Safety and efficacy of tramadol hydrochloride on treatment of premature ejaculation

Clinical and Laboratory Factors Related to Seizure and Serotonin Toxicity in Tramadol Intoxication: An Egyptian Study

BACKGROUND AND OBJECTIVES

Tramadol is a centrally acting analgesic with a lower risk of addiction compared to opioids. Tramadol overdose is becoming a health crisis in Egypt and is associated with serious and severe adverse effects. This study aims to identify clinical and laboratory findings associated with tramadol-induced seizure and serotonin toxicity in adult Egyptian patients with tramadol overdose.

METHODS

This prospective study included adult patients admitted for tramadol overdose with or without symptoms of seizure or serotonin toxicity. Basic demographic information, clinical symptoms, laboratory measurements, and plasma tramadol concentrations were collected.

RESULTS

A total of 71 patients (79% males) were included in the study. Seizure occurred in 38% of the subjects and was prevalent in male patients with metabolic acidosis or high tramadol concentrations. Serotonin toxicity occurred in 41% of the subjects and was prevalent in patients with hyperthermia, high pulse rate, and high tramadol levels.

CONCLUSION

Seizure and serotonin toxicity are severe adverse effects of tramadol overdose that occur in high frequency among young Egyptians. High tramadol concentrations in plasma seem to play a key role in prevalence of seizure and serotonin syndrome in tramadol-intoxicated adult Egyptians.

Majority of men with premature ejaculation do not receive pharmacotherapy

Premature ejaculation is the most common male sexual dysfunction, with therapies including selective serotonin reuptake inhibitors, clomipramine, topical anesthetics, dapoxetine and tramadol. However, it is currently unknown how many men are receiving pharmacotherapy for premature ejaculation. Using the TriNetX Research network, a large multicenter database containing over 75 million patient records from hospitals across the United States, we evaluated prescribing patterns for treatment of premature ejaculation and assessed variations in prescription patterns among patients from 2015-2021. In addition, we examined if the prescription patterns for tramadol changed with the establishment of Prescription Drug Monitoring Programs. We found that most men (51.7%) were not receiving any pharmacotherapy for premature ejaculation. However, men with mental health disorders, were more likely (56.0%), to have been treated than those without (44.4%). On further analysis, men with mental health diagnoses were significantly more likely to be treated with Selective Serotonin Reuptake Inhibitors (45.0 vs 32.2%) and Tramadol (5.1% vs 3.5%). While the pharmacotherapy for premature ejaculation has been well researched, our findings revealed that most patients diagnosed with premature ejaculation do not receive pharmacotherapy and that patients are more likely to be prescribed premature ejaculation medications if they have a pre-existing mental health diagnosis.

SeDeM tool-driven full factorial design for osmotic drug delivery of tramadol HCl: Formulation development, physicochemical evaluation, and in-silico PBPK modeling for predictive pharmacokinetic evaluation using GastroPlus™

The study is based on using SeDeM expert system in developing controlled-release tramadol HCl osmotic tablets and its in-silico physiologically based pharmacokinetic (PBPK) modeling for in-vivo pharmacokinetic evaluation. A Quality by Design (QbD) based approach in developing SeDEM-driven full factorial osmotic drug delivery was applied. A 2⁴ Full-factorial design was used to make the trial formulations of tramadol HCl osmotic tablets using NaCl as osmogen, Methocel K4M as rate controlling polymer, and avicel pH 101 as diluent. The preformulation characteristics of formulations (F1-F16) were determined by applying SeDeM Expert Tool. The formulation was optimized followed by in-vivo predictive pharmacokinetic assessment using PBPK “ACAT” model of GastroPlus™. The FTIR results showed no interaction among the ingredients. The index of good compressibility (ICG) values of all trial formulation blends were ≥5, suggesting direct compression is the best-suited method. Formulation F3 and F4 were optimized based on drug release at 2, 10, and 16 h with a zero-order kinetic release (r² = 0.992 and 0.994). The SEM images confirmed micropores formation on the surface of the osmotic tablet after complete drug release. F3 and F4 were also stable (shelf life 29.41 and 23.46 months). The in vivo simulation of the pharmacokinetics of the PBPK in-silico model revealed excellent relative bioavailability of F3 and F4 with reference to tramadol HCl 50 mg IR formulations. The SeDeM expert tool was best utilized to evaluate the compression characteristics of selected formulation excipients and their blends for direct compression method in designing once-daily osmotically controlled-release tramadol HCl tablets. The in-silico GastroPlus™ PBPK modeling provided a thorough pharmacokinetic assessment of the optimized formulation as an alternative to tramadol HCl in vivo studies.

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.

The Influence of Tramadol on Intravaginal Ejaculatory Latency Time and Sexual Satisfaction Score in Treating Patients With Premature Ejaculation: A Network Meta-Analysis

This network meta-analysis aimed at assessing the influence of tramadol on the intravaginal ejaculatory latency time (IELT) and sexual satisfaction score (SSS) in treating patients with premature ejaculation (PE). The PubMed, Embase, Cochrane Library databases (until July 2021), and original references of the included articles was systematically retrieved. The PRISMA checklist was followed. Finally, 14 articles including 1971 patients were included in this analysis. The results indicated that patients who were treated with tramadol (50 mg, 62 mg, 89 mg, and 100 mg) were superior to those treated with placebo in terms of IELT (p = .003, p < .00001, p < .00001, and p < .00001, respectively), but 25 mg tramadol did not show a significant advantage (p = .06). Patients who were treated with tramadol (50 mg and 100 mg) had a better efficacy than who were treated with 25 mg tramadol in the IELT (p < .00001 and p < .00001), but the effect of 50 mg tramadol and 100 mg tramadol were not significantly different (p = .17). The tramadol group had the better effect than the placebo group in the SSS (p < .0001). And 50 mg tramadol showed a significant improvement compared with 20 mg paroxetine, as assessed by the IELT (p = .03) and SSS (p = .03). Safety assessments including adverse events suggested that tramadol was well tolerated. Tramadol showed a better improvement of IELT and SSS than placebo or paroxetine, and 50 mg tramadol may be a more reasonable therapeutic dose for patients with PE.

Gonadotoxic effect of tramadol administration: A prospective controlled study

Objective

To detect the possible gonadotoxic effects of tramadol dependence on seminal fluid parameters, and prolactin and testosterone hormone levels.

Patients, Subjects, and Methods

There were 94 participants who were divided into a tramadol-dependent group (T-group; 56 patients) and a control group (C-group; 38 healthy volunteers). The following variables were evaluated: testosterone level, prolactin level, erectile function, libido, semen parameters, and effect of tramadol dose and dependence duration.

Results

There was a significant increase in erectile dysfunction (ED) and decreased libido in the T-group vs C-group. Also, the serum testosterone level was lower in the T-group vs the C-group, while the serum prolactin level was significantly higher in the T-group vs the C-group. All semen parameters were low in the T-group except for abnormal forms, which were high. As the dose of tramadol increased there was a more negative effect on the previous parameter, while ED, libido, semen volume and concentration showed no significant changes. When comparing tramadol doses of 400–1000 mg/day to >1000 mg/day, the tramadol blood level increased with high doses, while serum testosterone level decreased when the dose increased and the prolactin level increased when the dose increased. Progressive motility of the sperm decreased and abnormal forms increased. Also increased duration of tramadol administration was also accompanied by a more negative effect on these parameters

Conclusion

Tramadol administration has a negative effect on hormone levels, libido, erectile function, and semen characters.Abbreviations: ED: erectile dysfunction; EF: erectile function

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.

Online Public Attention Toward Premature Ejaculation in Mainland China: Infodemiology Study Using the Baidu Index

BACKGROUND

Premature ejaculation (PE) is one of the most described psychosocial stress and sexual complaints worldwide. Previous investigations have focused predominantly on the prospective identification of cases that meet researchers' specific criteria. The genuine demand from patients with regard to information on PE and related issues may thus be neglected.

OBJECTIVE

This study aims to examine the online search trend and user demand related to PE on a national and regional scale using the dominant major search engine in mainland China.

METHODS

The Baidu Index was queried using the PE-related terms for the period of January 2011 to December 2020. The search volume for each term was recorded to analyze the search trend and demographic distributions. For user interest, the demand and trend data were collected and analyzed.

RESULTS

Of the 36 available PE search keywords, 4 PE searching topics were identified. The Baidu Search Index for each PE topic varied from 46.30% (86,840,487/187,558,154) to 6.40% (12,009,307/187,558,154). The annual percent change (APC) for the complaint topic was 48.80% (P<.001) for 2011 to 2014 and -16.82% (P<.001) for 2014 to 2020. The APC for the inquiry topic was 16.21% (P=.41) for 2011 to 2014 and -11.00% (P<.001) for 2014 to 2020. For the prognosis topic, the annual APC was 11.18% (P<.001) for 2011 to 2017 and -19.86% (P<.001) for 2017 to 2020. For the treatment topic, the annual APC was 14.04% (P<.001) for 2011 to 2016 and -38.83% (P<.001) for 2016 to 2020. The age distribution of those searching for topics related to PE showed that the population aged 20 to 40 years comprised nearly 70% of the total search inquiries (second was 17.95% in the age group younger than 19 years). People from East China made over 50% of the total search queries.

CONCLUSIONS

The fluctuating online popularity of PE searches reflects the real-time population demands. It may help medical professionals better understand population interest, population concerns, regional variations, and gender differences on a nationwide scale and make disease-specific health care policies. The internet search data could be more reliable when the insufficient and lagging registry data are completed.

Evaluation of vitamin C protective effect on the cerebrocortical antioxidant defense, histopathological, pro-apoptotic p53 and anti-apoptotic Bcl2 expressions against tramadol neurotoxicity in rats

BACKGROUND

Reported tramadol toxicity emphasizes the necessity to recognize its mechanism of toxicity, particularly to the brain tissue.

AIM

This study aimed to evaluate the protective effect of vitamin C (Vit C) in cerebrocortical toxicity mediated by tramadol in rats using biochemical and histological parameters.

MATERIAL AND METHODS

Forty-eight albino rats were randomly divided into eight groups, (n = 6/group) as follow: the control group received normal saline and vitamin C group received vitamin C (200 mg/kg per oral). Tramadol 50, 100, 150 groups received tramadol in doses of (50, 100 and 150 mg/kg per oral, respectively); Tramadol 50+ Vit C, 100+ Vit C, 150+ Vit C groups received vitamin C (200 mg/kg per oral) plus tramadol in doses of (50, 100 and 150 mg/kg per oral, respectively). Rats had received vitamin C and tramadol daily for 30 days. Blood and brain tissues samples were harvested for biochemical, histopathological, immunohistochemical and electron microscopic examinations.

RESULTS

Tramadol administration leads to a significant elevation of MDA, NO levels and a significant decrease in antioxidants parameters (CAT, SOD and GSH) in the tissues of cerebral cortices in rats which were directly proportional to the dose of tramadol. In histological investigations, tramadol-treated groups showed pyknotic pyramidal cells, multiple red neurons and shrinking red neurons with hallows around it and apoptotic cells were detected. These biochemical abnormalities and histological impairment were ameliorated in groups with tramadol low doses by the co-treatment with vitamin C.

CONCLUSION

vitamin C has antioxidant and anti-apoptotic potentials against tramadol neurotoxicity via suppression of oxidative stress, lipid peroxidation, structural abnormalities, and down-regulation of p53 and overexpression of Bcl2 in the nervous tissues.

Tramadol abuse among workers in an industrial city in mid-Nile Delta region, Egypt

Tramadol abuse is an increasingly alarming phenomenon among Egyptian Community especially among workers and drivers. Study profile and factors affecting tramadol abuse among industrial workers in Mid-Nile Delta Region. A cross sectional study among minibus drivers, construction and textile industries workers. From each target group 300 males were chosen randomly. The total sample size was 900 persons. Interview questionnaire was used for data collection. Diagnosis of tramadol abuse was according DSM-5 Criteria. Intake of tramadol was high among construction workers (92.3%) followed by bus drivers (53.0%) and lastly textile workers (25.3%). The main source of tramadol was friends (45.4%) followed by drug dealers (16.6%). The main reason of abuse was to improve mood (54.3%) followed by relief of pain and help to continue work (37.3%). Tramadol is prevalent among industrial workers due to different reasons related to the work load and stressful events. Ever intake of tramadol was high among construction workers followed by bus drivers and lastly textile workers. Drug testing for workers in workplace is a must to ensure community safety.

Sexual dysfunction in tramadol hydrochloride use disorder male patients: a case-control study

Evidence suggests that opioids can modulate gonadal function, with consequent decreased release of sex hormones. We attempted to investigate the sexual function of males using tramadol hydrochloride (HCL) and its relationship to levels of free testosterone, luteinizing hormone, and follicle stimulating hormone, and to compare them with heroin use disorder patients and healthy controls. Our sample consisted of 60 opiate use disorder patients (assessed by Structured Clinical Interview for DSM-IV Axis I) (30 heroin and 30 tramadol) and 30 healthy controls. Sexual dysfunction was assessed using the International Index of Erectile Function. Free testosterone, follicle stimulating hormone, and luteinizing hormone levels were measured in morning blood samples using enzyme-linked immunosorbent assay (ELISA). Results showed that there was a decrease of luteinizing hormone and free testosterone levels in opiate use disorder patients compared with healthy controls, with heroin-dependent patients having significantly lower levels than those using tramadol. Opiates' effect on follicle stimulating hormone had mixed results. Opioid-dependent patients (both tramadol HCL and heroin using patients) developed sexual dysfunction more than healthy controls, which was generalized, with erectile dysfunction being the most affected domain. These findings are of ultimate importance, considering the fact that people use opioids to enhance their sexual performance in many countries.

Population Size Estimation of Tramadol Misusers in Urban Population in Iran: Synthesis of Methods and Results

Background

Estimating the population who use drugs is essential for planning, monitoring, and evaluation of substance use prevention and treatment. This study aims to estimate the population who misuse tramadol in urban population in Iran.

Methods

We used the wisdom of the experts (WOTE) and network scale-up (NSU) methods to calculate the population of tramadol misusers in 10 provincial capitals of Iran, in 2016. The WOTE was conducted among pharmacists in drugstores and the personnel of traditional medicinal herbs stores. They guessed the best estimation of tramadol misusers population in their cities. The NSU method was conducted among the general population and participants were questioned about ever and daily, non-medical use of tramadol during last 12 months in their network. The median of the methods was used to calculate the proportion of the adult population (15-49 years old).

Findings

The population size of tramadol misusers in studied cities was 83300 [95% uncertainty limits (UL): 47960-256220]. This corresponded to 6.6 per 1000 (95% UL: 3.88-20.30) of the 15-49-year-old population. The projected number of tramadol misusers for all 31 provincial capitals was 118290 (95% UL: 68100-363130840) and 212440 (95% UL: 122310-653410) for all urban areas. NSU also estimated the number of people who misuse tramadol on daily basis. These numbers were 52000 (95% UL: 19940-176570) for studied cities, 73840 (95% UL: 28320-250740) for all 31 provincial capital cities, and 132610 (95% UL: 50860-450310) for all urban areas in Iran.

Conclusion

This study presents information on high prevalence of tramadol misuse in urban population. We need national control measures and demand reduction programs to control tramadol misuse.

Pharmacokinetic changes of tramadol in rats with hepatotoxicity induced by ethanol and acetaminophen in perfused rat liver model

Tramadol is an opioid agonist with activation monoaminergic properties. It can be administered orally, rectally, intravenously, or intramuscularly as a centrally acting analgesic. Liver injury can lead to changes in the metabolism of tramadol. In this study, the rate of tramadol metabolism in rats with damaged liver induced by ethanol and acetaminophen was assessed in a recirculation perfusion system. Acetaminophen is a mild analgesic and antipyretic agent, which can cause centrilobular hepatic necrosis in toxic doses, whereas alcohol causes death due to liver diseases. Alcoholic liver disease (ALD), such as alcoholic fatty liver, alcoholic hepatitis, and alcoholic fibrosis, is the most common liver disease. The aim of this study was to investigate the alteration in tramadol metabolism in different hepatotoxicity conditions in animal models. Male rats were randomly assigned to three groups. The control group received normal saline, group 2 received acetaminophen at the dose of 250 mg/kg/day, and group 3 received ethanol at the beginning dose of 3 g/kg/day, which was slowly increased to 6 g/kg/day. Tramadol was added to the perfusion solution at the concentration of 500 ng/mL. Samples were collected during 180 min, and analyte concentrations were determined by the High-Performance Liquid Chromatography (HPLC) method. The concentration of tramadol and its three main metabolites, O-desmethyltramadol (M1), N-desmethyltramadol (M2), and N,O-didesmethyltramadol (M5), were determined in perfusate samples. Ethanol and acetaminophen significantly affected the pattern of weight gain and liver weights before perfusion and caused a significant increase in enzyme activities. Moreover, histopathologic examination revealed that ethanol and acetaminophen caused liver damage. An increase in the elimination half-life and reduced clearance rate of tramadol were seen in the acetaminophen and ethanol groups, in comparison to the control group. Additionally, significant reductions in the Area Under the Curve (AUC) of metabolites of tramadol (M1, M2, and M5) were observed in the acetaminophen and ethanol groups in the perfused rat liver model. Liver damage caused by ethanol and acetaminophen during 45 days in animals leads to a significant reduction in the level of tramadol metabolites. Therefore, in patients with liver damage caused by ethanol and acetaminophen, caution needs to be considered when prescribing tramadol.

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.

Tramadol's Inhibitory Effects on Sexual Behavior: Pharmacological Studies in Serotonin Transporter Knockout Rats

Tramadol is an effective pharmacological intervention in human premature ejaculation (PE). To investigate whether the inhibitory action of tramadol is primarily caused by its selective serotonin reuptake inhibitory (SSRI) effects we tested the dose–response effects of tramadol on sexual behavior in serotonin transporter wild type (SERT^+/+), heterozygous (SERT^+/-), and knockout (SERT^-/-) rats. To investigate whether other mechanisms contribute to the inhibitory effects, WAY100,635, a 5-HT_1A receptor antagonist and naloxone, a μ-opioid receptor antagonist, were tested on sexual behavior together with tramadol. Tramadol dose-dependently decreases sexual activity in all genotypes. In all studies, SERT^+/- rats did not respond differently from SERT^+/+ rats. WAY100,635 did not affect sexual activity in SERT^+/+, but dose-dependently reduced sexual activity in SERT^-/- rats. WAY100,635 (0.3 mg/kg) combined with tramadol (20 mg/kg) significantly reduced sexual activity in SERT^+/+ and even stronger in SERT^-/- rats. Naloxone did not affect sexual behavior consistently in SERT^+/+ rats, while in SERT^-/- rats all doses reduced ejaculation frequency mildly. Combining naloxone (20 mg/kg) and tramadol (20 mg/kg) decreased ejaculation frequencies in both genotypes. Interestingly, combining tramadol (20 mg/kg), WAY100,635 (0.3 mg/kg) and naloxone (20 mg/kg) led to complete elimination of all sexual activity in both SERT^+/+ and SERT^-/- rats. These findings suggest that the inhibitory effects of tramadol on male sexual behavior in SERT^+/+ rats is mainly, if not exclusively, due to SERT inhibition, with an important role for 5-HT_1A receptors, although influence of other systems (e.g., noradrenergic) cannot be excluded. As SSRIs exert their sexual inhibition after chronic administration, tramadol may be therapeutically attractive as “on demand” therapy for PE.

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.

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.

Dapoxetine and the treatment of premature ejaculation

Background

Premature ejaculation (PE) is the most common male sexual complaint. Off-label oral selective serotonin reuptake inhibitors (SSRIs) are commonly prescribed for the treatment of PE. Dapoxetine is a short-acting SSRI specifically designed for on-demand use. The objective of this communication is to summarize the clinical and physiological evidence regarding the role of the serotonergic pathway and specifically dapoxetine in the treatment of PE.

Methods

A PubMed search was conducted on articles reporting data on dapoxetine for the treatment of PE. Articles describing the pathophysiology and treatment options for PE were additionally included for review.

Results

The etiology of PE is multi-factorial in nature. There are many treatment options for PE such as psychological/behavioral therapy, topical anesthetic agents, phosphodiesterase type 5 (PDE-5) inhibitors, and tramadol hydrochloride. SSRIs play a major role in PE treatment. Animal and clinical studies in addition to its pharmacokinetic document dapoxetine’s clinical efficacy and safety for on-demand treatment of PE.

Conclusions

Dapoxetine demonstrates clinical efficacy and a favorable side effect profile. Dapoxetine is currently the oral drug of choice for on-demand treatment of PE.

Interventions to treat premature ejaculation: a systematic review short report

BACKGROUND

Premature ejaculation (PE) is commonly defined as ejaculation with minimal sexual stimulation before, on or shortly after penetration and before the person wishes it. PE can be either lifelong and present since first sexual experiences (primary), or acquired (secondary), beginning later (Godpodinoff ML. Premature ejaculation: clinical subgroups and etiology. J Sex Marital Ther 1989;15:130-4). Treatments include behavioural and pharmacological interventions.

OBJECTIVE

To systematically review evidence for clinical effectiveness of behavioural, topical and systemic treatments for PE.

DATA SOURCES

The following databases were searched from inception to 6 August 2013 for published and unpublished research evidence: MEDLINE; EMBASE; Cumulative Index to Nursing and Allied Health Literature; The Cochrane Library including the Cochrane Systematic Reviews Database, Cochrane Controlled Trials Register, Database of Abstracts of Reviews of Effects and the Health Technology Assessment database; ISI Web of Science, including Science Citation Index, and the Conference Proceedings Citation Index-Science. The US Food and Drug Administration website and the European Medicines Agency (EMA) website were also searched.

METHODS

Randomised controlled trials (RCTs) in adult men with PE were eligible (or non-RCTs in the absence of RCTs). RCT data were extrapolated from review articles when available. The primary outcome was intravaginal ejaculatory latency time (IELT). Data were meta-analysed when possible. Other outcomes included sexual satisfaction, control over ejaculation, relationship satisfaction, self-esteem, quality of life, treatment acceptability and adverse events (AEs).

RESULTS

A total of 103 studies (102 RCTs, 65 from reviews) were included. RCTs were available for all interventions except yoga. The following interventions demonstrated significant improvements (p < 0.05) in arithmetic mean difference in IELT compared with placebo: topical anaesthetics - eutectic mixture of local anaesthetics (EMLA(®), AstraZeneca), topical eutectic mixture for PE (Plethora Solutions Ltd) spray; selective serotonin reuptake inhibitors (SSRIs) - citalopram (Cipramil(®), Lundbeck), escitalopram (Cipralex(®), Lundbeck), fluoxetine, paroxetine, sertraline, dapoxetine (Priligy(®), Menarini), 30 mg or 60 mg; serotonin-noradrenaline reuptake inhibitors - duloxetine (Cymbalta(®), Eli Lilly & Co Ltd); tricyclic antidepressants - inhaled clomipramine 4 mg; phosphodiesterase-5 (PDE5) inhibitors - vardenafil (Levitra(®), Bayer), tadalafil (Cialis(®), Eli Lilly & Co Ltd); opioid analgesics - tramadol (Zydol SR(®), Grünenthal). Improvements in sexual satisfaction and other outcomes compared with placebo were evident for SSRIs, PDE5 inhibitors and tramadol. Outcomes for interventions not compared with placebo were as follows: behavioural therapies - improvements over wait list control in IELT and other outcomes, behavioural therapy plus pharmacotherapy better than either therapy alone; alpha blockers - terazosin (Hytrin(®), AMCO) not significantly different to antidepressants in ejaculation control; acupuncture - improvements over sham acupuncture in IELT, conflicting results for comparisons with SSRIs; Chinese medicine - improvements over treatment as usual; delay device - improvements in IELT when added to stop-start technique; yoga - improved IELT over baseline, fluoxetine better than yoga. Treatment-related AEs were evident with most pharmacological interventions.

LIMITATIONS

Although data extraction from reviews was optimised when more than one review reported data for the same RCT, the reliability of the data extraction within these reviews cannot be guaranteed by this assessment report.

CONCLUSIONS

Several interventions significantly improved IELT. Many interventions also improved sexual satisfaction and other outcomes. However, assessment of longer-term safety and effectiveness is required to evaluate whether or not initial treatment effects are maintained long term, whether or not dose escalation is required, how soon treatment effects end following treatment cessation and whether or not treatments can be stopped and resumed at a later time. In addition, assessment of the AEs associated with long-term treatment and whether or not different doses have differing AE profiles is required.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42013005289.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Current and Emerging Treatments for Premature Ejaculation

INTRODUCTION

Over the past 20-30 years, the premature ejaculation (PE) treatment paradigm, previously limited to behavioral 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).

AIM

The objective of this article is to review current and emerging PE interventions.

METHODS

Contemporary data on the treatment of PE were reviewed and critiqued using the principles of evidence-based medicine.

MAIN OUTCOME MEASURE

Integrated pharmacotherapy and cognitive behavioral therapy (CBT) may achieve superior treatment outcomes in some patients. Phosphodiesterase type 5 inhibitors alone or in combination with selective serotonin reuptake inhibitors (SSRIs) should be limited to men with acquired PE secondary to comorbid erectile dysfunction (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.

RESULTS

Multiple well-controlled evidence-based studies have demonstrated the efficacy and safety of 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 intravaginal ejaculation latency time compared with on-demand SSRIs. On-demand SSRIs are less effective but may fulfill the treatment goals of many patients.

CONCLUSIONS

Current evidence suggests that psychosexual CBT has a limited role in the contemporary management of PE and confirms the efficacy and safety of dapoxetine, off-label SSRI drugs, and topical anesthetics drugs. Treatment with tramadol, α1-adrenoceptor antagonists cannot be recommended until the results of large, well-designed randomized controlled trials 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 pharmacotherepeutic armamentarium. McMahon CG. Current and emerging treatments for premature ejaculation. Sex Med Rev 2015;3:183-202.

Behavioral Therapies for Management of Premature Ejaculation: A Systematic Review

INTRODUCTION

Premature ejaculation (PE) is defined by short ejaculatory latency and inability to delay ejaculation causing distress. Management may involve behavioral and/or pharmacological approaches.

AIM

To systematically review the randomized controlled trial (RCT) evidence for behavioral therapies in the management of PE.

METHODS

Nine databases including MEDLINE were searched up to August 2014. Included RCTs compared behavioral therapy against waitlist control or another therapy, or behavioral plus drug therapy against drug treatment alone. [Correction added on 10 September 2015, after first online publication: Search period has been amended from August 2013 to August 2014.].

MAIN OUTCOME MEASURE

Intravaginal ejaculatory latency time (IELT), sexual satisfaction, ejaculatory control, and anxiety and adverse effects.

RESULTS

Ten RCTs (521 participants) were included. Overall risk of bias was unclear. All studies assessed physical techniques, including squeeze and stop-start, sensate focus, stimulation device, and pelvic floor rehabilitation. Only one RCT included a psychotherapeutic approach (combined with stop-start and drug treatment). Four trials compared behavioral therapies against waitlist control, of which two (involving squeeze, stop-start, and sensate focus) reported IELT differences of 7-9 minutes, whereas two (web-based sensate focus, stimulation device) reported no difference in ejaculatory latency posttreatment. For other outcomes (sexual satisfaction, desire, and self-confidence), some waitlist comparisons significantly favored behavioral therapy, whereas others were not significant. Three trials favored combined behavioral and drug treatment over drug treatment alone, with small but significant differences in IELT (0.5-1 minute) and significantly better results on other outcomes (sexual satisfaction, ejaculatory control, and anxiety). Direct comparisons of behavioral therapy vs. drug treatment gave mixed results, mostly either favoring drug treatment or showing no significant difference. No adverse effects were reported, though safety data were limited.

CONCLUSIONS

There is limited evidence that physical behavioral techniques for PE improve IELT and other outcomes over waitlist and that behavioral therapies combined with drug treatments give better outcomes than drug treatments alone. Further RCTs are required to assess psychotherapeutic approaches to PE.

A randomized, double-blind, placebo-controlled, crossover trial of "on-demand" tramadol for treatment of premature ejaculation

Objectives:

The objective of this study is to assess the dose-related effects of tramadol on a group of patients with premature ejaculation (PE).

Subjects and Methods:

During the period of months between June 2010 and July 2012, 180 PE patients presented to outpatient clinic of our hospital. Patients were randomized in a 1:1:1 fashion to receive different sequences of the three medications: placebo, 50 mg of tramadol and 100 mg of tramadol. Every patient received 10 doses of each medication for 2 months. Intra-vaginal ejaculatory latency time (IELT) was recorded in seconds initially and for each arm. Successful treatment of PE is defined if IELT exceeded 120 s. Side-effects of medications were reported.

Results:

Of patients enrolled, 125 (69.4%) continued the study. Patients’ age range was 20-55 years with PE complaint of 1 to 10 years duration. Mean IELT was 72 at presentation, 82 for placebo, 150 for tramadol 50 mg, and 272 for tramadol 100 mg (P < 0.001 for all comparisons). PE was successfully treated in only 2.4% of patients with placebo, in contrast to 53.6% and 85.6% with 50 and 100 mg tramadol, respectively (P < 0.001 for all comparisons). On multivariate logistic regression analysis, baseline IELT was the only predictor of successful treatment of PE with both tramadol 50 mg (odds ratio [OR]: 1.05, 95% confidence interval [CI]: 1.03-1.07, P < 0.001) and tramadol 100 mg (OR: 1.07, 95% CI: 1.04-1.11, P < 0.001). Postmicturition dribble annoyed 12.8% of those who received 50 mg tramadol and 33.6% of those who received 100 mg tramadol (P < 0.001). Weak scanty ejaculation was the main complaint in 7.2% versus 21.6% of those using 50 and 100 mg tramadol, respectively (P = 0.002). Two patients discontinued tramadol 100 mg due to side-effects.

Conclusion:

Tramadol hydrochloride exhibits a significant dose-related efficacy and side-effects over placebo for treatment of PE.

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

BACKGROUND

Tramadol is a centrally acting analgesic prescribed off-label for the treatment of premature ejaculation (PE). However, tramadol may cause addiction and difficulty in breathing and the beneficial effect of tramadol in PE is yet not supported by a high level of evidence. The purpose of this study was to systematically review the evidence from randomised controlled trials (RCT) for tramadol in the management of PE.

METHODS

We searched bibliographic databases including MEDLINE to August 2014 for RCTs. The primary outcome was intra-vaginal ejaculatory latency time (IELT). Methodological quality of RCTs was assessed. Between-group differences in IELT and other outcomes were pooled across RCTs in a meta-analysis. Statistical and clinical between-trial heterogeneity was assessed.

RESULTS

A total of eight RCTs that evaluated tramadol against a comparator were included. The majority of RCTs were of unclear methodological quality due to limited reporting. Pooled evidence (four RCTs, 721 participants), suggests that tramadol is significantly more effective than placebo at increasing IELT over eight to 12 weeks (p = 0.0007). However, a high level of statistical heterogeneity is evident (I-squared = 74%). Single RCT evidence indicates that tramadol is significantly more effective than paroxetine taken on-demand, sildenafil, lidocaine gel, or behavioural therapy on IELT in men with PE. Tramadol is associated with significantly more adverse events including: erectile dysfunction, constipation, nausea, headache, somnolence, dry mouth, dizziness, pruritus, and vomiting, than placebo or behavioural therapy over eight to 12 weeks of treatment. However, addiction problems or breathing difficulties reported by patients for PE is not assessed in the current evidence base.

CONCLUSIONS

Tramadol appears effective in the treatment of PE. However, these findings should be interpreted with caution given the observed levels of between-trial heterogeneity and the reporting quality of the available evidence. The variability across placebo-controlled trials in terms of the tramadol dose evaluated and the treatment duration does not permit any assessment of a safe and effective minimum daily dose. The long-term effects and side effects, including addiction potential, for men with PE have not been evaluated in the current evidence base.

TRIAL REGISTRATION

The review is registered on PROSPERO 2013: CRD42013005289 .

Pharmacotherapy for premature ejaculation

PURPOSE OF REVIEW

As there are various drugs and different treatment strategies to delay ejaculation, a review of the current drug treatments for premature ejaculation is relevant for daily clinical practice.

RECENT FINDINGS

There are four premature ejaculation subtypes: lifelong premature ejaculation, acquired premature ejaculation, variable premature ejaculation and subjective premature ejaculation. These premature ejaculation subtypes vary in the duration of the intravaginal ejaculation latency time, their course in life and frequency of early ejaculations. Drug treatment is mainly required for lifelong and acquired premature ejaculation. On the other hand, counseling, psychoeducation and local anesthetics are particularly indicated for variable premature ejaculation and subjective premature ejaculation. Apart from the efficacy of various drugs, drugs against premature ejaculation can be taken on-demand or on a daily basis. However, apart from the on-demand use of dapoxetine, all other premature ejaculation treatments are off-label.

SUMMARY

Drug treatment is the first choice of treatment for lifelong premature ejaculation and may also be indicated for acquired premature ejaculation. Together with the patient, the clinician can choose which drug and which treatment strategy is most suitable for the patient and his partner.

Advances in treating premature ejaculation

In spite of its high prevalence and long history, the ambiguity regarding the definition, epidemiology and management of premature ejaculation continues. Topical anesthetic creams and daily or on-demand selective serotonin reuptake inhibitor (SSRI) treatment forms the basis of pharmacotherapy for premature ejaculation today, in spite of low adherence by patients. Psychotherapy may improve the outcomes when combined with these treatment modalities. Tramadol and phosphodiesterase type 5 inhibitors have a limited role in the management of premature ejaculation. Further research is required to develop better options for the treatment of this common sexual disorder.

An Update of the International Society of Sexual Medicine's Guidelines for the Diagnosis and Treatment of Premature Ejaculation (PE)

INTRODUCTION

In 2009, the International Society for Sexual Medicine (ISSM) convened a select panel of experts to develop an evidence-based set of guidelines for patients suffering from lifelong premature ejaculation (PE). That document reviewed definitions, etiology, impact on the patient and partner, assessment, and pharmacological, psychological, and combined treatments. It concluded by recognizing the continually evolving nature of clinical research and recommended a subsequent guideline review and revision every fourth year. Consistent with that recommendation, the ISSM organized a second multidisciplinary panel of experts in April 2013, which met for 2 days in Bangalore, India. This manuscript updates the previous guidelines and reports on the recommendations of the panel of experts.

AIM

The aim of this study was to develop clearly worded, practical, evidenced-based recommendations for the diagnosis and treatment of PE for family practice clinicians as well as sexual medicine experts.

METHOD

A comprehensive literature review was performed.

RESULTS

This article contains the report of the second ISSM PE Guidelines Committee. It offers a new unified definition of PE and updates the previous treatment recommendations. Brief assessment procedures are delineated, and validated diagnostic and treatment questionnaires are reviewed. Finally, the best practices treatment recommendations are presented to guide clinicians, both familiar and unfamiliar with PE, in facilitating treatment of their patients.

CONCLUSION

Development of guidelines is an evolutionary process that continually reviews data and incorporates the best new research. We expect that ongoing research will lead to a more complete understanding of the pathophysiology as well as new efficacious and safe treatments for this sexual dysfunction. We again recommend that these guidelines be reevaluated and updated by the ISSM in 4 years. Althof SE, McMahon CG, Waldinger MD, Serefoglu EC, Shindel AW, Adaikan PG, Becher E, Dean J, Giuliano F, Hellstrom WJG, Giraldi A, Glina S, Incrocci L, Jannini E, McCabe M, Parish S, Rowland D, Segraves RT, Sharlip I, and Torres LO. An update of the International Society of Sexual Medicine's guidelines for the diagnosis and treatment of premature ejaculation (PE). Sex Med 2014;2:60-90.

An update of the International Society of Sexual Medicine's guidelines for the diagnosis and treatment of premature ejaculation (PE)

INTRODUCTION

In 2009, the International Society for Sexual Medicine (ISSM) convened a select panel of experts to develop an evidence-based set of guidelines for patients suffering from lifelong premature ejaculation (PE). That document reviewed definitions, etiology, impact on the patient and partner, assessment, and pharmacological, psychological, and combined treatments. It concluded by recognizing the continually evolving nature of clinical research and recommended a subsequent guideline review and revision every fourth year. Consistent with that recommendation, the ISSM organized a second multidisciplinary panel of experts in April 2013, which met for 2 days in Bangalore, India. This manuscript updates the previous guidelines and reports on the recommendations of the panel of experts.

AIM

The aim of this study was to develop clearly worded, practical, evidenced-based recommendations for the diagnosis and treatment of PE for family practice clinicians as well as sexual medicine experts.

METHOD

A comprehensive literature review was performed.

RESULTS

This article contains the report of the second ISSM PE Guidelines Committee. It offers a new unified definition of PE and updates the previous treatment recommendations. Brief assessment procedures are delineated, and validated diagnostic and treatment questionnaires are reviewed. Finally, the best practices treatment recommendations are presented to guide clinicians, both familiar and unfamiliar with PE, in facilitating treatment of their patients.

CONCLUSION

Development of guidelines is an evolutionary process that continually reviews data and incorporates the best new research. We expect that ongoing research will lead to a more complete understanding of the pathophysiology as well as new efficacious and safe treatments for this sexual dysfunction. We again recommend that these guidelines be reevaluated and updated by the ISSM in 4 years.

Sexual dysfunction in 2013: Advances in epidemiology, diagnosis and treatment

OBJECTIVES

To provide a contemporary review of the epidemiology, diagnosis and treatment of premature ejaculation (PE) and erectile dysfunction (ED).

METHODS

We searched for English-language articles published in the past 12 months using the PubMed database. Relevant articles on the subjects of sexual dysfunction, ED and PE were selected for review.

CONCLUSIONS

Recent studies on male sexual dysfunction have provided new therapeutic possibilities. Tramadol, a well-used analgesic, has a new role in the treatment of PE. Super-selective targeting of dorsal penile nerves by surgery or cryoablative technologies might become a viable treatment option for refractory PE in the future. The role of ED as a harbinger of important comorbidities allows for the early detection and intervention of these conditions, which can optimise therapeutic outcomes. The long-term effect of chronic phosphodiesterase-5 inhibitors on endothelial dysfunction, the angiogenic potential of low-intensity extracorporeal shock wave therapy, and further advances in drug-eluting endovascular stents might in future allow clinicians to treat ED more definitively.