Current Pharmacological Management of Premature Ejaculation: A Systematic Review and Meta-analysis

The patient-perceived intravaginal ejaculation latency time cut-off for lifelong premature ejaculation

BACKGROUND

The current cutoff values of intravaginal ejaculation latency time for diagnosing lifelong premature ejaculation do not always match clinical practice, and the inconsistency in the cutoff values of intravaginal ejaculation latency time among different definitions has also posed challenges to both clinical management and research of premature ejaculation.

OBJECTIVES

To re-evaluate the intravaginal ejaculation latency time and to find evidence-based cut-off values for diagnosing lifelong premature ejaculation that can be widely accepted and match clinical practice.

MATERIALS AND METHODS

We addressed the flaws of previous studies. Lifelong premature ejaculation was diagnosed based on both patient self-report of premature ejaculation status and scores on the Premature Ejaculation Diagnostic Tool, with a control group consisting of non-premature ejaculation individuals included for comparison. Utilizing receiver operating characteristic curve analysis, the optimal self-estimated cutoff value for intravaginal ejaculation latency time in diagnosing lifelong premature ejaculation was determined.

RESULTS

A total of 307 heterosexual participants (mean age = 30.7 ± 6.4) were included, comprising 187 lifelong premature ejaculation patients (mean age = 28.0 ± 4.6) and 120 non-premature ejaculation individuals (mean age = 35.0 ± 6.5). 2.7% of lifelong premature ejaculation patients experienced anteportal ejaculation. 59.9%, 92%, and 97.9% of lifelong premature ejaculation patients displayed intravaginal ejaculation latency times within 1, 2, and 3 min, respectively. The receiver-operating characteristic curve's area under the curve was 0.996 with a 95% confidence interval of 0.991-1.000 (p < 0.0001). The perceived intravaginal ejaculation latency time cut-off at 3.5 (sensitivity = 97.9%, specificity = 99.2%) showed the highest Youden index compared with other options.

DISCUSSION

Although we found that 92.0% of lifelong premature ejaculation patients had a perceived intravaginal ejaculation latency time within 2 min, a perceived intravaginal ejaculation latency time cutoff value of less than 3.5 min for diagnosing lifelong premature ejaculation could encompass a larger proportion (97.9%) of patients seeking medical help for complaints of PE, and increasing the perceived intravaginal ejaculation latency time cutoff value to 3.5 min would not significantly increase the false-positive rate.

CONCLUSION

The perceived intravaginal ejaculation latency time cutoff value for diagnosing lifelong premature ejaculation within a clinical practice context is 3.5 min.

Dapoxetine, a Selective Serotonin Reuptake Inhibitor, Suppresses Zika Virus Infection In Vitro

Zika virus (ZIKV) belongs to the Flavivirus genus of the Flaviviridae family, and is a pathogen posing a significant threat to human health. Currently, there is a lack of internationally approved antiviral drugs for the treatment of ZIKV infection, and symptomatic management remains the primary clinical approach. Consequently, the exploration of safe and effective anti-ZIKV drugs has emerged as a paramount imperative in ZIKV control efforts. In this study, we performed a screening of a compound library consisting of 1789 FDA-approved drugs to identify potential agents with anti-ZIKV activity. We have identified dapoxetine, an orally administered selective serotonin reuptake inhibitor (SSRI) commonly employed for the clinical management of premature ejaculation (PE), as a potential inhibitor of ZIKV RNA-dependent RNA polymerase (RdRp). Consequently, we conducted surface plasmon resonance (SPR) analysis to validate the specific binding of dapoxetine to ZIKV RdRp, and further evaluated its inhibitory effect on ZIKV RdRp synthesis using the ZIKV Gluc reporter gene assay. Furthermore, we substantiated the efficacy of dapoxetine in suppressing intracellular replication of ZIKV, thereby demonstrating a concentration-dependent antiviral effect (EC50 values ranging from 4.20 μM to 12.6 μM) and negligible cytotoxicity (CC50 > 50 μM) across diverse cell lines. Moreover, cell fluorescence staining and Western blotting assays revealed that dapoxetine effectively reduced the expression of ZIKV proteins. Collectively, our findings suggest that dapoxetine exhibits anti-ZIKV effects by inhibiting ZIKV RdRp activity, positioning it as a potential candidate for clinical therapeutic intervention against ZIKV infection.

Regular penis-root masturbation: A promising behavioral treatment method for lifelong premature ejaculation

AIM

We aimed to determine the effectiveness of penis-root masturbation (PRM), a newly defined behavioral therapy (BT) technique, in patients with unsuccessful medical treatment due to premature ejaculation (PE).

MATERIAL AND METHODS

The study included 35 patients aged 25-43 years, who were diagnosed with lifelong PE. Patients and their partners were informed about the PRM technique and asked to practice PRM three times a week for three months, with or without sexual intercourse. The patients' Premature Ejaculation Diagnostic Tool (PEDT) scores and intravaginal ejaculatory latency time (IELT) were recorded and compared before PRM training (T0) and at the third (T3) month after the start of PRM training.

RESULTS

The mean±SD PEDT scores were 16.26±1.94 at T0, 10.63±1.14 at T3. When compared to T0, the PEDT values at T3 were significantly lower (P=0.021). In terms of IELT, the mean T3 values (192.43±56.71) were significantly longer (P=0.035) than at T0 (50.43±13.84seconds).

CONCLUSION

PRM BT shows promise for lifelong PE patients who do not benefit from or discontinue to pharmacotherapy. Larger prospective trials are required to confirm these findings.

Acupuncture for premature ejaculation: a systematic review and meta-analysis

Background

Although acupuncture is widely used to treat premature ejaculation (PE), its effectiveness remains highly controversial.

Aim

To evaluate the efficacy and safety of acupuncture on PE.

Methods

According to the relevant keywords, 11 major English and Chinese databases were searched for randomized controlled trials (RCTs) of acupuncture alone or in combination with other treatments for PE. The quality of evidence across studies was assessed by the GRADEpro tool.

Outcomes

Study outcome measures included the intravaginal ejaculation latency time (IELT), the Premature Ejaculation Diagnostic Tool (PEDT), the Chinese Index of Premature Ejaculation-5 (CIPE-5), treatment success rate, and adverse events.

Results

Seven trials were included in this review for a total of 603 participants. A low quality of evidence suggests that it is not possible to determine whether acupuncture, as compared with a selective serotonin reuptake inhibitor, has an advantage in improving the IELT (standardized mean difference [SMD], -1.75; 95% CI, -6.12 to 2.63; P = .43, I2 = 98%), PEDT scores (SMD, 0.32; 95% CI, -0.68 to 1.32; P = .53, I2 = 85%), and treatment success rate (risk ratio, 0.69; 95% CI, 0.41-1.14; P = .15). However, participants receiving acupuncture had a lower CIPE-5 (SMD, -1.06; 95% CI, -1.68 to -0.44; P < .01). As compared with sham acupuncture, acupuncture significantly improved the IELT (SMD, 1.47; 95% CI, 1.01-1.92; P < .01, I2 = 0%) and PEDT scores (SMD, -1.23; 95% CI, -1.78 to -0.67; P < .01, I2 = 37%). When compared with other treatments alone, a combined treatment with acupuncture can significantly improve the IELT (SMD, 7.06; 95% CI, 2.53-11.59; P < .01, I2 = 97%), CIPE-5 (SMD, 0.84; 95% CI, 0.45-1.22; P < .01, I2 = 0%), and treatment success rate (SMD, 1.60; 95% CI, 1.18-2.16; P < .01, I2 = 53).

Clinical Implications

The results suggest a significant effect of acupuncture in the treatment of certain important indicators of PE; however, this finding needs to be treated with caution because of the quality of the RCTs included.

Strengths and Limitations

Comprehensive inclusion of available RCTs has been performed. However, limitations include a low number of studies and a lack of detailed information to allow subgroup analysis.

Conclusion

The present systematic review and meta-analysis show that acupuncture has a significant effect on several subjective PE parameters, such as improving the feeling of control over ejaculation and distress, particularly when used in an integrated way. However, due to the low quality of evidence, acupuncture still needs larger well-designed RCTs to be confirmed.

Possible Pathophysiological Roles of Neurotransmitter Systems in Men With Lifelong Premature Ejaculation: Protocol for a Scoping Review

BACKGROUND

Lifelong premature ejaculation (LPE) is a rare sexual condition believed to be caused by genetic neurobiological disorders. In the field of LPE, 2 main types of research have been conducted: direct genetic research and pharmacotherapeutic interference of neurotransmitter systems that can relieve the symptoms of LPE in male patients.

OBJECTIVE

We aim to provide an overview of studies on neurotransmitter systems as the pathophysiological cause of LPE by investigating direct genetic research or pharmacotherapeutic interference that relieves the main symptom of LPE in male patients.

METHODS

This scoping review will use the PRISMA-ScR tool (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews). In addition, this study will use a peer-reviewed search strategy. Systematic searches will be conducted using 5 scientific databases (Cochrane Database of Systematic Reviews, PubMed or MEDLINE, Cumulative Index to Nursing and Allied Health Literature [CINAHL], EMBASE, and Epistemonikos). Additionally, pragmatic searches for relevant information in gray literature databases will be performed. Two reviewers will independently include relevant studies in a 2-stage selection strategy. Finally, data will be extracted from the studies and charted to summarize relevant study characteristics and key findings.

RESULTS

As of July 2022, we completed the preliminary searches according to the PRESS 2015 guidelines and started to determine the final search terms that we will use in all selected 5 scientific databases.

CONCLUSIONS

This scoping review protocol is the first to focus on neurotransmitter pathways in LPE by combining the results from the genetic and pharmacotherapy studies. The results could help identify potential research gaps or target candidate proteins and neurotransmitter pathways in LPE for further genetic research.

TRIAL REGISTRATION

Open Science Framework 10.17605/OSF.IO/JUQSD; https://osf.io/juqsd.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/41301.

Phosphodiesterase type 5 inhibitors and premature ejaculation: an overview of systematic reviews/meta-analyses using the AMSTAR 2, ROBIS, and GRADE tools

Introduction

The place of phosphodiesterase type 5 inhibitors (PDE5-Is) in treating premature ejaculation (PE) remains a therapeutic challenge.

Objectives

(1) To summarize the evidence of the efficacy and safety of PDE5-Is from published systematic reviews/meta-analyses (SRs/MAs). (2) To evaluate the reporting, methodological quality, and evidence quality of SRs/MAs concerning PE.

Methods

Nine databases were searched to retrieve SRs/MAs on using PDE5-Is for PE from inception to July 2022. Methodological quality and risk of bias were assessed with the AMSTAR 2 (A Measurement Tool to Assess Systematic Reviews) and ROBIS (Risk of Bias in Systematic Reviews). GRADE criteria (Grading of Recommendations, Assessment, Development, and Evaluations) were used to assess the evidence quality.

Results

The literature search revealed 15 relevant SRs/MAs covering 28 primary studies (9 pairwise MAs and 6 network MAs) rated as low or very low quality and high risk of bias except 1 review that was rated as moderate quality and low risk of bias. Among the 27 outcome measures related to efficacy and safety, the quality of evidence according to GRADE criteria was low in 4 and critically low in 23. Oral PDE5-Is have demonstrated a possible benefit over placebo in lifelong PE and mixed PE. The results of pairwise and network MAs advocated that the combined use of PDE5-Is and SSRIs is of possible benefit as compared with either SSRIs or PDE5-Is alone. The total adverse effects were more frequent with PDE5-Is than placebo.

Conclusion

PDE5-Is are of a possible benefit than placebo in lifelong PE and mixed PE. The results favor coadministration of PDE5-Is plus SSRIs over SSRIs alone or PDE5-I monotherapy. These conclusions should be interpreted cautiously due to the low methodological quality and low quality of evidence of most available reviews. Additional higher-quality randomized controlled trials, SRs, and MAs are warranted to provide a better estimate of any effect size.

Reasons and treatment strategy for discontinuation of dapoxetine treatment in premature ejaculation patients in China: A retrospective observational study

To assess dapoxetine discontinuation rates and the reasons for discontinuation in Chinese men with premature ejaculation (PE). Information on 906 PE outpatients was obtained from the hospital information system (HIS) in 2019. Of these, 150 patients were chosen. We analysed the dapoxetine discontinuation rate and the reasons for discontinuation over a 12-week follow-up period. The mean age of all patients was 33.6 years (range = 18-55), the mean PE duration was 12.36 ± 9.45 months. The 5-item International Index of Erectile Function (IIEF-5) score was 21.51 ± 3.80. A total of 37.3% of all the patients remained on the treatment until the 12th week. The cumulative discontinuation rates at the 4th, 8th and 12th weeks were 12%, 41.3% and 62.7%, respectively. The discontinuation rates for all the patients in weeks 0-4, weeks 4-8 and weeks 8-12 were 19.1%, 46.8% and 34.0%, respectively. After 4 weeks, the discontinuation rates dropped sharply. The reasons for patients' discontinuation were as follows: overexpectation of efficacy (30.9%), relapsing after drug withdrawal (26.6%), high cost (25.5%), side effects (9.6%), fear of drug addiction (4.3%), failure of follow-up (2.1%) and choosing other treatments (1.1%). The dapoxetine treatment discontinuation rate was very high. The main reasons for discontinuation were overexpectation of efficacy and high cost.

An up-to-date overview of the pharmacotherapeutic options for premature ejaculation

INTRODUCTION

Premature ejaculation (PE) is a sexual dysfunction of unknown etiology affecting a substantial number of males and deteriorating sexual health and quality of life of the patient and his partner. Treatment still remains challenging; however, pharmacotherapy is considered the mainstay of therapy with behavioral and psychosexual interventions being particularly important as adjudicate procedures, within the context of a holistic approach.

AREAS COVERED

The authors review the literature on the available medications for PE, both officially registered and non-registered. Currently, only dapoxetine and an anesthetic spray containing lidocaine and prilocaine (Fortacin™) are officially approved, with the rest being used off-label. Herein, updated data regarding the efficacy and safety of the pharmaceutical agents are presented.

EXPERT OPINION

On-demand dapoxetine is reportedly efficacious and safe in treating lifelong PE and is the first medication to be approved for this purpose. Fortacin has also shown considerable efficacy and may be reliably used on-demand. Phosphodiesterase type 5 inhibitors (PDE5Is) have been found to be effective in the treatment of PE and are therefore recommended either as monotherapy or combined with other therapies (i.e. dapoxetine). Adverse events of any therapy should be taken under consideration. Physicians should encourage patients to discuss their needs and expectations and grade any improvement of their condition with treatment.

Short- and long-term follow-up results of daily 5-mg tadalafil as a treatment for erectile dysfunction and premature ejaculation

Objective

To evaluate the safety and effectiveness of daily 5-mg tadalafil treatment for men who have erectile dysfunction (ED) and premature ejaculation (PE), and to assess the long-term follow-up for ED and PE improvement persistence years after the cessation of medication.

Patients and Methods

A prospective, single-blind, randomised study included 160 patients with ED and PE. All were evaluated using the International Index of Erectile Function (IIEF-5) questionnaire to evaluate ED and intravaginal ejaculatory latency time (IELT) for PE. Patients were subdivided into two equal groups. Group I (80 patients) treated with daily 5-mg tadalafil for 3 months, and Group II (80 patients) treated with a placebo for the same period. After 3 months of treatment and 2 years later after cessation of tadalafil, all patients were assessed for ED and PE.

Results

The mean (SD) IELT and IIEF-5 score pre-treatment were 37 (11.24) s and 13.2 (4.2) for Group I, while in Group II they were 35.98 (10.8) s and 13.12 (4.11), respectively. After 3 months of treatment, the mean (SD) IELT in Group I showed a highly significant improvement from 37 (11.24) s to 120.5 (47.37) s (P < 0.001) but Group II showed no significant improvement from baseline to [39.43 (13.6) s; P > 0.05]. For the IIEF-5 score, there was a highly significant improvement from baseline to 20.45 (4.5) in Group I (P < 0.001), while there was no significant difference in Group II from baseline to [15 (4.84); P > 0.05]. At 2 years after cessation of tadalafil, there was statistically significant improvement in the IELT and IIEF-5 from baseline to endpoint .

Conclusion

Oral daily 5-mg tadalafil was effective, tolerable, and safe treatment for patients with ED and PE. Long-term follow-up at 2 years confirmed the persistence of a significant improvement for both ED and PE.

Abbreviations: ED: erectile dysfunction; IIEF-5: five-item version of the International Index of Erectile Function questionnaire; IELT: intravaginal ejaculatory latency time; OAD: once-daily; PDE5i: phosphodiesterase-5 inhibitors; PE: premature ejaculation; PRN: pro re nata

Selective Serotonin Re-Uptake Inhibitors for Premature Ejaculation in Adult Men: A Cochrane Systematic Review

PURPOSE

Selective serotonin re-uptake inhibitors (SSRIs) are frequently used to treat premature ejaculation (PE) in men. We performed a Cochrane review to assess the efficacy of SSRI treatment for PE.

MATERIALS AND METHODS

We extensively searched a range of databases up to May 2020 and only included randomized controlled trials.

RESULTS

A total of 31 studies with 8,254 men were included in this analysis. We found that SSRI treatment probably improves self-perceived PE symptoms (defined as a rating of 'better' or 'much better'; risk ratio [RR], 1.92; 95% confidence interval [CI], 1.66-2.23; moderate-certainty evidence) and satisfaction with intercourse (defined as a rating of 'good' or 'very good'; RR, 1.63; 95% CI, 1.42-1.87; moderate-certainty evidence) compared to placebo. Furthermore, SSRI treatment likely improve participants' self-perceived control over ejaculation (defined as rating of 'good' or 'very good'; RR, 2.29; 95% CI, 1.72-3.05; moderate-certainty evidence) and probably lessens distress (defined as rating of 'a little bit' or 'not at all') about PE (RR, 1.54; 95% CI, 1.26-1.88; moderate-certainty evidence). SSRI treatment may increase IELT compared to placebo (mean difference, 3.09 minutes higher; 95% CI, 1.94 higher to 4.25 higher; low-certainty evidence). However, SSRIs may increase treatment cessations due to adverse events compared to placebo (RR, 3.80; 95% CI, 2.61-5.51; low-certainty evidence).

CONCLUSIONS

SSRI treatment for PE appears to substantially improve a number of outcomes of direct patient importance such as symptom improvement, satisfaction with intercourse and perceived control over ejaculation when compared to placebo.

Safety and efficacy of "on-demand" tramadol in patients with premature ejaculation: an updated meta-analysis

INTRODUCTION

Tramadol has been used for the treatment of premature ejaculation, however, the studies published for the same are not well designed. The primary objective of this study was to explore the literature pertaining to the use of tramadol in patients with PE to determine its safety and efficacy in this population. Materials ande methods: Systematic literature search of various electronic databases was conducted to include all the randomized studies and quasi-randomized studies. Standard PRISMA (Preferred reporting Items for Systematic reviews and Meta-analysis) guidelines were pursued for this review and study protocol was registered with PROSPERO (CRD42019123381).

RESULTS

Out of 9 studies included in this review, 5 were randomized controlled trials, and rests of the 4 studies were quasi-randomized studies. Tramadol resulted in significantly higher improvement of IELT with the mean difference (MD) of 139.6 seconds and confidence interval (CI) 106.5-172.6 seconds with a p-value of p < 0.00001. All dosages except 25mg fared well as compared to placebo. Tramadol fared better than placebo at 1 month, 2 months, and 3 months after initiation of therapy as compared to the placebo. Tramadol group had reported a significantly higher number of adverse events with treatment as compared to placebo but none of them were serious.

CONCLUSION

Tramadol appears to be an effective drug for the management of PE with a low propensity for serious adverse events. However, evidence obtained from this study is of low to moderate quality. Furthermore, effective dose and duration of therapy remain elusive.

Clinical use of hyaluronic acid in andrology: A review

Background

Hyaluronic acid is a glycosaminoglycan widely used in the fields of orthopedics, ophthalmology, and aesthetic medicine due to its significant ability to reduce the synthesis of pro‐inflammatory proteins and its activity against oxidative stress, a feature of many degenerative illnesses.

Objectives

The objective of the present review is to provide a comprehensive narrative review of the most recent literature on the use of hyaluronic acid in andrology in order to facilitate the use of this therapeutic device in the common clinical practice of many physicians. Specific conditions covered in the review are Peyronie's disease, premature ejaculation, and penile enlargement.

Materials and methods

A broad and comprehensive literature search included Medline, EMBASE, and the Cochrane Libraries, with no time restriction up to December 2020 and restricted to English language publications. Unpublished studies were not included. The study was registered as “The role of hyaluronic acid in andrology: A systematic review and meta‐analysis” in PROSPERO with the ID CRD42021223416.

Discussion and conclusion

Hyaluronic acid is a valid choice for the treatment of Peyronie's disease in terms of the resolution of the acute phase of the disease and of contributing to stabilizing the disease as a bridge to potential surgery. Data, furthermore, suggest that hyaluronic acid is frequently associated with an overall clinical improvement, allowing the patient to resume normal sexual activity.

With regard to premature ejaculation, data suggests hyaluronic acid‐based treatments were effective in prolonging intra‐vaginal ejaculation time. Furthermore, hyaluronic acid was found to be safe and well‐tolerated, with main adverse events limited to local discomfort, ecchymosis, papule formation, and glans numbness, all of which were reported to resolve spontaneously.

Last, with regard to penile enlargement, the overall perception of experts is that hyaluronic acid may be an extremely well‐tolerated compound with potential for application in specific areas of male sexual health that are often neglected as compared to more common, and relatively simpler to treat, conditions.

European Association of Urology Guidelines on Sexual and Reproductive Health-2021 Update: Male Sexual Dysfunction

CONTEXT

The present summary of the European Association of Urology (EAU) guidelines is based on the latest guidelines on male sexual health published in March 2021, with a last comprehensive update in January 2021.

OBJECTIVE

To present a summary of the 2021 version of the EAU guidelines on sexual and reproductive health.

EVIDENCE ACQUISITION

A literature review was performed up to January 2021. The guidelines were updated, and a strength rating for each recommendation was included based on either a systematic review of the evidence or a consensus opinion from the expert panel.

EVIDENCE SYNTHESIS

Late-onset hypogonadism is a clinical condition in the ageing male combining low levels of circulating testosterone and specific symptoms associated with impaired hormone production and/or action. A comprehensive diagnostic and therapeutic work-up, along with screening recommendations and contraindications, is provided. Erectile dysfunction (ED) is the persistent inability to attain and maintain an erection sufficient to permit satisfactory sexual performance. Along with a detailed basic and advanced diagnostic approach, a novel decision-making algorithm for treating ED in order to better tailor therapy to individual patients is provided. The EAU guidelines have adopted the definition of premature ejaculation (PE), which has been developed by the International Society for Sexual Medicine. After the subtype of PE has been defined, patient's expectations should be discussed thoroughly and pharmacotherapy must be considered as the first-line treatment for patients with lifelong PE, whereas treating the underlying cause must be the initial goal for patients with acquired PE. Haemospermia is defined as the appearance of blood in the ejaculate. Several reasons of haemospermia have been acknowledged; the primary goal over the management work-up is to exclude malignant conditions and treat any other underlying cause.

CONCLUSIONS

The 2021 guidelines on sexual and reproductive health summarise the most recent findings, and advise in terms of diagnosis and treatment of male hypogonadism and sexual dysfunction for their use in clinical practice. These guidelines reflect the multidisciplinary nature of their management.

PATIENT SUMMARY

Updated European Association of Urology guidelines on sexual and reproductive health are presented, addressing the diagnosis and treatment of the most prevalent conditions in men. Patients must be fully informed of all relevant diagnostic and therapeutic options and, together with their treating physicians, decide on optimal personalised management strategies.

Real-life use of the eutectic mixture lidocaine/prilocaine spray in men with premature ejaculation

Topical anaesthetics are considered a first-line therapy option in men with premature ejaculation (PE). A cross-sectional retrospective analysis was performed to evaluate the real-life use of the eutectic mixture of prilocaine/lidocaine spray (FORTACIN™) in a cohort of 198 white-European men who had been consecutively and prospectively seen at a single tertiary-referral andrology centre for self-reported PE and naive for previous PE treatments. Descriptive statistics was used to describe the whole cohort and the paired t-test was applied to investigate potential differences throughout a 12-month follow-up (baseline, 1, 3, 6 and 12 months). Overall, mean (SD) age was 37 (6.5) years. Of all, lifelong, acquired and subjective PE were reported in 101 (51%), 59 (29.8%) and 38 (19.2%) patients at baseline, respectively. FORTACIN™ use increased up to 6 months, with 184 (92.9%) and 128 (66.4%) men who had tried and regularly used the compound, respectively. At 12-month follow-up, 53 (26.8%) men reported a regular use of the compound. Mean Premature Ejaculation Diagnostic Tool score significantly decreased at 6 and 12 months compared to baseline (all p < 0.05). Conversely, mean IELT significantly improved at 6-month follow-up compared to baseline (all p ≤ 0.04). Overall, FORTACIN™ emerged to be a safe and effective treatment option in PE patients of various types, with almost one fourth of patients still under treatment after 12 months. Timing and dosing of the drug can deserve to be adjusted according to patient's needs and their sexual ecology.

Feasibility, safety, and efficacy of ultrasound-guided transperineal laser ablation for the treatment of benign prostatic hyperplasia: a single institutional experience

PURPOSE

To evaluate the feasibility, safety, and efficacy of ultrasound-guided transperineal laser ablation (TPLA) as a new minimally invasive surgical therapy (MIST) for the treatment of lower urinary tract symptoms (LUTS) secondary to benign prostatic hyperplasia (BPH).

MATERIALS AND METHODS

Under local anesthesia and conscious sedation up to two laser fibers for each prostatic lobe were inserted under US-guidance by a percutaneous approach. TPLA was performed using a continuous wave diode laser (SoracteLite-EchoLaserX4) able to generate a light-induced thermal heating and subsequent coagulative necrosis of the prostatic tissue. Patients were evaluated at 3, 6, and 12 months after TPLA.

RESULTS

Twenty-two consecutive patients were prospectively enrolled (median age 61.9 years). All procedures were well tolerated and no procedural complications were recorded. Median catheterization time was 7 days, while the median hospitalization time was 1 day. Three out of twenty-two patients (13.6%) experienced acute urinary retention and two (9.1%) of them urinary tract infection requiring major antibiotic treatment. At 3, 6, and 12 months, median prostate volume significantly decreased by a - 21.3%, - 29%, and - 41%, respectively. At the same time point, median IPSS was 8 (- 63.6%), 5 (- 74%), and 6 (- 75%), while median QoL score was 1 in all the scheduled timepoints of follow-up. The median postoperative Qmax at 3, 6, and 12 months improved by + 57.8%, + 98%, and + 115.8%, respectively. Ejaculatory function was preserved in 21 out of 22 patients (95.5%).

CONCLUSIONS

TPLA of the prostate appears to be a promising MIST for BPH. Long-term results and comparative studies against standard treatments are warranted before implementations of this technique in the urologist's armamentarium.

Selective serotonin re-uptake inhibitors for premature ejaculation in adult men

BACKGROUND

Premature ejaculation (PE) is a common problem among men that occurs when ejaculation happens sooner than a man or his partner would like during sex; it may cause unhappiness and relationship problems. Selective serotonin re-uptake inhibitors (SSRIs), which are most commonly used as antidepressants are being used to treat this condition.

OBJECTIVES

To assess the effects of SSRIs in the treatment of PE in adult men.

SEARCH METHODS

We performed a comprehensive search using multiple databases (the Cochrane Library, MEDLINE, Embase, Scopus, CINAHL), clinical trial registries, conference proceedings, and other sources of grey literature, up to 1 May 2020. We applied no restrictions on publication language or status.

SELECTION CRITERIA

We included only randomized controlled clinical trials (parallel group and cross-over trials) in which men with PE  were administered SSRIs or placebo. We also considered 'no treatment' to be an eligible comparator but did not find any relevant studies.

DATA COLLECTION AND ANALYSIS

Two review authors independently classified and abstracted data from the included studies. Primary outcomes were participant-perceived change with treatment, satisfaction with intercourse and study withdrawal due to adverse events. Secondary outcomes included self-perceived control over ejaculation, participant distress about PE, adverse events and intravaginal ejaculatory latency time (IELT). We performed statistical analyses using a random-effects model. We rated the certainty of evidence according to GRADE.

MAIN RESULTS

We identified 31 studies in which 8254 participants were randomized to receiving either SSRIs or placebo. Primary outcomes: SSRI treatment probably improves self-perceived PE symptoms (defined as a rating of 'better' or 'much better') compared to placebo (risk ratio (RR) 1.92, 95% confidence interval (CI) 1.66 to 2.23; moderate-certainty evidence). Based on 220 participants per 1000 reporting improvement with placebo, this corresponds to 202 more men per 1000 (95% CI 145 more to 270 more) with improved symptoms with SSRIs.  SSRI treatment probably improves satisfaction with intercourse compared to placebo (defined as a rating of 'good' or 'very good'; RR 1.63, 95% CI 1.42 to 1.87; moderate-certainty evidence). Based on 278 participants per 1000 reporting improved satisfaction with placebo, this corresponds to 175 more (117 more to 242 more) per 1000 men with greater satisfaction with intercourse with SSRIs. SSRI treatment may increase treatment cessations due to adverse events compared to placebo (RR 3.80, 95% CI 2.61 to 5.51; low-certainty evidence). Based 11 study withdrawals per 1000 participants with placebo, this corresponds to 30 more men per 1000 (95% CI 17 more to 49 more) ceasing treatment due to adverse events with SSRIs.  Secondary outcomes: SSRI treatment likely improve participants' self-perceived control over ejaculation (defined as rating of 'good' or 'very good') compared to placebo (RR 2.29, 95% CI 1.72 to 3.05; moderate-certainty evidence). Assuming 132 per 1000 participants perceived at least good control, this corresponds to 170 more (95 more to 270 more) reporting at least good control with SSRIs.  SSRI probably lessens distress (defined as rating of 'a little bit' or 'not at all') about PE (RR 1.54, 95% CI 1.26 to 1.88; moderate-certainty evidence). Based on 353 per 1000 participants reporting low levels of distress, this corresponds to 191 more men (92 more to 311 more) per 1000 reporting low levels of distress with SSRIs.  SSRI treatment probably increases adverse events compared to placebo (RR 1.71, 95% CI 1.48 to 1.99; moderate-certainty evidence). Based on 243 adverse events per 1000 among men receiving placebo, this corresponds to 173 more (117 more to 241 more) men having an adverse event with SSRIs.  SSRI treatment may increase IELT compared to placebo (mean difference (MD) 3.09 minutes longer, 95% CI 1.94 longer to 4.25 longer; low-certainty evidence).

AUTHORS' CONCLUSIONS

SSRI treatment for PE appears to substantially improve a number of outcomes of direct patient importance such as symptom improvement, satisfaction with intercourse and perceived control over ejaculation when compared to placebo. Undesirable effects are a small increase in treatment withdrawals due to adverse events as well as substantially increased adverse event rates. Issues affecting the certainty of evidence of outcomes were study limitations and imprecision.

Topical Treatment of Premature Ejaculation: The Rise of Anesthetic Spray Formulations?

Topical anesthetics are one of the first line therapeutical options for men with premature ejaculation (PE). Real-life PE management often involves a range of interventions including systemic drug treatments (such as off-label and on-label selective serotonin reuptake inhibitors (SSRIs), tricyclic antidepressants, phosphodiesterase-5 inhibitors (PDE5Is)), topical anesthetic creams and sprays, and behavioral approaches. Among them, on-demand dapoxetine and lidocaine/prilocaine spray formulations are the only approved treatment options for lifelong PE. The earliest strategy to treat PE was based on the use of topical anesthetic agents. The rationale behind the use of anesthetics is that by reducing the glans penis sensitivity, the spinal and cerebral input of sexual arousal impulses may also be reduced. Oral SSRI proved to be effective to treat PE, but their high rate of side effects limit treatment adherence and both short and long term follow up data are lacking. Conversely, topical anesthetics have proved to increase ejaculatory latency, control, and sexual satisfaction in couple affected by PE with limited rates of adverse events. In this context, we aimed to perform a narrative review to summarize the most recent findings regarding the use of topical treatments for PE.

Comparison of the safety and efficacy of the on-demand use of sertraline, dapoxetine, and daily use of sertraline in the treatment of patients with lifelong premature ejaculation: A prospective randomised study

This study compared the safety and efficacy of the on-demand (OD) use of sertraline (50 mg), sertraline (100 mg) and dapoxetine (30 mg), and the daily use of sertraline (50 mg) in the treatment of patients with premature ejaculation (PE). This prospective randomised study involved 120 lifelong PE patients (intravaginal ejaculatory latency time [IELT]: <1 min; Arabic Index of Premature Ejaculation [AIPE] score: < 30) without secondary causes of PE, identified between March 2018 and May 2020. Patients were divided into 4 groups (30 patients per group) and treated for 8 weeks. Assessments were conducted using the AIPE form as a diagnostic tool. Sertraline (50 mg, daily; 196.7 ± 115.5 s) and sertraline (100 mg, OD; 173.3 ± 97.0 s) had similar IELT and AIPE scores. The latter groups had better results in comparison with sertraline (50 mg, OD; 100.5 ± 54.4 s) and dapoxetine (93.7 ± 53.5 s; p < 0.01). Sertraline (100 mg, OD) had a similar efficacy to that of sertraline (50 mg, daily) and was more effective than sertraline (50 mg, OD) and dapoxetine (30 mg, OD). Sertraline (100 mg, OD) can be considered in the treatment of lifelong PE treatment, having tolerable side effects.

Efficacy and safety of dapoxetine for premature ejaculation: an updated systematic review and meta-analysis

We conducted a systematic review and meta-analysis of published randomised controlled trials of dapoxetine for premature ejaculation. We systematically searched Embase, PubMed, Cochrane, Web of Knowledge, FDA.gov and Clinical Trials.gov for studies reporting dapoxetine in men with premature ejaculation. Efficacy endpoints included intravaginal ejaculatory latency times (IELT), personal distress related to ejaculation (PDRE) and treatment-emergent adverse events (TEAEs) was used to evaluate safety. Data were analysed using a random-effects model. Electronic search identified 276 papers. The final analysis included eight papers (n = 8422 subjects). Analysis of the pooled results indicated efficacy in both IELT (weighted mean difference (WMD) = 1.67, 95% confidence interval (CI) 1.45-1.89) and PDRE (relative risk = 1.26, 95% CI 1.18-1.35). Subgroup analysis indicated efficacy (i.e. increase in IELT) for 30- and 60-mg on-demand dapoxetine (WMD 1.38 (95% CI 1.01-1.75) and 1.62 (95% CI 1.40-1.84) respectively), as well as daily use of 60 mg dapoxetine (WMD 2.18, 95% CI 1.71-2.64). The safety profile was acceptable. Based on the different effects of magnitude of the three dosing regimens, we recommend a stepwise approach, starting with 30 mg on demand, then 60 mg on demand and finally 60 mg dapoxetine daily.

The effect of plasma melatonin levels in the treatment of lifelong premature ejaculation with selective serotonin reuptake inhibitors

The aim of our study was to compare melatonin levels of patients with lifelong premature ejaculation (LPE) (n:60) with healthy controls (n:30) and to investigate the changes of melatonin levels in the treatment with dapoxetine and sertraline. Age, body mass index, duration of marriage, weekly intercourse number, International Index of Erectile Function scores, Intravaginal Ejaculation Latency Time (IELT) and melatonin levels were recorded. LPE patients were divided into two treatment groups. The first group was included 30 patients, who received 60 mg dapoxetine for six weeks, twice a week, an hour before intercourse. The second group received 50 mg of sertraline daily, for six weeks. IELT and melatonin measures were repeated after the treatment. IELT (dapoxetine group: 41.22 ± 21.3 s, sertraline group: 48 ± 23.11 s, control group: 195.54 ± 84.14 s; p < .001) and melatonin levels (dapoxetine group: 5.75 ± 2.04 pg/mL, sertraline group: 5.49 ± 2.88 pg/mL, control group: 13.4 ± 12.09 pg/mL; p < .001) of both LPE groups were significantly lower than control group. Following the six-week sertraline (before: 48 ± 23.11 s, after: 101.01 ± 59.55 s; p < .001) and dapoxetine (before: 41.22 ± 21.3 s, after: 97.39 ± 44.1 s; p < .001) treatments, IELT increased. The melatonin levels increased in the sertraline group (before: 5.49 ± 2.88 pg/mL, after: 10.6 ± 7.37 pg/mL; p < .001). Our results indicate that melatonin levels of LPE patients are lower than levels of healthy volunteers. Furthermore, we found a significant increase in melatonin levels following sertraline treatment.

Regular penis-root masturbation, a novel behavioral therapy in the treatment of primary premature ejaculation

The primary premature ejaculation (PPE) is a common male sexual disorder. We proposed a novel behavioral therapy for PPE through regular penis-root masturbation (PRM). Nine heterosexual men with PPE completed the self-controlled study. After a 3-month PRM training, the median intravaginal ejaculatory latency time (IELT) increased from 60 s to 180 s (P = 0.018), and the mean Premature Ejaculation Diagnostic Tool (PEDT) score decreased from 14.8 ± 3.7 to 12.8 ± 4.1 (P = 0.074). Five out of eight patients had the prolonged dorsal nerve somatosensory evoked potential (DNSEP). The results suggest that PRM has a short-term therapeutic effect. Randomized controlled trials are needed to validate the efficacy.

Trends in reported male sexual dysfunction over the past decade: an evolving landscape

We investigated changes in patterns of reported male SDs at a single academic centre over a 10-year time frame. Comprehensive data of 2013 patients consecutively assessed for the first time by a single Sexual Medicine expert between 2006 and 2019 has been analysed. All patients were assessed with a thorough sexual and medical history. Primary reason for seeking medical help at first assessment was recorded for all patients and categorized as: erectile dysfunction (ED), premature ejaculation (PE), low/reduced sexual desire/interest (LSD/I), Peyronie's disease (PD), and other SDs. Linear and logistic regression models tested the association between different reasons for seeking medical help and the time at first evaluation. Local polynomial regression model explored the probability of reporting different SDs over the analysed time frame. Median (IQR) age at first clinical assessment was 50 (38-61) years. Overall, most patients were assessed for ED (824; 41%), followed by PD (369; 18%), PE (322; 16%), LSD/I (204; 10%) and other SDs (294; 15%). Significant changes in terms of reported SD over the analysed time frame were observed. The likelihood of assessing patients for ED significantly increased up to 2013, with a decrease in the past 5 years (p < 0.001). PE assessment at presentation linearly decreased over time (OR: 0.94; 95% CI: 0.91-0.96; p < 0.001). Patients assessed during the past few years were more likely to report PD (OR: 1.20; 95% CI: 1.15-1.25; p < 0.001) and LSD/I (OR: 1.21; 95% CI: 1.16-1.26; p < 0.001), with a linear increase over the evaluated time frame. Likewise, patients were also more likely to report other SDs (Coeff: 1.06; 95% CI: 1.02-1.10; p = 0.004), with a linear increase over time. These results may reflect real changes in SD incidence, increased public awareness towards different SDs and the possible impact of novel treatments available on the market throughout the same time frame.

Phosphodiesterase-5 Inhibitors for Premature Ejaculation: Systematic Review and Meta-Analysis of Placebo-Controlled Trials

The purpose of this analysis is to assess the efficacy and safety of phosphodiesterase-5 inhibitors (PDE5Is) for the treatment of premature ejaculation (PE). A comprehensive search was performed to ascertain from trials about PDE5Is for the treatment of PE and compare the results, including intravaginal ejaculatory latency time (IVELT), score of sexual satisfaction scale, and side effects, between the group treated with PDE5Is and that treated with placebo. Seven studies involving a total of 471 patients were included in this meta-analysis. This analysis showed that patients who were treated with PDE5Is had significantly increased IVELT (mean difference [MD] 2.60; 95% CI [1.85, 3.36]; p < .00001) and score of sexual satisfaction scale (MD 2.04; 95% CI [0.78, 3.30]; p = .002) compared with the group on placebo. More patients had side effects while taking PDE5Is, such as headache, dizziness, flushing, and nasal congestion. PDE5Is were significantly more effective than placebo in the treatment of PE. Side effects were more common among patients who were treated with PDE5Is.

Progresses in pharmaceutical and surgical management of premature ejaculation

OBJECTIVE

Premature ejaculation (PE) is regarded as one of the most common male sexual dysfunctions. This review introduced several pharmaceutical and surgical methods for the management of PE. The definition, etiology, behavioral, and psychological therapy of PE were also discussed.

DATA SOURCES

"Premature," "ejaculation," or "sexual dysfuction" were used as the medical subject headings (MeSH) to obtain relevant articles before June 2019 on Pubmed, Google Scholar and CNKI. Most articles used were written in English and several Chinese articles were also cited.

STUDY SELECTION

Full-text articles of retrospective/prospective/randomized controlled trials were analyzed. Animal experiments and letters were excluded.

RESULTS

There are four PE sub-types: lifelong PE, acquired PE, natural variable PE, and subjective PE. Behavioral therapy, psychotherapy, medication, topical anesthetics, and surgery are currently used for the treatment of PE. However, all the above treatments have limitations. Therefore, novel ways should be investigated to more efficiently control PE.

CONCLUSIONS

The pharmaceutical therapy that is currently being used in clinical practice for the management of PE is still the main choice globally due to its good efficacy. Surgery may be a choice for patients who are resistant to medication. However, it should be performed cautiously.

A Double Blind, Placebo Controlled, Randomized Trial to Evaluate the Efficacy and Tolerability of On-Demand Oral Pregablin (150 mg and 75 mg) in Treatment of Premature Ejaculation

INTRODUCTION

Although premature ejaculation (PE) is a common sexual dysfunction, the available options for PE treatment remain unsatisfactory.

AIM

To evaluate the effect of on-demand oral pregabalin on the intravaginal ejaculation latency time (IELT).

METHOD

We conducted a multiarm double-blinded placebo-controlled randomized clinical trial that enrolled 120 patients with PE who were divided equally into 3 groups (A, B, and C). 4 patients were excluded, 39 patients received 150 mg pregabalin (group A), 39 patients received 75 mg pregabalin (group B), and 38 patients received placebo (group C). All patients were encouraged to engage in sexual relations twice per week for 2 weeks and to take the medication 1-2 hours before sexual intercourse. A stopwatch was used to evaluate IELT.

MAIN OUTCOME MEASURE

The main outcome measure are the improvement of IELT and the reported adverse events.

RESULTS

IELT significantly improved in patients who received 150 mg pregabalin, but there was no change in the other groups.

CLINICAL IMPLICATIONS

Most PE patients showed a significant improvement after receiving on-demand pregabalin (150 mg).

STRENGTH & LIMITATIONS

The strength of this study is that it is the first randomized controlled trial to evaluate the efficacy of pregabalin in treatment of PE. The main limitations were the small number of patients, IELT was the only primary outcome of the study, and the pregabalin cap can be identified by the patient.

CONCLUSION

Oral pregabalin seems to be a promising drug for additional evaluation as a new treatment for PE. More studies are needed to evaluate the suitable dose, duration, timing, and its safety profile. El Najjar MR, El Hariri M, Ramadan A, et al. A Double Blind, Placebo Controlled, Randomized Trial to Evaluate the Efficacy and Tolerability of On-Demand Oral Pregablin (150 mg and 75 mg) in Treatment of Premature Ejaculation. J Sex Med 2020;17:442-446.

Which of available selective serotonin reuptake inhibitors (SSRIs) is more effective in treatment of premature ejaculation? A randomized clinical trial

Purpose:

To compare the efficacy and safety of available selective serotonin reuptake inhibitors (SSRIs) in order to find the most effective drug with the least number of side effects in treatment of premature ejaculation (PE).

Materials and Methods:

This study was a randomized clinical trial. Four hundred and eighty patients with PE in the 4 groups referred to Imam Reza hospital Tehran, Iran from July 2018 to February 2019 were enrolled in the study. The patients received sertraline 50mg, fluoxetine 20mg, paroxetine 20mg and citalopram 20mg, every 12 hours daily. The intravaginal ejaculatory latency time (IELT) before treatment, fourth and eighth weeks after treatment was recorded by the patient's wife with a stopwatch.

Results:

Mean IELT before, 4 and 8 weeks after treatment in four groups were: sertraline 69.4±54.3, 353.5±190.4, 376.3±143.5; fluoxetine 75.5±64.3, 255.4±168.2, 314.8±190.4; paroxetine 71.5±69.1, 320.7±198.3, 379.9±154.3; citalopram 90.39±79.3, 279.9±192.1, 282.5±171.1 seconds, respectively. The ejaculation time significantly increased in all groups (p <0.05), but there was no significant difference between the groups (P=0.75). Also, there was no significant difference in drugs side effects between groups (p >0.05). The most common side effects were drowsiness and dyspepsia, which were not severe enough to cause discontinuation of the drug.

Conclusions:

All available SSRIs were effective and usually had no serious complications. In patients who did not respond to any of these drugs, other SSRI drugs could be used as a salvage therapy.

Comparative study of on-demand and daily use of sertraline in treatment of premature ejaculation: A randomized clinical trial

Objective

The intravaginal ejaculatory latency time (IELT) may increase less in on-demand compared to daily intake, but may fulfill a suitable treatment for specific patients. We decided to compare the efficacy and safety of on-demand and daily use of sertraline in order to find the most effective and least complicated method in treatment of premature ejaculation (PE).

Methods

This study was parallel or concurrent control randomized clinical trial. Two hundred and forty patients with PE diagnosed by urologist in the two groups of 120 from July 2017 to February 2019 enrolled in the study. In the first group, it is prescribed 50 mg sertraline each 12 h daily and the second group received 50 mg 4 h before coitus for 4 and 8 weeks. The IELT before treatment and during all coitus after treatment were recorded by the patient's wife with a stopwatch.

Results

Mean IELT before, 4 and 8 weeks after treatment in two groups were: On-demand group 101.62±65.44 s, 208.75±128.02 s and 265.87±145.70 s; daily use group 102.50±81.22 s, 276.87±181.08 s and 353.75±176.45 s, respectively. The ejaculation time increased significantly in both groups (p<0.05). However, increase in ejaculation time in daily use group was significantly higher than the on-demand group in 4 weeks (p=0.036), especially in 8 weeks (p=0.009). The percent of side effects in daily use group (26.7%) was higher than on-demand group (20%) (p<0.05). Drowsiness, diarrhea and vertigo were significantly higher in the daily use than on-demand (p<0.05).

Conclusions

On-demand and daily use of sertraline are effective and usually have no serious complications, but the on-demand method is considerably more tolerable. In patients who did not tolerate to daily use of this drug, on-demand could be used as a salvage therapy.

Transcutaneous electric nerve stimulation to treat patients with premature ejaculation: phase II clinical trial

A phase II single-arm trial was conducted from June 2017 to October 2018 to evaluate the efficacy and safety of transcutaneous posterior tibial nerve stimulation (TPTNS) for premature ejaculation (PE) treatment. Twelve men with PE and no prior treatment were enrolled, one was withdrawn and 11 subjects provided data for the main outcome. TPTNS consisted of 30-min sessions of the application of 20 Hz with a pulse amplitude of 200 µsec. The intensity was adjusted based on individual sensibility. The participants received 3 weekly sessions for 12 consecutive weeks. Follow-up continued for 9 months after therapy completion. The main outcome was a threefold increase in the intravaginal ejaculation latency time (IELT) at week 12. Eleven patients completed therapy, and 54.5% (p = 0.037) showed tripled baseline IELT scores at week 12. The IELT increased 4.8-fold, 6.8-fold, and 5.4-fold at weeks 12, 24, and 48, respectively. One episode of constipation was reported, and one patient reported a sensation of heat in the leg during one therapy session. The findings suggest that TPTNS therapy delays ejaculation in patients with lifelong premature ejaculation, with no serious secondary effects. Controlled trials with larger sample sizes are needed to verify these results.

Comparison of the treatment efficacies of paroxetine, fluoxetine and dapoxetine in low socioeconomic status patients with lifelong premature ejaculation

Introduction

To assess the treatment efficacies of paroxetine, fluoxetine and dapoxetine in patients with lifelong premature ejaculation (PE).

Material and methods

One hundred and seventy male patients with lifelong PE were included in our study. Premature ejaculation profile (PEP) and Intravaginal ejaculation latency times (IELT) were recorded. Paroxetine 20 mg/d was given in Group 1 (n = 64), fluoxetine 20 mg/d was given in Group 2 (n = 47) and dapoxetine 30 mg on demand (at least two times/week) was given in Group 3 (n = 59) patients. After 1 month of treatment, the patients' IELT, PEP and patient reported clinical global impression of change (CGIC) were completed.

Results

The mean age was 36 ±9.2 years. There was no difference between the groups' age, PEP and IELT before treatment (p >0.05). PEP and IELT improved in all three groups (p <0.001). The changes in the 1^st and 3^rd questions of PEP was significantly higher in group 1 than in the other groups (pPEP-1 = 0.042, pPEP-3 = 0.001). The changes in the 2^nd and 4^th questions of PEP were similar between groups (pPEP-2 = 0.444, pPEP-4 = 0.442). In group 1 and 3 IELT changes were better than group 2 (pIIEL1-3 = 0.297, pIIEL1-2 = 0.017, pIIEL2-3 = 0.100). There was no difference between CGIC scores (p = 0.087). The treatment was terminated by 8 patients in Group 1 and 9 patients in Group 2 because of side effects.

Conclusions

While paroxetine treatment seemed to be better than the other medications, dapoxetine 30 mg treatment has less side effects than the two others and its' on demand usage makes it more prominent than the others.

Interventions to Treat Erectile Dysfunction and Premature Ejaculation: An Overview of Systematic Reviews

INTRODUCTION

Sexual dysfunction in men is common, and optimal treatment is complex. Although several systematic reviews concerning treatment approaches exist, a comprehensive overview without limitations concerning the population, interventions, or outcomes is lacking.

AIM

To conduct a "review of reviews" to compare the effectiveness of pharmacologic, non-pharmacologic, and combined interventions.

METHODS

9 electronic databases, relevant journals, and reference lists up to July 2018 were searched. For each intervention, only the most recent and comprehensive meta-analysis or systematic review was included. The methodologic quality of the reviews was appraised using the Assessment of Multiple Systematic Reviews-2 tool.

MAIN OUTCOME MEASURE

Sexual functioning (via intravaginal ejaculatory latency time and international index of erectile function), sexual satisfaction, and adverse effects.

RESULTS

30 systematic reviews were included. For premature ejaculation, several treatments, including oral pharmacotherapy (selective serotonin inhibitors, phosphodiesterase type 5 [PDE5] inhibitors, tricyclic antidepressants, and opioid analgesics), topical anesthetics, and combined drug and behavioral therapies demonstrated significant improvements of 1-5 minutes in the intravaginal ejaculatory latency time. Pharmacologic interventions (PDE5 inhibitors, penile injection, and testosterone), shockwave therapy, lifestyle modifications, and combined therapies (PDE5 inhibitors and psychological intervention) were effective in treating erectile dysfunction. Most pharmacologic therapies were associated with adverse effects.

CONCLUSIONS

There is suggestive evidence that pharmacologic interventions or combined therapies are more effective than non-pharmacologic interventions for treating sexual dysfunction in men; however, a range of treatment options should be presented to individual patients so they may consider the risks and benefits of treatments differently. Evidence related to behavioral and psychological interventions is insufficient compared with that related to drug trials, highlighting the necessity for larger and better randomized controlled trials. Ciocanel O, Power K, Eriksen A. Interventions to Treat Erectile Dysfunction and Premature Ejaculation: An Overview of Systematic Reviews. Sex Med 2019;7:251-269.

Discovery of SHR1653, a Highly Potent and Selective OTR Antagonist with Improved Blood-Brain Barrier Penetration

The oxytocin receptor (OTR) plays a major role in the control of male sexual responses. Antagonists of the OTR have been reported to inhibit ejaculation in animal models and serve as a potential treatment for premature ejaculation (PE). Herein, we describe a novel scaffold featuring an aryl substituted 3-azabicyclo [3.1.0] hexane structure. The lead compound, SHR1653, was shown to be a highly potent OTR antagonist, which exhibited excellent selectivity over V_1AR, V_1BR, and V₂R. This novel molecule was shown to have a favorable pharmacokinetic profile across species, as well as robust in vivo efficacy in a rat uterine contraction model. Interestingly, SHR1653 exhibited excellent blood-brain barrier penetration, which might be beneficial for the treatment of CNS-related PE.

Efficacy and safety of dapoxetine/sildenafil combination tablets in the treatment of men with premature ejaculation and concomitant erectile dysfunction-DAP-SPEED Study

Premature ejaculation (PE) and erectile dysfunction (ED) are the most prevalent sexual disorders in men. ED is commonly reported among patients with PE. Although recent guidelines recommend to treat ED first in men with both PE and ED, this recommendation is not based on evidence and there are limited data about the efficacy and safety of dapoxetine/sildenafil combination therapy for these patients. The aim of this study is to evaluate the clinical efficacy and safety of the dapoxetine/sildenafil combination (Dapoxil^® 30/50 mg film-coated tablet) in the treatment of patients with PE and concomitant ED. In a single-center, single-arm, open-label clinical study conducted between October 2016 and September 2017, 74 patients with lifelong or acquired PE and ED were included. All patients were instructed to record their intravaginal ejaculatory latency time (IELT) with a stopwatch for 4 weeks. After the screening, they were requested to complete Premature Ejaculation Diagnostic Tool (PEDT), Premature Ejaculation Profile (PEP), and International Index of Erectile Function-Erectile Function (IIEF-EF) questionnaires before the treatment. The patients received on demand Dapoxil^® 1-3 h before sexual intercourse for the next 4 weeks (2 days a week and no more than once a day). The patients were also assessed with global impression of change (GIC) question for the treatment satisfaction and the side effects were recorded. The study was completed with 53 patients (53/74, 71.62%). Mean age of the patients was 45.32 ± 10.05 years. At the end of the 4-week treatment period, the geometric mean IELT of the patients significantly increased (from 22.72 ± 15.16 to 68.25 ± 82.33 s; p < 0.001). Similarly, significant improvements were observed in the mean PEP index score (0.86 ± 0.72 vs. 2.36 ± 1.13; p < 0.001) and mean IIEF-EF domain score (13.17 ± 3.33 vs. 24.60 ± 3.96; p < 0.001). According to the GIC results, 81.13% of the patients were satisfied with the treatment. Non-serious adverse events occurred in 10 patients (18.87%) and 4 (7.55%) of these patients dropped out of the treatment. The most common adverse events were headache, palpitation, and flushing. The dapoxetine/sildenafil combination therapy significantly improves the IELT values and patient reported outcome measures of PE patients who also suffer from ED. Although several side effects were reported, these were mild and transient.

Pharmacotherapy of premature ejaculation: a systematic review and network meta-analysis

PURPOSE

The purpose of the study was to conduct a systematic evaluation of the different general prescribed drugs for premature ejaculation (PE).

METHODS

A systematic literature search of MEDLINE, Cochrane Central Register of Controlled Trials, and Web of Science for Systematic Reviews was performed on 1 March 2018. Intravaginal ejaculation latency time (IELT) was the main outcome. Analysis was performed under multivariate random-effects network model and efficacies of drugs were ranked with surface under the cumulative ranking (SUCRA) probabilities.

RESULTS

A total of 48 studies were reviewed and 40 of them were further enrolled into network meta-analysis. The majority of RCTs were of unclear methodological quality. Pooled evidence suggested that topical anaesthetic creams (TAs), tramadol, selective serotonin reuptake inhibitors (SSRIs), and phosphodiesterase type 5 inhibitors (PDE5is) are more effective at prolonging IELT comparing with placebo. TAs (90%) on demand (OD) and PDE5is plus SSRI (89.8%) had the highest SUCRA, which meant the most probable to be the most effective intervention.

CONCLUSIONS

We recommend the initial use of dapoxetine 30 mg OD for PE because it has been tested in largest and better designed clinical trials rather than it is more effective than the other drugs studied. TAs and tramadol 50 mg OD can be used as a viable alternative to oral treatment with SSRIs. PDE5is combined with SSRIs are more effective than SSRIs monotherapy but are also associated with more side effects. PDE5is OD can be recommended to PE patients with ED.

Dapoxetine for the treatment of premature ejaculation: a meta-analysis of randomized controlled trials with trial sequential analysis

BACKGROUND

The safety and efficacy of dapoxetine for the treatment of premature ejaculation (PE) is still controversial. Thus, we decided to conduct a meta-analysis using trial sequential analysis (TSA) to determine the sufficiency of conclusions.

OBJECTIVE

Evaluate the efficacy and safety of dapoxetine in the treatment of patients with PE and assess the reliability of the findings.

DESIGN

Meta-analysis of randomized controlled trials (RCTs).

METHODS

Electronic databases including PUBMED, EMBASE, Cochrane Library, CNKI and Wanfang data were reviewed up to July 2017. RCTs evaluating the efficacy of dapoxetine in patients with PE and reporting intravaginal ejaculatory latency time (IELT), patient global impression of change (PGIC) and/or adverse events (AEs) were included.

MAIN OUTCOME MEASURES

Mean differences between trials in efficacy for IELT, and risk ratios for PGIC and treatment-emergent AEs.

SAMPLE

8 RCTs.

RESULTS

For IELT and PGIC, significant effects were found for all doses of dapoxetine versus placebo, and similar results were obtained in subgroups of the 30-mg dose versus 60-mg dose. There were also statistically different dose-related effects on AEs. Trial sequential analysis showed that the result of our meta-analysis was confirmed and further trials are unnecessary.

CONCLUSIONS

The evidence suggests that dapoxetine may be a safe and effective drug for patients with PE.

REGISTRATION

Not registered, no published protocol.

CONFLICT OF INTEREST

No relationship with manufacturer of drug.

Phase I and phase II clinical trials for the treatment of male sexual dysfunction-a systematic review of the literature

INTRODUCTION

The prevalence of sexual dysfunctions has increased over the last decades; despite a number of available treatments for erectile dysfunction (ED), premature ejaculation (PE), and Peyronie's disease (PD), still several unmet therapeutic needs deserve to be fulfilled. The aim of this review is to detail on phase I and II clinical trials investigating novel medical treatments for ED, PE, and PD.

AREAS COVERED

We conducted a systematic review of the literature including both published and ongoing phase I and II registered trials focused on medical treatment of ED, PE, and PD during the last 5 years. A total of 35 trials have been identified. Most studies (63%) investigated ED treatments and 26% were still ongoing. Stem cells (SCs) therapy was assessed in 28% of trials.

EXPERT OPINION

SCs therapy represent a promising treatment for ED although only few patients have been treated to date. Likewise, the oral selective oxytocin receptor antagonists for treating PE showed excellent safety profile and deserve further investigations in phase III trials. Preliminary results of novel topical treatments for PD with fibrinolytic and antiinflammatory drugs are encouraging, but urgently need to be confirmed in large placebo-controlled trials.

Pharmacological interventions for premature ejaculation: a mixed-treatment comparison network meta-analysis of randomized clinical trials

Premature ejaculation (PE) is the most common sexual dysfunction in men. The present study is a network meta-analysis of drugs used for treating PE. Electronic databases were searched for randomized controlled trials comparing medical interventions with either placebo or with other active drugs in patients with PE. Inverse variance heterogeneity model was used for mixed-treatment comparisons. Intravaginal ejaculatory latency time (IELT) and adverse events were the main outcome measures. A total of 44 studies were included in the meta-analysis. Dapoxetine 30 and 60 mg, tadalafil, sildenafil, paroxetine with sildenafil, topical lidocaine, dapoxetine 30 mg with mirodenafil, vardenafil, fluoxetine, and tadalafil, pindolol with paroxetine, tramadol, topical lidocaine with tadalafil, paroxetine with tadalafil, and topical eutectic mixture of local anesthetics were associated with a significant increase in IELT. Similarly, dapoxetine 60 mg, venlafaxine, fluoxetine, tramadol at 25, 50, and 100 mg, and combined fluoxetine and tadalafil were associated with an increased risk of adverse events. Dapoxetine 30 mg has a high likelihood of being the "best" in the interventional pool. Dapoxetine at 30 mg could be used as the first-line agent in the management of PE.

Central Neural Correlates During Inhibitory Control in Lifelong Premature Ejaculation Patients

Lifelong premature ejaculation (LPE) is a common male sexual dysfunction. Lack of active control for rapid ejaculation brought great distress to sexual harmony and even fertility. Previous neurophysiology studies revealed an ejaculation-related control mechanism in the brain. However, it remains unclear whether this inhibitory network is altered in LPE patients. The present study investigated the central inhibitory network function of LPE patients by using stop signal task (SST)-related functional magnetic resonance imaging (fMRI) and resting-state functional connectivity (FC) analysis. The results showed no difference in task-related behavioral performance or neural activation during response inhibition between LPE patients and controls. However, LPE patients showed a significantly different correlation pattern between the stop signal reaction time (SSRT) and left inferior frontal gyrus (IFG) activation during successful inhibition, in which a typical negative correlation between SSRT and the activation was completely disappeared in patients. In addition, using the left IFG as a seed, patients showed weaker FC between the seed and two areas (left dentate nucleus (DN) and right frontal pole) compared with controls. These data suggest that LPE patients have an abnormal brain control network, which may contribute to the reduced central control of rapid ejaculation. This study provides new insights into the neural mechanism of LPE involving the central inhibitory network, which may offer an underlying intervention target for future treatment.

Premature ejaculation: challenging new and the old concepts

Premature ejaculation remains a difficult condition to manage for patients, their partners, and the clinician. Whilst prevalence rates are estimated to be 20-40%, determining a diagnosis of premature ejaculation is difficult, as the definition remains both subjective and ill-defined in the clinical context. As our understanding of the ejaculatory pathway has improved, new opportunities to treat the condition have evolved with mixed results. In this review, we explore some of these controversies surrounding the aetiology, diagnosis, and treatment of this condition and discuss potential novel therapeutic options.

Effect of tadalafil 5mg daily treatment on the ejaculatory times, lower urinary tract symptoms and erectile function in patients with erectile dysfunction

Objective

To investigate the effect of a 5mg daily tadalafil treatment on the ejaculation time, erectile function and lower urinary tract symptoms (LUTS) in patients with erectile dysfunction.

Materials and Methods

A total of 60 patients diagnosed with erectile dysfunction were retrospectively evaluated using the international index of erectile function questionnaire-5 (IIEF-5), intravaginal ejaculatory latency time (IELT) and international prostate symptoms scores (IPSS). After the patients were treated with 5mg tadalafil once a day for three months, their erection, ejaculation and LUTS were assessed again. The fasting levels of blood glucose, total testosterone, low-density lipoprotein cholesterol, high-density lipoprotein cholesterol and total cholesterol were measured. The independent-samples t-test was used to compare the pre- and post-treatment scores of the patients.

Results

The mean age of the 60 participants was 50.4±7.9 and the mean baseline serum total testosterone, total cholesterol, and fasting blood sugar were 444.6±178.6ng dL^-1, 188.7±29.6mg/dL^-1,104 (80-360) mg dL^-1, respectively. The mean baseline scores were 2.2±1.4 min for IELT, 9.5±3.7 for IIEF-5 and 14.1±4.5 for IPSS. Following the three-month daily 5mg tadalafil treatment, the scores were found to be 3.4±1.9 min, 16.1±4.7, and 10.4±3.8 for IELT, IIEF and IPSS, respectively. When the baseline and post-treatment scores were compared, a statistically significant increase was observed in the IELTs and IIEF-5 values whereas there was a significant decrease in IPSS (p<0.01).

Conclusion

A daily dose of 5mg tadalafil can be safely used in the treatment of erectile dysfunction and LUTS, that prolongs the ejaculatory latency time.

Comparison of the clinical efficacy and safety of the on-demand use of paroxetine, dapoxetine, sildenafil and combined dapoxetine with sildenafil in treatment of patients with premature ejaculation: A randomised placebo-controlled clinical trial

The aim of the study was to compare the clinical efficacy and safety of the on-demand use of paroxetine, dapoxetine, sildenafil and combined dapoxetine with sildenafil in treatment of patients with premature ejaculation (PE). In a single-blind placebo-controlled clinical study, 150 PE patients without erectile dysfunction (ED) were included during the period of March 2015 to May 2016. Patients were randomly divided into five groups (30 patients each). On demand placebo, paroxetine (30 mg), dapoxetine (30 mg), sildenafil citrate (50 mg) and combined dapoxetine (30 mg) with sildenafil citrate (50 mg) were given for patients for 6 weeks in each group respectively. All patients were instructed to record intravaginal ejaculatory latency time (IELT) and evaluated with Premature Ejaculation Diagnostic Tool (PEDT) and the patient satisfaction score before and after treatment. The mean of IELT, satisfaction score and PEDT in all groups was significantly improved after treatment (p value = .001). Combined dapoxetine with sildenafil group had the best values of IELT, satisfaction scores and PEDT in comparison with other treatment groups (p value <.001). The combined dapoxetine with sildenafil therapy could significantly improve PE patients without ED as compared to paroxetine alone or dapoxetine alone or sildenafil alone with tolerated adverse effects.

Discontinuation of Dapoxetine Treatment in Patients With Premature Ejaculation: A 2-Year Prospective Observational Study

Introduction

Although dapoxetine is the only oral pharmacologic agent approved for the treatment of premature ejaculation (PE) and is very effective, the discontinuation rate is high.

Aim

To assess the discontinuation rate of patients with PE and the reasons for discontinuation in real-world practice.

Methods

In total, 182 consecutive patients were enrolled. Type of PE, self-estimated intravaginal ejaculation latency time, and medical history were evaluated in all patients who also completed the erectile function domain of the International Index of Erectile Function (IIEF). Visits were scheduled 1, 3, 6, 12, and 24 months after initiation of therapy; treatment status and the reasons for discontinuation in those who did discontinue were checked. The relations of discontinuation rates were compared with various parameters and the time to discontinuation after treatment commencement.

Results

Of all patients, 9.9% continued treatment to 2 years. The cumulative discontinuation rates at 1, 3, 6, 12, and 24 months were 26.4%, 61.6%, 79.1%, 87.3%, and 90.1%, respectively. Moreover, 79.1% of all patients discontinued treatment within 6 months. After 12 months, the discontinuation rate decreased sharply. The reasons for discontinuation were cost (29.9%), disappointment that PE was not curable and that dapoxetine was required every time sexual intercourse was contemplated (25%), side effects (11.6%), perceived poor efficacy (9.8%), a search for other treatment options (5.5%), and unknown (18.3%). Patients with acquired PE (vs lifelong PE), with intravaginal ejaculation latency time longer than 2 minutes before treatment, on phosphodiesterase type 5 inhibitors, and with IIEF erectile function scores lower than 26 tended to discontinue early and thus exhibited high dropout rates.

Conclusion

The treatment discontinuation rate of dapoxetine was very high. The main reasons for discontinuation were the cost and disappointment that treatment was required every time adequate sexual function was required.

Park HJ, Park NC, Kim TN, et al. Discontinuation of Dapoxetine Treatment in Patients With Premature Ejaculation: A 2-Year Prospective Observational Study. Sex Med 2017;5:e99–e105.

Emerging and investigational drugs for premature ejaculation

Over the past 20−30 years, the premature ejaculation (PE) treatment paradigm, previously limited to behavioural psychotherapy, has expanded to include drug treatment. Pharmacotherapy for PE predominantly targets the multiple neurotransmitters and receptors involved in the control of ejaculation which include serotonin, dopamine, oxytocin, norepinephrine, gamma amino-butyric acid (GABA) and nitric oxide (NO). The objective of this article is to review emerging PE interventions contemporary data on the treatment of PE was reviewed and critiqued using the principles of evidence-based medicine. Multiple well-controlled evidence-based studies have demonstrated the efficacy and safety of selective serotonin reuptake inhibitors (SSRIs) in delaying ejaculation, confirming their role as first-line agents for the medical treatment of lifelong and acquired PE. Daily dosing of SSRIs is likely to be associated with superior fold increases in IELT compared to on-demand SSRIs. On-demand SSRIs are less effective but may fulfill the treatment goals of many patients. Integrated pharmacotherapy and CBT may achieve superior treatment outcomes in some patients. PDE-5 inhibitors alone or in combination with SSRIs should be limited to men with acquired PE secondary to co-morbid ED. New on-demand rapid acting SSRIs, oxytocin receptor antagonists, or single agents that target multiple receptors may form the foundation of more effective future on-demand medication. Current evidence confirms the efficacy and safety of dapoxetine, off-label SSRI drugs, tramadol and topical anaesthetics drugs. Treatment with α1-adrenoceptor antagonists cannot be recommended until the results of large well-designed RCTs are published in major international peer-reviewed medical journals. As our understanding of the neurochemical control of ejaculation improves, new therapeutic targets and candidate molecules will be identified which may increase our pharmacotherapeutic armamentarium.

Relationship between premature ejaculation and depression: A PRISMA-compliant systematic review and meta-analysis

BACKGROUND

Premature ejaculation (PE) is the most prevalent male sexual dysfunction. Epidemiologic findings are inconsistent concerning the risk for depression associated with PE.

OBJECTIVE

The aim of this study was to investigate the potential association between between depression and risk of PE.

DATA SOURCES

We conducted a literature search of PubMed, Embase, and the Cochrane Library from these databases' inception through June 2014 for observational epidemiological studies examining the association between depression on risk of PE.

STUDY ELIGIBILITY CRITERIA

Studies were selected if they reported the risk estimates for PE associated with depression.

PARTICIPANTS

patients>18 years of age suffering from PE.

INTERVENTIONS

a history of depressive disorder.

STUDY APPRAISAL AND SYNTHESIS METHODS

These odds ratios (ORs) were pooled using a random or fixed effects model and were tested for heterogeneity. Subgroup analysis was employed to explore heterogeneity.

RESULTS

Eight trials involving 18,035 patients were included in the meta-analysis. Depression were statistically significantly associated with the risk of PE (OR = 1.63, 95% CI:1.42-1.87). There was no evidence of between-study heterogeneity (P = 0.623, I = 0.0%). The association was similar when stratified by mean age, geographical area, study design, sample size, publication year, and controlling key confounders.

LIMITATIONS

The severity of depression and PE could not be identified due to unavailable data of trials. No evidence of publication bias was observed.

CONCLUSIONS

These findings provide evidence that depression is associated with a significantly increased risk of PE. In addition, more prospective studies are necessary to evaluate the association and identify the ideal treatment.

SYSTEMATIC REVIEW REGISTRATION NUMBER

CRD42016041272.