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Premature Ejaculation Treatment - DrugsPremature ejaculation (PE) is - at least in part - a learned behavior or conditioned response partly caused by stress and anxiety, which may originate in early sexual experiences. Anxiety promotes the release of adrenalin, and this makes the smooth muscle of the penis contract (a possible cause of secondary erectile dysfunction). Treatment strategies developed by psychologists and sex therapists ranged from psychoanalysis to Masters & Johnson's squeeze technique. But these techniques need to be practiced regularly to maintain the gains from the initial treatment. We can define PE as the recurrent approach of orgasm and ejaculation with little or no sexual stimulation, shortly before or after penetration and before the sexual partners wish for it to happen. While the established view is that the cause is psychological, some research suggests that disturbances of 5-hydroxytryptamine (5-HT) neurotransmission - better known as serotonin - might be a causative factor, and hence drug therapies which target the 5-HT system might be an effective treatment. And indeed, it's been known for a long time that serotonergic antidepressant drugs (SSRIs) may cause retarded or delayed ejaculation in men who take them for depression. As a result of this observation, certain anti-depressants, drugs known as selective serotonin reuptake inhibitors (SSRIs), have been used unofficially, or off label, as it is termed, for some time to stop premature ejaculation. Ann ideal drug for slowing ejaculation would be discreet, preferably oral; work rapidly, be eliminated rapidly, not accumulate in the body, and be well tolerate with few side-effects. Dapoxetine - The Slowest Of All Premature Ejaculation Cures?Dapoxetine, a relatively new short-acting SSRI is a powerful inhibitor of serotonin reuptake and is a serotonin transporter inhibitor. Experiments on animals have shown that intravenous Dapoxetine in varying doses has the capacity to reduce the emission and expulsion phases of ejaculation directly proportional to the dosage. Dapoxetine works - at least in rats - by increasing the pudendal motor neuron (nerve cell) reflex latency period. In one study, just over 1700 men tried varying doses of Dapoxetine (0, 30 mg and 60 mg) taken between 1 and 3 hours before sexual intercourse. On follow-up, the men revealed increased satisfaction with sexual intercourse, increased control of what was previously premature ejaculation, and reduced symptom severity. What's more, Dapoxetine was shown to work equally well in acquired and lifelong premature ejaculation (a finding which has since been questioned). Men who had the shortest time between penetration and ejaculation (thirty seconds or less) showed a more or less 7 fold increase in the length of time for which they could make love. Those who previously lasted between 1 and 2 minutes could now last for three times as long. The most common side-effect of Dapoxetine seems to be nausea. Dapoxetine does not apparently accumulate in the body to a significant extent, and seems to be rapidly eliminated. But it is a fairly major stretch to imagine this heavy duty pharmaceutical will be licensed for the treatment of premature ejaculation by FDA approval in the USA, though it is licenced and marketed as Priligy in Europe. Why? Not least because it interferes
with brain chemistry - and SSRIs are associated with undesirable and
sometimes troublesome side-effects after long-term application, such as
mental and emotional issues, psychiatric problems, skin reactions,
weight gain, lowered libido, sickness and nausea, headache, stomach
upsets, dry mouth, nervousness, headache, drowsiness, gastrointestinal
upset, diarrhea and restlessness and muscle weakness. According to other research, most doctors seem to think that PE causes only minor or no distress to men who have it (a trifle odd, since presumably a lot of doctors have it and know how it affects them). About a tenth of all men with the condition have spoken to a doctor about PE and a massive 85% of them report there was little or no improvement after consultation. In this, as in so many other ways, it seems doctors are letting their patients down - even if the only recommendation they can make is for sexual therapy. So it would seem there is tremendous pressure for a PE pill - could Dapoxetine fit the bill? Before answering that question, here's a little bit of history first: SSRIs have actually long been administered to increase ejaculatory delay because they are associated with delayed ejaculation or even anorgasmia (unfortunately they are also associated with erectile dysfunction). Equally unfortunately, continual administration of SSRIs is linked to dry mouth, nausea, drowsiness, and reduced libido. However, dapoxetine hydrochloride (DPX) is a serotonin transport inhibitor (STI) which has a pharmokinetic profile suitable for "on-demand" usage in the treatment of premature ejaculation. Unlike other oral agents, DPX works quickly and is effective from the first dose. [Editor's note: FDA approval has not yet been forthcoming.] For example, prior to the development of Dapoxetine, these compounds were investigated: 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 these treatment regimes, therefore, is that they were "woefully inadequate". Obviously the ideal drug for controlling PE 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. Dapoxetine: a drug developed for treatment of premature ejaculationThe New Scientist has reported the outcome of a study of the effectiveness of Dapoxetine treatment on nearly 2000 men who were diagnosed with either moderate or severe 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. 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. But do drugs really represent an effective treatment for premature ejaculation?Dapoxetine 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 such as fluoxetine, sertraline, and paroxetine work by increasing the level of 5-HT neurotransmission but 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 severe 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 2.78 minutes. 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. Having said that, this drug seems to be pretty well tolerated by men with premature ejaculation, who seem to have a different side effect profile than men with depression using these drugs. However, one has to ask if these are desirable side-effects: yawning, nausea, perspiration, fatigue and loose bowel movements! Even if, as is claimed, these adverse effects gradually disappear with use, ingesting serotonergic compounds still seems a dramatic way to try and prevent premature ejaculation and last a bit longer during sex! Furthermore, some men will experience much worse symptoms, which include SSRI discontinuation syndrome, diabetes, bleeding, and so on. Dr Gerald Brock, a prominent Canadian sexual health doctor and renowned urologist, has made the observation that prescribing SSRIs for premature ejaculation treatment is now becoming more common in Canada. In the absence of specifically approved treatment methodologies and drugs approved for this purpose, SSRIs such as sertraline and paroxetine are now offered to patients as well as some non-SSRIs such as clomipramine. Many men do not seek treatment for this potentially embarrassing condition, and many others are not offered good treatment when they do....... so are prescription drugs an appropriate therapy anyway? Here's a warning if you decide to use SSRIs for treating your own premature ejaculation! Most men who do this try the drug without first telling their partners. And since the drug produces a significant increase between penetration and ejaculation, your partner will probably reach the conclusion you must be having an affair! (Which is, after all, one reasonable explanation for reduced libido and increased sexual latency.) Furthermore, a lot of men stop using the drug after a short period of time because they find they are perfectly happy to ejaculate quickly. It seems that long lasting lovemaking is not everyone's real desire! Dr Brock has observed that SSRIs can be effective, but like many others working in the field points out the side effects. For one thing, they have long half-lives - a measure of how fast the drug decays in the body - and of course they are not designed for premature ejaculation ejaculation. The side-effects can include nausea and fatigue. Much worse, though, these drugs can apparently cause ejaculation failure and even complete impotence. Clearly, therefore, drug treatment is only part of the answer. Dr Brock states that a three-pronged approach is needed: premature ejaculation is an important medical issue and needs careful treatment and the men who lack ejaculatory control deserve to be taken seriously. This three pronged approach of which he speaks involves education, so any stigma attached to seeking treatment is removed; the recognition that sexual therapies and psychotherapy can be effective in helping to cure PE; and finally, the carefully considered administration of SSRI prescriptions, perhaps with psychological therapy. Perhaps We Need Lingering Ejaculation TreatmentDrug & Psychological Therapy Combined?In another study administered by Zeiss 20 heterosexual couples were studied under three conditions: treatment self-administered with no therapist present or available; self-administered treatment with a little therapist communication; and treatment administered by a therapist. The results were assessed between 15 and 20 weeks after the start of treatment: Zeiss reviewed the man's tendency to ejaculate quickly and the level of sexual satisfaction, and how long they lasted during sex before ejaculation, before and after treatment. Treatment in this case consisted of providing the man with a manual describing the causes of premature ejaculation and descriptions of the various techniques that can be used to treat it, including sensate focus and the stop-start and squeeze technique. There was also a lesson every week in sexual communication between members of the couple, which was designed to promote intimacy and communication. The group who received therapist contact had one hour of tuition from the therapist for a period of between 12 and 20 weeks. The outcome of this research was very clear: not a single couple within the group who had no contact with a therapist achieved an increase in IELT (intra vaginal ejaculatory latency times) of more than three minutes, nor did any of the men manage to last for more than five minutes before reaching orgasm during sexual intercourse. By contrast, five of the six couples who had minimal contact with the therapist achieved these goals, as did all six couples in the group that was administered by therapist. And the results of therapist contact were impressive: intravaginal ejaculatory latency time increased from just under 2 minutes to 10 minutes for the group who had minimal therapist contact, and from just under 2 minutes to nearly 11 minutes for the therapist administered group. The research also clearly demonstrated that contact with a therapist, whether in person or by telephone, produced a significant delay in ejaculation, and an increase in sexual satisfaction compared to those who received no contact. Of course another research approach to stopping premature ejaculation is to consider the effect of psychological therapy administered together with pharmacological therapy. There are many pages on this website which describe the effectiveness of pharmacological interventions, but few controlled studies have been conducted to discover whether psychotherapy and medication act in complementary fashion. However, there is actually some evidence that combination therapy of this kind results in a higher rate of completion of therapy, as well as increased satisfaction with the outcome.
Tang et al conducted an investigation in which they
administered Sildenafil citrate (Viagra) in combination with behavioral therapy
to 60 men experiencing rapid ejaculation. The measure of success of the
treatment was the intravaginal ejaculatory latency time (IELT) and satisfaction
with sex of both partners before and after the combined treatment. (It's not entirely clear why Tang chose to use Viagra for this experiment, since this is an agent for the treatment of erectile issues, not premature ejaculation. One can speculate, however, that the increased hardness of a man's erection boosted his confidence, thereby allowing him to maintain significantly greater control over his progress towards ejaculation.) Li conducted a study with 90 patients using the same basic research parameters as above but substituting Clomipramine for Viagra. The scores for control of ejaculatory reflex, sexual satisfaction and self-esteem around sex did show significant increases in a combined therapy and drug treatment group when compared with a control group who received only behavioral therapy. Similar results have been obtained with SSRIs. However, we do know that men who have adequate access to psychotherapy can use the pause and squeeze technique perfectly well to extend the duration of sexual activity and there is a concomitant increase in partner satisfaction. In any event, what is abundantly clear is that men require close attention from a therapist whatever premature ejaculation treatment method may be chosen. Video - Using Priligy (Dapoxetine) For Delayed Ejaculation
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