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Weekly UpdatesThe Problem
A 63-year-old retired mechanic with a history of diabetes mellitus and hypertension presents to you for a new medical issue. One year ago you treated him for tobacco dependence with 6 months of varenicline, and he has remained abstinent from tobacco. Three months after discontinuing varenicline, he presented with his wife for lifelong issues with depression, which became more manifest after he quit smoking. You diagnosed him with depression and started him on bupropion SR, and his mood subsequently improved. He has now presented alone for issues related to premature ejaculation "for as long as he can remember," which has become a significant issue in his marriage. He reports little voluntary control over his ejaculation and says that he is developing significant "performance anxiety." He says that he achieves intromission about 20% of the time. He denies issues with libido or erectile dysfunction. He is currently on lisinopril, metformin, bupropion, aspirin, and simvastatin. He is reluctant to take more medications and is wondering if there is something that he could take "as needed." You are aware that selective serotonin reuptake inhibitors (SSRIs) have some efficacy for this but wonder if he can take them as needed.
The Question
In patients with premature ejaculation, are SSRIs taken as needed more helpful for prolonging ejaculatory latency than placebo?
The Search
You log on to PubMed (www.pubmed.gov) and enter search terms "premature ejaculation" AND "antidepressants" and limit the search to randomized, controlled trials. You find a relevant study. (See box at right.)
Our Critique
In this crossover study, subjects had a reasonable washout period of 3 weeks before they crossed over to the other treatment arm. As suggested by the authors, the improvement in ejaculatory intervals within the first 2 weeks of paroxetine treatment suggest that this effect is mediated by a direct blocking of central serotonergic reuptake and not through alleviation of depressive symptoms, which typically takes several weeks. The dose given (20 mg) is the starting dose for depression and is only taken as needed, which makes this an attractive clinical intervention with proven benefit and a low likelihood of significant side effects. Your patient would have been excluded from the current study because he is on an antidepressant.
Clinical Decision
You continue the bupropion SR and prescribe paroxetine 20 mg by mouth as needed to be taken 3-4 hours before sexual intercourse.
RELATED ARTICLE: C.G. McMahon and K. Touma
Treatment of premature ejaculation with paroxetine hydrochloride as needed: Two single-blind, placebo-controlled crossover studies. J. Urol 1999;161:1826-30.
* Design: Two single-blind, crossover studies were included in this report. The first study prescribed paroxetine ad lib, and the second prescribed paroxetine ad lib after a 3-week course of daily paroxetine. The first study is most relevant to our patient who wishes to take a medication only "as needed."
* Subjects: Eligible subjects had to be male, heterosexual, in a stable relationship, and have normal sexual potency. Potential subjects were excluded if they had a sexual disorder, erectile dysfunction, reduced sexual desire, inhibited male orgasm, alcohol or substance abuse, use of psychotropic or antidepressant medications, or a chronic depressive, psychiatric, or physical illness.
* Intervention: Subjects were randomized to 20 mg paroxetine (group A) or placebo (group B) as needed 3-4 hours before planned intercourse for 4 weeks. Crossover was conducted after a 3-week drug-free washout period. Subjects crossed over for an additional 4 weeks of treatment.
* Outcomes: The primary outcome was coital frequency and ejaculatory latency times. Pretreatment ejaculatory latency time was measured during a 3-week baseline period during which time patients were asked to have sexual intercourse 3 times per week. Pretreatment coital frequency was the mean number of attempts during the previous 3 months. Subjects were given a diary to record the frequency of coitus, quality of erection and orgasm, and measurement of ejaculatory latency time using a stopwatch.
* Results: A total of 26 men with mean age of 39.5 years (range 19-55), mean pretreatment ejaculatory latency time of 0.3 minutes, and mean pretreatment coital frequency of 0.5 times/were randomized into two groups. For group A, both parameters increased during initial paroxetine treatment (3.2 minutes and 3.2 times/week 4) and decreased during subsequent placebo treatment (0.45 minutes and 0.9 times/week at week 11). For group B, both parameters increased slightly during initial placebo treatment (0.6 minutes and 1.3 times/week at week 4) but increased dramatically during subsequent paroxetine treatment (3.5 minutes and 3.1 times/week at week 11). Ejaculatory latency time for groups A and B was statistically superior with the drug, compared with placebo. Intra-vaginal ejaculation was achieved by one-third of patients who had never achieved it after 2 weeks of treatment. Intravaginal ejaculation was not achieved with placebo.
BY JON O. EBBERT, M.D., AND ERIC G. TANGALOS, M.D.
DR. EBBERT and DR. TANGALOS are with the Mayo Clinic in Rochester, Minn. They have no conflict of interest to report. To respond to this column or suggest topics for consideration, write to Dr. Tangalos at our editorial offices or e-mail them at imnews@elsevier.com.
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