There are some experts who think drug therapy should be more widely used. An article in Current Opinion in Investigational Drugs called for increased use of SSRI therapy, on the grounds that its overview of these drugs had established that paroxetine was the most effective treatment for PE.
They also observed that daily intake gives better ejaculation control (by which we mean delay between penetration and ejaculation) than treatment on an ad hoc basis. (This means of course that the drugs are permanently in the patient’s body, which has implications for tolerance and raises concerns about possible side-effects.)
A study reported in The Journal of Clinical Psychopharmacology concluded that the time between penetration and ejaculation could be extended from one minute or less to about two minutes in men who had received treatment with paroxetine, fluoxetine, and sertraline. In my opinion, the risks of drug treatment far outweigh the rewards for an improvement of such a short time – especially when more conventional sexual-therapy-based methods can effectively provide complete control. The problem seems to be that we are in a society where the drug treatment of PE potentially rewards the drug companies with massive profits and the patients with little effort.
UroToday.com defines PE, quite correctly, as the recurrent approach of orgasm and ejaculation with little or no sexual stimulation, shortly before or after penetration and certainly before the sexual partners wish for it to happen.
The journal then observes that while the established view is that PE is a psychological condition, recent opinion suggests that disturbances of serotonergic 5-hydroxytrptamine (5-HT) neurotransmission might be a causative factor – and hence drug therapies which target the 5-HT system might be an effective treatment. Francisco Giuliano has studied the efficiency of Dapoxetine in the treatment of premature ejaculation and published his results in the July 2007 European Urology Supplements.
Dapoxetine hydrochloride is a selective serotonin reuptake inhibitor (SSRI), but it has the benefit of having a short half life, which means it stays in the body for a much shorter time. It’s been developed specifically for the treatment of men with PE.
“Older” SSRI’s work by increasing the level of 5-HT neurotransmission but the majority of SSRI’s such as fluoxetine, sertraline, and paroxetine (all of which can increase the time delay between intromission or penetration and ejaculation) don’t reach the maximum level in the bloodstream for several hours after they have been taken.
This means that men who wish to try this remedy for premature ejaculation cannot take these SSRI drugs just before sex (as is possible with Viagra in cases of erectile dysfunction). By contrast, Dapoxetine inhibits serotonin reuptake and takes only one hour to reach maximum concentration in the bloodstream.
In addition, it is eliminated quickly from the body and it therefore has the profile of an on-demand medication which gives it both greater commercial possibilities and greater effectiveness for the man who, together with his doctor, wishes to adopt this as a treatment for premature ejaculation.
The studies which demonstrated the potential effectiveness of Dapoxetine involved over 2600 men who were given between 30 and 60 mg of Dapoxetine between one and three hours before sex.
The average age of the men taking part in the drug treatment trial was forty years – surprisingly old, for I have always had the impression that men lose their tendency to premature ejaculation as they get older.
It would therefore seem likely that these men were suffering from both long-standing and sever premature ejaculation. Indeed, almost two-thirds of the men reported life-long problems with premature ejaculation, and about a third of the men has developed premature ejaculation after a period of normal sexual relationships (i.e. satisfactory vaginal intercourse).
The researchers measured the time between intromission and ejaculation and found that although a placebo did lead to an increase in the length of intercourse, it was nowhere near as significant as the increased length of intercourse with dapoxetine.
At 30 mg dosage, intercourse increased from an average of 0.92 minutes to 2.78minutes. With 60 mg of dapoxetine, it increased from an average of 0.92 minutes to 3.32 minutes. This improvement was maintained over the twelve weeks of the study.
Of course, the issue of side-effects always comes up: but the Dapoxetine produced relatively few side-effects, which included nausea and headache. Nausea occurred in 8.7% of men given 30 mg and 20.1% of men given 60 mg. Headaches occurred in 5.9% of the men given 30 mg and 6.8% of the men given 60 mg.
Unfortunately 4% of men taking the lower dose had sufficiently severe effects to require the cessation of treatment, as did 10% of men given the higher dose. These are rather high figures for a drug which seems to have limited use as a premature ejaculation treatment and only produces a relatively short increase in vaginal intercourse duration.
Giuliano F Eur Urol Supp. 6(13):780-6, July 2007
A drug developed for treatment of premature ejaculation
The New Scientist has reported the outcome of this study of the effectiveness of Dapoxetine treatment on nearly 2000 men who were diagnosed with either moderate or sever premature ejaculation.
Before taking the drug, these men had an average time before ejaculation of less than one minute after penetration. Again, they were given either a placebo “treatment” or 30 or 60 mg of dapoxetine, which was taken between one and three hours before intercourse.
After twelve weeks of taking the drug treatment, the average time before ejaculation had gone up from less than a minute to 2.8 minutes for the lower dose and 3.3 minutes for the higher dose. Hardly delayed ejaculation, but still better for the female partner due to longer lasting intercourse (and presumably more satisfying in bed, too).
Even better, the authors of the study suggested that the men’s subjective view of how well they could control their ejaculation and how satisfied they were with sex had improved markedly, as had their partner’s level of satisfaction.
No license for drug treatment of premature ejaculation
Dapoxetine was developed for controlling premature ejaculation, but although the researchers have claimed it to be safe and effective, the FDA has not given it a license.
The side effects include nausea, diarrhea, headaches and dizziness. And the other problem is this: according to Marcel Waldinger, a neuropsychiatrist at Leyenburg Hospital in The Hague, existing SSRIs have already found a place in the treatment regime for premature ejaculation, and work with greater efficiency.
He says that the best way to prevent PE is by continual use of existing SSRIs. he observes that these drugs produce an increase in time between intromission and ejaculation of about nine times, while Dapoxetine only increases the time by a factor of three. According to Waldinger, one also has to ask about the motives of the drug companies in developing a drug specifically to treat PE.
Waldinger has studied the time that men last between penetration and ejaculation on average: his findings make interesting reading. The study was carried out in 2005 and he discovered that – in the general population – not just among men seeking treatment or cure for premature ejaculation – the average length of intercourse was just 5.4 minutes in The Netherlands, the UK, the US and Spain. In Turkey the average time to ejaculation was 3.7 minutes.
So where does this leave us? Men who identify as having premature ejaculation, and who seek treatment for it, may actually be in the normal range of sexual activity for men in their general population.
This does not mean that treatment should be denied, for as we have seen, the definition of PE these days is tailored specifically to include a factor of the man’s subjective satisfaction (or lack thereof) with his sexual performance.
But the danger is that the drug companies create a pathology out of a normal condition so that they can sell drugs to deal with it. And most men will sometimes experience a rapid ejaculation – it is normal.
This of course brings back into play the difficulty of definition: PE has been described as the most common male sexual problem, affecting between a fifth and a third of all men. But what does that mean, if it is so common? Isn’t it then a “normal” condition? Waldinger concludes by observing that he believes only men who have experienced lifelong PE should receive drugs. As he (in my opinion correctly) observes, lifelong PE is a much rarer problem, and probably only affects 1% to 5% of men. New Scientist 8 September 2006 and The Lancet (volume 368, p 929)
More scientific reviews of drug treatment of premature ejaculation
What follows is a summary of treatment of premature ejaculation adapted from Medscape.
SSRIs have been administered to increase ejaculatory delay; because they are associated with inability to ejaculate and erectile dysfunction. Unfortunately, continual administration of SSRIs is linked to dry mouth, nausea, drowsiness, and reduced libido. Dapoxetine hydrochloride (DPX) has been studied and indeed has undergone Phase III trials. DPX is a serotonin transport inhibitor (STI) which has a pharmokinetic profile suitable for “on-demand” usage in the treatment of PE.
Unlike other oral agents, DPX works quickly and is effective from the first dose. [Editor: as previously mentioned, FDA approval has not yet been forthcoming.] The worst side-effects of SSRIs is that they not only cause decreased libido but they can cause erectile dysfunction.
Another category of drugs which have been studied as possible candidates for the management of premature ejaculation are Phosphodiesterase-5 (PDE-5) inhibitors. The somewhat tenuous connection with quick climax is their ability to prolong erections.
It’s been established that PDE-5 inhibitors are useful in the treatment of men who have premature ejaculation secondary to erectile dysfunction, and that they can be used in association with other drugs such as SSRIs.
Anesthetic substances which can be administered to the surface of the penis have been tested in the treatment of premature ejaculation. [Editor: though some studies have shown an increase in ejaculatory delay times, evidence from my own experience with men who have premature ejaculation is that these creams, whether administered to the surface of the penis or contained in a condom, do not have much impact on PE, but they do remove sensation, thereby making sex even less satisfactory for both partners.]
Clomipramine: at 25 – 50 mg per day increases sexual latency from 1 minute to 3 to 6 minutes
Fluoxeline: at 5 – 60 mg per day increases sexual latency from 1 minute to 2 to 9 minutes
Paroxeline: at 20 – 40 mg increases sexual latency from 1 minute to 3 to 10 minutes
Sertraline: at 25 – 100 mg increases sexual latency from 1 minute to 3 to 6 minutes
The higher the dose, the longer the ejaculatory delay. But at high does, there are unpleasant psychotropic side-effects. These drugs stay in the body for a long time, and they cannot be given on-demand. As soon as the drugs are reduced, the man’s inability to control his ejaculation returns. The summary of this treatment regime, therefore, is that it is “woefully inadequate”.
Obviously the ideal drug for controlling premature ejaculation is going to interfere with the signal from the brain to the penis in a way that allows on-demand treatment (i.e. you take it just before sex), be fast-acting with a short half-life, and deal with the specific serotonin receptors that deal with ejaculation.
It’s worth making the observation at this point that the behavioral therapies are effective but they do require a co-operative partner. The simple fact is that premature ejaculation is underdiagnosed and undertreated. None of the current drug treatments are FDA-approved.