Assessing satisfaction in men with premature ejaculation after dapoxetine treatment in real-world practice

Effects of One-Shot Hyaluronic Acid Injection in Lifelong Premature Ejaculation: A Pilot Study

The therapeutic management of premature lifelong ejaculation (PE) ranges from behavioral therapy to pharmacological and surgical treatments. Hyaluronic Acid (HA) injection into the glans penis is a non-surgical procedure, intended to reduce glans hypersensitivity, improving the intravaginal ejaculation latency time (IELT). HA injection can be performed through different techniques that, although safe and effective, rarely can cause local complications. In this pilot uncontrolled study, we tested the effectiveness of a new technique based on a single HA injection into the frenulum of the glans, to improve IELT in a sample of patients affected by PE. We observed a significant increase of the IELT after one (median 73.3, IQR 66.2–79.9 s) and two months (66.2, 63.1–73.9) that gradually decreased at three months, remaining still significantly higher than at baseline (34.8, 30.9–37.4). PEDT and IIEF questionnaires significantly improved compared to baseline in the first two months of follow-up (p < 0.001). In conclusion, the preliminary results emerging from this pilot uncontrolled study, highlight the effectiveness of this one-shot HA injection approach, although a larger sample and longer follow-up time are needed to standardize the procedure.

Ejaculatory dysfunction in men with diabetes mellitus

Diabetes mellitus (DM) is a metabolic disorder that is characterized by elevated blood glucose levels due to absolute or relative insulin deficiency, in the background of β-cell dysfunction, insulin resistance, or both. Such chronic hyperglycemia is linked to long-term damage to blood vessels, nerves, and various organs. Currently, the worldwide burden of DM and its complications is in increase. Male sexual dysfunction is one of the famous complications of DM, including abnormal orgasmic/ejaculatory functions, desire/libido, and erection. Ejaculatory dysfunction encompasses several disorders related to DM and its complications, such as premature ejaculation, anejaculation (AE), delayed ejaculation, retrograde ejaculation (RE), ejaculatory pain, anesthetic ejaculation, decreased ejaculate volume, and decreased force of ejaculation. The problems linked to ejaculatory dysfunction may extend beyond the poor quality of life in diabetics as both AE and RE are alleged to alter the fertility potential of these patients. However, although both diabetes patients and their physicians are increasingly aware of diabetic ejaculatory dysfunction, this awareness still lags behind that of other diabetes complications. Therefore, all these disorders should be looked for thoroughly during the clinical evaluation of diabetic men. Besides, introducing the suitable option and/or maneuvers to treat these disorders should be tailored according to each case. This review aimed to explore the most important findings regarding ejaculatory dysfunction in diabetes from pre-clinical and clinical perspectives.

A comprehensive assessment of genetic variation in serotonin transporter gene (5-HTTLPR+rs25531) and the response to dapoxetine in Chinese patients with premature ejaculation

This study was to explore whether serotonin transporter gene-linked polymorphic region polymorphisms (5-HTTLPR+rs25531) influence the response to dapoxetine treatment in a Chinese population with premature ejaculation (PE). 112 patients with PE re-enrolled from our previous study received dapoxetine monotherapy. At the endpoint, patients with S'S' had a significant increased risk of nonresponse compared with L' carriers (p < .001). The improvement in S'S' genotype was significantly lower in premature ejaculation profile (PEP) items of 'control over ejaculation' (p = .035) and 'distress related to ejaculation' (p = .017) than that in L' carriers. As to clinical global impression of change (CGIC), results in S'S' subjects showed significantly lower scores (p = .008) and a less satisfaction rate reporting at least 'better' (p = .020) compared with L' carriers. Moreover, our findings suggested that patients with S'S' were more likely to develop adverse effects (AEs) compared with L' carriers (p = .040). This study suggests that PE patients bearing the S'S' genotype have an inferior comprehensive efficacy and safety of dapoxetine treatment, which consist of poorer response in IELTs, less improvement in patient-reported outcome (PRO) measures and greater incidence of AEs, than L' carriers. Variants of triallelic 5-HTTLPR may play a major role as a predictor of treatment response to dapoxetine.

An Internally Validated Nomogram for Predicting the Likelihood of Improvement of Clinical Global Impression in Patients With Lifelong Premature Ejaculation Treated With Dapoxetine

BACKGROUND

Although the introduction of dapoxetine has ushered in a new era in the treatment of premature ejaculation, many patients with lifelong premature ejaculation (LPE) exhibit an unimproved clinical global impression even after treatment with dapoxetine.

AIM

To investigate independent predictors of the improvement of Clinical Global Impression (iCGI) in patients with LPE treated with dapoxetine and develop a nomogram to predict a patient's likelihood of achieving iCGI.

METHODS

Data of 243 patients with LPE diagnosed at Xijing Hospital (Xi'an, China) and Northwest Women's and Children's Hospital (Xi'an, China) from January 2019 to May 2020 were analyzed. Independent predictors of iCGI were identified, and a nomogram was developed using R software based on a multivariate logistic regression model. The predictive accuracy of the nomogram was measured using the area under the receiver operating characteristic curve. The nomogram was calibrated by comparing predictions with observations.

MAIN OUTCOME MEASURES

The primary outcome was the patient-rated Clinical Global Impression of Change scale score after a 4-week course of dapoxetine treatment, which was collected via an online questionnaire. A Clinical Global Impression of Change score of ≥1 was defined as iCGI in this study.

RESULTS

Patients with LPE with at least a bachelor's degree, a self-reported intravaginal ejaculation latency time of >1 minute, and an International Index of Erectile Function question 5 score of ≥3 were independent factors associated with achieving iCGI, whereas a Premature Ejaculation Diagnostic Tool question 1 score of ≥2 was an independent factor negatively associated with achieving iCGI. The predictive accuracy of the nomogram, which was developed by integrating all variables with independent predictive significance, was 0.710 (95% confidence interval: 0.702-0.718). In addition, the calibration plot demonstrated excellent agreement between predictions and observations.

CLINICAL IMPLICATIONS

If the predictive performance of our nomogram is further proven in multiple external validations, it can be used to select suitable patients for dapoxetine treatment, thereby reducing the number of patients discontinuing treatment.

STRENGTHS & LIMITATIONS

This study developed the first nomogram for predicting the likelihood of achieving iCGI in patients with LPE treated with dapoxetine. However, our nomogram was not externally validated using independent cohorts from other institutions.

CONCLUSION

This study identified several independent predictors of iCGI in patients with LPE treated with dapoxetine. An effective nomogram was developed to predict their likelihood of achieving iCGI. External validations using data of Western patients with LPE are required to test the broader applicability of this Chinese patient-based tool. Hou G, Gao M, Zhang L, et al. An Internally Validated Nomogram for Predicting the Likelihood of Improvement of Clinical Global Impression in Patients With Lifelong Premature Ejaculation Treated With Dapoxetine. J Sex Med 2020;17:2341-2350.

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.

Efficacy of dapoxetine treatment in Chinese patients with premature ejaculation and possible factors affecting efficacy in the real-world practice

BACKGROUND

The treatment effect of dapoxetine in real-world practice is not well established. This study was to investigate the factors influencing efficacy of dapoxetine for the treatment of Premature ejaculation (PE) in the real-world setting.

METHODS

Altogether 154 patients were followed up between Jan 2015 and Dec 2015. The clinical global impression of change (CGIC), premature ejaculation profile (PEP), the estimated intravaginal ejaculation latency time (eIELT) and estimated number of intravaginal thrusts before ejaculation (NITBE) were collected. The clinical characteristics of patients with CGIC = 0 and CGIC≥1 were compared.

RESULTS

After 4 weeks treatment, an obvious improvement compared with the baseline was found regarding mean eIELT (2.4 ± 1.6 min vs 1.0 ± 0.7 min, P < 0.001) and mean NITBE (85.9 ± 61.9 times vs 37.4 ± 28.6 times, P < 0.001). The proportion of patients with a self-evaluation of at least "slightly better" and were categorized into "CGIC≥1" group was 70.1%. There were significant differences between patients in the "CGIC = 0" and "CGIC≥1" groups regarding mean NITBE (P = 0.010) and PEDT (P = 0.009) score at baseline. The adverse effects were acceptable.

CONCLUSION

Dapoxetine was well-tolerated and improved the sexual satisfaction of patients with PE. The severity of PE based on PEDT and NITBE suggest that there could be an effectiveness change with dapoxetine use in real-world practice.

Sexual Dysfunction in Men with Prediabetes

INTRODUCTION

Previous studies have shown a strong association between diabetes mellitus (DM) and the frequency and severity of some aspects of male sexual dysfunction (SD). The same relationship with prediabetes (preDM) has been less well investigated.

AIM

To systematically review the current literature on the association between preDM and SD, focusing on erectile dysfunction (ED), sex steroid hormone alterations, and premature ejaculation (PE).

METHODS

The present review was conducted in accordance with the PRISMA declaration standards for systematic reviews. A systematic search for the terms "male sexual dysfunction," "prediabetes," "IFG or IGT," "glycemia," "ED," "ejaculation," and "hypoactive sexual desire disorder" was carried out in the PubMed and Embase databases.

MAIN OUTCOME MEASURE

Prevalence of SD in men with preDM and severity of ED, PE, and hormone alterations in men with preDM compared with controls.

RESULTS

12 studies reporting data on the association between SD and preDM were found in the literature. According to these studies, ED is more prevalent in men with preDM compared with controls, the severity of ED increases progressively as a function of impaired glucose metabolism, testosterone values and preDM are strongly correlated, men with preDM are at increased risk of testosterone deficiency and hypogonadism, men with hypogonadism have a higher prevalence of preDM, and the association between PE and preDM is controversial.

CONCLUSION

PreDM is a common and underdiagnosed clinical condition that is strongly associated with male SD. A detailed glucose metabolism investigation should be performed in every patient with SD to screen for glucose abnormalities and eventually to implement prevention program to decrease their chances of developing life-changing chronic illnesses. Boeri L, Capogrosso P, Ventimiglia E, et al. Sexual Dysfunction in Men with Prediabetes. Sex Med Rev 2019;8:622-634.

Practice Patterns Among Korean Urologists for Glans Penis Augmentation Using Hyaluronic Acid Filler in the Management of Premature Ejaculation

Introduction

Glans penis augmentation (GPA) using hyaluronic acid (HA) gel has been developed for treating premature ejaculation (PE) with penile hypersensitivity. The injected HA filler creates a barrier that reduces the tactile stimuli to the hypersensitive dorsal nerve. Although the HA filler is biodegradable and is believed to not cause permanent loss of sexual function, the current International Society for Sexual Medicine guideline for PE does not recommend this procedure owing to concerns regarding sexual dysfunction.

Aim

To investigate the practice patterns for GPA using HA filler among Korean urologists, and to identify whether urologist experienced patient reports of sexual dysfunction post-treatment.

Methods

Between March 2016 and July 2016, a specially designed questionnaire was mailed to 86 selected Korean urologists who had used injectable materials to treat PE.

Main Outcome Measures

The prevalence and awareness of sexual dysfunction after GPA using HA filler were evaluated.

Results

Overall, 56 urologists completed the survey (response rate: 69.2%), of which 36 (64.3%) had performed GPA using HA filler. They reported having performed a combined total of 4,344 such GPA procedures. Most urologists (72.7%) performed GPA using HA filler in patients who benefit from topical anesthetics. Patients with a history of failed pharmacotherapy (59.1%) and selective dorsal nerve neurotomy (45.5%) were selected for GPA using HA filler. The respondents (44.4%) encountered overall 206 (4.7%) cases of patients reports of recurrence of PE. Interestingly, only 36 (0.8%) cases of glans pain or paresthesia and no cases of erectile dysfunction post-treatment were reported.

Conclusion

Korean urologists performed GPA using HA filler when pharmacotherapy failed or if there was a response to topical treatment. Paresthesia and hypoesthesia after GPA using HA filler are rare, and no cases of erectile dysfunction were encountered by Korean urologists.

Jeong HG, Ahn ST, Kim JW, et al. Practice Patterns Among Korean Urologists for Glans Penis Augmentation Using Hyaluronic Acid Filler in the Management of Premature Ejaculation. Sex Med 2018;6:297–301.

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.

Diagnosis and Treatment of Premature Ejaculation by Urologists in South Korea

Purpose

This study discusses the treatment of premature ejaculation (PE) using various approaches with the goal of evaluating the methods of diagnosis and treatment of PE in clinical practice in 2014 in South Korea.

Materials and Methods

We surveyed 200 urologists and andrologists who treated patients with PE from July 1, 2014 to July 29, 2014 using an online questionnaire. The questionnaire was composed of 4 parts: disease, comorbidities, diagnosis, and treatment. Using the answers to this survey, current trends in the diagnosis and treatment of PE were investigated using weighted averages.

Results

The median number per month of patients who were diagnosed with PE was 14 patients (interquartile range, 7~24). The time to ejaculation necessary for a diagnosis of PE was considered to be <1 minute by 12% of respondents, <2 minutes by 27%, <3 minutes by 28%, <5 minutes by 13%, and 20% stated that diagnosis was based on a patient's subjective complaint. The treatment methods preferred by PE patients were reported to be pharmacological treatment (87%), surgical treatment (9.5%), and behavioral management (3.5%). The treatment methods used by respondents were pharmacological treatment (77%), surgical treatment (15%), and behavioral management (14%). The most commonly used pharmacological treatment was the oral administration of dapoxetine (97%).

Conclusions

In 2014 in South Korea, various methods were used to diagnose and treat PE. The most commonly used treatment for PE was the oral administration of dapoxetine. It was also found that surgical treatment was applied in some cases.

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.

Efficacy and safety of dapoxetine in treatment of premature ejaculation: an evidence-based review

BACKGROUND

Premature ejaculation (PE) is a major issue in male sexual health, with a global prevalence estimated to be between 20% and 40%, making it the most common sexual dysfunction in men. PE causes distress and reduced quality of life for patients and has a negative impact on interpersonal relationships. Historically, it has been treated with cognitive therapy, behavioural methods and off-label use of selective serotonin reuptake inhibitors (SSRIs) usually used to treat depression and other psychological disorders. Dapoxetine is the only SSRI specifically designed to treat PE.

MECHANISM OF ACTION

Dapoxetine hydrochloride is a potent inhibitor of serotonin reuptake transporters. Dapoxetine is suited for 'on-demand' treatment of PE because of its rapid absorption and short initial half-life.

EFFICACY

Evidence from published studies showed that dapoxetine 30 mg or 60 mg taken 'on-demand' results in a significant increase in intravaginal ejaculatory latency time (IELT) when compared with placebo. Most patient-reported outcomes are clearly improved relative to placebo following dapoxetine therapy, indicating greater control over ejaculation, more satisfaction with intercourse, less ejaculation-related distress and significantly reduced interpersonal difficulties.

SAFETY

The most common adverse events with dapoxetine are nausea, dizziness, somnolence, headache, diarrhoea and insomnia. Usually they do not lead to drug discontinuation.

CONCLUSION

Dapoxetine is the only effective and safe available on-label oral treatment for PE, and its use can result in better quality of life for the patient and their sexual partner.

The office management of ejaculatory disorders

Premature ejaculation (PE), delayed ejaculation (DE), anejaculation (AE) and retrograde ejaculation (RE) are four main ejaculatory disorders (EjDs) observed in clinical practice. Despite their high prevalence, EjDs remain underdiagnosed and undertreated. Primary care physicians should incorporate the discussion of sexual health topics into routine visits to facilitate EjD diagnosis and treatment. Because the causes of EjDs are multifactorial, the management of EjDs is etiology-specific and may require a holistic approach. Dapoxetine, a selective serotonin reuptake inhibitor, is the only drug approved for on-demand treatment of lifelong and acquired PE. In clinical practice, scheduled follow-up visits, risk factor treatment, appropriate dose escalation, adequate sexual attempts, patient education, and partner involvement are critical factors responsible for optimal overall management of PE and dapoxetine treatment outcomes.