Paroxetine outdoes fluoxetine, escitalopram for premature ejaculation
The selective serotonin reuptake inhibitor paroxetine fared better than fluoxetine and escitalopram in managing premature ejaculation (PE), demonstrating improved intravaginal ejaculatory latency time (IELT), according to a meta-analysis. Moreover, combining paroxetine with tadalafil or behavioural therapy was better than paroxetine alone in improving IELT.
A pooled analysis was performed using 19 randomized trials comparing paroxetine with placebo, dapoxetine, tramadol, sertraline, phosphodiesterase 5 inhibitors, fluoxetine, behavioural therapy, local lidocaine gel, duloxetine, escitalopram, and combined therapy. The majority of the trials were of 4–12 weeks’ duration. [BMC Urol 2019;doi:10.1186/s12894-018-0431-7]
Among all comparisons, paroxetine was found to be significantly more effective than fluoxetine (mean difference [MD], 0.54, 95 percent confidence interval [CI], 0.07–1.02; p=0.02) or escitalopram (MD, 0.20, 95 percent CI, 0.08–0.32; p=0.001) based on IELT.
Paroxetine combined with tadalafil (MD, -0.79, 95 percent Cl, -1.23 to -0.35; p=0.0004) or behavioural therapy (MD, -0.40, 95 percent Cl, -0.62 to -0.18; p=0.0003) was more efficacious than paroxetine alone in improving IELT.
“Paroxetine … increases the amount of 5-hydroxytryptamine in post-synaptic membrane receptors, thus delaying ejaculation,” said the researchers. However, conflicting evidence surrounds the efficacy of paroxetine in treating PE, with some reflecting better efficacy, [J Reprod Infertil 2018;19:10-15; Eur Urol 2011;59:765-771] while others demonstrate similar findings with other agents. [Arab J Urol 2013;11:392-397; Andrologia 2018;doi:10.1111/and.12829]
According to the researchers, these could be due to the different definitions of PE and treatment periods. “[T]he definition of PE has changed greatly [recently] and the main outcomes only include IELT,” said the researchers. Therefore, PE definitions should be standardized in future trials which should also include subgroup analysis based on PE definition, they said.
Although dapoxetine is FDA*-approved, it does not equate to better efficacy compared with other agents for PE. Evidence shows that paroxetine outdoes dapoxetine in terms of cost and dropout rates. [Int J Impot Res 2015;27:75-80; Asian J Androl 2014;16:725-727] “[Nonetheless,] urologists [are advised to] update their articles because paroxetine is still not [FDA-approved].”
Given the small sample and short duration of the trials in this meta-analysis, longer trials conducted in larger populations are warranted to further explore the efficacy and safety of paroxetine in this landscape, said the researchers.
Moreover, the new ISSM** guidelines identified personal emotions and the ability to control ejaculation as important factors in PE. [Sex Med 2014;2:41-59] “Therefore, it is not convincing … to compare IELT only between different drugs in the treatment of PE,” said the researchers, hence the need to examine other variables such as sexual satisfaction, libido, and frequency of intercourse, and parameters for evaluating PE (ie, IIEF, PEDT, and PEP***).