Pearls of Wisdom: Management of Premature Ejaculation
Stanley is a 42-year-old man who has been married 16 years. His wife recently read an article in a popular magazine about medical treatments for premature ejaculation and suggested that he consult you about it. Stanley’s intravaginal ejaculatory latency time (IELT) is 30 to 60 seconds and has been that way since he was a teenager. He has had 8 lifetime sexual partners, with all of whom he has experienced premature ejaculation.
What might you offer Stanley?
A) Oxycodone 5 mg/acetaminophen 325 mg on demand
B) Tramadol 25-50 mg on demand
C) Cyclobenzaprine 10 mg 3 times a day
D) Spironolactone 50 mg on demand
What is the correct answer?
(Answer and discussion on next page)
Louis Kuritzky, MD, has been involved in medical education since the 1970s. Drawing upon years of clinical experience, he has crafted each year for almost 3 decades a collection of items that are often underappreciated by clinicians, yet important for patients. These “Pearls of Wisdom” often highlight studies that may not have gotten traction within the clinical community and/or may have been overlooked since their time of publishing, but warrant a second look.
Now, for the first time, Dr Kuritzky is sharing with the Consultant360 audience. Sign up today to receive new advice each week.
In contrast to erectile dysfunction, where it is very common for patients to speak to their clinician about the condition, many patients do not directly address clinicians about their premature ejaculation. Further, many clinicians do not address the issue with their patients, unless they feel that there is some reason to. In recent years, direct-to-consumer advertising has made many of our patients more comfortable to address "sensitive" issues such as bowel function, bladder function, and sexual function, but none of this informational augmentation has focused upon premature ejaculation. Hence, if sufferers don’t think there is any effective (or FDA approved) pharmacologic intervention, why should they broach the topic?
Note: the primary metric in measuring premature ejaculation is the IELT, which is, admittedly, somewhat antiquated, in that it ignores a portion of the population with same-sex sexual partners or ejaculation in heterosexual partners not involving the vagina
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Previous studies have examined the use of paroxetine or other selective serotonin reuptake inhibitor (SSRIs) and sildenafil, finding that they could increase the duration of intercourse to some degree.
The Research
In a study published in the International Journal of Impotence Research, researchers conducted a literature review of articles published between January 2000 and July 2014 on the use of tramadol for premature ejaculation. Overall, 8 studies were identified. In all of the studies, IELT was used as the primary outcome.
The Results
The researchers found that on-demand dosing of tramadol, particularly among those taking 25 mg and 50 mg doses taken 1 to 2 hours precoitally, was well tolerated and effective at lengthening IELT in men with varying degrees of premature ejaculation.
The researchers noted that although there is a risk of abuse and dependence, it is rare, particularly with low doses taken intermittently.
While the data set supporting SSRI’a for premature ejaculation is substantial, many patients are only able to gain therapeutic advantage of SSRI’s when taken on a daily basis. Having a highly effective treatment that can be taken as needed reduces concerns about potential toxicity.
What’s the “Take-Home”?
Our long-term experience with tramadol makes it a particularly attractive option for the treatment of premature ejaculation, especially because the dose required is modest, it can be used on demand (rather than daily, as is commonly the requirement for SSRI’s), and the safety profile of tramadol is already well established. Because clinicians have used tramadol effectively in other disease states for so long, most of us feel comfortable about its adverse effect profile: tramadol is generally well tolerated at such low doses.
Reference:
Kirby EW, Carson CC, Coward RM. Tramadol for the management of premature ejaculation: a timely systematic review. International Journal of Impotence Research. 2015;27:121-127.