ejaculatory latency times; however, long-term safety and efficacy studies are lacking. New agents are being developed specifically for the management of PE. Among these are a topical formulation and numerous oral agents. Only one agent--dapoxetine hydrochloride (DPX)--has undergone Phase III trials. DPX is a serotonin transport inhibitor (STI) with a pharmacokinetic profile conducive to on-demand dosing for the management of PE. Unlike the current oral agents, DPX has a rapid onset of action and is effective from the first dose.

CONCLUSIONS

Well-designed clinical trials utilizing appropriate outcome measurements are needed to provide safe and effective pharmacologic options for men with PE.

Effect of the 5-HT receptor agonist DOI on female rat sexual behavior

INTRODUCTION

Female rats display a repertoire of behaviors during a sexual encounter with a male, including sexually receptive (the lordosis response) and proceptive (darts and hops, and ear wigglings) behaviors.

AIM

We investigated the effects of subcutaneous injection of the 5-HT(2A/2C) receptor agonist (2,5-dimethoxy-4-idophenyl)-2-aminopropane hydrochloride (DOI) on sexual behaviors of ovariectomized female rat hormonally supplemented with estradiol benzoate (10 microg) and progesterone (250 microg).

METHODS

Both female and male sexual behaviors were observed for 10 minutes (pretest). Then females were injected with the treatment and after a 10-minute delay replaced with the same male for a 30-minute mating test (posttreatment period).

RESULTS

DOI (0.5 and 1 mg/kg) significantly increased the number of darts and hops/mounts. In contrast, no significant differences in ear wigglings/mounts were observed. In addition, DOI failed to modify sexual receptivity.

CONCLUSION

These data suggest that 5-HT(2A/2C) receptors are important in the regulation of female proceptivity.

Efficacy of type-5 phosphodiesterase inhibitors in the drug treatment of premature ejaculation: a systematic review

This review examines the role of nitric oxide (NO) as a neurotransmitter involved in the central and peripheral control of ejaculation, the methods of phosphodiesterase type 5 inhibitor (PDE5I) drug treatment studies for premature ejaculation (PE), the adherence of methods to the contemporary consensus of ideal PE drug trial design, the impact of methods on treatment outcomes and the role of PDE5Is in the treatment of PE. NO/cGMP transduction is involved in both the central and peripheral control of emission, but evidence for a direct central or peripheral effect of PDE5Is on ejaculation is speculative. Thirteen of the 14 studies reviewed failed to fulfil the evidence-based medicine criteria for ideal PE drug trial design. Limitations of the studies include inadequately defined study populations, the lack of a double-blind placebo-controlled study design, and the absence of consistent objective physiological measures or sensitive, validated outcome assessment instruments as study endpoints. The broad range of intravaginal ejaculatory latency time (IELT) fold-increases reported with PDE5Is, on-demand selective serotonin re-uptake inhibitor (SSRI) drugs, and combined PDE5I/on-demand SSRIs is testament to the unreliability of data and conclusions from methodologically flawed studies. The one study that fulfilled the evidence-based medicine criteria of an ideal clinical trial design reported that treatment with sildenafil failed to significantly increase baseline IELT, supporting our conclusion that there is no convincing evidence to support any role for PDE5Is in the treatment of men with lifelong PE and normal erectile function. However, there is limited evidence to support a potential role for PDE5Is alone or combined with daily or on-demand SSRIs in the treatment of acquired PE in men with comorbid erectile dysfunction. Further controlled studies adhering to the contemporary consensus of ideal clinical trial design are required to clarify the role of PDE5Is in this subgroup of men with acquired PE.

Pharmacologic treatment strategies for sexual dysfunction in patients with epilepsy and depression

Sexual dysfunction is a frequently encountered comorbid condition in patients with many medical and psychiatric conditions, such as epilepsy and depression. Most depressed patients experience some type of sexual dysfunction, decreased sexual desire being the most common. The association of sexual dysfunction with epilepsy is less clear. Changes in sex hormone levels are common in patients with epilepsy and may be attributable to the disease or to antiepileptic drugs (AEDs). Sexual dysfunction associated with depression or epilepsy is generally treated according to standard guidelines for the management of sexual disorders, since data from special populations are not available. The most common forms of female sexual dysfunction are lack of sexual desire and difficulty achieving orgasm. There are no approved pharmacotherapies for female hypoactive sexual desire disorder or female orgasmic disorder. Female sexual arousal disorder is treated with estrogen replacement therapy when indicated or vaginal lubricants. The most common male sexual dysfunction disorders are premature ejaculation and erectile dysfunction. Phosphodiesterase type-5 inhibitor drugs are now the first-line treatment for erectile dysfunction, and selective serotonin reuptake inhibitors and topical anesthetic creams are nonapproved but effective treatments for premature ejaculation. Testosterone and aromatase inhibitors have been used investigationally to treat sexual dysfunction in men taking AEDs. Patient education and follow-up appointments are essential to ensure optimal outcomes of pharmacologic treatments for sexual dysfunction.

Single- and multiple-dose pharmacokinetics of dapoxetine hydrochloride, a novel agent for the treatment of premature ejaculation

Dapoxetine is a serotonin transporter inhibitor currently in development for the treatment of premature ejaculation. This randomized, 2-sequence, 2-treatment crossover study assessed the single- and multiple-dose pharmacokinetics of dapoxetine following once-daily administration of dapoxetine 30 mg and 60 mg to healthy male volunteers. Dapoxetine was rapidly absorbed following oral administration, with peak plasma concentrations reached approximately 1 hour after dosing; plasma concentrations after single doses of dapoxetine decreased rapidly to approximately 5% of peak concentrations by 24 hours. Elimination was biphasic, with an initial half-life of approximately 1.4 hours and a terminal half-life of approximately 20 hours. Dapoxetine showed time-invariant pharmacokinetics and dose proportionality between doses, and its pharmacokinetics was unaffected by multiple dosing. The pharmacokinetics of dapoxetine metabolites, desmethyldapoxetine and dapoxetine-N-oxide, was similarly unaffected by multiple dosing. There were no serious adverse events; the most commonly reported adverse events were diarrhea, dizziness, and nausea.

Treatment of premature ejaculation

Premature ejaculation (PE) is a common problem, the treatment of which has received an increasing interest in recent years. Traditional management continues to be psychotherapy, with techniques such as the 'squeeze' and 'stop-start' most commonly employed. The application of local anaesthetics to the glans to delay ejaculation, first described over 60 years ago, continues to be used both in medical practice and as an 'over-the-counter' remedy. Over the years, a variety of psychopharmacological agents, especially antidepressants, have been described as treatments for PE. At the present time, the selective serotonin re-uptake inhibitors, licensed for other indications, emerge as the most effective agents to delay ejaculation, but none are licensed for the treatment of PE. There appears to be a high relapse rate irrespective of the mode of therapy used.

Salvage of sildenafil failures with cabergoline: a randomized, double-blind, placebo-controlled study

To evaluate the safety and efficacy of cabergoline in men with erectile dysfunction (ED) who did not respond to sildenafil. Four hundred two sildenafil nonresponders aged from 21 to 59 years were included in the study. Patients were randomly divided into group 1, those who received 0.5-1 mg cabergoline weekly for 6 months and group 2, who received placebo for the same period. They underwent preliminary assessment, including medical and sexual history, self-administered International Index of Erectile Function (IIEF) and intravaginal ejaculatory latency time (IVELT) evaluation. Standard biochemistry and hematological laboratory tests, and measurement of serum testosterone and prolactin levels were also carried out. When indicated, other tests were used to establish the diagnosis of vasculogenic and neurogenic ED, including penile color duplex Doppler ultrasonography, pudendal nerve conduction test and impaired sensory-evoked potentials studies. The efficacy of two treatments was assessed every 2 weeks during treatment, at the end of the study, using responses to IIEF, IVELT evaluation, mean intercourse satisfaction domain, mean weekly coitus episodes and adverse drug effects. The trial was completed by 370 (92%) men. Positive clinical results were seen in 31.2% of patients in the cabergoline group compared with 7.1% of patients in the placebo group (P=0.04). The mean weekly intercourse episodes increased from pretreatment values of 1.4 and 1.2 to 2.2 and 1.4, for cabergoline and placebo, respectively (P=0.04). Baseline mean intercourse satisfaction domain values of IIEF 10 and 11 reached to 15 and 10 at 6-month treatment in groups 1 and 2, respectively (P=0.04). The IVELT after cabergoline and placebo gradually increased from 98 and 101 s to approximately 242 and 116 s, respectively (P=0.001). More drug-related adverse effects occurred in cabergoline group and 12 (5.9%) had to discontinue treatment (P=0.001). Cabergoline is moderately effective salvage therapy for sildenafil nonresponse. Further studies with different dosages and treatment regimens are necessary to draw final conclusions on the efficacy of this drug in ED.

The etiology and management of premature ejaculation

Premature ejaculation (PE) is a common male sexual disorder. Normative data suggest that men with an intravaginal ejaculatory latency time of less than 1 min have 'definite' premature ejaculation, while men with intravaginal ejaculatory latency times of between 1 and 1.5 min have 'probable' premature ejaculation. Although there is insufficient empirical evidence to identify the etiology of PE, there is correlational evidence to suggest that men with PE have high levels of sexual anxiety and altered sensitivity of central 5-hydroxytryptamine receptors. Pharmacological modulation of the ejaculatory threshold using daily or on-demand selective serotonin reuptake inhibitors offers patients a high likelihood of achieving improved ejaculatory control within a few days of initiating treatment, leads to improvements in sexual desire and other sexual domains, and is well tolerated.

Tolerability and safety of fluvoxamine and other antidepressants

Selective serotonin [5-hydroxytryptamine (5-HT)] reuptake inhibitors (SSRIs) and the 5-HT noradrenaline reuptake inhibitor, venlafaxine, are mainstays in treatment for depression. The highly specific actions of SSRIs of enhancing serotonergic neurotransmission appears to explain their benefit, while lack of direct actions on other neurotransmitter systems is responsible for their superior safety profile compared with tricyclic antidepressants. Although SSRIs (and venlafaxine) have similar adverse effects, certain differences are emerging. Fluvoxamine may have fewer effects on sexual dysfunction and sleep pattern. SSRIs have a cardiovascular safety profile superior to that of tricyclic antidepressants for patients with cardiovascular disease; fluvoxamine is safe in patients with cardiovascular disease and in the elderly. A discontinuation syndrome may develop upon abrupt SSRI cessation. SSRIs are more tolerable than tricyclic antidepressants in overdose, and there is no conclusive evidence to suggest that they are associated with an increased risk of suicide. Although the literature suggests that there are no clinically significant differences in efficacy amongst SSRIs, treatment decisions need to be based on considerations such as patient acceptability, response history and toxicity.

Comorbidity between social phobia and premature ejaculation: study on 242 males affected by sexual disorders

Several studies have reported high comorbidity between psychiatric and sexual disorders, particularly between anxiety and mood disorders and sexual dysfunction. The goal of the present study is to examine the comorbidity between premature ejaculation and Axis I psychiatric disorders. Of 242 males referred to an outpatient clinic of sexology between November 2000 and July 2003, 52 were diagnosed with premature ejaculation (PE). These patients were also administered the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID; First, Spitzer, Gibbon, & Williams, 1995) for the evaluation of Axis I psychiatric disorders and a modified SCID based on Diagnostic and Statistical Manual of Mental Disorders (DSM-IV; American Psychiatric Association, 2000) criteria for the evaluation of sexual disorders. We also determined the age of onset of the disorders. We found that 21.5% of the overall clinical population was affected by PE, and 64.4% of PE patients were affected by at least one Axis I psychiatric disorder. PE was highly associated (p=0.015) with social phobia (SP), with an odds ratio of 2.55. The debut of SP preceded the onset of PE. Social phobia may represent risk factor for the development of PE, and adrenergic hyperactivity may represent a pathophysiology common to both disorders.

Disorders of orgasm and ejaculation in men

INTRODUCTION

Ejaculatory/orgasmic disorders, common male sexual dysfunctions, include premature ejaculation, inhibited ejaculation, anejaculation, retrograde ejaculation and anorgasmia.

AIM

To provide recommendations/guidelines concerning state-of-the-art knowledge for management of ejaculation/orgasmic disorders in men.

METHODS

An International Consultation in collaboration with the major urology and sexual medicine associations assembled over 200 multidisciplinary experts from 60 countries into 17 committees. Committee members established specific objectives and scopes for various male and female sexual medicine topics. The recommendations concerning state-of-the-art knowledge in the respective sexual medicine topic represent the opinion of experts from five continents developed in a process over a 2-year period. Concerning the Disorders of Ejaculation/Orgasm in Men Committee, there were nine experts from six countries.

MAIN OUTCOME MEASURE

Expert opinion was based on grading of evidence-based medical literature, widespread internal committee discussion, public presentation and debate.

RESULTS

Premature ejaculation management is dependent upon etiology. When secondary to ED, etiology-specific treatment is employed. When lifelong, initial pharmacotherapy (SSRI, topical anesthesia, PDE5 inhibitors) is appropriate. When associated with psychogenic/relationship factors, behavioral therapy is indicated. When acquired, pharmacotherapy and/or behavioral therapies are preferred. Retrograde ejaculation, diagnosed with spermatozoa and fructose in centrifuged post-ejaculatory voided urine, is managed by education, patient reassurance, pharmacotherapy or bladder neck reconstruction. Men with anejaculation or anorgasmia have a biologic failure of emission and/or psychogenic inhibited ejaculation. Men with age-related penile hypoanesthesia should be educated, reassured and be instructed in revised sexual techniques which maximize arousal.

CONCLUSIONS

More research is needed in understanding management of men with ejaculation/orgasmic dysfunction.

Late-stage clinical development in lower urogenital targets: sexual dysfunction

In recent years, late-stage clinical drug development that primarily focuses on urogenital targets has centered around four areas of medical need (both unmet need and aiming to improve on existing therapies). These include male sexual dysfunction (MSD), female sexual dysfunction (FSD), prostatic pathology (neoplastic, pre-neoplastic, and non-neoplastic), and improvement in lower urinary tract symptoms. Despite the regulatory approval of compounds to treat erectile dysfunction (ED), benign prostatic hyperplasia, a number of treatments for overactive bladder, and stress urinary incontinence, there remains a deficiency in addressing a number of conditions that arise out of pathophysiological dysfunction resulting in lower urogenital tract sexual conditions. In terms of late-stage clinical development, significant progress has most recently been made in MSD development, especially in understanding further a common and complex sexual dysfunction--that of premature ejaculation. The search also continues for compounds that improve ED in terms of better efficacy and superior safety profile compared to the currently marketed phosphodiesterase-5-inhibitors. Whilst there are no approved medications to treat the subtypes of FSD, there has been significant progress in attempting to better understand how to appropriately assess treatment benefit in clinical trial settings for this difficult to diagnose and treat condition. This review will focus on late-stage human clinical development pertaining to MSD and FSD.

Evidence for an involvement of peripheral serotonin in p-chloroamphetamine-induced ejaculation of rats

The purpose of the present study was to determine the mechanism of the ejaculatory response induced by the 5-HT-releasing compound p-chloroamphetamine (PCA) in rats. The ejaculatory response was assessed by weighing the coagulated seminal materials accumulated over 1 h. Intraperitoneal injection of PCA (0.5-5.0 mg/kg) produced a dose-related increase in both the incidence of ejaculation and the weight of the accumulated seminal materials. The ejaculatory response induced by PCA (5.0 mg/kg) was abolished by pretreatment with the 5-HT synthesis inhibitor p-chlorophenylalanine, the 5-HT receptor antagonists methysergide and MDL72222, or by the selective 5-HT reuptake inhibitor citalopram, suggesting that the 5-HT-releasing property of PCA mainly involved the expression of ejaculation. Neither the section of the spinal cord at thoracic (T8-9) level nor the lumbosacral spinal 5-HT denervation by intrathecal (i.t.) injection of 5,7-dihydroxytryptamine affected the ejaculatory response induced by PCA. The i.t. injection of PCA (20-160 microg/rat) at lumbosacral spinal level did not exert the systemic PCA-like prominent effect on ejaculation, whereas i.t. injection of lidocain at the same site completely abolished the response to systemic PCA. Additionally, the peripherally administered 5-HT (0.1 and 0.25 mg/kg, i.p.) enhanced the proejaculatory effect at a threshold dose (1.0 mg/kg, i.p.) of PCA. From these observations, it is concluded that the ejaculatory response induced by PCA is mainly a spinally mediated reflex response that is triggered by the release of 5-HT in the peripheral sites.

Dapoxetine, a novel treatment for premature ejaculation, does not have pharmacokinetic interactions with phosphodiesterase-5 inhibitors

Potential pharmacokinetic interactions between dapoxetine, a serotonin transporter inhibitor developed for the treatment of premature ejaculation (PE), and the phosphodiesterase-5 inhibitors tadalafil and sildenafil, agents used in the treatment of erectile dysfunction (ED), were investigated in an open-label, randomized, crossover study (n=24 men) comparing dapoxetine 60 mg, dapoxetine 60 mg+tadalafil 20 mg, and dapoxetine 60 mg+sildenafil 100 mg. Plasma concentrations of dapoxetine, tadalafil, and sildenafil were determined by liquid chromatography-tandem mass spectrometry. Tadalafil did not affect the pharmacokinetics of dapoxetine, whereas sildenafil increased the dapoxetine AUCinf by 22%; these effects were deemed not clinically important. Dapoxetine did not appear to affect the pharmacokinetics of tadalafil or sildenafil. Most adverse events were mild in nature. Thus, dapoxetine has no clinically important pharmacokinetic interactions with tadalafil or sildenafil, and the combinations are well tolerated.

Differential effects of simultaneous or sequential administration of paroxetine and WAY-100,635 on ejaculatory behavior

Clinical treatment of depression or anxiety with selective serotonin reuptake inhibitors (SSRIs) often results in delayed ejaculation or anorgasmia. Co-treatment with subtype-selective serotonin receptor antagonists may alter the timing of onset of action and potentiate or reduce sexual side effects. Sexual behavior in male Sprague-Dawley rats was examined after acute administration of the SSRI, paroxetine and the serotonin1A antagonist, WAY-100,635. Acute administration of paroxetine alone did not alter male ejaculatory behavior. However, administration of paroxetine plus WAY-100,635 resulted in a significant delay in mounting behavior and increased the time to ejaculation. Simultaneous administration of paroxetine and WAY-100,635 produced a greater delay in initiation of mounting behavior and ejaculation compared to sequential administration of paroxetine followed by WAY-100,635. The differential effect on sexual behavior or addition of specific serotonin receptor antagonists may be relevant for clinical treatment therapies of premature ejaculation.

The pharmacological management of depression

Depressive disorders are common, recurrent, and chronic, and require treatment A review of the symptom picture and current drug targets demonstrates the need for accument of depression severity, including suicidaliltial focus of treatment is rapid resolution of: during an acute phase, followed by continuation. Maintenance treatment is indicated if the risk of recurrence is high. The range of available medications is considerable and the benefit/risk ratio is acceptable. Depression is diagnosable across the life span and treatable at every age (although recent disagreement has arisen with regard to young patients). Comorbidity, both psychiatric and medical, need to be assessed, as does the possible presence of two subtypes of depression (psychotic and bipolar) often requiring different interventions. It is expected that the next generation of antidepressants would be associated with more specific disease and outcome biomarkers.

Safety and efficacy of citalopram in the treatment of premature ejaculation: a double-blind placebo-controlled, fixed dose, randomized study

We evaluate the efficacy and safety of citalopram, a potent and highly selective serotonin reuptake inhibitor (SSRI) antidepressant, in patients with premature ejaculation (PE). In total, 58 potent men with PE were included in the study. Patients were randomly assigned to receive 20 mg oral daily citalopram (group 1, n = 29) or placebo (group 2, n = 29), during a 12-week period for each agent. Pretreatment evaluation included history and physical examination, intravaginal ejaculatory latency time (IVELT) evaluation, International Index of Erectile Function (IIEF) and Meares-Stamey test. The efficacy of two treatments was assessed every 2 weeks during treatment, at the end of study and in 3- and 6-month follow-up after cessation of treatment, using responses to IIEF, IVELT evaluation, mean intercourse satisfaction domain, mean weekly coitus episodes and adverse drug effects. The trial was completed by 51 (88%) men. Analysis revealed a difference in the evolution of IVELT delay over time (P < 0.001). The IVELT after citalopram and placebo gradually increased from 32 and 28 s to approximately 268 and 38 s, respectively. The mean weekly intercourse episodes increased from pretreatment values of 1.3 and 1.2 to 2.4 and 1.4, for citalopram and placebo, respectively (P < 0.05). Baseline mean intercourse satisfaction domain values of IIEF 10 and 11 reached to 16 and 10 at 12-week treatment in groups 1 and 2, respectively (P < 0.05). Mean IVELT in group 1 was 210 and 198 s at 3- and 6-month follow-up, while in group 2 it was 27 and 25 s (P < 0.001), respectively. At 3- and six-month intercourse satisfaction domain values of IIEF were 15 and 14 in group 1 and 10 and 10 (P < 0.05) in group 2, respectively. Group 1 patients reported a significantly higher number of intercourse episodes per week (P < 0.05). Mean number of adverse events was 12 for citalopram and 4 for placebo (P < 0.05). In conclusion, these results indicate that citalopram has significantly better results in terms of IVELT and intercourse satisfaction versus placebo. Further studies with different dosages and treatment regimens are necessary to draw final conclusions on the efficacy of this drug in PE and to prolong the efficacy.

ORIGINAL RESEARCH—EJACULATION DISORDERS: A Multinational Population Survey of Intravaginal Ejaculation Latency Time

INTRODUCTION

Intravaginal ejaculation latency time (IELT), defined as the time between the start of vaginal intromission and the start of intravaginal ejaculation, is increasingly used in clinical trials to assess the amount of selective serotonin reuptake inhibitor-induced ejaculation delay in men with premature ejaculation. Prospectively, stopwatch assessment of IELTs has superior accuracy compared with retrospective questionnaire and spontaneous reported latency. However, the IELT distribution in the general male population has not been previously assessed.

AIM

To determine the stopwatch assessed-IELT distribution in large random male cohorts of different countries.

METHODS

A total of 500 couples were recruited from five countries: the Netherlands, United Kingdom, Spain, Turkey, and the United States. Enrolled men were aged 18 years or older, had a stable heterosexual relationship for at least 6 months, with regular sexual intercourse. The surveyed population were not included or excluded by their ejaculatory status and comorbidities. This survey was performed on a "normal" general population. Sexual events and stopwatch-timed IELTs during a 4-week period were recorded, as well as circumcision status and condom use.

MAIN OUTCOME MEASURES

The IELT, circumcision status, and condom use.

RESULTS

The distribution of the IELT in all the five countries was positively skewed, with a median IELT of 5.4 minutes (range, 0.55-44.1 minutes). The median IELT decreased significantly with age, from 6.5 minutes in the 18-30 years group, to 4.3 minutes in the group older than 51 years (P<0.0001). The median IELT varied between countries, with the median value for Turkey being the lowest, i.e., 3.7 minutes (0.9-30.4 minutes), which was significantly different from each of the other countries. Comparison of circumcised (N=98) and not-circumcised (N=261) men in countries excluding Turkey resulted in median IELT values of 6.7 minutes (0.7-44.1 minutes) in circumcised compared with 6.0 minutes (0.5-37.4 minutes) in not-circumcised men (not significant). The median IELT value was not affected by condom use.

CONCLUSION

The IELT distribution is positively skewed. The overall median value was 5.4 minutes but with differences between countries. For all five countries, median IELT values were independent of condom usage. In countries excluding Turkey, the median IELT values were independent of circumcision status.

Selective Serotonin-Reuptake Inhibitors in the Treatment of Premature Ejaculation

OBJECTIVE

To review the use of selective serotonin-reuptake inhibitors (SSRIs) in the treatment of premature ejaculation.

DATA SOURCES

Articles were retrieved through a MEDLINE search (1966–January 2004). Search terms used to identify articles included serotonin uptake inhibitors, premature ejaculation, rapid ejaculation, and sexual behavior, as well as the generic names of currently available SSRIs: fluoxetine, fluvoxamine, paroxetine, sertraline, citalopram, and escitalopram. The literature search was limited to articles published in the English language containing human subjects.

STUDY SELECTION AND DATA EXTRACTION

Articles obtained through the literature search were evaluated, and randomized controlled trials were included in this review. Information from noncontrolled trials or case reports was considered for inclusion if it contributed to the completeness of this review and if it was the highest level of evidence available.

DATA SYNTHESIS

Premature ejaculation is a commonly reported sexual difficulty. Delayed ejaculation is a widely reported sexual adverse effect of SSRIs. In some men exhibiting premature ejaculation, the ability of the SSRIs to delay ejaculation has been therapeutic. Trials evaluating the ejaculation-delaying ability of SSRIs demonstrated that paroxetine, fluoxetine, sertraline, and citalopram produce a statistically significant increase in the ejaculation latency time compared with placebo.

CONCLUSIONS

Taking advantage of the ejaculation-delaying effects of SSRIs increases the treatment options available to prescribers and patients. Convenience and minimal adverse effect profile make these agents an alternative to previously used behavior modalities and older pharmacologic agents. Although some questions still surround the details of their use, SSRIs have the potential to improve the quality of life for men with premature ejaculation and their partners.

Proposal for a Definition of Lifelong Premature Ejaculation Based on Epidemiological Stopwatch Data

INTRODUCTION

Consensus on a definition of premature ejaculation has not yet been reached because of debates based on subjective authority opinions and nonstandardized assessment methods to measure ejaculation time and ejaculation control.

AIM

To provide a definition for lifelong premature ejaculation that is based on epidemiological evidence including the neurobiological and psychological approach.

METHODS

We used the 0.5 and 2.5 percentiles as accepted standards of disease definition in a skewed distribution. We applied these percentiles in a stopwatch-determined intravaginal ejaculation latency time (IELT) distribution of 491 nonselected men from five different countries. The practical consequences of 0.5% and 2.5% cutoff points for disease definition were taken into consideration by reviewing current knowledge of feelings of control and satisfaction in relation to ejaculatory performance of the general male population.

MAIN OUTCOME MEASURES

Literature arguments to be used in a proposed consensus on a definition of premature ejaculation.

RESULTS

The stopwatch-determined IELT distribution is positively skewed. The 0.5 percentile equates to an IELT of 0.9 minute and the 2.5 percentile an IELT of 1.3 minutes. However, there are no available data in the literature on feelings of control or satisfaction in relation to ejaculatory latency time in the general male population. Random male cohort studies are needed to end all speculation on this subject. Exact stopwatch time assessment of IELT in a multinational study led us to propose that all men with an IELT of less than 1 minute (belonging to the 0.5 percentile) have "definite" premature ejaculation, while men with IELTs between 1 and 1.5 minutes (between 0.5 and 2.5 percentile) have "probable" premature ejaculation. Severity of premature ejaculation (nonsymptomatic, mild, moderate, severe) should be defined in terms of associated psychological problems.

CONCLUSION

We define lifelong premature ejaculation as a neurobiological dysfunction with an unacceptable increase of risk to develop sexual and psychological problems anywhere in a lifetime. By defining premature ejaculation from an authority-defined disorder into a dysfunction based on epidemiological evidence it is possible to establish consensus based on epidemiological evidence. Additional epidemiological stopwatch studies are needed for a final decision of IELT values at both percentile cutoff points.

Lifelong premature ejaculation: definition, serotonergic neurotransmission and drug treatment

The ejaculation distribution theory (EDT) postulates a biological continuum of the intravaginal ejaculation latency time (IELT) in men. Such an continuum has recently been found in two epidemiological stopwatch studies. In addition, a continuum of ejaculation latency time has also been demonstrated in laboratory rats. It is suggested that the invariable parts of ejaculation, i.e. premature and retarded ejaculation are highly influenced by genetic and neurobiological factors. In contrast, superimposed on biological roots, ejaculation of men, in the middle part of the continuum, is probably more easily influenced by environmental and psychological factors. A meta-analysis of 35 daily SSRI and clomipramine treatment studies demonstrated a similar efficacy for paroxetine, clomipramine, sertraline and fluoxetine, with paroxetine exerting the strongest effect on ejaculation. Based on fundamental insights into serotonergic neurotransmission, it is suggested that on-demand conventional SSRI treatment will not lead to similarly impressive ejaculation delay as that found after daily conventional SSRI treatment. Future studies with SSRIs with short half-lives, short T(max) and high C(max )should elucidate whether these pharmacokinetic properties are able to affect the pharmacodynamics of 5-HT neurons in such a way that immediate clinically relevant ejaculation delay occurs.

Diagnosis and Treatment of Premature Ejaculation: The Physician's Perspective

Premature ejaculation (PE) is a common condition associated with significant adverse effects on the sexual and overall quality of life of men with this condition. Behavioral therapies, such as the "squeeze" and "stop-start" techniques, and psychotherapy, have been the mainstay of PE management for many years. However, evidence of their short-term efficacy is limited while support for their long-term benefit is lacking. There are currently no medications licensed specifically for the treatment of PE. This paucity of pharmacological treatment may, in turn, contribute to the absence of systematic procedures for the identification, evaluation, and treatment of PE patients. Current "off-label" pharmacotherapeutic approaches include topical anesthetics, phosphodiesterase-5 inhibitors, and serotonin reuptake inhibitors. Of these, the serotonin reuptake inhibitors show the greatest efficacy and an increasing body of evidence is illuminating their mode of action. Nevertheless, all current "off-label" pharmacotherapeutic approaches fall short of the ideal therapy for PE. In the absence of a cure, such a treatment should be tolerable, inconspicuously used, effective from first dose, rapid in onset of action, and available as a prn-dosing regimen. It is anticipated that agents in development for the specific indication of PE will come closer to this ideal than existing pharmacotherapeutic approaches.

Neurochemical, pharmacokinetic, and behavioral effects of the novel selective serotonin reuptake inhibitor BMS-505130

BMS-505130 is a potent and selective serotonin transport inhibitor; K(i) for binding to the serotonin transporter = 0.18 nM (K(i) values for binding to the norepinephrine and dopamine transporters = 4.6 and 2.1 microM, respectively). In platelet serotonin uptake studies BMS-505130 (5 mg/kg, p.o.) produced a robust inhibition of serotonin uptake. In microdialysis studies oral dosing with BMS-505130 produced a dose-dependent increase in cortical serotonin levels that reached a maximal effect of 200% above baseline at a dose of 1 mg/kg, p.o.; the peak serotonin response was transient in nature. Following oral administration, peak plasma concentrations of BMS-505130 reached Tmax at 1.6 +/- 0.7 h and then declined to concentrations <10% of Cmax within the following 6 h; plasma half-life following i.v. dosing was 0.46 +/- 0.02 h. Parallel microdialysis and pharmacokinetic studies revealed that changes in serotonin levels in the cortex mirrored changes in the brain concentration of BMS-505130. In a behavioral assay known to be sensitive to selective serotonin reuptake inhibitors (SSRIs), mouse tail suspension, BMS-505130 produced a robust response after either oral or intraperitoneal dosing. BMS-505130 exhibits a pharmacological, neurochemical and behavioral profile consistent with a potent SSRI. Moreover, BMS-505130's short half-life may be advantageous for the treatment of premature ejaculation where an acute effect to delay ejaculation followed by a relatively rapid fall in SSRI plasma concentrations might be desirable.

Venlafaxine extended release for the treatment of patients with premature ejaculation: a pilot, single-blind, placebo-controlled, fixed-dose crossover study on short-term administration of an antidepressant drug

In this study, we aimed at evaluating the efficacy and safety of venlafaxine extended release 75 mg, a serotonin and noradrenaline reuptake inhibitor, in the treatment of patients with premature ejaculation. Thirty-one patients with intravaginal ejaculation latency of less than 2 min received venlafaxine XR (75 mg/day) or placebo during a 2-week period for each agent with a washout period of 1 week between agents. Efficacy was assessed for each agent with changes in ejaculation latency measured with a stopwatch and sexual satisfaction scores of patients and partners. Side-effects, pre- and post-treatment levels of biochemical and spermiogram parameters, follicle-stimulating hormone (FSH), luteinizing hormone (LH), prolactin and total testosterone were recorded for each agent. Statistical analysis was performed on 21 patients. After 2 weeks of treatment with placebo and venlafaxine, ejaculation latency time was significantly increased from 60.1 +/- 39.1 to 126.9 +/- 98.3 sec and to 178.1 +/- 122.8 sec, respectively (p < 0.0001 for each one). However, the difference between the two agents was insignificant (p = 0.144). Venlafaxine and placebo increased sexual satisfaction scores of both patients and partners similarly, no statistically significant difference was found between them in this respect. The incidence of side-effects with venlafaxine was indifferent than that of placebo (p > 0.1) except nausea (p = 0.035). Both agents did not change the blood and spermiogram parameters significantly, except FSH increases. Short-term use of venlafaxine XR 75 mg has only a placebo effect on ejaculation latency and sexual satisfaction scores, therefore, is not appropriate for the patients with premature ejaculation. Further dose-time studies are required to draw final conclusions on the inefficacy of this drug in premature ejaculation.

On-demand SSRI treatment of premature ejaculation: pharmacodynamic limitations for relevant ejaculation delay and consequent solutions

INTRODUCTION

Recently, the idea has emerged that on-demand use of serotonin reuptake inhibitors (SSRIs), particularly short half-life, should be equally effective in delaying ejaculation as daily SSRI treatment of premature ejaculation.

AIM

To provide evidence that SSRI-induced ejaculation delay is mainly dependent on pharmacodynamic properties of the drug and hardly on pharmacokinetic factors, and that combined SSRI administration with specific 5-hydroxytryptamine (5-HT) receptor antagonism leads acutely to stronger ejaculation delay than acute SSRI monoadministration.

METHODS

We performed a detailed analysis of serotonin neurotransmission and reviewed animal studies with 5-HT(1A) receptor antagonists. In addition, we critically reviewed existing on-demand SSRI treatments publications and the current debate on a definition of premature ejaculation.

MAIN OUTCOME MEASURES

Intravaginal ejaculation latency time (IELT).

RESULTS

Acute SSRI administration leads to only a mild or no increase of 5-HT neurotransmission and concomitant stimulation of postsynaptic 5-HT receptors. Existing on-demand SSRI treatment studies suffer from methodological insufficiencies, and the reported high-fold increases of ejaculation time contradict with neuropharmacological insights from serotonin metabolism. Animal studies show that SSRI coadministration with 5-HT(1A) receptor antagonists significantly increases the ejaculation time acutely compared to acute SSRI monoadministration.

CONCLUSION

On-demand SSRI treatment has less ejaculation-delaying effects than daily SSRI treatment. SSRIs with a short half-life are likely leading to much less ejaculation delay than current registered SSRIs. Combined use of SSRIs with 5-HT(1A) receptor antagonists increases the likelihood of clinically relevant ejaculation delay after on-demand treatment. On-demand SSRIs with short half-life that insufficiently delay ejaculation in men with IELTs less than 1 minute should be called ejaculation-delaying drugs rather than drugs against premature ejaculation.

On-Demand Treatment of Premature Ejaculation with Clomipramine and Paroxetine: A Randomized, Double-Blind Fixed-Dose Study with Stopwatch Assessment

OBJECTIVE

To investigate the degree of ejaculation delay induced by on-demand treatment with 20 mg paroxetine and 25 mg clomipramine and to assess the type and severity of non-sexual side-effects of treatment at the day of and the day after treatment with these drugs.

METHOD

A randomized, double-blind, fixed-dose, on-demand study in 30 men with lifelong premature ejaculation was performed. During a 1-month baseline period and a 4-week drug treatment period patients assessed the intravaginal ejaculation latency time (IELT) at home with a stopwatch. Only men with an IELT <1 min were randomly assigned to drug treatment. Patients assessed the drug coitus interval time (DCIT) and used the UKU side effect scale questionnaire at baseline, the day of and the day after intercourse.

RESULTS

On-demand treatment with 25 mg clomipramine, with a mean DCIT of 5.14 h, led to a 4.05 (95%CI: 3.26-5.02) fold-increase of the IELT. On-demand treatment with 20 mg paroxetine, with a mean DCIT of 5.39 h, led to a 1.41 (95%CI: 1.22-1.63) fold-increase of the IELT. Both drugs had a high incidence of non-sexual side effects at the coitus day and the next day. At the day of coitus paroxetine led to significant sleepiness and yawning compared to clomipramine. At the day after coitus clomipramine induced significant nausea compared to paroxetine.

CONCLUSION

On-demand treatment with 25 mg clomipramine led to a clinical relevant ejaculation delay. In contrast, 20 mg paroxetine had no clinical relevant ejaculation delay in men with lifelong premature ejaculation with an IELT of less than 1 minute. Both drugs exert mostly mild yet annoying non-sexual side effects both at the coitus day and the next day.

Fluvoxamine-controlled release formulation for the treatment of generalized social anxiety disorder

BACKGROUND

Generalized social anxiety disorder is a highly prevalent anxiety disorder with deleterious effects on social and family relationships, as well as work performance. We report the results of a multicenter, randomized, placebo-controlled trial comparing the efficacy, safety, and tolerability of fluvoxamine controlled release (CR) to placebo in patients with generalized social anxiety disorder.

METHODS

A total of 279 adult patients meeting all inclusion/exclusion criteria was recruited at 23 United States sites and randomly assigned to receive either fluvoxamine CR (100-300 mg/d) or placebo for 12 weeks. The dose could be increased, based on efficacy and tolerability, in increments of 50 mg/d at weekly intervals. The dosage remained constant during weeks 6 to 12.

RESULTS

Treatment with fluvoxamine CR resulted in statistically and clinically significant improvements in symptoms associated with generalized social anxiety disorder as early as week 4 on the Liebowitz Social Anxiety Scale and the Clinical Global Impression Scale Global Improvement, and at week 6 on the Sheehan Disability Scale, Clinical Global Impression Scale Severity of Illness and the Patient Global Impression of Improvement Scale. The most frequent adverse events reported by patients on fluvoxamine CR were headache, nausea, somnolence, and insomnia. No weight gain was observed for either treatment group, and at end point, there were no differences between treatments on overall sexual function, as measured by the Arizona Sexual Experience Scale.

CONCLUSIONS

Both physician and patient-rated scales indicate that fluvoxamine CR is effective and safe for the treatment of generalized social anxiety disorder.

In vivo rat model to measure hypogastric nerve stimulation-induced seminal vesicle and vasal pressure responses simultaneously

This study presents a modified in vivo model in which the intraluminal pressures of the seminal vesicle and vas deferens can be measured simultaneously. Male Sprague-Dawley rats were grouped based on agent administered: serotonin, clomipramine, fluoxetine, sertraline, paroxetine, prazosin, terazosin, and tamsulosin. The control responses to hypogastric nerve stimulation (HNS) were recorded in each animal, and HNS was repeated after each drug administration. Serotonergic agents resulted in concentration-dependent inhibition of the HNS-induced seminal vesicle pressure increases (clomipramine>serotonin>fluoxetine>sertraline approximately paroxetine). On the other hand, only serotonin and clomipramine significantly inhibited vasal pressure responses. alpha-Adrenergic blockers inhibited both intraluminal pressure responses in a concentration-dependent manner. This model illustrates the importance of the hypogastric nerve for the stimulation of the seminal tract, with attention focused on the seminal vesicle. This model may be useful for the evaluation of drugs for the treatment of premature ejaculation.

Relevance of methodological design for the interpretation of efficacy of drug treatment of premature ejaculation: a systematic review and meta-analysis

The aim of this systematic review and meta-analysis is to evaluate whether the design and methodology of drug-treatment studies of premature ejaculation affect the efficacy outcome differently. Therefore, methodological, design and efficacy data from 79 studies (3034 males), published between 1943 and 2003, are reviewed. A meta-analysis is performed on 43 selective serotonin reuptake inhibitors (SSRIs) and clomipramine studies (1514 males), published between 1973 and 2003; these studies were pooled to provide a summary variance-weighted effect size. The antidepressant-induced percentage increase of the intravaginal ejaculation latency time (IELT) was calculated and examined against various methodological items. A significant difference in efficacy between SSRIs was observed. Using daily treatment, paroxetine appeared more effective than the other SSRIs. Retrospective use of a questionnaire, subjective reports, single-blind and open study designs generate far greater variability of ejaculation time both at baseline and during active drug treatment than real time assessment by stopwatch. In conclusion, at daily treatment, the overall efficacy of paroxetine, clomipramine, sertraline and fluoxetine is comparable, but paroxetine exerts the strongest ejaculation delay. Only eight (18.5%) studies on antidepressant treatment fulfilled all criteria used in evidence-based medicine, for example, randomised, double-blind studies with prospective real time (stopwatch) assessment of the IELT at each intercourse. Single-blind studies, open designs, retrospective reporting, or the use of a questionnaire to assess ejaculation time should be avoided.

Predicting responsiveness to the treatment of rapid ejaculation with 25 mg clomipramine as needed

Clomipramine (25 mg) taken as needed increases ejaculatory latency in men with rapid ejaculation (RE), although only about half the men treated respond to this regimen. It would therefore be clinically advantageous to know the patient's potential responsiveness to an 'as needed' regimen prior to treatment. The present study attempted to identify a priori factors that might enable prediction of patients' response or nonresponse to 'as needed' clomipramine. Variables relevant to rapid ejaculation were examined in 23 men with RE, 12 of whom had responded to clomipramine. Logistic regression indicated that three factors assessed prior to treatment--initial ejaculation latency, overall sexual satisfaction, and ejaculation frequency each week--significantly improved the prediction of responsiveness to this treatment regimen. Specifically, RE men with initial ejaculatory latencies over 60 s, self-reported sexual satisfaction of 5 or higher (on a seven-point scale), and ejaculation frequency of twice or more weekly were more likely to benefit from 25 mg 'as needed' clomipramine. As such, men meeting these criteria might be considered for this treatment regimen. Those not matching these characteristics might better be considered for 20 or 30 mg clomipramine given on a daily basis.

Lifelong premature ejaculation: from authority-based to evidence-based medicine

Historically, four periods can be distinguished in the approach to and treatment of lifelong premature ejaculation. Although drug treatment has been an option for many decades, psychotherapy prevailed as the first choice of treatment. However, the application of the principles of evidence-based medicine shows that there is little evidence to support the psychological approach and behavioural treatment. In contrast, controlled trials with selective serotonin reuptake inhibitors, clomipramine and anaesthetic ointments have repeatedly shown the efficacy of both daily and 'as-needed' drug treatment to delay ejaculation. Currently, an evidence-based approach is gradually replacing the authority-based psychological attitude that characterized the view of premature ejaculation. Based on psychopharmacological studies there is evidence that premature ejaculation is related to a diminished serotonergic neurotransmission, and 5-HT2C or 5-HT1A receptor disturbances. Moreover, animal studies show the presence of a distinct ejaculation-related neural circuit in the central nervous system; its role in premature ejaculation remains to be elucidated.

Towards evidence-based drug treatment research on premature ejaculation: a critical evaluation of methodology

In the last decade, an increasing number of drug studies on premature ejaculation have been published. The methodology used in these studies differed widely. In this review, it is therefore questioned as to how far the differences in methodology could have influenced clinical outcomes. The aim of the present review was to compare the different methodologies that were used in drug studies on premature ejaculation. The majority of these studies were conducted between 1973 and 2003 and were strikingly different in study design and in the quantification of clinical outcomes. It appeared that in some of these studies, placebo and active drug effects were neglected due to an erroneous methodology. The few studies that were using stopwatch assessment at each intercourse at baseline and during treatment and in which the intravaginal ejaculation latency time (IELT) was included appeared to be comparable in their results. The use of a well-defined definition of premature ejaculation, for example, an IELT of less than 1 min revealed reproducible results. Finally, the retrospective use of a questionnaire or a subjective report on ejaculation time induced higher effects with regard to placebo effects and an underestimation of active drug effects. In conclusion, for drug treatment research of premature ejaculation it is recommended to use a randomized double-blind prospective design, the use of the IELT, the use of a stopwatch at each coitus both during a baseline period and during drug treatment and a definition of premature ejaculation as an ejaculation that occurs within 1 min after vaginal penetration.

Antidepressants and ejaculation: a double-blind, randomized, fixed-dose study with mirtazapine and paroxetine

A double-blind, fixed-dose study in healthy men with lifelong early ejaculation was performed to evaluate potential differences in their effects on ejaculation latency, between clinically relevant doses of the selective serotonin reuptake inhibitor paroxetine and the noradrenergic and specific serotonergic antidepressant mirtazapine. Twenty-four men with an intravaginal ejaculation latency time (IELT) less than 1 minute were randomly assigned to paroxetine (20 mg/d) or mirtazapine (30 mg/d) for a period of 6 weeks; half the dosage was given in the first week. During the preceding 1-month baseline and 6-week treatment period, intravaginal ejaculation latency times were measured at home using a stopwatch procedure. The trial was completed by 18 men. Analysis of variance revealed a between-group difference in the development of the delay in intravaginal ejaculation latency time over time (P < 0.001); the intravaginal ejaculation latency time after paroxetine and mirtazapine gradually increased from 15 to 119 s and from 23 to 28 s, respectively, after 6 weeks. Paroxetine 20 mg/d exerted a strong delay (maximum 5.7-fold increase), whereas mirtazapine 30 mg/d did not delay ejaculation (0.9-fold increase). These results confirm earlier findings that paroxetine, but not mirtazapine, significantly delays orgasm and ejaculation in men with early ejaculation, whereas mirtazapine is devoid of any effect on it.

Medications and sexual function

There seems to be a reluctance to self-report sexual dysfunction during clinical interviews. The rate of reported sexual dysfunction increases when information is sought aggressively in the clinical interview. The relationship to a specific therapeutic agent, however, can be clouded by the patient's perception and coexisting morbidity. Most of the data relating sexual dysfunction to specific drugs are anecdotal. The strongest proof of a casual effect is improvement in sexual function after withdrawal of the medication. Most of the adverse sexual effects of commonly used medications can be predicted from a simplified understanding of the human sexual response and physiologic mediators. Alternative therapeutic agents can be substituted by understanding these physiologic mechanisms and a careful clinical interview. Although polypharmacy is a problem for older persons, in some cases sildenafil can be used to correct drug-induced impotence.

Fluvoxamine versus fluoxetine in major depressive episode: a double-blind randomised comparison

A double-blind, multinational study was conducted to compare the efficacy and safety of fluvoxamine and fluoxetine in outpatients with major depressive episode; 184 patients were randomised to fluvoxamine (100 mg/day) or fluoxetine (20 mg/day) for 6 weeks. Both drugs were effective and there were no statistically significant differences between them in the area under the curve of change from baseline in the Hamilton depression rating scale (HAMD) total score. However, the percentage of HAMD responders (>or= 50% decrease in HAMD total score) at week 2, the clinical global improvement severity of illness score at week 2 and the depression subscale of the irritability, depression and anxiety scale at weeks 1, 2 and 4, all showed significant advantages for fluvoxamine. During the last 2 weeks, fluvoxamine was significantly more effective in improving the HAMD sleep disturbance scale. Both drugs were well tolerated and there were no marked differences in their side effect profiles which were typical of SSRIs. Fluvoxamine and fluoxetine have similar efficacy and safety profiles in the treatment of major depressive episode; the findings of this study indicate that fluvoxamine may have a faster onset of action with respect to resolution of depressive symptoms and result in a better improvement in sleep quality.

Citalopram treatment of paroxetine-intolerant depressed patients

We assessed the tolerability and antidepressant response to citalopram in a group of patients who could not tolerate a recent trial of paroxetine therapy. Sixty-one outpatients with major depressive disorder and a confirmed history of intolerance to paroxetine (mean final dose: 26.7 mg/day) were switched after at least a 1 week washout to citalopram therapy (20 mg/day). During the 6-week, open label treatment protocol, citalopram could be titrated up to a maximum dose of 40 mg/day. Response was evaluated using the Clinical Global Impressions CGI scale, the 24-item Hamilton Rating Scale for Depression, and several other measures of symptoms and quality of life. Fifty-three patients (87%) completed 6 weeks of citalopram therapy (mean intent-to-treat dose: 23.9 mg/day). The specific side effects that were reported to be intolerable during the earlier paroxetine trial typically recurred only less than 30% of the time during citalopram therapy; only 6 patients (10%) dropped out because of adverse events. The intent-to-treat CGI response rate was 56% at study endpoint; 62% of the completers responded. Significant improvement from pretreatment was observed on various symptom measures after two weeks of citalopram therapy. Citalopram therapy was well tolerated, and more than one half of the patients who began treatment improved significantly. Although further work is necessary to assess the relative merits of this within-class switching strategy (as compared to other options), these data provide further evidence that the various selective serotonin reuptake inhibitors do not have interchangeable tolerability profiles.

Efficacy of sildenafil as adjuvant therapy to selective serotonin reuptake inhibitor in alleviating premature ejaculation

OBJECTIVES

To evaluate the efficacy of sildenafil and selective serotonin reuptake inhibitor in alleviating premature ejaculation (PE) in patients in whom other treatments had failed.

METHODS

Healthy men evaluated for primary PE graded their ejaculation on a scale of 0 to 8 (0 = almost never, 8 = almost always). The intravaginal ejaculatory latency time (IVELT) was graded on a scale of 0 to 3 (0 = longer than 5 minutes, 3 = shorter than 1 minute). The 138 men who scored their PE as 4 or greater and IVELT as 2 or greater comprised the study group. Psychological and behavioral counseling was provided during the study. PE was graded using the same scales 3 months after the initiation of each treatment. Topical 5% lidocaine ointment comprised the initial treatment: dissatisfied patients (PE grade 4 or greater, IVELT 2 or greater), took one tablet of paroxetine 20 mg for 30 days and then one tablet 7 hours before intercourse. Sildenafil was added to the treatment of patients dissatisfied with paroxetine alone.

RESULTS

The mean initial PE grade was 5.67 +/- 0.13 and that for IVELT was 2.9 +/- 0.19 for all participants (mean age 28.7 years). Thirty-eight reported improvement (PE grade 2.0 +/- 0.8, P <0.01; IVELT 0.13 +/- 0.34, P <0.001) after local lidocaine application. Of the 100 treated with paroxetine, 42 reported improvement (PE grade 2.5 +/- 0.1, P <0.01; IVELT 0.28 +/- 0.46, P <0.001), and 56 of the remaining 58 who were treated with a combination of paroxetine and sildenafil reported improvement (PE grade 1.78 +/- 0.23, P <0.001; IVELT 0.16 +/- 0.37, P <0.001). Two patients remained dissatisfied with all treatment modalities.

CONCLUSIONS

Sildenafil combined with paroxetine and psychological and behavioral counseling alleviated PE in patients in whom other treatments failed.

The neurobiological approach to premature ejaculation

PURPOSE

Data showing the neurobiological background of rapid ejaculation was reviewed. In addition, new hypotheses to integrate clinical symptomatology, psychopharmacotherapy and psychotherapy of rapid ejaculation with brain function are provided.

MATERIALS AND METHODS

A computerized MEDLINE search, and manual bibliographic review of cross-references and neurobiological animal studies were performed. These reports were analyzed, summarized and compared with the studies performed by the author.

RESULTS

The literature on premature ejaculation published between 1887 and 2001 was reviewed. It appeared that the various psychological hypotheses and psychotherapies have not adequately been investigated. In contrast, psychopharmacological treatment studies, animal research data and stopwatch assessments in men with rapid (premature) ejaculation indicate that lifelong rapid ejaculation is a neurobiological phenomenon related to central serotonergic neurotransmission and likely influenced by hereditary factors.

CONCLUSIONS

Basic and clinical psychopharmacological studies suggest that premature ejaculation is a not a psychological disturbance but a neurobiological phenomenon.

Diagnosis and treatment of ejaculatory dysfunction

The normal ejaculatory process requires complex coordination and integration of neurologic, physiologic, anatomic, and psychologic events. An understanding of these processes is critical to evaluate properly and manage patients with ejaculatory dysfunction. With the advent of improved techniques to treat patients, some men with ejaculatory dysfunction are being offered the opportunity to reproduce. Further research on the ejaculatory process and associated dysfunctional states should continue to improve treatment for patients presenting with ejaculatory disorders.

Female sexual disorders: psychiatric aspects

OBJECTIVE

This manuscript reviews the current information concerning female sexual dysfunction that is relevant to general psychiatric practice.

METHOD

Research identified by the key words sexual dysfunction and prevalence, comorbidity, psychiatric drugs, or pharmacotherapy is reviewed.

RESULTS

Epidemiologic studies indicate that approximately 30% of female subjects between ages 18 and 59 years have sexual complaints of at least 3 months' duration in the past year. A high comorbidity with other psychiatric syndromes exists. Many psychiatric drugs are associated with sexual dysfunction. Drug treatments for female sexual dysfunction are being investigated.

CONCLUSION

Knowledge concerning the treatment of female sexual dysfunction is important to the general psychiatric clinician.